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Psychological Management of the Myocardial Infarction Patient Dr. Thomas P. Hackett M.D. M.D.

a b

& Dr. Ned H. Cassem

c b

a

Department of Psychiatry , Massachusetts General Hospital , Boston, USA b

Harvard Medical School , USA

c

Massachusetts General Hospital , Boston, USA Published online: 09 Jul 2010.

To cite this article: Dr. Thomas P. Hackett M.D. & Dr. Ned H. Cassem M.D. (1975) Psychological Management of the Myocardial Infarction Patient, Journal of Human Stress, 1:3, 25-38, DOI: 10.1080/0097840X.1975.9939544 To link to this article: http://dx.doi.org/10.1080/0097840X.1975.9939544

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PSYCHOLOGICAL MANAGEMENT OF THE MYOCARDIAL INFARCTION PATIENT

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THOMAS P. HACKETT, M.D.,* and NED H. CASSEM, M.D.** The acute coronary experience is divided into three parts. I n tht1,first.the pre-hospital phase, attention is devoted to t he widespread phenomenon of‘pa tien t delay. Evidence is given to indicate that the source of’ delay is entire1.v psvchological and centers around the inubility to decide whether or not to seek help. The second part. or hospitul phase. describes the response of the patient to the various aspects of’ the coronar?, care unit, including monitoring. julse alarms. witnessing arid sustaining N cardiac arrest. The third phase. the post-hospital convalescence, centers on the principal ps.vchologica1 problem of‘ this period. depression. Its C U U S P S . manifbstations. and methods ot’ management are discussed.

The psychological management of the patient with an acute MI can be divided into three sections, each with its specific problem: 1) the pre-hospital phase, in which the main issue is delay: 2) the hospital phase, in which anxiety about the present and future predominates; and 3) the post-hospital or convalescent

*Dr. Hackett is Acting Chief of the Department of Psychiatry at the Massachusetts General Hospital in Boston, and is Associate Professor of ’ Psychiatry at the Harvard Medical School. **Dr. Cassem is Director of Residency Training at the Massachusetts General Hospital in Boston, and is Assistant Professor of Psychiatry at the Harvard Medical School.

September, I9 75

phase, which centers around the management of depression. Although the response to any acute illness can be similarly divided, there are factors which separate myocardial infarction from most of the others. The two most important are its prevalence - it is nearing epidemic proportions in the USA - and its lethality. Coronary heart disease is America’s number one killer. There is an average of 1,000 coronary deaths a day in this country. Nearly half of our total death rate is due to coronary disease and well over half of those who die before their 65th birthday succumb to this disorder. PRE-HOSPITAL PHASE In the last five years a number of studies have been published on the extent of delay in coronary heart disease. 1 . 2 ” All of their findings agree that the average man or woman struck down with severe chest pain will delay four or five hours before seeking medical help. Since it is estimated that well over 60 percent of coronary deaths occur between one half to one hour after the onset of chest pain, it is apparent that delay of this sort occurs at the very time when the patient is in most danger of dying. Many of these deaths would be preventable if the patient were treated properly at the time the syniptom developed. It is estimated that a good 50 percent of these deaths could be avoided by prompt, proper treatment.

Journal of Human Stress 25

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ACUT.E CORONARY EXPERIENCE The most common response that seems to occur in an individual experiencing sudden intense chest pain which lasts more than five minutes is not to call a doctor but to reach for an antacid. Eighty to ninety percent of patients queried attribute their distress to acute indigestion. Even though the symptoms may be unlike any attack of indigestion the person has ever experienced, he still prefers to think it stems from the stomach rather than the heart. The reason, of course, is that the stomach is a safer organ to have afflicted than the heart. If the thoughr of having a heart attack crosses the person’s mind. it is usually countered by the rationalization, “It couldn’t happen to me.” We have examined patients who responded to chest pain by doing vigorous push-ups or running up a flight of stairs - reasoning that they could not be experiencing heart attack, since the exertion had not caused them to drop dead. Others drink tea or coffee or alcohol, in a vain attempt to diminish or extinguish the pain. In this respect it is important to point out that the pain in all of the studies cited is of sufficient magnitude to curtail the individual’s activity. In other words, the coronaries we are discussing do not fall into the category of the “silent coronary.” The following is a typical case ofdellay. A 47-year-old man was visiting a city for a business meeting. After a heavy meal he retired to a hotel room and began to experience severe pericardial pains. Immediately, he took two aspirin followed by sodium bicarbonate. The pain did not abate; he began to pace the room rapidly and then did some sitting-up exercises in an attempt to “bring up the gas.” When this was unsuccessful he took a sleeping pill and consumed four ounces of bourbon -his customary nightcap. Upon his lying down, the pain spread into his left

