Heart disease (HD) is one of the most important health issues of the 21st Century and most important cause of mortality in our community. According to centers for disease control and prevention, heart disease is the leading cause of death for both men and women. From last few months there is an alarming rise in heart attack among people of J&K particularly in young generation, which had left us with painful shocking experiences.
A heart attack (also known as myocardial infarction) happens when one of the coronary arteries becomes blocked and the blood supply to part of the heart is interrupted. The arteries become blocked as the result of a disease called as coronary heart disease or (CHD) also called as coronary artery disease or ischemic heart disease. A heart attack results from Atherosclerosis (fatty buildups) in the arteries that carry blood to the heart muscle. Plaque buildup narrows the inside of the arteries, making it harder for blood to flow. If a plaque in a heart artery ruptures (breaks open), a blood clot forms. The clot further blocks the blood flow. When the blood to the heart is completely stopped, due to entire blockage of arteries heart attack occurs. Arrhythmias occur when there is an irregular rhythm of the heart beat. Heart beat can either too fast, too slow or can have an irregular rhythm. Many Arrhythmias are harmless but can life threatening. If heart rate is abnormal, efficiency of the heart to pump blood is affected which may lead damage to the brain, heart and other organs. There are certain proven risk factors that may lead to heart diseases. Although most the literature is suggesting that heart diseases are mainly focused on the biological risk factors and life styles, some evidence have revealed that psychological and psychiatric factors have a very important role in the etiology, development duration, and outcome this disease. The most important factors are depression, anxiety, unemployment, poor socio-economic status, socio and political conflict, life style, isolation and stress.
Psychological Risk Factors in Heart Disease.
Depression
Depression is a risk factor for morbidity and mortality in patients with coronary heart disease. Depression is an important disorder that leads to an increase in cardiovascular events and common among Heart Diseases patients, there is an ample evidence that prevalence of depression is 20% higher in patients with heart failure than in healthy individuals High levels of depression and anxiety have consistently been associated with incident coronary heart disease, while associations with hostility and social support have been mixed. However, psychosocial factors have been examined less often in Heart Failure.
Among Heart Failure patients, depression is the most commonly researched psychosocial risk factor.
Approximately 1 in 5 Heart Failure patients meet the criteria for major depression. Depression is also a predictor of repeated hospitalization in Heart Failure patients.
Anxiety
Research suggests that physical and psychological symptoms of anxiety in Heart Disease patients revealed that anxiety is correlated with physical factors such as palpitation without any physical exercise, anger and redness in the face, shivering, abnormal heart beat, and muscle tension that increases the risk of heart disease especially in females. Anxiety has also been examined in association with incident heart failure, with mixed results, and anger has been modestly associated with incident heart failure .Lack of social support has also been associated with greater incident Heart Failure risk.
Several plausible pathways could explain the relationship between psychosocial factors and Heart Failure. One pathway suggests that people with adverse levels of psychosocial factors may be more likely to experience a variety of poor physiological effects that may lead to Heart Failure. Potential biologic pathways include inflammation, endothelial dysfunction, platelet activity, hormones, and brain-derived neurotrophic factor (BDNF).
For example, depression causes heightened activation of the sympathetic nervous system. Which is involved in the pathogenesis of Heart failure, specifically left ventricular dysfunction and renal sodium retention. Additionally, stress has been associated with impaired left ventricular function. Also, depression and anxiety are associated with elevated inflammatory marker levels, which have been associated with heart failure Another plausible pathway is that people with psychosocial problems are less likely to adhere to medical and behavioral guidelines, which makes them more likely to develop diseases such as Heart Failure.
Stress:
Many studies indicate that persistent psychological stress, manifested in anxiety, depressed mood, anger and irritability is a associated with a variety of health difficulties from infancy to adulthood. For example, stress elevates heart rate and blood pressure and depresses the immune response—reactions that may explain its relationship with cardiovascular disease, infectious illness and several form of cancer.
