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?
Show Answer
The correct answer is: D. Be consistent and supportive, remind your patient that you have done everything possible to prevent future shock, gently explore and suggest counseling with a local mental health professional.*
Approximately 20% of patients with an implantable cardioverter defibrillator (ICD) meet clinical cutoff for PTSD. Previous research has found that patients with ICDs, found to have elevated symptoms of PTSD at baseline, have a greater risk of experiencing shock storm (defined as greater than 5 defibrillations) and mortality within five years of initial evaluation than ICD patients with no PTSD symptoms at baseline, even after controlling for disease and demographic factors.1
Patients with ICDs are also at an elevated risk for depression and anxiety disorders.2 Risk factors for the development of psychological distress include female gender,3 young age (< 50 years old),4 history of a previous psychological disorder,5 history of receipt of greater than five shocks,6,7 low social support,4 and type D (distressed) personality.4 A person may have a type D personality if they have a pattern of behavior which includes negative emotionality and social inhibition.
In addition to awareness of risk factors and behavioral observations of the patient, self-report screeners are effective tools for determining which patients may need a mental health referral. For example, the Florida Patient Acceptance Scale (FPAS)8 and Florida Shock Anxiety Scale (FSAS)7 were developed to evaluate ICD-specific quality of life and shock anxiety. The PTSD Check List (PCL-C) can be scored to determine whether or not a person would meet diagnostic criteria for PTSD or scored to determine severity of symptoms.9 The Patient Health Questionnaire (PHQ9) is a very quick and reliable measure of depression in medical settings.10
A stepped-care model, where intervention begins with meaningful discussion with physicians and progresses to a mental health referral for more severe distress, is advocated by experts in cardiac psychology11 and trauma interventions.12
Overall, cognitive-behavioral psychotherapy (CBT) has been shown to be safe in cardiac patients13 and result in large effect size (d = .83 – 1.43) reductions in trauma symptoms such as re-experiencing, hypervigilence, and avoidance.14,15 Specific CBT interventions with high success rates are cognitive processing therapy, which focuses on helping patients restructure thoughts related to the traumatic event16 and prolonged exposure, which focuses on gradually exposing patients to anxiety provoking stimuli.17 These treatments can be delivered by trained mental health professionals such as clinical social workers, psychological associates, and psychologists. In contrast, pharmacological treatment for PTSD patients have limited efficacy. For example, only 20-30% of patients show improvement with SSRIs.18 The results of randomized control trials of benzodiazapines have been equivocal.19
References
Ladwig KH, Baumert J, Marten-Mittag B, Kolb C, Zrenner B, Schmitt C. Posttraumatic stress symptoms and predicted mortality in patients with implantable cardioverter-defibrillators: Results from the prospective living with an implanted cardioverter-defibrillator study. Archives of General Psychiatry 2008; 65: 1324-1330.
Magyar-Russell G, Thombs BD, Cai JX, Baveja T, Kuhl EA, Singh PP, Ziegelstein RC. The prevalence of anxiety and depression in adults with implantable cardioverter defibrillators: A systematic review. Journal of Psychosomatic Research 2011; 71:223-231.
Vazquez L, Kuhl E, Shea J, Kirkness A, Lemon J, Whalley D, Conti JB, Sears SF. Age specific differences in women with implantable cardioverter defibrillators: An international multi-center study. Pacing and Clinical Electrophysiology 2008; 31: 1528 – 1534.
Pedersen S, Domburg R, Theuns D, Jordaens L, Erdman RAM. Type D personality is associated with increased anxiety and depressive symptoms in patients with an implantable cardioverter defibrillator and their partners. Psychosomatic Medicine 2004; 66:714-719.
Pedersen SS, Sears SF, Burg MM, Van Den Broek KCV. Does ICD indication affect quality of life and levels of distress? Pacing and Clinical Electrophysiology 2009; 32:153-156.
Pedersen S, Theuns D, Jordaens L, Kupper N. Course of anxiety and device-related concerns in implantable cardioverter defibrillator patients the first year post implantation. Europace 2010; 12:1119-11126.
Kuhl EA, Dixit NK, Walker KL, Conti JB, Sears SF. Measurement of patient fears about implantable cardioverter defibrillator shock: An initial evaluation of the Florida shock anxiety scale. Pacing and Clinical Electrophysiology 2006; 29:614-8.
Burns JL, Serber ER, Keim S, Sears SF. Measuring patient acceptance of implantable cardiac device therapy: Initial psychometric investigation of the Florida patient acceptance survey. Journal of Cardiovascular Electrophysiology 2005; 16,384-390.
Ruggiero KJ, Ben KD, Scotti JR, Rabalais AE. Psychometric properties of the PTSD checklist – civilian version. Journal of Traumatic Stress 2003; 16: 495-502.
Kroenke K, Spitzer RL, Williams JBW. The PHQ9: Validity of a brief depression severity measure. Journal of General Internal Medicine 2001; 16: 606-13.
Ford J, Cutitta KE, Woodrow LK, Kirian K, Sears SF. Caring for the heart and mind in ICD patients. Cardiac Electrophysiology Clinics 2011; 31:451-462.
Green KE, Iverson KM. Computerized cognitive behavioral therapy in a stepped care model of treatment. Professional Psychology: Research and Practice 2009; 48:96-103.
Shemesh E, Annunziato RA, Weatherley BD, Cotter G, Feaganes JR, Santra M, Yehuda R, Rubinstein D. A randomized controlled trial of the safety and promise of cognitive-behavioral therapy using imaginal exposure in patients with posttraumatic stress disorder resulting from cardiovascular illness. The Journal of Clinical Psychiatry 2011; 72:168-174.
Nemeroff CB, Bremner JD, Foa EB, Mayberg HS, North CS, Stein MB. Posttraumatic stress disorder: A state-of-the-science review. Journal of Psychiatric Research 2006; 40:1-21.
Bradly R, Greene J, Russ E, Dutra L, Westen D. A multidimensional meta-analysis of psychotherapy for PTSD. American Journal of Psychiatry 2005; 162:214-227.
Resick PA, Uhlmansiek MO, Clum GA, Galovski TE, Scher CD, Young-xu Y. A randomized clinical trial to dismantle components of cognitive processing therapy for posttraumatic stress disorder in female victims of interpersonal violence. Journal of Consulting and Clinical Psychology 2008; 76:243-258.
Foa EB, Keane TM, Friedman MJ (eds.). Effective treatments for PTSD: Practice guidelines from the international society for traumatic stress studies. 2000; New York, NY: Guilford Press.
Chorchs F, Nutt DJ, Hood S, Bernik M. Serotonin and sensitivity to trauma-related exposure in selective reuptake inhibitors-recovered posttraumatic stress disorder. Biological Psychiatry 2009; 66:17-24.
Ravindran LN, Stein MB. Pharmacotherapy of PTSD: Premises, principles, and priorities. Brain Research 2009; 1293:24-39.
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