|Year : 2017 | Volume
| Issue : 1 | Page : 42-49
Psychotherapy for posttraumatic stress disorders among cardiac patients after implantable cardioverter defibrillator shocks. Feasibility and implementation of a psychocardiological therapy manual in inpatient cardiac rehabilitation
Ludmila Peregrinova, Jochen Jordan
Department of Psychocardiology, Kerckhoff-Clinic Heart and Thorax Center, Bad Nauheim, Germany
|Date of Web Publication||24-May-2017|
Department of Psychocardiology, Kerckhoff-Clinic Heart and Thorax Center, Ludwigstr. 41, Bad Nauheim 61231
Source of Support: None, Conflict of Interest: None
Context: The reported psychopathological symptoms in patients following implantable cardioverter defibrillator (ICD) shocks differ. Reports concern mostly psychosocial distress with trauma-related symptoms: high hyperarousal, re-experiencing, and avoidance behavior. Patients suffering from these impairments require targeted therapy. Until now, only a few publications report psychological treatment for patients with ICD shocks. The aim of the present work was to examine whether the implementation of the specific psychotherapy, including eye movement desensitization and reprocessing (EMDR), during inpatient cardiac rehabilitation is safe and feasible (health-care study) and to explore whether this intervention leads to a reduction of psychopathology in cardiac patients after ICD shocks. As we have no control group design, we can only describe the change but we do not know whether the health status would be the same without our intervention. Methods: Twenty cardiac patients who were distressed after receiving ICD shocks were included in this study. Before and after the 3–5-week psychocardiological inpatient treatment (cardiac rehabilitation including psychotherapy) as well as 6 and 12 months after discharge, the patients were assessed for the following psychological variables: posttraumatic stress, depression, anxiety, and various measures of vital exhaustion and self-efficacy (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-4th Edition Disorders [SCID], Impact of Events Scale-Revised [IES-R], Beck Depression Inventory [BDI], Hospital Anxiety and Depression Scale [HADS] [Hospital Anxiety and Depression Scale-Anxiety (HADS [A])/Hospital Anxiety and Depression Scale-Depression (D)], Shortened Maastricht Exhaustion Questionnaire [MQ], and General Self-Efficacy Scale [SE]). Results: At baseline, 84.2% (n = 16) of the participants suffered from posttraumatic stress symptoms as assessed by the SCID (68.4% [n = 13] measured by the IES-R). Symptoms of depression were observed in 72.2% (BDI) or in 63.2% (HADS [D]) of patients and anxiety in 78.9% of patients (HADS [A]). The measurements confirm a significant reduction in the symptoms of posttraumatic stress (IES-R: P =0.000), depression (BDI: P = 0.009; HADS [D]: P = 0.000), anxiety (HADS [A]: P = 0.000), and vital exhaustion (MQ: P = 0.006), 1 year after patients underwent treatment. No significant changes were observed in perceived SE (P = 0.194). No significant correlations between medical variables and psychopathology were found (adequate/inadequate shocks; number of shocks; primary/secondary prevention). No appropriate/inappropriate shocks were delivered within the treatment period. Conclusion: Our results suggest that an inpatient cardiac rehabilitation program with intensive targeted psychotherapy including EMDR is a safe intervention for posttraumatic stress in patients who are distressed after receiving ICD shocks. In particular, patients accepted the EMDR treatment, emotional arousal was tolerable, and no cardiac complications occurred during EMDR confrontation. Future strategies could be investigating the impact of intervention on long-term effect, stability, and mortality in this population. In addition, our study showed that some patients had a very long time between ICD shocks and the beginning of the professional therapy. Hence, this leads to the finding that a waiting control group could be acceptable by the ethical commission.