26 Journal of Human Stress

arm and caused him to think he was having an attack of bursitis, a condition he had had in the past. Even though his bursitic pains always had been confined to the shoulder and left arm - totally unlike the chest pain he was experiencing -he was able to take comfort from this diagnosis and went into a light sleep. About an hour later he was awakened by an increase in the severity of his chest pain. By this time he felt “as though a truck had run over my chest.” Until then the thought that he was having a heart attack had not crossed his mind - even though he had a family history of coronary disease, including a father who had angina pectoris. Rather than call the hotel physician he phoned his wife and described his situation to her, hoping to gain some reassurance. Instead, she instantly thought of a heart attack and insisted that he call the hotel physician. Knowing that he had a tendency to procrastinate, she made the call for him. The next thing he knew, a doctor was knocking at his door. After a cursory examination the physician sent him to the hospital where a diagnosis of anterior myocardial infarction was confirmed. The time lapse between the onset of chest pain and his arrival at the hospital was four and one-half hours. Often we have heard it said that delay in coronary heart disease is confined chiefly to the uneducated or to the lower socioeconomic classes. In our study and in others the phenomena of delay cuts across all of the usual socioeconomic variables. Age, sex, level of education, socioeconomic status and even history of a previous heart attack do not appear to reduce the tendency to delay. The delay times of the physicians we have interviewed, including three cardiologists, have not been distinguished by the swiftness oftheir response. September, I9 75

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HACKETT and CASSEM While there has been a tendency for delay times to be less when the severity of the pain mounts, the relationship between these two factors is by no means direct. Certainly, it has been our experience that the presence of severe pain in no way insures a speedy response. Originally we had thought that a symptom such as shortness of breath might be an added inducement for the patient to respond quickly, but this finding has not been reported. Many of our colleagues have expressed the opinion that delay is explained by traffic or by the necessity to arrange for transportation in getting to the hospital or in finding a doctor for examination. More recent work points out that threefourths of the time taken up by delay is used to make the decision to consult the In fact, approximately 10 percent of the total delay time was accounted for by traffc or transportation. It would seem then that the principal cause for delay is pyschological. The decision making process gets jammed by the patient's inability to admit that he is mortally sick. How can one reduce delay? Since the patient's chance of dying is lessened by one-third once he reaches a hospital, it is obvious that this is a major goal. There are a few clues for developing a strategy to cut down delay. One is that a patient's response to obtain help quickens when he recognizes that the heart is the source of his difficulty. However, of all the factors that work in favor of getting an individual to respond promptly, the one that is most effective is the advice of another party. If the patient is struck by chest pain at work and is told to visit the hospital by his foreman, he does so immediately. Similarly, the individual. clutched by pain in the midst of a busy September, I975

sidewalk and spotted by a policeman, is much more apt to find himself in the emergency ward than he would if he had the same pain at home. Curiously. the least effective source of advice is the spouse. One could almost say that the more impersonal authority invested in the advisor the more swiftly the patient is to seek aid, and the time lag follows a linear decrement as a function of diminishing authority. A case in point has to do with the wife of one of our patients who stated that she had pleaded with her husband for three hours while he lay on the sofa racked with chest pain during his second MI. He kept insisting that it was indigestion from some goulash she had failed to prepare properly while she continued to goad him with the knowledge it was another coronary. We could not help but wonder why she did not take the initiative and simply call the police or their family doctor. There are a few suggestions we can make in the hope of reducing delay time. The first is to anticipate with the patient that his initial tendency will be to explain chest pain by some means other than its coming from the heart. This will probably be true even when the patient has had a previous MI. As a consequence we give the following formula to patients: When you .find yourself' reaching .for an antacid and talking about indigestion with pain in the chest on either side that has lasted .tor longer than two-anda-half' minutes, rather than head.tor the medicine shelf: call your physician. We also make it a point to inform the spouses of coronary patients or those in a high-risk category that they should take the initiative and make the necessary Journal of Human Stress 27

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ACUTE CORONARY EXPERIENCE arrangements for an examination inimediately when their spouse complaiins of chest pain lasting longer than two to three minutes. Of equal importance in dealing with the immediate reaction to chest pain is to give the patient a background of factual information on coronary artery disease. We know that society often unfairly assigns the role of a cardiac cripple to those who have been stricken with this condition, even when there is no basis for doing so. It is important to point out that many leaders in the community have led successful and fulfilling lives after sustaining an M I and that individuals with uncomplicated MIS often return to the same level of work and physical activity which they enjoyed before. The silniple information that most people who recover from heart attacks can work and lead normal lives often comes as a surprise to patients. Certainly the fact that the quality of life need not be markedly reduced is heartening information to survivors. HOSPlTALlZATlON

The hospital phase begins when the patient arrives at the emergency ward or receiving area. In the majority of medical installations in this country a person with chest pain is ushered into an examining room immediately, thereby circumventing tedious and dangerous delays such as the gathering of insurance information. The fact that his symptoni is taken seriously instantly, and that he is attached to a monitor, examined by a doctor and tended by a nurse is far more assuring than distressing to the majority of patients. Most express a feeling of great relief when they finally reach a medical center and find themselves cared for. There are two potential sources of

