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In Cardiac Psychology, Dr. Robert Allan demonstrates his approach to working with patients who have or are at risk for coronary heart disease, the leading cause of death and disability in Western civilization. Arguably, the field of cardiac psychology/behavioral cardiology is informed by the largest empirical database in behavioral medicine. Because many of the risk factors surrounding cardiac health have behavioral components, psychologists may be of great service to people at risk for this health problem.
Dr. Allan's approach is to meet an individual "where he or she is." Most important, this requires helping the patient identify which risk factors may be involved in their developing coronary disease and help him or her change those conditions, which include behavioral factors, such as cigarette smoking, sedentary lifestyle, and unhealthy diet, as well as such psychosocial factors as depression, social isolation, anger, and cardiac denial. Often, this approach requires providing education about risk factors and cardiac function.
In this particular session, Dr. Allan works with a 54-year-old African American long-haul truck driver who has recently suffered a heart attack. He discusses the biological basis of cardiac problems and risk factors for heart disease and then works with the patient to devise strategies to reduce risk of a future cardiac event, as well as ways to respond to cardiac symptoms, should they recur, to spare unnecessary damage to his heart and possibly even save his life.
Emergence of Cardiac Psychology
Coronary heart disease (CHD) is the leading cause of death and disability in the United States (American Heart Association, 1995). CHD also is a major source of death and disability for the rest of the Western world, particularly in industrialized countries (Zevallos, Chiriboga, & Herbert, 1992). The manifestations of CHD—angina pectoris (chest pain due to CHD), myocardial infarction (MI, or heart attack), and sudden cardiac death (SCD)—are almost always the result of atherosclerosis: deposition of fat and cholesterol-laden plaques in the linings of the coronary arteries (Zevallos et al., 1992). In addition, stroke and peripheral vascular disease, two other important diseases of the cardiovascular system, are often the result of the atherosclerotic process in the arteries that nourish the brain and legs, respectively.
Atherosclerosis is not caused by a single agent, such as a viral or bacterial infection, but results from a number of risk factors, many of which are determined by a person's lifestyle. Behavioral factors play a key role in the prevalence and severity of several of the well-accepted risk factors for atherosclerosis. Cigarette smoking, sedentary living, and dietary intake of cholesterol rich and high-saturated fat or high-calorie foods are life choices. Hypertension also has a behavioral component for those who are salt-sensitive, overweight, or both. Thus, each of the four major modifiable risk factors for CHD has a behavioral component.
Psychological stress, the Type A behavior pattern, anger and hostility, and social isolation or lack of social support are some of the psychosocial variables that have been linked to the development of CHD in otherwise healthy populations. In addition, depression has been shown to increase CHD risk and mortality after MI. Other psychosocial variables that may contribute to CHD risk include job strain, vital exhaustion (lack of energy, demoralization, and increased irritability), anxiety, and cardiac denial (ignoring the significance of cardiac symptoms).
Contemporary cardiology excels at managing life-threatening conditions (e.g., acute MI and unstable angina) with high-tech methods for diagnosis and treatment such as the coronary care unit, thrombolysis (medication to dissolve the thrombus that causes most MIs), cardiac catheterization, percutaneous transluminal coronary angioplasty (PTCA), and CABG surgery.
However, cardiologists have generally been far less interested in the day-to-day support that is often needed to help patients maintain a heart-healthy lifestyle and thus reduce the risk for cardiac events. It is here that psychologists and other mental health practitioners may find their expertise of great benefit, particularly for individuals who develop CHD before the age of 65, when the disease is considered premature and often has a substantial lifestyle component.
Psychological intervention with cardiac patients reduces psychological pain—severe anxiety, hostility, and depression—and thus improves quality of life as well. Successful psychological treatment of cardiac patients has resulted in more satisfying lives, not only for patients but also for their families.
The most compelling data in behavioral medicine today are to be found in cardiac psychology. There is a large database linking behavioral and psychological factors with the onset of CHD as well as with secondary cardiac events in individuals who already have CHD. Furthermore, a number of clinical trials have demonstrated reduced CHD morbidity and mortality with lifestyle programs that include a psychosocial component. Indeed, if the results of these clinical interventions can be replicated and the methodology transferred to other mental health professionals, then a revolution is possible in cardiac care. This direction seems particularly relevant in light of the current economic climate promoting reduced medical costs through prevention.
Cardiac psychology promises to be an important new specialty in mental health. The coming decade should bring many coronary risk reduction programs, particularly for secondary prevention of CHD, springing up at hospitals and cardiac rehabilitation centers around the world. (Note: This previous section is adapted from Heart and Mind: The Practice of Cardiac Psychology, [pp. 3–7], by R. Allan and S. Scheidt [Eds.], 1996, Washington, DC: American Psychological Association. Adapted with permission.)