Keywords: Anxiety, depression, eye movement desensitization and reprocessing, implantable cardioverter defibrillator, posttraumatic stress disorder, psychotherapy
|How to cite this article:|
Peregrinova L, Jordan J. Psychotherapy for posttraumatic stress disorders among cardiac patients after implantable cardioverter defibrillator shocks. Feasibility and implementation of a psychocardiological therapy manual in inpatient cardiac rehabilitation. Heart Mind 2017;1:42-9
|How to cite this URL:|
Peregrinova L, Jordan J. Psychotherapy for posttraumatic stress disorders among cardiac patients after implantable cardioverter defibrillator shocks. Feasibility and implementation of a psychocardiological therapy manual in inpatient cardiac rehabilitation. Heart Mind [serial online] 2017 [cited 2022 Dec 2];1:42-9. Available from: http://www.heartmindjournal.org/text.asp?2017/1/1/42/206963
| Introduction|| |
The implantation of an implantable cardioverter defibrillator (ICD) is indicated for the prevention of sudden cardiac death due to life-threatening ventricular arrhythmias. To restore a normal heartbeat, the device delivers an electrical shock. ICD shocks can elicit stress, and significant psychological stress arising from such adverse experiences leads to a decline in psychological well-being and reduces the quality of life., Patients lose the ability to carry out normal daily functions and the majority of them subsequently develop affective psychopathological symptoms such as significant anxiety, sleep disorders, and/or depression. Case reports and clinical experience further show that patients experienced their ICD shocks as life-threatening, traumatic, and dangerous and that they felt helpless., As a result, patients suffer from trauma-related memories corresponding to posttraumatic stress disorder (PTSD) such as intrusion, avoidance, and hyperarousal. Preliminary studies reported different prevalence of PTSD in ICD patients depending on the methods, times of measurements, and included subgroups of ICD patients.,,, PTSD was increased in patients who received ICD shocks compared to those without ICD shocks. Previous studies suggest that the risk of mortality is greater in ICD patients with PTSD than without PTSD. It is possible that PTSD might increase cardiovascular risk of morbidity and mortality in these patients as an independent factor which could already be shown for major depression. The standard guidelines for the treatment of PTSD recommend evidence-based psychotherapeutic and psychopharmacological treatments. Consequently, treatment of PTSD with special trauma-focused elements is crucial for patients with cardiac traumatic experiences. Until now, there are no studies treating PTSD in patients after ICD shocks according to treatment guidelines.
Psychocardiology is a specialized, multimodal field in cardiac health care that explores standardized treatments adopted for routine clinical use. This implies research into different cardiological patterns, multidisciplinarity (epidemiology, medicine, psychology, psychosomatics, rehabilitation, and sociology) and specific multimodal therapeutic interventions., Initial results appear to be promising in terms of the effectiveness of eye movement desensitization and reprocessing (EMDR) therapy, developed by Shapiro, in patients after cardiac events, although the reports are not specific for patients after ICD shocks. To our knowledge, there are no findings in literature to date using this method in patients who are traumatized after ICD shocks, which might be due to an earlier warning to use this method in patients with unstable coronary diseases. As the ICD shock is usually a singular trauma, we assumed that this method will be effective as a short-term intervention in this case. According to the theory model for EMDR, the intention is an internal reorganization of dysfunctionally remembered traumatic experiences. After intensive stabilization exercises, the traumatic event is re-processed by bilateral stimulation, the blocked process is activated, and positive cognitions are fixed. Thus, the stress is reduced and hyperarousal is decreased. Our manual for the treatment of acute and PTSDs after multiple ICD shocks includes EMDR units and encourages therapists and cardiologists to practice this treatment, for example, during cardiac rehabilitation.
This short-term intervention was incorporated initially within the framework of a cardiac rehabilitation program in this special cardiac population. The aim of the present study was to show whether EMDR is a safe and feasible intervention for patients with ICD shocks and whether this technique reduces the symptoms of PTSD in this cardiac population.
| Methods|| |
Design and treatment
This study presents qualitative analyses of the feasibility of the specific psychotherapeutical intervention according to the therapy manual by Jordan et al. The cardiac rehabilitation with psychological treatment of affective disorders and posttraumatic stress in patients after ICD shocks is supported by extensive expertise in the Department of Psychocardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany. The manual for the psychotherapy by Jordan et al. was developed systematically and was derived from a multimodal high dose of focal psychotherapy in in- and out-patient settings. The final inpatient psychocardiological treatment comprised cardiac rehabilitation and psychotherapy. Regular interdisciplinary meetings with psychotherapists, cardiologists, and physicians took place. In the time of planning and start of our study, we had no other publications concerning psychological interventions. It was not possible to decide whether we can take the responsibility for a control group design because usual care means that the existence of the PTSD would not be realized and treated. The ethical commission proposed a health-care study without control group as the first step. As a result of our study we now know that some patients had a long period between multiple shocks and professional therapy. The next step can be a randomized controlled trial study or a study which compares different psychological interventions and dosages.
