Cardiovascular Psychology

The Role of Psychology in Coronary Heart Disease

• Interaction of factors:
- Individual difference, e.g. development, genes
- Perceived stress
- Behaviour responses, e.g. diet, smoking, drinking and exercise
- All above contribute to the physiologic response and allostatic load
- This allostatic load is the amount the body need to respond to and adapt
• Evidences of psychological effect:
- Increased susceptibility to common cold with increased stress
- Increased time of mucosal wound healing is impaired by exam stress
- Great number of MI cases with stress as compared to control
- CHD risk is 3 times higher in those with depression
• Dampened response: response to stress is dampened after repeated exposure, e.g. stress related inflammatory response continues s and disrupts wound repair when organism is damaged.
- Prolonged stress will damage organs that cope with stress
• Importance of emotional support: mortality of MI decreases greatly with increased number of support.
• Work characteristics associated with CHD:
- Low control over work and high conflicting demand
- Low ability to make decisions
- Discrepancy between education and occupational level
- Low job security
• Psychobiological mechanism:
- Psychological stress: increased heart rate and vasoconstriction in peripheral areas (wear and tear cause lesions)
- Hormonal changes: catecholamines reduce resilience of blood vessels
- Lipid profile contribute to atherosclerosis
• Type A behaviour: strives to achieve even as task gets more difficult
- Excessive competitive drive
- Impatience
- Hostility
- Rapid speech
- Need for control
• Contribution of type A to CHD:
- Cynical hostility: suspiciousness, resentment, frequent anger and distrust in others leads to increased coronary event
- Child rearing practises: punitiveness, non-supportive, high in conflict
- Expression of anger related to CHD
- Difficult in extracting social support
• Risk factor of hostility:
- Higher caffeine use
- Higher weight
- Smoking
- Alcohol use
- Lower compliances with medication
- Shorter relapse in quitting smoking
• Type B personality: at higher demand, stress will level off unlike type A.
• Type D personality
- Negative affectivity: tendency to experience psychological stress across time and situation
- Social inhibition: inhibit negative emotions in social situation
• Contribution of type D to CHD: greater proportion of type D patients suffer cardiac death
• Relationship of psychosocial factors to cardiac death:
- Distress-induced sympathetic nervous system activation
- Weaker parasympathetic function
- Non-compliance with medication or cardiac rehabilitation
- More stressful daily existence
- Poorer health habits
• Risk of Smoking:
- 48% drop in CHD in England due to reduction in smoking
• Fear appeals: frightening people to stop smoking
- Relationship between fear and behaviour change is not consistent
- Too much fear can create paralysis
- Recommendations for action and information is more important
• Personal optimism: protective of CHD. A belief that ill health won’t occur with oneself creates a sense of control and security.

Recovery Following Myocardial Infraction

• Reactions to MI
- Denial and minimization
- Anxiety and fear
- Depression
- Somatic preoccupation
- Cardiac invalidism
• Denial: unable to rapidly adjust psychology leading to signs of protest and insisting to return to normal activities, difficult to manage.
- Short term advantages
- Long term advantages
• Wants of MI patients:
- Honest answers from doctor
- Understand specifics about condition
- Usefulness of exercise
- Procedures during emergency
- Prevention: lifestyle (diet, smoking, exercise), control (BP, lipid and glucose), drug (ACEi, statin, beta-blocker and aspirin)
- Time to resume activity
- Work effect on heart
• Post hospital phase:
- Difficulty in coping is actually not associated with seriousness of MI
- Cardiac invalidism with restricted activity, excessive dependency and helplessness
- Compliance with new lifestyle is low
• Problems with lifestyle intervention:
- Smoking cessation is very effective but many do not or quit and relapse
- Exercise reduce coronary event but drop out rate is high
- Dietary changes have impact on whole family (everybody have to change)
• Factors related to exercise dropout:
- Smoking
- Poor physical condition
- Obesity
- Anxiety and depression: fear of reoccurrence and lower limitation and activity levels. Mainly associated with poorer outcomes such as higher hospitalization rates
- Sedentary lifestyles
- Low occupational and education groups
• Factors promoting returning to work:
- Younger age
- Better physical heath
- White collar job
- Lower emotional stress and depression
- Lower family dysfunction
• Effect on spouse and family:
- Level of distress almost as high as patient
- Overprotective of the patient leading to increase in household chores
- Change in occupation to suit patient, e.g. quit full time job to take care at home
- Becomes independent
• Sexual activity:
- Psychological concerns often more relevant than physiological ones
- Increased anxiety and depression can interfere with functioning
- MI may occur during sex (death in saddle) – 0.68%
- Patient reluctant to talk about worries
• Positive changes with heart attack: majority of patients (62%) have positive outlook
- Great appreciation of life: better lifestyle
- Changes in personal priorities: do what you want to do
- Improved intimate relationships
- Great sense of personal strength
- Recognition of new life opportunities
- Spiritual change
• Behavioural challenges after MI:
- Returning to work even when physically capable
- Increased use of medical care and decrease satisfaction associate with disabilities
- Not attending rehabilitation programmes
- Compliance to cardiac drugs
• Misconception:
- Cardiac: any excitement and shock would lead to another heart attack; heart disease due to work and stress; dead part of the heart can burst under pressure
- Angina: angina damages your heart and should rest as much as possible
- Negative feedback: resting with angina causes cardiac deconditioning and leads to more angina; chest tightness perceived as a heart attack can lead to stress and autonomic arousal, increase BP and augment chest pain.
• Illness perception intervention:
- Session 1: explanation and introduction of intervention
- Session 2: planning and set goals. Discuss benefits and method
- Session 3: Spouse centred and link to plan. Explain role of spouse
- Session 4: solve concerns, setting up home routine, positive actions in family and address emergency situations
• Stimulus for compliance to health plan:
- Threat to health is severe
- Perceived vulnerability is high
- Capacity to perform
- Behaviour is evident to overcoming health threat
• Exercise adherence:
- convenient
- enjoyable
- social
- regular monitoring
- goals
• Fostering Optimistic Beliefs
- Perception of illness are important
- Clear up misunderstandings and deal with pessimistic interpretations
- Encourage action plan and positive attitude

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