Symposium on Psychiatry in Internal Medicine
Psychological Aspects of Myocardial Infarction Ned H. Cassem, M.D.,* and Thomas P. Hackett, M.D.**
Newspaper headlines recently acclaimed a 55 year old man with chest pain for about one year. A stress test given by his cardiologist was found to be markedly abnormal. Angiography revealed obstruction in three coronary arteries, greater than 95 per cent in two and about 75 per cent in the other. Coronary bypass surgery was recommended. The patient refused. Instead, he decided to diet, lost 37 pounds and began an exercise program. Subsequently he ran in a number of marathons, first in the Honolulu marathon, and later in greater than 90 degree heat, the Boston marathon. So concluded the newspaper item: man defies doctors and medical science. What few know is that during the Honolulu Marathon this man developed chest pain which persisted for 6 hours. Even so, on the very next day he began training for a subsequent marathon. When he returned to his cardiologist for follow-up examination, the electrocardiogram revealed that he had sustained a myocardial infarction. Undaunted by the news, he continues to train for future marathons. What ifno follow-up tracing had been taken? What ifhe had stopped running in Honolulu and had it taken then? You might say that in the first case, medical science had been defied, and, in the second, vindicated. Yet there seems to remain some truth in both. At the very least this case illustrated that psychological reactions to heart disease can be more astonishing and dramatic than those of the cardiovascular system itself. Studies with coronary patients at the Massachusetts General Hospital have, since 1967, focused on the psychological consequences of myocardial infarction. 6 ,7,11,12,19 Some of the basic reactions are outlined below.
Emotional Problems in the Acute l\hase Of all the potentially emotional features of coronary artery disease, none is more significant than its capacity to kill its owner. The major threat, then, is death. Gold, Leinbach et al. 10 reviewed the outcome of the first 100 patients treated for cardiogenic shock with the intra-aortic "Associate Professor of Psychiatry, Harvard Medical School, at Massachusetts General Hospital; Director of Liaison Psychiatry, Massachusetts General Hospital, Boston *':'Professor of Psychiatry, Harvard Medical School, at Massachusetts General Hospital; Chief of Psychiatry, Massachusetts General Hospital, Boston
Medical Clinics of North America-Vol. 61, No. 4, July 1977
NED H. CASSEM AND THOMAS
balloon pump (IABP). From a psychological perspective, Figure 1, which presents their data, strikes a sober note on the possible consequences of coronary artery disease. Of the 14 patients who were balloon independent, 12 survived. Of the 86 who were balloon dependent, 19 did not undergo angiography (literally did not make it there): all 19 died. Of the 67 undergoing angiography, lesions in 24 were inoperable-all 24 died. Of the 33 patients with operable lesions, 6 never made it to surgery (2 of them refusing), and all 6 died. Thirty-seven did make it to surgery, of whom 21 died and 16 survived. Actually, 28/100 was not a bad salvage rate for 100 patients in cardiogenic shock, but the somber cascade of Figure 1 dramatically reminds us that the primary threat an individual realizes when something is wrong with his heart is that he or she may die. One could argue that the fatal implications of a myocardial infarction are hidden from the patient with a routine, stable myocardial infarction, but the physician has no way of knowing what the individual's experiences with heart disease have been and what conditioned fears lurk in his mind. Blacher 3 has underlined the universality of fears about the heart. Even if the patient is spared knowledge of all possible complications of a myocardial infarction, the staff (both doctors and nurses) of the coronary care unit are not. Their reactions to the development of a potentially fatal complication such as cardiogenic shock are an important feature of experience in the coronary care unit. Using an Atmosphere Assessment Scale 5 to assess unit morale, reactions of the coronary care unit staff were documented during the terminal days of a balloon-dependent shock patient (Fig. 2). Four subscales are depicted: harmony (unit feels harmonious, together, etc.), depression (staff feel blue, depressed, sad, etc.), anxiety (staff feel uptight, tense, etc.) and conflict (staff feel in Patients with Cardiogenic Shock Treated with Intra-Aortic Balloon Pump
Balloon Independent 14
Balloon Dependent 86
No Angiography 19
No Operation 6
Died 6 Figure 1.