The patients' cardiac program included supervised exercises such as bicycle ergometry, deep-breathing exercises, group and endurance workouts, group gymnastics (stretching, isometric exercises), instruction concerning a balanced diet and a healthy lifestyle, social counseling, and regular clinical consultations with cardiologists. The psychotherapy integrated an individually determined number of psychotherapy units including trauma therapy for emotional support and stabilization: imagination exercises and psycho-education units. The relaxation techniques were performed daily. For confrontation with traumatic events (ICD shocks), the EMDR technique was used., EMDR is a psychotherapeutic intervention for the treatment of PTSD and based on the Adaptive Information Processing Model. A manualized 8-step procedure is performed in each session: history taking and treatment planning (phase 1), client preparation (phase 2), assessment (phase 3), desensitization and reprocessing (phase 4), installation (phase 5), body scan (phase 6), closure (phase 7), and reevaluation of treatment effect (phase 8). EMDR protocol involves behavioral, cognitive, emotional, and physical components. The patients define the current negative cognition (related to traumatic event), future positive cognition, their subjective units of disturbance (range 1 [minimum strain] −10 [maximum strain]), and related body sensations. A key factor of this treatment is bilateral stimulation (therapist-guided eye movements or hand-tapping) which link traumatic memories with neutral stimuli. The patients' daily plan included a minimum of one unit of physiotherapy, psychotherapy, and relaxation techniques.
Quality standards in performing psychotherapy
Psychological evaluation (including psychometric assessments) and psychotherapy were performed by three different therapists in the Department of Psychocardiology, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany. Qualifications of psychotherapists who performed the treatment included an education in psychotherapy (in one therapist, cognitive behavioral therapy (CBT), and in two therapists, psychodynamic therapy) and advanced training in EMDR at the EMDR Institute, Bergisch-Gladbach, Germany (Dr. A. Hofmann) and psychocardiological health care (in cooperation with the German Cardiac Society). EMDR treatments were overseen regularly by a certified supervisor of the EMDR-Institute (Dr. med. Franz Ebner).
Between November 2012 and May 2015, 23 patients were recruited for this study. The data were collected in the Department of Psychocardiology, Bad Nauheim, Germany. A total of three patients dropped out of the study: two were transferred to another hospital due to poor physical health and one discontinued participation without giving reasons. Thus, the treatment was performed in twenty patients who had all experienced ICD shocks. An in-hospital admission screening was carried out and cardiological/electrophysiological treatment following ICD shocks was completed. The eligibility criteria for the participation involved a diagnosis of adjustment or posttraumatic stress symptoms following ICD shocks in the patients' medical history and the availability of cardiologist at any time of inpatient treatment. The exclusion criteria were cognitive impairments and poor physical health which interfered with feasibility of psychocardiological rehabilitation. Written informed consent was obtained from all participants. The study design was approved by the Local Ethics Committee.
