Effect of discontinuance of type A behavioral counseling on type A behavior and cardiac recurrence rate of post myocardial infarction patients

Relationship of Psychological Characteristics to Daily Life Ischemia: An Analysis From the National Heart, Lung, and Blood Institute Psychophysiological Investigations in Myocardial Ischemia

OBJECTIVE

Cardiac ischemia during daily life is associated with an increased risk of adverse outcomes. Mental stress is known to provoke cardiac ischemia and is related to psychological variables. In this multicenter cohort study, we assessed whether psychological characteristics were associated with ischemia in daily life.

METHODS

This study examined patients with clinically stable coronary artery disease (CAD) with documented cardiac ischemia during treadmill exercise (n = 196, mean [standard deviation] age = 62.64 [8.31] years; 13% women). Daily life ischemia (DLI) was assessed by 48-hour ambulatory electrocardiophic monitoring. Psychological characteristics were assessed using validated instruments to identify characteristics associated with ischemia occurring in daily life stress.

RESULTS

High scores on anger and hostility were common in this sample of patients with CAD, and DLI was documented in 83 (42%) patients. However, the presence of DLI was associated with lower anger scores (odds ratio [OR] = 2.03; 95% confidence interval [CI] = 1.12-3.69), reduced anger expressiveness (OR = 2.04; 95% CI = 1.10-3.75), and increased ratio of anger control to total anger (OR = 2.33; 95% CI = 1.27-4.17). Increased risk of DLI was also associated with lower hostile attribution (OR = 2.22; 95% CI = 1.21-4.09), hostile affect (OR = 1.92; 95% CI = 1.03-3.58), and aggressive responding (OR = 2.26; 95% CI = 1.25-4.08). We observed weak inverse correlations between DLI episode frequency and anger expressiveness, total anger, and hostility scores. DLI was not associated with depression or anxiety measures. The combination of the constructs low anger expressiveness and low hostile attribution was independently associated with DLI (OR = = 2.59; 95% CI = 1.42-4.72).

CONCLUSIONS

In clinically stable patients with CAD, the tendency to suppress angry and hostile feelings, particularly openly aggressive behavior, was associated with DLI. These findings warrant a study in larger cohorts, and intervention studies are needed to ascertain whether management strategies that modify these psychological characteristics improve outcomes.

Psychological Correlates of Mental Stress-induced Ischemia in the Laboratory: The Psychophysiological Investigation of Myocardial Ischemia (PIMI) Study

Participants consisted of 184 patients (160 males, 24 females) with positive angiograms or prior myocardial infarctions who displayed at least 1 mm of ST segment depression on a standardized treadmill test. Mean scores on the Reward Dependence subscale of the Tridimensional Personality Questionnaire were higher in patients displaying ischemia during mental stress. Patients who reported higher levels of irritability/anger in response to the Speech stressor were also more likely to display ischemia. However, this result was primarily a result of the females in the sample whose ratings of interest and irritability were associated with ischemia during the Speech task. Psychometric measures previously found in prospective studies to predict acute cardiac events were unrelated to mental stress-induced ischemia in the laboratory.

Symptoms of anxiety and depression are correlates of angina pectoris by recent history and an ischemia-positive treadmill test in patients with documented coronary artery disease in the pimi study

Objective. We tested the association of specific psychological characteristics in patients having stable coronary disease with the reporting of anginal symptoms during daily activities, and positive exercise testing. Methods. One hundred and ninety-six patients with documented CAD enrolled in the Psychophysiological Investigations of Myocardial Ischemia (PIMI) Study completed an anginal history questionnaire and a battery of psychometric tests. They also underwent standardized exercise treadmill tests. Results. Patients with a recent history of angina were more likely to be female, and had higher Beck Depression (P = .002), State Anxiety (P = .001), Trait Anxiety (P = .03), Harm Avoidance (P = .04) and Muscle Tension (P = .004) scores than patients who had no recent history of angina. Along with several treadmill variables indicating more severe disease state and reduced exercise tolerance, patients who developed angina on a positive treadmill test also displayed higher scores on the Beck Depression Inventory (P = .003) and State Anxiety (P = .004) scales. Conclusions. Several psychological characteristics, and most notably anxiety and depression, are strong correlates of recent angina and angina in the presence of ischemia provoked by treadmill testing.