28 Journal of Human Stress

stress for patients immediately after entrance into the hospital. 'The first is being left alone and the second is having the last rites administered. It is a simple matter to assign a nurse or attendant to stay at the patient's side and in this way avert the first source of fear. If no one else is around it is well to leave a relative in the same room with the patient. Early in our work with coronary patients we made a special study of the effect of administering the sacrament of the sick to patients.' Our findings pointed to the obvious fact that patients can accept a great deal of adversity as long as the individual administering it is kind and tactful. The majority of Catholics who had the sacrament of the sick felt comforted py it but all agreed their response was almost entirely dependent upon the manner of the priest administering it. When the priest presented the ritual as a routine, stating that everybody with a possible heart attack received it and went about his task in a calm and relaxed way, he was apt to provide far more hope and comfort than distress. Women seem to respond more positively than men, and private patients more positively than ward patients. As would be expected, those to whom religion was important in preniorbid life were the most appreciative responders. When patients complained of being given last rites, invariably it was the manner of the priest that bore the brunt of their criticism. An example of this may be observed in the recollections of a 72year-old boiler-room worker admitted with his first MI: "The priest comes in and tells me, 'I come in a rush . . . They just called me up and told nie they got you in here and to come and anoint you.' " 'What do you mean,' I says, 'Anoint me? Anoint me for what?' September, 1975

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HACKETT and CASSEM “He replies, ‘For death, of course, ‘cause we can’t be too careful. Anybody with a heart attack can shuffle out in no time.’ “I laughed, he was so nervous. We joked about it for a few minutes and then went through with the formalities and I bid him goodbye.” Both the patient and his wife, who had been present, agreed that the priest’s presentation could have been improved as it caused unnecessary anxiety which was not leavened by humor until later. Although the majority of patients have amnesia for part or all of their emergency ward experience, some are able to recall emphatically what they were told by their admitting physician. O u r research reveals two traits that were appreciated most in their doctors: compassion and forthrightness. One patient remembered a physician saying to him, “You’ve had a heart attack but it is not a large one. However, all heart attacks are serious and you will need our attention.” He appreciated the double message - that it was not massive but was serious enough to warrant admission. It is worth mentioning that of the hundreds of patients we have examined, not one has complained of being told too much in the emergency ward. A possible rule of thumb for those physicians who are unsure of what to disclose could be, “It is safer to err on the side of openness rather than being closemouthed.” Needless to say, one should not run down a list of possible eventualities or emphasize all the conceivable complications. Confidence and enlightened optimism are the keynotes for this early phase of admission. Patients who are desperately in need of medical help are apt to respond positively to the smallest intimation of competence on the part of their physician, so the latter need not work September. 1975

very hard to embellish this impression. Sources of Stress Once admitted to the hospital the patient is more than likely sent to the coronary care unit (CCU), where there are three main sources of psychological stress: the first is being continuously monitored; the second is witnessing a cardiac arrest in another patient; and the third is undergoing and surviving cardiac arrest. Continuous Monitoring The experience of being monitored is central to occupying a bed in the CCU. In our first encounter with patients in the CCU. in 1958, we regarded the electrodyne monitor pacemaker as a formidable instrument. We believed it was bound to inspire a considerable amount of apprehension in the patients attached to it. The results of a preliminary study did anything but confirm our susp i c i o n ~ .Far ~ more patients were reassured by the monitor than were frightened by it. Even those who underwent painful external pacing regarded the machine with a mixture of awe and gratitude. One of the principal reasons for their overall positive response had to do with the way in which they were introduced to the monitor. A nurse described the instrument as a “mechanical guardian angel.” She went on to say, “As long as you’re attached to it you couldn’t die if you wanted to.” This proved to be a remarkably effective stratagem in a population that was predominantly Irish Catholic. This humbling experience taught us three valuable lessons. The first is that when one identifies with a seriously ill patient and attributes to him emotions which one imagines one would feel in his predicament, there is bound to

Journal of Human Stress 29

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ACUTE CORONARY EXPERIENCE be a wide margin of error by virtue of the fact that the investigator is not seriously ill and as a consequence does not think like a sick man. The second lesson plertains to the value of explanations and how they can deflate much fearful fantasy. The third is the usefulness of the defense of denial in individuals faced with severe stress. A sick patient is apt to fix on the benefit he derives from an instrument and to negate its more threatening aspect, particularly if it causes no pain. He also will eagerly absorb explanations of its function, and his natural tendency will be to deny the connotation that constant monitoring means his llife may be in danger. The psychological defense of denial is defined as the repudiation of part or all of the total available meaning of an event in order to reduce painful affects such as anxiety." A simple example of denial occurs i n everyday life when we board an airplane. We are far more concerned with the sleek design and the contident expressions of the pilot and copilot than we are with the possibility of midair collisions. hijackings. and faulty circuiting which might necessitate an emergency landing. Once aloft. we are less aware of defying gravity than we are of the scenery spreading beneath and of the prospect of a forthcoming cocktail or supper. We deny the sources of possible peril, a human virtue that is just as apt to be found in the CCU as aboard a luxury airliner. Along with introducing the machine in the manner described, nurses routinely take the precaution of removing an electrode to demonstrate how this can seit off a false alarm. In this way she is able to reduce the amount of "startle response" when the alarm sounds. She goes on to demonstrate how body movements can cause artifacts and static on the monitor