To assess the posttraumatic stress symptoms, the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-4th Edition Axis I Disorders (SCID) and the Impact of Events Scale-Revised (IES-R), German version, were used. The IES-R questionnaire is a self-rating instrument and consists of 22 items (eight items of “intrusion;” eight items of “avoidance;” and six items of “hyperarousal”) with a cutoff score >0 (regression equation: X = [−0.02 × intrusion] + [0.07 × avoidance behavior] + [0.15 × hyperarousal] −4.36) and describes subjective distress after traumatic events. The items are rated on a 4-point scale ranging from “not at all” to “extremely.” The internal consistency of the IES-R is between 0.79 and 0.90 for all scales. In the SCID interview, the symptoms are further divided with regard to severity of acute and PTSDs (3 = high; 2 = mild; 1 = low). The reliability is 0.93 and the sensitivity of this method is 81.2%. To assess anxiety and depression, the Hospital Anxiety and Depression Scale (HADS) and Beck Depression Inventory (BDI) scales were used. The HADS is a self-evaluation questionnaire and consists of 14 items (seven items related to “anxiety,” Anxiety and Depression Scale-Anxiety [HADS (A)] cutoff >11; seven items related to “depression,” Hospital Anxiety and Depression Scale-Depression [HADS (D)] cutoff >11) with the following ranking: 0–7 no anxiety/depression; 8–10 moderate anxiety/depression; and >11 extreme anxiety/depression. For measuring the severity of depression symptoms, the self-report questionnaire BDI (cutoff >18) was used. The interpretation of scores is as follows: ≤10, no depression; 11–17, moderate depression; and >18, clinically relevant depression. To assess subjective vital exhaustion, the patients were asked to complete the Shortened Maastricht Exhaustion Questionnaire (MQ) with nine items, which was derived from the original Maastricht Questionnaire with 21 items. A cutoff score >11 for high vital exhaustion (0–3 low; 4–10 moderate) was used. To measure a sense of perceived self-efficacy, the general Self-Efficacy Scale (SE) was applied. The scale consists of ten items, and the responses are rated on a 4-point scale with the score ranging from 10 to 40. All measurements were completed before (t 1) and after (t 2) the treatment as well as 6 (t 3) and 12 (t 4) months after the date of discharge. In the catamnesis, the SCID was carried out by phone interview.
Data were analyzed using the software package SPSS Statistics 22 for Windows (IBM SPSS Statistics, Version 21, IBM, New York, USA). Associations between variables were tested by bivariate correlation measures (Pearson's product-moment correlation). Description of sample characteristics was accomplished by descriptive measures and measures of frequency. Parametric and nonparametric measures of mean differences (t-tests) were applied to document group differences regarding gender and sociodemographic or medical variables. The general linear model of repeated measures was used to analyze the data collected.
| Results|| |
A total of twenty patients (5 [25%] women and 15 [75%] men) were included in the study. The average age was Mean = 52.4 years (standard deviation = 15.3; minimum 23 – maximum 75). Seventeen (85%) patients retired. Five (25%) patients reported previous affective disorders (two major depressive disorders, one phobic anxiety disorder, and two psychoactive substance abuse). Sixteen (80%) patients were married or had a partner. Fifteen (75%) patients experienced adequate ICD shocks and five (25%) received inadequate shocks. The average number of experienced shocks was 24 (ranging from 1 to 220). Eight (40%) patients survived previous sudden death with reanimation; thus, their ICDs had been implanted for secondary prevention (in 12 [60%] patients, the ICDs were for primary prevention). The mean time between the last experienced shocks and the beginning of the treatment was 14 weeks (range: 1–52 weeks). The patients received a mean of 11 (range: 5–20) psychotherapy units, including six EMDR sessions.
Prevalence of psychopathology in cardiac population after implantable cardioverter defibrillator shocks
[Table 1] presents psychological symptoms of the twenty patients in the study group at all time points of measurement, and an overview of the values of the main variables of the study is shown in [Table 2]. We observed a significant positive correlation between age and avoidance behavior (r = 0.58; P < 0.01) and a significant negative correlation between ability to work and posttraumatic stress (r = −0.63; P < 0.01). Furthermore, patients with previous psychiatric disorders displayed higher depression scores in BDI than patients without psychiatric history (M = 25.60 ± 9.76 vs. M =16.15 ± 6.44; t = −2.42; P < 0.05). No influence of medical variables on the psychopathology was observed (adequate/inadequate shocks; number of shocks; primary/secondary prevention). In addition, neither appropriate nor inappropriate shocks were delivered within the study period.
|Table 2: Mean and standard deviations in psychological variables for all times of measurement|
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Posttraumatic stress disorders
Both SCID and IES-R confirmed a significant decrease in posttraumatic stress symptoms (P < 0.05). The most marked reduction of symptoms and improvement of psychological well-being were observed after discharge. The greatest continuous reduction in trauma symptoms was observed for hyperarousal, followed by intrusion and avoidance behavior. According to the IES-R results, patients presented with very low psychopathological mean scores (M < 0) as early as t 2. The changes in posttraumatic stress symptoms within 1 year measured by SCID are shown in [Figure 1].