Research has begun to focus on the role that acute stress and anger may play as triggers for the development of coronary artery disease. Studies have observed that stressful life events, such as the death of a spouse, often occurred within the 24 hours preceding death among patients who died suddenly from coronary disease. The occurrence of natural disasters and personal traumas has also been correlated with an increase in cardiac events. In addition to the effects of acute or short-term stressors, the possible pathophysiological effects of chronic stressors were studied in conjunction with heart disease risk. Socio and political conflicts, Unemployment and Work-related stress are the most widely studied form of chronic stress.
Social Isolation and Lack of Social Support:
Lack of social support was indicated as a predictor of onset and prognosis of heart disease, and mortality among both sexes;
however, it was more consistent in males. The risks are increased 2-3-fold and 3-5-fold for females and males, respectively. The association between social isolation and lack of social support with Heart Disease exists for subjects who live in different countries and are of various age groups.
Type A Behavior And Hostility:
Research data indicated that type A behavior pattern, which is primarily characterized by hostility, intense ambition, competitive drive, constant preoccupation with deadlines, and a sense of time urgency, was related to the development of heart disease. Studies on American and European populations have demonstrated that high levels of anger and hostility are predictive of coronary heart disease mortality.
Life-Style and Health Practices:
People may believe heart disease correlates solely with physical actions (a lack of exercise, poor diets, smoking, excessive drinking), however, attitudes, emotions, and thoughts are equally significant. Thought processes can accelerate the onset of heart disease and hinder taking concrete strides to promote health. A few may sense a loss of control over their life with taking medication, making time for exercise and giving up favorite foods. Making modifications in everyday life is not easy as it takes training to instill these new practices. To sneak a cigarette or cheat on a diet may satisfy an immediate desire, but will hinder the long-term goal of improving health. Cultivating a healthy lifestyle can diminish the risk of heart disease or manage the condition, even if a higher risk is due to uncontrollable determinants such as sex, family history or age.
Hypertension (HTN):
Hypertension or high blood pressure, sometimes called arterial hypertension, is a chronic medical condition in which the blood in the arteries is elevated. This requires the heart to work harder than normal to circulate blood through the blood vessels.
Hypertension is a major risk factor for stroke, myocardial infarction (heart attacks), heart failure, aneurysms of the arteries (e.g. aortic aneurysm), and peripheral arterial disease and is a cause of chronic kidney disease. Even moderate elevation of arterial blood pressure is associated with a shortened life expectancy.
What Next?
ROLE OF CLINICAL PSYCHOLOGISTS:
When psychological problems will become worse in person’s daily life then it is hectic challenge for parents and family members to handle their children in such situations. Here professionals (clinical psychologists) can play a vital role and help parents as well people suffering from these problems. Psychological interventions are important in this. Anxiety and stress are common among people in our society. Its aim is to prevent the situation from becoming chronic and to enable the individual to return his social life as soon as possible. It seeks to ensure that the individual will be helped to make an adequate readjustment and return to full participation at home and community setting with a minimum of delay and difficulty. Most doctors are generally not very comfortable in handling patient’s real life stress. They have difficulty in taking the role of a counselor or psychotherapist. This is largely because undergraduate and post graduate medical training does not prepare the future doctor or specialist to recognize and care for the emotional needs of his patients. Here clinical psychologist plays a vital role. They use a wide array of psychological approaches in practice:
1) Psychotherapy/ Counseling: Psychotherapy/ counseling in the cardiovascular disease setting are shaped by the realities of the patient’s situation, since all patients referred are dealing with psychological problems. The patient’s state of physical and mental health will determine both the type of therapeutic work possible and the focus of such work. Tailoring the therapeutic intervention to the patient’s specific needs and flexibility in altering and adapting therapeutic strategies over time in line with the patient’s changing needs is essential. Although periods of treatment may range from single session to long term, supportive, insight oriented, group, family, cognitive and behavioral techniques have all been used successfully in a cardiovascular issues, with measurable impact on well-being. Clinical psychologist attempts to restore the emotional equilibrium. It involves listening to a person in distress about his difficulties, understanding the nature of his problem and talking to him.