Working With Patients Who Have CHD
Much of the interaction on the video with Chester is educational rather than the traditional work of psychotherapy. This was intentional on Dr. Allan's part because Chester needs to learn, and more important, to incorporate into his life, a great deal about heart health to avoid the real risk of a cardiac recurrence. This education is a major goal of treatment.
Chester sought prompt medical attention for his chest pains. This choice warranted strong validation: Too many patients deny the significance of their symptoms, delaying entry into the medical system and causing greater damage to their hearts than is necessary. "Time is muscle" is an important axiom in cardiology. It wasn't until near the end of the session that Chester and Dr. Allan approached issues that are more squarely in the domain of psychology—focusing on the "hook" (Type A behavior modification) and the avoidance of excessive cardiovascular reactivity.
The clinical cardiac psychologist will undoubtedly work with patients who vary widely in their knowledge about CHD. Generally, the more thorough the patient's understanding of the disease, the greater the opportunity to focus on psychological issues.
After an initial interview or a few individual sessions, group therapy is often the treatment of choice. Patients enjoy the camaraderie and benefit from their shared experience managing risk factors and dealing with the emotional effects of this chronic and generally progressive disease.
The cardiac psychologist will also likely encounter patients who have received implantable cardiac defibrillators (ICDs), a new and rapidly expanding population. Many such individuals have suffered a cardiac arrest and are at high risk for sudden death as well as posttraumatic stress disorder.
The budding cardiac psychologist should expect considerable resistance from the cardiology community. From Dr. Allan's experience, it has been far from easy to develop a practice, but it has been a very rewarding opportunity to evolve alongside an exciting new specialty.
Robert Allan, PhD, is clinical assistant professor of psychology in medicine as well as cofounder (in 1983) and codirector of the Coronary Risk Reduction Program at Weill Medical College of Cornell University and New York Presbyterian Hospital. His practice specialty is the psychological treatment of cardiac patients and their families.
Dr. Allan is coeditor, with cardiologist Stephen Scheidt, MD, of Heart and Mind: The Practice of Cardiac Psychology (American Psychological Association, 1996), as well as numerous book chapters and journal articles in the field.
Dr. Allan established the first stress reduction support group program for cardiac patients in the New York metropolitan area in 1982 at the Nassau County chapter of the American Heart Association. He currently treats individual patients and leads stress reduction support groups at New York Presbyterian Hospital and its affiliated Cardiac Health Centers in Manhattan and Queens.
- Allan, R., & Scheidt, S. (Eds.). (1996). Heart and mind: The practice of cardiac psychology. Washington, DC: American Psychological Association.
- American Heart Association. (1995). Heart and stroke facts: 1996 statistical supplement. Dallas, TX: Author.
- Blumenthal, J. A., Babyak, M., Wei, J., O'Connor, C., Waugh, R., Eisenstein, E., et al. (2002). Usefulness of psychosocial treatment of mental stress-induced myocardial ischemia in men. American Journal of Cardiology, 89, 164–168.
- Curtis B. M., & O'Keefe, J. H. (2002). Autonomic tone as a cardiovascular risk factor: The dangers of chronic fight or flight. Mayo Clinic Proceedings, 77, 45–54.
- Denollet, J., & Brutsaert, D. L. (2001). Reducing emotional distress improves prognosis in coronary heart disease. Circulation, 104, 2018–2023.
- Friedman, M., Thoresen, C. E., Gill, J. J., Ulmer, D., Powell, L. H., Price, V. A., et al. (l986). Alteration of Type A behavior and its effect on cardiac recurrences in post myocardial infarction patients: Summary results of the Recurrent Coronary Prevention Project. American Heart Journal, 112, 653–665.
- Friedman, M., & Ulmer, D. (1984). Treating Type A behavior and your heart. New York: Knopf.
- Krantz, D., & McCeney, M. K. (2002). Psychosocial factors and organic disease. Annual Review of Psychology, 53, 343–369.
- Mittleman, M. A., Maclure, M., Sherwood, J. B., Mulry, R. P., Tofler, G. H., Jacobs, S. C., et al. (1995). For the determinants of myocardial infarction onset study investigators. Triggering of acute myocardial infarction onset by episodes of anger. Circulation, 92, 1720–1725.
- Zevallos, J. C., Chiriboga, D., & Herbert, J. R. (1992). An international perspective on coronary heart disease and related risk factors. In I. S. Ockene & J. K. Ockene (Eds.), Prevention of coronary heart disease (pp. 147–170). Boston: Little, Brown.
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