30 Journal of Human Stress

screen. Pointing out the patterns caused by artifact is particularly important in the care of blue-collar patients. We found that they are less apt to know about the machinery of intensive care than are their white-collar counterparts.' It is our belief that the more the patient understands the purpose and function of the mechanical devices in the unit the less fear these will produce. In well over 700 patients whom we have followed through the CCU we rarely have found one who objected to being monitored. If criticism was voiced, usually it was directed toward the physical irritation caused by the electrode paste. Occasionally the "beeping" of the monitor was bothersome, but this occurred far less often than we would have supposed. The noise elicited more comment from staff and visitors than from patients. I n fact. visitors impressed us as being more intimidated and frightened by the equipment than were patients. In viewing the response of patients to the instrumentation of intensive care such as pacemakers, respirators and monitoring systems, we have noted how infrequently one hears the fear of a mechanical failure. Whether this would be true in a less mechanically oriented culture is unknown; Americans seem able to put their trust in motors. Witnessing Cardiac Arrest

To avoid the major stress of a patient's observing cardiac arrest in another person, there has been a trend in the design of newer coronary units which supplant the open ward with a series of cubicles that insure visual isolation. Of those patients in our series who witnessed a fatal cardiac arrest. about 20 percent readily admitted being frightened by the sight. The others claimed not to have been.n The initial response to watching

September. 1975

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HACKETT and CASSEM the arrest was anger and annoyance at the afflicted patient. This seemed a particularly uncharitable response until we examined it. As we all know from personal experience, one of the best ways to reduce anxiety or fear is through anger. If a child. intimidated by a bully, can convert fear into anger. there is a consequent reduction in his anxiety. The same mechanism applies to the coronary care patient. What begins as fear for the arresting patient is quickly transformed into a more palatable and endurable anger. In conjunction with anger a number of other responses quickly occur which may explain why only 20 percent of our patients were frightened by watching an arrest. The next response most commonly elicited was of being impressed by the speed at which the arrest team responded and by the amount of time they spent in revitalizing the patient. “They came in like gangbusters.” “They just popped in out of the walls.” “They worked on her for hours.” These were typical comments. We also noted that, although the majority of onlookers empathized with the arresting victim, none identified with the person experiencing arrest or imagined himself/herself to be in the same position. This held true even when both the victim and the observers shared the same age, sex and social background. In general, unaided, the patient was able to find some difference to separate the arresting person’s condition from his own. When death occurred, the staff quickly assured the survivor that the heart of the deceased had been much worse than his own. Even when the excuses given were quite obviously overdrawn, the survivor was apt to accept them without question or reservation. The response of those who witnessed an arrest offers a good example of September, I975

how patients can grasp the most comforting meaning of an otherwise terrifying event while denying or overlooking the threatening aspects. It would be unfair to imply that viewing an arrest is not a source of great stress. There have been reports by others, notably Bruhn,’ that there is an increase in anxiety as well as in systolic blood pressure in patients who recently have been present at an arrest. Some of our nurses report that more requests for tranquilizers and pain medication occur in the wake of an arrest. Another reason to believe that watching an arrest takes an emotional toll has to do with room selection. We ask all patients whether they would prefer to be in a single room or a four bed ward should they require another hospitalization in the future. All of those occupying a four bed ward at the time of our question choose the same setting for readmission except those who have witnessed an arrest; these prefer a single room. They have no idea of the reason for our question except that it pertains to administrative needs. This unobtrusive measure tells its own story. Survival of Cardiac Arrest

We have interviewed and followed a sizeable number of people who have gone through cardiac arrest. The majority had difficulty remembering anything about the event. Some vaguely recalled being thumped on the chest and hearing voices, but the majority remembered nothing at all. The most complete account we have was given by a young teacher. He was brought into the emergency ward by his fiancie after having been stricken by severe chest pain. While being examined in the emergency ward, he arrested. After his resuscitation he recounted a vivid dream in which he found himself on a conveyor belt heading toward the Journal of Human Stress 31

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ACUTE CORONARY EXPERIENCE checkout counter of a supermarket. He was trussed up like a package of meat. A s he got closer to the cashier, he said to himself, and then aloud. "Oh, no. Oh, no. they don't. They're not going to check me out!" He awoke with a start after the second jolt of cardioversion. Looking around and finding himself encircled by men in white, he exclaimed, "Christ. what a batch of clerks in this butcher shop." Everybody laughed and then his doctor explained what had happened. I f he had not been told what had occurred, thic man probably would have had no clear recollection of the event or of its significance. It may have been renienibered only as a bad dream whose basis in fact he may have doubted. This is by far the most common type of impression victinis have oftheir arrest. One of the first reports in i.he psychiatric literature of the aftermath of recovery from a cardiac arrest described the result in ternis reminiscent of a traumatic neurosis. '" The survivors had recurrent nightmares. existed in a state of chronic anxiety and depression and often felt unable to return to a normal way of life. They looked upon themselves as being different from their fellow men. I t was as though they had died and then had been raised from the dead. With the passage of time more experience has been gained in the use of defibrillating techniques, and cardioversion has become more a standard part of the operating procedure in the CCU. Now patients are told what has happened to them after a n arrest has occurred: also. they are told that being defibrillated does not necessarily influence their chance for recovery or alter their prognosis. When the aforementioned pioneer study was carried out, these techniques were not known. nor was there any established procedure outlining what to tell a sur32 Journal of Human Stress