2) Relaxation training: Relaxation training is a simple psychological technique which can be taught to patients quickly and then practiced at home with audiotapes. It is simple to learn but requires regular practice. Progressive muscle relaxation, developed by Jacobson and modified by Wolpe is the simplest and most popular method used for relaxation. Another technique is autogenic training, square breathing, originally developed by Shultz and Luthe,“ is a form of self-hypnosis. The subjects are instructed to close their eyes, breathe deeply and concentrate on the right hand while thinking ‘my right hand is getting heavier and heavier or abdominal breathing can be used for those who are facing difficulty in learning other relaxation techniques.
3) Supportive psychotherapy: Through this therapy clinical psychologists aims at enhancing the already existing capabilities of the client to deal with the problem. They focus on the problem at the present and difficulties the client has in facing them. Simple psychological skills can be employed by most healthcare professionals to help patients navigate their way through the problem process.
4) Cognitive behavior therapy: Many experts recommend cognitive behavioral therapy as the ideal treatment for depression and anxiety. The therapy allows the client to shift their thoughts, replacing those that lead to disturbed pattern of thinking with healthier thinking patterns. As its name implies, cognitive behavioral therapy allows a person to modify their thoughts, feelings and ultimately behavior for the better. Therapists start treatment by identifying and focusing on the thoughts that start the chain of emotional problems and help the client begin their transition from there.
5) Mindfulness therapy: Mood and anxiety disorders are among the most common psychiatric disorders in the Kashmir and are frequently co-morbid with other mental and medical disorders. Common symptoms of those diagnosed with psychiatric disorders include depressed mood, anxiety, tension, uncomfortable thoughts, and pain. It has been demonstrated that mindfulness-based stress reduction (MBSR) is effective in modulating the aforementioned symptoms. Additionally mindfulness-based therapy has been shown to be effective in treating anxiety and mood difficulties. Unfortunately, the length of such interventions has been a challenge to implementing them in acute settings, such as in a consultation service.
6) Problem Solving: problem solving therapy is a clinical intervention approach aimed at increasing an individual’s ability to cope with stressful problems. It is based on the observation that emotional symptoms are generally induced by problems of living, and has its theoretical roots in cognitive approaches to depressive disorders.
7) Anger Management: Anger Management therapy is a goal- orientated therapeutic strategy that targets anger prevention and control it often helps people with anger issues and allows people to reduce stress. It can also lower the risk for serious health problems such as heart disease and high blood pressure. Successful Anger Management therapy develops healthy ways for people to express anger and frustration. It reduces the emotional and physical arousal that anger can cause. A person can learn to control reactions and respond in a socially appropriate manner. Additionally some social skills are also taught to client with respect of communication and other assertive behavior’s and many more.
8) Cardiac Rehabilitation: It is also called cardiac rehab, is a customized outpatient program of exercise and education. The program is designed to help one to improve his health and recover from heart attack, other form of heart disease or surgery to treat heart disease. It often involves exercise training, emotional support and education about life style changes to reduce heart disease risk, such as eating a heart-healthy diet, maintaining a healthy weight and quitting smoking. The goal of cardiac rehabilitation includes estimating establishing a plan to help to regain strength prevent condition from becoming worse, reduce risk of future heart problems and improve health and quality of life.
9) Life style Modification or Life skill training: The aim is to improve and maintain patient functional capacity and well being by making and controlling risk symptoms. It includes exercising to loose or maintain body weight, smoking cessation to reduce high blood pressure caused to the heart, monitoring of daily fluid intake incase of fluid buildup, eating healthy diet, monitoring of blood pressure, avoiding alcohol.
Muzzafar Ahmad is a (Clinical Psychologist) and can be reached at [email protected]