|Figure 1: Frequencies of posttraumatic stress disorders as measured by SCID.|
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Depression and anxiety
A substantial reduction of depression and anxiety symptoms was observed within the treatment period [from t 1 to t 2; [Figure 2]. From t 2 onward, all values were below the cutoff scores. In the first 6 months after treatment, the values for depression (BDI) increased marginally and then remained stable (normal to mild).
|Figure 2: Depression and anxiety scores as measured by BDI and HADS scales.|
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All patients reported severe mental fatigue at admission [Figure 3]. Vital exhaustion decreased within 1 year. The score correlated well with other psychopathology scores: with posttraumatic stress (at t 1: Pearson's r = 0.71 P < 0.001; higher scores in PTSD [IES-R] indicate high vital exhaustion; at t 2: r = 0.73 P < 0.000), with depression measured by BDI (at t 1: r = 0.70 P < 0.001; at t2: r = 0.50 P < 0.005; at t 3: r = 0.62 P < 0.005; at t 4: r = 0.62 P < 0.01), by HADS (D) (at t 1: r = 0.87 P < 0.000; at t 2: r = 0.69 P < 0.001; at t 3: r = 0.75 P < 0.000; at t 4: r = 0.80 P < 0.0000), and with anxiety as assessed by HADS (A) (at t 1: r = 0.87 P < 0.000; at t 2: r = 0.50 P < 0.05; at t 3: r = 0.67 P < 0.005; at t4: r = 0.84 P < 0.0000).
|Figure 3: Frequencies of vital exhaustion derived from the Shortened Maastricht Exhaustion Questionnaire.|
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At baseline, the mean scores of perceived self-efficacy were in a standard range and did not change significantly within the investigated study period [P = 0.194, [Figure 4].
At t 1, there were significant gender differences in avoidance behavior and depression. Women showed less avoidance behavior and more depression symptoms than men. The following figures show average subjective ratings of posttraumatic stress [Figure 5] and [Figure 6], depression, and anxiety [Figure 7] during the time course of the intervention for both genders. All measures decreased significantly after the treatment. The mean time between ICD shocks and the beginning of treatment was 6 weeks in women and 17 weeks in men. No significant gender differences were observed in the number of shocks, psychotherapy sessions, and duration or components of cardiac rehabilitation.
|Figure 5: Gender scores as measured by Impact of Event Scale (w=women/m=men; cut-off = 0).|
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|Figure 6: Means scores in trauma symptoms measured by Impact of Event Scale (w=women/m=men).|
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| Discussion|| |
This is the first study examining a specific psychocardiological intervention including EMDR in cardiac patients after (multiple) ICD shocks. The main finding of this study is that the implementation of this treatment within the framework of inpatient cardiac rehabilitation is feasible and that this short-term intervention is safe. Furthermore, there is an improvement of psychopathological outcome due to this specific intervention.
Our conclusion of EMDR being a safe and feasible intervention in traumatized ICD patients is supported by the finding of any cardiac complication, side effect, or decompensation within the EMDR units. Furthermore, after the treatment, patients reported acceptance and satisfaction with this treatment, reduction of physiological arousal, higher active participation in daily life, and greater interest and ability to regain strength. The present findings are in accordance with previous studies assuming a safety of EMDR in diverse survivors of life-threatening cardiac events. Thus, after the first warning, we suggest that an all-clear might be given for EMDR in cardiac patients with trauma-related symptoms after ICD shocks.