vivor about the event. Subsequently. as more information became available and a routine of information dispersal developed. there have been far less emotional sequelae tollowing recovery from an arrest. In our series we have scarcely any traumatic neuroses or mental incapacity directly linked to a saved arrest. Dobson and his coworkers in Great Britain, who followed a series of arrest survivors for some years, report a uniformly good response." I n their opinion the best policy is to tell the patient what has happened. and to deal with it in a niatter-offact way. The aim is to avoid making the patient feel singled out by fate as someone who has died and come back to life. We emphasize the fact that the purpose of the CCU is to provide exactly this type of service. There is nothing unique about sustaining a cardiac arrest and surviving. In this decade survivors number in the millions; many of them bear illustrious titles and have positions of signal importance i n this country. One ofour patients felt that he enjoyed a unique status as the result of surviving a n arrest. He was a man who wanted to be an astronaut and, in fact, had been enrolled in a program that eventually might have put him into space, but he was unable to complete his training. A brief time after returning to civilian life he suffered an unexpected myocardial infarction and arrested shortly after being admitted to the CCU. His resuscitation was uncomplicated and his recovery was complete. When told of what had happened he felt that his experience had been just as good as going to the moon. He described it as a true 20th-century journey. in which he had been to the other side and returned with the personal knowledge that insofar as he was concerned. there was no hereafter. September. I9 75

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HACKETT and CASSEM Aside from the three major sources of stress as described previously, what can be said concerning the ordinary variety of anxiety that is found in the coronary unit? We have observed elsewhere that anxiety is difficult to identify in the CCU because patients either simply do not ex: perience it or, deliberately or unconsciously, they deny it.” If anxiety is present, it often takes the patient time to get around to expressing it in terms of specific fears. As a consequence, physicians who make their rounds hastily are not apt to be able to judge adequately their patient’s mental condition. Oftentimes the busy physician would do well to inquire of the nurse about the feeling tone of his patient. We believe that mild to moderate anxiety is more common than the outward appearance of patients in the unit might suggest. Since it is unreasonable to expect the busy practitioner to spend a sufficient amount of time with each patient to unearth covert anxiety, we believe it is advisable to regard every patient as anxious and to treat him accordingly, even though supporting evidence might be lacking. A minor tranquilizer (diazepam 5 mg. 4 i.d. or chlordiazepoxide 10 mg. 4 id.) is ordered for all patients with the stipulation that it can be deleted or decreased at the patient’s bidding. Rather than place the medication on a p.r.n. basis we order it around the clock because CCU patients, in our experience, are apt to suffer in silence rather than trouble the nurse for more attention, as in requesting p.r.n. medication. We found the benzodiazepine group of tranquilizers to be the most effective in that they have a smaller number of side effects than do barbiturates and do not interfere with warfarin corn pound^.'^ In using them one must be alert to the possibility of their paradoxical effect of producing September, 1975

rage or lowered threshold for anger, although it rarely is encountered in our experience. It is useful to remember that bedtime sedation often can be provided by doubling or tripling the sedative dose of the benzodiazepines. Flurazepam HCI, because it has minimal interference with REM sleep, has been widely used in ICU settings and is considered a good hypnotic with a minimum of side effects. Although most patients prefer to be sedated, there is a small percentage who dislike the feeling of being drugged. These should be given the privilege of having no tranquilizers if this is their desire. We believe it is necessary to emphasize the importance of mental rest and to assure patients that tranquilizers are CCU standard medications. Although their number seems to be decreasing, there are some men who equate the need for sedation with weakness and the lack of manliness. This kind of thinking must be corrected. Depression is apt to be felt as the danger of the acute stage wanes. It occurs toward the end of the patient’s stay in the CCU or shortly after being transferred to the convalescent ward. The depression is reactive in nature and generally centers around a fear for the future. In the hospital it is apt to be so mild that it escapes the doctor’s attention. The standard signs are a saddened face, disinterest, listlessness, slowness of speech or. much less frequently, weeping. It is good practice to ask the patient about his state of mind. particularly about discouragement or depression because these are easier affects to hide than anxiety, and they are feelings which many individuals, particularly men, often feel ashamed to express. Depression focuses on concerns about reduced earning power, restrictions of activity, sexual incompetence. invalidism, Journal of Human Stress 33