Screening, diagnosis & monitoring of depression/distress in CHF patients

Objective and validated measures of depression/distress (anxiety and anger) are available and readily usable at the bedside or in clinic. Foremost among these is the Patient's Health Questionnaire--an adaptation of DSM IV criteria for Major Depressive Disorder that permits administration and scoring by nursing or physician personnel, and quantification of the intensity of depression. A score of 10 or greater indicates a need for evaluation/treatment. Because of patient denial/minimization/alexithymia, PHQ negatives should undergo further screening by having a spouse or friend complete a depression/distress rating scale. The only standardized, normed, and validated spouse/friend scale presently available is the Ketterer Stress Symptom Frequency Checklist, which is available by internet.

Empirically Derived Psychometric Screening for Emotional Distress in Coronary Artery Disease Patients

BACKGROUND AND RESEARCH OBJECTIVES

Multiple types of evidence implicate emotional distress as a cause of adverse outcomes in individuals with coronary artery disease. The present study was intended to determine the most accurate and user-friendly means of screening patients with coronary artery disease for emotional distress using age at initial diagnosis as the criterion.

SUBJECTS AND METHODS

Two clinical databases consisting of patients with documented coronary artery disease, each contained multiple measures of emotional distress, were used. These databases were investigated by tests of covariation of the emotional distress measures with age at initial diagnosis. If these were statistically significant, sequential testing of cutpoints yielded the minimum score for positivity. Sensitivity, specificity, and positive predictive value calculations were made for the significant measures. Single-sex tests of covariation were also examined.

RESULTS AND CONCLUSIONS

The Patient Health Questionnaire was the only significant bedside measure of emotional distress (Pearson r = -0.149, P = .058), with a cutpoint of 10 or greater. The Beck Depression Inventory, Hospital Anxiety and Depression Scale, and Crown-Crisp Phobic Anxiety Scale failed to reach significance as covariates of age at initial diagnosis. Substantially greater sensitivity occurs with larger and more cumbersome measures of emotional distress. For example, the Ketterer Stress Symptom Frequency Checklist yielded consistent results with greater variance explained, particularly in men (Pearson r for self-ratings of anger = -0.339, P = .001; depression = -0.363, P = .005; anxiety = -0.273, P = .028). Brief bedside/clinic screening of emotional in populations with coronary artery disease is possible and necessary to improve quality of life, compliance (eg, smoking cessation), and possibly morbidity/mortality. Initial screening can and should occur at the bedside/clinic by cardiology or primary care personnel using the Patient Health Questionnaire.

Post-MI psychiatric syndromes: six unanswered questions

Depression, anxiety, and other psychological variables following acute myocardial infarction (MI) have been the subject of intense study over the last two decades. Through selective literature review and editorial commentary, we address six vital, unanswered questions concerning these psychological variables and their impact on coronary outcome. The picture that emerges is complex. Despite all that has been learned about the nature, consequences, and management of post-MI depression and related disorders, there remain many open issues. First, the prevalence, phenomenology, medical impact, and method of diagnosis of post-MI depression and other psychiatric syndromes remain unclear. In addition, at least four pathophysiologic mechanisms have been proposed to explain the link between depression and cardiac disease, but evidence of causation remains elusive. There have been increasingly well-designed treatment studies of post-MI depression, but the optimal agents and timing of treatment have yet to be defined. Finally, few recent studies of post-MI anxiety have been conducted. To make further progress, large, multicenter trials that use optimized screening tools, obtain data at several time points, consider multiple psychosocial variables, and correct carefully for medical/cardiac severity are required.

Cardiac rehabilitation: a review of current developments

An overview is given of the current status of cardiac rehabilitation and its effects on morbidity and mortality. While there is an emphasis in most current programs upon physical exercise as an important autonomous risk factor for Coronary Heart Disease (CHD), there is at the same time a tendency in cardiac rehabilitation to go beyond mere physical exercise towards adding more multimodal psychoeducational modules in rehabilitation programs; those approaches are aimed at educating the patient about a less risky and healthier way of life. Such psycho-education is more and more aimed at the "toxic" aspects of negative emotions. The in-between classic Type A Behavior Pattern (TABP) might, in general, be less powerful in predicting later CHD morbidity or mortality than some specific emotional components of TABP, such as anger and hostility. The literature is reviewed as to risk factors and CHD and the role of negative affectivity in development and or maintenance of CHD. Approaches for modification are discussed against the background of their effectivity in cardiac rehabilitation. The recent Dutch guidelines, issued by the Dutch Heart Foundation, appear to incorporate many of the elements mentioned in the research literature on cardiac rehabilitation. On a scientific level they form an excellent audit to evaluate and to contour efficiently the until-now very heterogeneous field of cardiac rehabilitation.