PSYCHOLOGICAL ASPECTS OF MYOCARDIAL INFARCTION
Figure 2. Morale scores of CCU nursing staff associated with the approaching death of a patient with an inoperable lesion treated with intra-aortic balloon pressure.
conflict, hostile, etc.). Scores were recorded as a 34 year old man with inoperable triple vessel disease, ineffective ventricular function, and an expanding aneurysm approached death. After his first episode of ventricular tachycardia, the depression scores rose steadily until his death. Despite the significant elevation in feelings of despondency, the feeling of harmonious group action was unaffected, if not enhanced. Yet the fatal implications of heart disease affect staff as well as the patient, a fact not to be disregarded in intensive care settings. Death, even when expected in the coronary care unit, as in the case illustrated in Figure 2, exacts its emotional toll from all concerned. When it is sudden and unexpected, the psychological consequences are even more intense. Figure 3 illustrates the AAS scores following sudden cardiac arrest in a 51 year old man admitted on the preceding night with a routine inferior myocardial infarction. Arrest occurred during morning rounds. Instant efforts at resuscitation progressed smoothly but failed, and later postmortem examination confirmed ventricular rupture. All
Figure 3. Morale scores of CCU Nursing Staff after a sudden death on morning rounds, with assessments before and after a staff meeting. 8
NED H. CASSEM AND THOMAS
subscale scores, taken 5 hours later, were the highest recorded for a 15 month period. The value of a 45 minute staff meeting in reducing anxiety, depression, and conflict scores among the staffis also demonstrated. In order to assess the incidence of psychological difficulties in acute coronary patients, we surveyed a 15 month period in the coronary care unit at the Massachusetts General Hospital. 6 Of 445 patients admitted during that time, 145 (33 per cent) were referred for psychiatric consultation. The reasons for consultation are presented in Table 1. The most frequently reported difficulties were anxiety and depression. Management-of-behavior consultations were prompted when patients wanted to sign out or were acting out dependency conflicts, by whining, by demanding behavior, or by aggressive rejection of therapeutic limitations. In order to summarize the complex set of emotional reactions a normal individual might have to a myocardial infarction, we took careful note of the timing of the consultations (most for anxiety occurred on day 1 or 2, those for signing out on the second day, and those for depression on days 3 to 5) and constructed Figure 4.
Table 1. Requests for Consultation According to Frequency PROBLEM SPECIFIED
NUMBER OF TIMES
47 44 30
Anxiety Depression Management of behavior Hostility Delirium Functional contribution to symptoms Family intervention Sleep disturbances Medication advice
12 11 8 7 6 5
OAY IN CCV Figure 4. Hypothetical schedule of onset of emotional and behavioral reactions of a patient in a coronary care unit.
PSYCHOLOGICAL ASPECTS OF MYOCARDIAL INFARCTION
Interpreting this, one could say that the typical patient, a few hours removed from his life-threatening experience with crushing chest pain, is anxious when he is admitted to the coronary care unit. At this point the patient is preoccupied with death or its possibility as signalled by recurrence of pain or shortness of breath, a sense of imminent danger or doom, or simply the intimidation of the unknown. As the patient feels better, denial is mobilized. He may find it hard to believe that he really had a heart attack. If the damage is unconfirmed, he may protest his detention in the unit and insist on returning to important business obligations. By the third or fourth day, however, the implications of his cardiac injury begin to take the shape of a specific concern. As he becomes more cognizant of his true condition, despondency sets in. The more devastating the effects of the infarct, the more profound the depression is likely to be. (This is expanded below.) If he also has premorbid abrasive personality traits, especially those centering on dependency or passivity, he may, after a "civil interval," start irritating or perplexing the staff by his behavior. Provocative behavior usually begins around the fourth day, when the immediate threat to life seems to have passed. 6 It has been our experience that hostile, disruptive behavior in a coronary care unit patient on the first day is almost always due to anxiety and subsides as the sense of security increases. Patients who become difficult after the threat is over usually remain so, reverting to life patterns characterizing behavior styles prior to admission to the coronary care unit. Many emotional reactions stem from the basic threat of death, as mentioned above. One 45 year old psychoanalyst eloquently described his own anxiety: "I continue to regard myself as living under the sword of Damocles, but as the years go by I also begin to see how neurotic and damaging such an attitude is. I do not believe I will ever totally adapt to it and begin to think that perhaps in essence, worrying about my heart becomes a way oflife for me. As each year goes by I damn myself for all the unnecessary concern I've had, and yet I face the coming year with new doubts-a vicious circle which gets me nowhere! I cannot tell you why I feel my pulse or dread the prospect of surgery except to relate it to a basic fear of death and viewing the heart as a symbolic fountain oflife, a fear and a symbolic meaning which I believe are present in all men."l If anxiety is the commonest feeling of coronary patients, depression ranks a very close second. Anxiety is produced by the greatest threat to the individual with coronary disease: death. The second major threat faced by the coronary patient is that to his self-esteem. One might say, in fact, that a myocardial infarction produces an ego infarction. 