We further suggest that the EMDR technique is an effective procedure for the treatment of posttraumatic disorders and for concomitant depression and anxiety after stressful experiences such as ICD shocks. The significant reduction of trauma-related symptoms which could be showed in IES-R has been achieved within the treatment period (3–5 weeks); after discharges, the values decreased only marginally. The most obvious reduction in stress markers was observed for the symptoms of hyperarousal and intrusion. Especially, the symptoms of overwhelming experiences and physiological stress could be treated successfully, reflected by significantly decreasing IES scores. Our results reveal additionally that symptoms of anxiety (fear of death or fear of shocks or device malfunction) and depression decreased significantly within the treatment period. After 6 months, the scores of both psychopathological variables remained stable. In anxiety, the values are still in the moderate range. This general significant reduction of psychopathology is mainly caused by targeted trauma therapy and by general improvement in psychological well-being. This includes further psychocardiological steps: stabilization (somatic, medical, psychological, and social), processing of traumatic memories, improvement in physical performance and reduction of cardiovascular risk factors, development of an appropriate disease concept and future perspectives, and if necessary, an inclusion of partners in the psychotherapy. The psycho-education units focus the following psychological themes: negative cognitions, attribution, ambivalence between death and rescue, biography and life events, personality characteristics (psychological autonomy/dependency tendencies), experiences related to heart disease, and the experiences in the situation of ICD shocks (reactions of the persons present).
A combination of psychotherapy and restoration of physical performance is an important requirement. To restore confidence in own body functions and to learn to tolerate an increase in heart rate, patients need to be supervised by trained physicians to undertake physical activity to the real limits of their endurance. The fact that a cardiologist was constantly available certainly helped our patients to stabilize and gave them a feeling of security. Physical inactivity may also be caused by strong avoidance behavior (more in men than in women), misapprehended relieving posture, or excessive protection by the partners or family. Zen et al. reported less physical activity in PTSD patients with cardiovascular disease than in patients without PTSD, which is consistent with our clinical experiences. Patients' partners also become distressed due to cardiac events of their relatives so that the risk of manifesting psychopathological symptoms is high. Furthermore, adverse social and emotional experiences of patients during ICD shocks can add the vulnerability of stress and result in unfavorable disease processing and additional psychological symptoms. Therefore, future research should consider the psychological diagnostics of partners who were present during an ICD event.
On almost all scales, women achieved better results; it appears that women's psychological health improved more within 1 year although they were not more distressed than men at baseline. Furthermore, women started their treatment earlier; they developed less avoidance behavior and were available for the treatment earlier than men. A significant positive correlation was observed between age and avoidance behavior (r = 0.58; P < 0.01) and a significant negative correlation between ability to work and posttraumatic stress (r = −0.63; P < 0.01). Thus, the work might decrease the risk of PTSD.
With this intervention, we also aimed to prevent the development of chronic psychopathology and to minimize the risk of PTSD. The present findings show that the almost daily dose of psychotherapy can easily be integrated into the cardiac rehabilitation program. Furthermore, opportunities for short-term interdisciplinary team meetings play an important role and are needed (cardiologists, physiotherapists, and physicians).
This study has several limitations. It had a longitudinal design without a control group. Due to the great psychological distress of these patients and the necessity of psychological intervention, it was not ethically tenable to randomize patients into a control group with no intervention; however, it is possible to test two therapies against each other (CBT versus EMDR). To confirm the results, medical and physical variables should also be recorded in future studies. Furthermore, overall, a relatively high variance was observed among the symptoms. This suggests diversity of symptoms and implies prospective investigation of targeted therapy for symptom subgroups. The total patient sample was already preselected because all patients suffered from psychopathological symptoms and they were sent by their doctors specifically to our department. This investigation is the first one with a sample, i.e., n > 5, in this population, which has heretofore only been documented in case reports. During the recruitment process, it became clear that treating these patients in a psychosomatic clinic is difficult due to the frequent absence of a cardiologist. The availability of a cardiologist gives the patient and the psychotherapist a certain security for the implementation of EMDR therapy. Despite these limitations, the results might be very interesting for cardiologists and psychotherapists who have to deal with this distressed cardiac patient population.
| Conclusion|| |
The special psychocardiological intervention program including EMDR performed in the setting of cardiac inpatient rehabilitation resulted in a significant reduction of psychopathology in cardiac patients who experienced ICD shocks. Thus, EMDR is a safe and effective technique for treating trauma-related symptoms in these patients: no ICD shock delivery or cardiac event was observed during EMDR confrontations. Consequently, cardiologists and consulting psychiatrists should be aware of the potential for PTSD to develop in association with ICD implantation.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2]