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ACUTE CORONARY EXPERIENCE premature old age and recurrence of illness. The main issue in any depression is loss. The loss may be quite real, as in the death of a spouse or the bankruptcj of a business. It also may be symbolic, as in imagined loss of youth with the advent of gray hair. In either, the loss produces feelings of loneliness, inadequacy and sadness - all of which come under the heading of mourning. In order to cope with these feelings individuals develop a variety of defenses. Some quickly attempt to replace the loss (the rebound marriage is an example of this). Others attempt to deny it by suppression (“I simply won’t think of it”) or through minimization (“It really isn’t too bad - after all. others have lived through the same type of thing”). None of these coping tactics is bad so long as it allows some mourning to be expressed. Long experience and research have demonstrated that grieving is a necessary and natural reaction to loss. To stifle or thwart appropriate sorrow is to block a natural function, the equivalent of censoring joy. The patient who has sustained an MI recently should be encouraged to express whatever sentirnents of sorrow, frustration, anger O K depression he harbours. It is altogether normal for him to have these feelings, and the sooner they emerge the more quickly something can be done about them. POST-HOSPITAL CONVALESCENCE

As has been noted earlier, depression is one of the main psychiatric complications of convalescence. The latter is defined as the time between discharge from the hospital and the poirit of maximum yield in rehabilitation, in terms of job, family role and personal happiness. It has been said that the

34 Journal of Human Stress

depression following MI causes unwarranted invalidism which, in turn, accounts for a tremendous loss of man hours. Certainly, as any rehabilitation counselor or family physician can attest, prodigious amounts of misery are suffered during coronary convalescence, much of which can be avoided. Although not every person with coronary artery disease is a candidate for a post-MI depression, we favor a program of prevention which assumes that depression can occur in anyone who has sustained an MI. It is inaugurated in the CCU on or about the third day. The physician or a nurse-clinician trained in cardiology sits down with the patient to go over the facts of hidher illness. The nature of the infarction is explained, as is the process of repair. We have found that while white-collar patients are accurately informed about the damage to heart muscle and its repair through scar formation, the same cannot be said for their blue-collar counterparts. The latter understand infarction in terms of a damaged and weakened heart, but they are altogether unaware of the process of mending. As a consequence, some bluecollar patients picture their heart as permanently punctured. They conceptualize the infarct as a hole punched out of the heart that remains an eternal source of leakage. Providing information to remedy this conception can do more to insure peace of mind than any type of medication. Since the largest part of the depression suffered by the post-coronary patient usually revolves about the fear of being unable to resume work and lead an active life, one can remedy this by providing both from the national scene and from the local community, examples of individuals who have sustained an MI and returned to an active and productive life. September, I975

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HACKETT and CASSEM We have found that the majority of our patients are unprepared for the extent of patients are dogged by outmoded the depressive reaction that occurs. stereotypes which equate heart disease of While hospitalized they eagerly look forany degree with permanent invalidism. ward to being allowed home and welcome Union practices and corporate policy the actuality, as it means that the heart bylaws often encourage this archaic has been restored to a point where it can mythology. The information that eight function on its own. Soon after arriving runners who completed a recent Boston home and walking about, many patients marathon previously had sustained an experience a sense of sudden physical MI is heartening news for a man in the weakness. One reason for this is CCU who is mourning what he regarded physiological; they are out of condition. as the loss of his active life. In the hospital they were confined to a Aside from educating the patient small area. Even though they could pace through correcting misinformation and the halls they were in no way prepared for clarifying what he can expect in terms of the amount of activity available to them his specific myocardial lesion, the next upon coming home. Unfortunately, best treatment for depression is a weakness often signifies to the patient program of physical conditioning. Some that his heart is not as sound as he suphospitals start patients with un- posed. It sometimes serves to confirm a complicated MIS on such a program by hidden fear that invalidism will be his lot. the third CCU day. By using carefully An example is that of a 39-year-old teachgraduated passive then active exercises, er who did very well following his MI function is slowly restored. The reports of until he returned home. In his words, all of these programs to date indicate “I felt great in the hospital. No matter that anxiety and depression are less what anyone told me, I pictured myself troublesome when the patient is actively breaking records in getting back to work. engaged in physical c ~ n d i t i o n i n g ’ ~ .The ’ ~ first week home I could hardly walk which gives the patient a sense of par- the length of the house without being ticipating in his recovery rather than exhausted. I felt like a cooked goose, as if being a passive recipient. I were done for. It took me another two It is important to note that as in- weeks until I started feeling better.” This hospital time is reduced in the treatment is a prototypical statement, one that of MI, more privileges are allowed would apply to the majority of patients in patients during their hospital stay. For early convalescence at home. The sense example, businessmen who become of weakness often is the trigger that restive and irritable when denied access springs an underlying depression into the to a phone are now sometimes provided open. with this and dictating equipment as At the point of hospital discharge, let well, assuming their cardiac status is us tally the number of restraints binding stable or improving. Enforced passivity the convalescent cardiac patient: for some may be an exquisite form of The omnipresent threat of recurrence stress. and possible sudden death; We have used the term homecoming depression due to inactivity and job depression to describe the reaction of uncertainty; patients returning home after discharge from the hospital. The majority of deprivation or limitation of food, September, 19 75