7 Even while in the coronary care unit a patient begins to ruminate about all that his heart attack has done to him: his job is in danger, earning power is lost, he is getting old, falling apart; he will not be able to drive, exercise, satisfy his wife sexually; intercourse, smoking, eating, drinking-all may be forbidden. Even ifhe survives the heart attack, most of life's pleasures have been forfeited. Such thoughts are the content of the "homecoming depression" experienced by many patients after leaving the hospital. Again, Abram depicts this poignantly: "I feel the agony of living with heart disease. Denial, the most prevalent
NED H. CASSEM AND THOMAS
defense mechanism used by patients with somatic illness, seems lacking in me. I see the worst and dread heart surgery and death from one day to the next. Do I wish such a course and do I protest too much? My middle age leaves me depressed. I wonder what I have missed in life, what I could have done, what I have accomplished, how I have failed and what is left. Do I dread death for fear of annihilation and nothingness or do I dread it for the separation from loved ones and the loss I will inflict on them? I suspect both."1
Patterns of Adaptation What are some of the coping strategies used by cardiac patients to counteract the threats to life and self-esteem? The most common is denial. Croog et al. 8 documented in a large sample of post-coronary patients, all of whom were explicitly told they had a heart attack, that three weeks after infarction, one of five stated that, whatever the doctor told them, he had not had a heart attack. It has been estimated that at the time of discharge after myocardial infarction one third of patients have no understanding whatsoever of the physiology of myocardial infarction. This does not appear to be related to intelligence but to the natural process by which persons protect themselves from thinking about the threatening implications of disease. A second style of coping is seen in patients who, like the marathon runner in the initial example, simply overdo it. We have all known patients who have refused to comply with most or all of the medicallimitations placed on them, and some of them seem to escape unscathed. On the other hand, some do not. Not long after the popularity of jogging became widespread in 1968, reports of jogging fatalities appeared in the literature. 4.16 A third response for the patient is to quit altogether. Having a heart attack, after all, is such an honorable way to retire from the traumas of daily life. Much of the early psychoanalytic literature stressed the importance of fear of competition in the etiology of heart disease, with an infarction often intervening to remove the individual from the need to face hostile rivals (surrogates for the parent of the same sex).15 A fourth even more troublesome reaction to myocardial infarction is the development of cardiac neurosis. Whether labeled as a special case of anxiety neurosis (usually present in some form prior to the myocardial infarction) or as malignant hypochondriasis, its manifestations are well known to the practitioner. A cardiologist did fairly well after his myocardial infarction, but repeated angina bought him back for triple saphenous vein bypass, and subsequent to that, after a period of three years, he became in his own words "a basket case." He was often seen lying in bed with his stethoscope placed over his heart, feeling for a liver edge, or inspecting his legs for the development of pedal edema. Despite the reminder that his pedal edema was unilateral and therefore on the basis of venous obstruction, neither his nor his physicians' knowledge brought him relief from worry. A second course of electroshock therapy helped him for a few months, but he became convinced he had carcinoid syndrome and colonic cancer. When his depression was again relieved, his
PSYCHOLOGICAL ASPECTS OF MYOCARDIAL INFARCTION
rumination about minor symptoms continued to fill his daytime hours. Cardiac neurosis is extremely resistant to treatment; recovery is very slow, at best. Intervention
What sort of intervention is available to reduce anxiety and prevent or contain extension of the ego infarction incurred in the wake of damage to the heart? While anxiety is accepted as a normal component of a patient's reaction to acute coronary disease, the increased sympathetic arousal is often uncomfortable and potentially haz