Risk factor modification through nonpharmacological interventions in patients with coronary heart disease

Coronary heart disease (CHD) is still the main cause of death in developed countries. Because of improved treatment, many patients survive the acute phase of a myocardial infarction, which makes secondary prevention of CHD of major importance. Most risk factors responsible for the development and progression of CHD are associated with behavior. Therefore, interventions aimed at behavior change may contribute to risk factor modification and secondary prevention of CHD. The effects of separate risk factor modification efforts by means of randomized, controlled clinical trials of nonpharmacological interventions in patients suffering from CHD are reviewed. Interventions aimed at healthy lifestyles may stimulate smoking cessation rates, reduce elevated serum total and low-density lipoprotein (LDL)-cholesterol concentrations, and favorably modify type A behavior in CHD patients. Moreover, reduction of coronary atherosclerosis has been reported after intensive lifestyle and exercise interventions, whereas exercise and type A interventions may also lead to reduced CHD morbidity and mortality. As for hypertension and obesity, studies aimed at secondary prevention are lacking.

Psychological factors affecting a medical condition: ischemic coronary heart disease

The criteria for scientific validation of the entities currently subsumed under the DSM-IV category of "Psychological Factors Affecting a Medical Condition" have never been clearly enumerated. Historically, its precursor category ("Psychophysiological Disorder") was rarely used, and predicated upon clinical observation of personality styles among patients with specific physical illnesses, or clinical observations relating psychosocial events and symptom exacerbation. Because of logical flaws with either of these methods, clarification of the most rigorous criteria for demonstrating a cause-effect relationship is necessary. With the increase in well-designed and carefully executed epidemiological and treatment studies, this diagnostic category has evolved into an arena where cutting-edge insights and therapies are becoming available for a growing variety of medical conditions, especially ischemic coronary heart disease. The present article reviews the nature of the scientific evidence necessary to accept an etiological or aggravating role for psychological events.

Family stress management following acute myocardial infarction: an educational and skills training intervention program

Although the experience of acute myocardial infarction (AMI) is a family affair, little has been available to guide stress and distress reduction efforts focusing on all members of the family compared to the somewhat larger literature addressing stress management interventions with cardiac patients. This article provides a conceptual background for a specific behavioral therapy approach to family stress management in dealing with the sequelae of AMI for all family members with the goal of reducing morbidity for all family members as they cope with ongoing survivorship issues. The family intervention program is described and its pilot implementation discussed. Evaluation of the pilot suggests that an individually tailored focus for that subset of families at higher risk for elevated persistent distress may be the most cost-effective use of such a family intervention program.

Group psychotherapy for patients with coronary heart disease

Group therapy with cardiac patients is a relatively new specialty. The field is supported by a substantial epidemiological and experimental literature demonstrating links between heart and mind. There are several clinical trials that have demonstrated less morbidity, improved quality of life, and, to some extent, lower mortality for patients who have received psychosocial intervention, generally group therapy, compared to control patients. Different theoretical orientations and a small number of clinical techniques have been developed to help cardiac patients make an adjustment to heart-healthy living. This article provides a brief review of the literature in cardiac psychology, suggestions for developing a psychotherapy practice specialty with cardiac patients, techniques for treating these patients, and conclusions by a psychologist-cardiologist team that has been active in this area for more than a decade.

Emotional distress among males with "syndrome X"

The present study examined traditional risk factors and various indices of emotional distress in males with positive angiograms (N = 122), "syndrome X" males with negative or nominal results on angiogram (N = 53), and age- and socioeconomic status-matched males with no manifest history of otherosclerotic disease (N = 56). Syndrome X patients reported more depression on the Ketterer Stress Symptom Frequency Checklist (KSSFC) than positive angiographic patients. And compared with healthy controls, they were more likely to be perceived by a spouse/friend as depressed and anxious on the KSSFC, scored higher on the Framingham Type A Scale, and reported more unprovoked nocturnal awakening. Syndrome X patients generally appear to be similar to patients with positive angiograms with regard to traditional risk factor history but are more distressed than healthy controls. This becomes most evident when denial is circumvented by discussion with significant others or inquiries are "framed" appropriately.