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ACUTE CORONARY EXPERIENCE alcohol, excitement and sex; (One young man commented, concerning these restrictions: “No smokes, no booze, low salt, low fat, low energy, low sex or no sex - I feel like a cardiological capon!”) depression due to possible disruption in interpersonal relationships. (Role changes in marriage are common following an MI - e.g.. the wife must return to work to support the family, and she becomes the breadwinner. In this setting sexual problems are coninlon. Premature ejaculation and potency disturbances have been found to be as high as 40 percent by some authors.”) What can be done about the homecoming depression? The favored method of approaching the problem is prevention, as has been mentioned. Anticipating with the patient that it will be normal if he feels depressed upon arriving home, and that a sense of weakness might dampen his spirits. is a good beginning. The doctor legitimizes the depression by predicting it. Realizing that others undergo the same senoe of sadness makes the patient feel less unique and alone. The family should be informed as well. We encourage the patient to take tranquilizers if they are needed. We emphasize the importance of sound sleep in the first three months and encourage the use of benzodiazepines as hypnotics. If early morning awakening is the problem he should be given a longer acting hypnotic such as chloralhydrate. Aside from using minor tranquilizers and selected hypnotics we do not rely on drugs to treat the post-MI depression. The tricyclic antidepressants are contraindicated, because their use is associated with disturbances of rate and rhythm. Along

36 Journal of Human Stress

with the phenothiazines, they have been implicated by some investigators in sudden death. Similarly, the M A 0 inhibitors are unsafe to use in coronary convalescence because, in combination with tyramine bearing foodstuffs, they can induce hypertensive crisis. Just as we did in the hospital we encourage patients who have returned home to become involved in programs of physical conditioning. This is perhaps the most important aspect of convalescence, in terms of its ability to control depression by raising self-esteem, a sense of independency and confidence in one’s ability. Physical conditioning must be carried out through convalescence until it has become a way of life with the patient. Many patients complain of having no structure to their days of convalescence. The doctor tells them to increase their activity slowly but does not specify where or how. Conditioning programs provide this guidance. In addition some patients, especially those with compulsive traits, must have a schedule or hourly activities set out for them. This can be done by a skillful nurse or physical therapist. It is surprising how much post-myocardial infarction patients need in the way of direction, especially those in the bluecollar category. One of the bulwarks of our program is education. After taking a careful history which reveals how the patient regards his condition. and particularly his views about returning to a more active life, we specifically mention some common misconceptions. For example, we state that some people believe that recurrence of infarction is most apt to occur during orgasm. After laying this myth to rest, we ask whether or not the patient has any personal beliefs that might complicate his recovery. The most common myths September. I9 75

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HACKETT and CASSEM are: Even mild exercise is dangerous. Sexual intercourse should never be attempted, because following a myocardial infarction one is “over the hill.” Repeated infarctions or sudden death is more likely to occur at sexual orgasm. Driving must be avoided. The arms must not be suddenly raised above the head, especially the left arm. The patient is apt to die at the same age as a parent who had had heart disease. Recurrence is apt to take place around the anniversary of the first infarction. The heart is more vulnerable to repeat infarctions and sudden death while the patient sleeps. Any educational efforts should include the patient’s spouse and children. They must be taught not to make the father or husband a cardiac cripple or treat him as though he were an infant. Since the best way to determine how a family works together is to watch them in a group meeting, after the patient is discharged we feel it is a good policy for the physician or nurse clinician to visit the home and meet with the entire family. In the group setting it has been valuable to anticipate various responses. For example, one can predict that a wife will become angry at her husband when he tends to overeat and will tend to discipline him as she would a child. The patient may expect to be waited upon, particularly when objects need to be moved, and he may become resentful toward his children when they do not leap to help him. He must be told to express his desires in a pleasant and acceptable way. When it comes time for him to return to work, one can anticipate that he will feel September, 1975

anxious and apprehensive until he is able to perform to his satisfaction without developing cardiac distress. Similarly, the patient can be told that he/she will feel anxious when new types of activity are attempted or the range of accustomed activities is extended. In general, the tendency of the family is toward overprotection while the tendency of the patient is toward irritability. Highlighting these trends sometimes serves to reduce their impact. We have found that conducting a telephone follow-up, at weekly intervals for the first three months following discharge, serves an important function. A nurse clinician makes the call and then talks to both the patient and to hidher spouse. The purpose of the call is to check on their progress and to find out if they have questions, or problems with which they need help. This service has been greatly appreciated by our patient population. There have been studies over the past few years on the usefulness of discussion groups or “heart clubs” in coping with the problems of convalescence. Eight or ten patients get together on a weekly basis under the guidance of a nurse clinician and discuss their experience in managing diet, change in habits, medication, moods, etc. Often, these provide valuable forums for the exchange of information and for learning from the experience of others, with the nurse serving as a source of answers. The overall value of these groups has not been tested as yet in a scientific manner, but it is the impression of most of us who have worked with them that potentially they have great merit .I * *O The outlook for the individual who has survived an acute myocardial infarction is increasingly brighter. This is especially so since the advent of coronary artery ’

Journal of Human Stress 37

ACUTE CORONARY EXPERIENCE bypass graft surgery. However, in spite of technological advances, there remains a miasma of myth and misinformation which works against the coronary survivor. It is our obligation as physicians to push back this ignorance and to give our patients the best and the most recent therapies available. We must let them know that they can live long lives that ran be extended even more by proper care. Downloaded by [Carnegie Mellon University] at 13:58 13 October 2014

INDEX T E R M S coronary convalescence, coronary heart disease, exercise programs, cardiac arrest, cardiac monitoring, delay, post-MI depression, heart club, telephone follow-up, homecoming depression.

