Managing PTSD Symptoms Secondary to ICD Therapy

A 40-year-old married African-American female patient presented to the Electrophysiology (EP) clinic for device interrogation after she reported that her ICD fired. Medical records review revealed a history of peripartum cardiomyopathy five years prior to this appointment, with left ventricular ejection fraction (LVEF) of 20% one year post-partum and subsequent device implantation. One year ago, she was inappropriately shocked three times during sex due to elevated heart rate, which triggered the manufacturer’s therapy algorithm. Following this event, the ICD’s programming was tailored in the Emergency Department (ED) by a device company representative. Two months ago, she was shocked 57 times due to lead fracture while playing with her children. The lead was extracted and replaced.

For this appointment, she presented to clinic 30 minutes late, fidgeting and wringing her hands. She reported that she feels like she is being shocked at night and cannot sleep. Device interrogation does not substantiate defibrillation report. She also relayed that she monitors her heart rate every hour and presented a heart rate and blood pressure chart to prove that she is “playing it safe” and that shocks were “not her fault.” She expressed fear of walking or running because she was chasing her children during the last shock storm. You re-assure her that she is receiving optimal therapy, that the device and her medications have been adjusted to reduce the likelihood of future shock, and that her device is there to protect her. You also provide her with patient educational materials.

One month later, she requests a follow-up appointment due to reported “shock.” Once again, interrogation is negative. Patient reports the same symptoms of anxiety and states that she quit her job and is having difficulty in her relationship with her husband due to fear of sex. The EP nurse gave her several screeners indicating that the patient has a high level of shock anxiety, low acceptance of her device, and significant symptoms of Posttraumatic Stress Disorder (PTSD).

Your patient’s device and medications have been appropriately tailored and adjusted to prevent the recurrence of device therapy. The patient has been reassured, but continues to suffer from symptoms of anxiety and PTSD, what is your next step in care?

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