Secondary prevention of ischemic heart disease. The case for aggressive behavioral monitoring and intervention

The hierarchy of evidence for arguing causality of a disease by any factor consists of epidemiological and, ultimately, treatment studies. The application of these criteria to chronic negative emotion as a risk factor for ischemic heart disease (IHD) is relatively new. However, controlled prospective evidence now indicates that anger, depression, and anxiety may play a major role in the genesis of IHD. And the strongest form of evidence, a controlled clinical trial that used randomly assigned subjects, exists, implicating anger as a strong predictor in the development of IHD. Resistance to the utility of this avenue of care is not based on evidence alone because widely accepted risk factors and/or treatment modalities often have less persuasive evidence, or less powerful effects, than do the emotional factors. Rather, such resistance is largely due to "paradigmatic scotomata"--conceptual difficulties for those not familiar with biopsychosocial research. Routine psychometric screening of IHD patients may provide a cost-effective means of alerting cardiologists and internists to the relatively high levels of distress among their patients.

Medical diagnosis of type A behavior

The objective of this investigation was to develop a medically oriented examination (including a search for physical signs in addition to elicitation of symptoms) for the accurate diagnosis of type A and type B behaviors. Comprising the study were 99 post-myocardial infarction patients, 15 clinically well persons in whom clinical coronary heart disease subsequently developed, and 23 healthy type B subjects. All participants were subjected to a videotaped clinical examination during which, in addition to eliciting responses to questions, 14 possible physical or psychomotor signs (many of which are newly discovered) of type A behavior were also observed. Each physical sign and symptom was given an arbitrarily weighted score (according to its observed frequency of occurrence in previously studied and authenticated type A behavior). These total scores were then statistically analyzed to obtain a critical "diagnostic score" for the presence of type A behavior. The medically oriented videotaped clinical examination detected the presence of type A behavior in 97 of 99 (98%) successively examined postinfarction patients and in 14 of 15 (93%) subjects who were clinically well at the time of their videotaped clinical examination but who subsequently had clinical coronary heart disease. Conversely type A behavior was diagnosed by videotaped clinical examination in only 1 of 23 (4%) healthy men who previously had been found to exhibit type B behavior by prior diagnostic procedures.

The Current Status of the Coronary Prone Behaviour Pattern

Despite over 30 years of increasingly vigorous research it is still not possible to claim with acceptable certainty that there is an identifiable pattern of coronary prone behaviour nor to say with any confidence that the idea is misguided. The scientific process that leads from initial tentative findings through generation of a hypothesis, to rigorous and cumulative tests of that hypothesis has not happened. Instead there has been a rather erratic series of positive and negative studies, and the generation and modification of essentially rather similar hypotheses. As a result we are still in the position of claiming that there may be a pattern of behaviour that predicts CHD and that it is probable that hostility is involved. It is not clear why the idea is so persistent but it may well lie in the combination of a widely held lay belief that heart disease relates to stress and personality, with tantalizing positive findings occurring every few years. While there has been little increase in understanding of the role of behavioural factors in CHD as a result of this 30 years of endeavour there have been clinical benefits. It has clearly been shown that what are regarded as coronary prone behaviours can readily be modified and that their modification appears to confer some health benefits and no detectable health hazards.

Mental precursors of myocardial infarction

Both cardiologists and psychiatrists have observed that the onset of myocardial infarction is often preceded by feelings of decreasing energy, general malaise, and minor depression. This paper describes these observations and tries to integrate the findings. It is proposed that the mental state preceding myocardial infarction can be best described as 'vital exhaustion'.

Type A behavior: its diagnosis, cardiovascular relation and the effect of its modification on recurrence of coronary artery disease

A general review of type A behavior and its possible relation to clinical coronary artery disease, hypertension and migraine is given. The humoral and lipid derangements initiated by type A behavior are described as well as the possible pathophysiologic phenomena this behavior effects leading to accentuation and hastening of the onset of clinical coronary artery disease. The correct method of diagnosing type A behavior as well as methods of diminishing its intensity both in the coronary and still symptomless person are described. The significant decline in coronary morbidity and mortality in patients with coronary artery disease given type A behavior counseling is described.