REFERENCES I . Hackctt. T.P.. and N.H. Casseni. "Factor5 Contributing to Delay in Responding to the Signs and Syniptoms of Acute Myocardial Infarction." Am. J . Curtliol.. Vol. 24. 1969. pp. 651 -658. 2. Simon. A.B. et al. "Components of Delay in1 the Pre-hospital Setting of Acute Myocardial Infarction." A m . J. Curdio/.. Vol. 30. 1972, pp. 475-482. 3. Moss. A.J. et al. "Delay I n Hospitalization During the Acute Coronary Period." Aiii. J. Curdid.. Vol. 24. 1969. p. 659.

"The Coronary Care Unit: An Appraisal of Its Psychological Hazards," N. Eitgl. J. Mrd.. Vol. 279. 1968. pp. 1365-1370. 9. Bruhn. J.G. et al. "Patients' Reactions to Death in a Coronary Care Unit." J. Psychosom. Rrs.. Vol. 14. 1970. pp. 65-70, 10. Druss. R.G.. and D.S. Kornfeld. "Survivors of

Cardiac Arrest: PFychiatric Study,'' J.A.M.A.. Vnl. 201, 1967. pp. 291-296.

I I . Dobson. M.. et al. "Attitudes in Long-Term Adjustment of Patients Surviving Cardiac Arrest." Br. Mrd. J.. Vol. 3. 1971. pp. 207-212. I2 Casseni. N.H.. and T.P. Hackett. "Psychiatric Consultation in a Coronary Care Unit." A ~ I I I . Irrtorrr. Mrd.. Vol. 75. 1971. pp. 9-14. 13 Hackett. T.P.. and N.H. Casseni. "Reduction of Anxiety in the CCU: A Double-Blind Comparison of Chlordiazepoxide and Aniobarbital." Crtrr. Thrr. Rrs.. Vol. 14. 1972, pp. 649.656. 14 Sanne. H. "Exercise Tolerance and Physical T r a i n i n g o f Non-selected Patients after Myocardial Infarction." Acru Mrd. S c u d I ~ I I / ) / J / . I. No. 551. 1973.

IS Heinzelnian. F. "Social and Psychological Factors that Intluence the Effectiveness of Exercise Programs." Exrrcist, Trstiiig U I I ~Exrrcisr Tririrriirg iir Cororrun! Hrurt Disrasr. John Naughton and Herman K. Hellerstein. eds.. pp. 275-287. Academic Press. New York. 1973. H.A.. T.P. Hackett. and N.H. Casseni. "Psychological Hazards of Convalescence Following MI." J.A.M.A.. Vol. 215. 1970. pp. 1292-1296.

16 Wishnie.

4. Cassem. N.H.. H.A. Wishnie and T.P. Hackett.

"How Coronary Patients Respond to Last Rites." fosfgrud. M e < / . . VOl. 45. 1969. pp. 147152.

5. Browne. I.W.. and T.P. Hackett. "Eniotional Reactions t o the Threat of Impending Death: A Study o f Patients on the Monitor Cardiac Pacemaker." Ir. J. M i d Sci.. Vol. 496. 1967. pp. 177-187. 6 Weisnian. A.D.. and T.P. Hackett. "Pretlilection to Death: Death and Dying a s a Psychiatric Problem." Pswhosor,r. M d . . Vol. 23. 1961. pp. 232-256.

7 Hackett. T.P.. and N.H. Casseni. "Blue-Collar and White-Collar Responses t o Having :I Heart A t t :+ck . Psych osoni at ic Soc ic t y N a t i o n a I Meeting. Boston. 1972. "

8 Hackett. T.P.. N.H. Casseni and H.A. Wishnie.

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17. Hellerstein. H.K.. and E.H. Freidnian. "Sexual Activity and the Postcoronary Patient." Arch. Irrtrrir. Mvtl.. Vol. 125. 1970. p. 987. 18. Rahe. R.H.. et al. "Group Therapy in the Out-

patient Management of Post-myocardial Int'arction Patients." Psvchiittp Mrd.. Vol. 4. 1973. pp. 77-88. 19. Bilodeau, C.B., and T.P. Hackett. "Issues Raised in a Group Setting by Patients Recovering from Myocardial Infarction," A m . J . P s y chiatry. Vol. 128, 1971, pp. 73-78. 20. Adsett. C.A.. and J.G. Bruhn. "Shorl-term Group Psychotherapy in Post-MI Patients and their Wives." Curt. M r d Assoc. J.. Vol. 99. I w.pp. 577-584.

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Psychological management of the myocardial infarction patient.

The acute coronary experience is divided into three parts. In the first, the pre-hospital phase, attention is devoted to the widespread phenomenon of ...
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