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Cognitive–Behavioral Treatment of Panic Disorder With Agoraphobia Triggered by AICD Implant Activity

Received January 24, 1997; revised June 18, 1997; accepted July 8, 1997. From the Department of Psychiatry, State University of New York (SUNY) Health Science Center at Brooklyn. Address reprint requests to Dr. Smith, Box 1203, 450 Clarkson Avenue, SUNY Health Science Center at Brooklyn, Brooklyn, NY 11203.

Key Words: cognitive-behavioral therapy • panic disorder • agoraphobia

The use of automatic implantable cardioverter defibrillators (AICDs) has been successful in reducing the incidence of sudden arrhythmic mortality in high-risk patients to less than 3% per year.¹ However, in addition to the stress associated with chronic cardiac disease, AICD patients face unique problems, such as device dependency and fear of unpredictable shocks, which make them particularly vulnerable to anxiety, depression, and other psychological disturbances. As many as 50% of these patients have been shown to develop a psychiatric disorder: 30% adjustment disorder–mixed type, 15% major depression, and 5% panic disorder.²

Supportive treatment, often within a group setting,^1,3and the use of psychotropic medications (primarily benzodiazepines) are common treatment modalities. Cognitive–behavioral therapy (CBT) in particular can be helpful in managing anxiety and fatigue, maximizing physical and social activity, and reframing the meaning of the AICD from the center of one's life to a neutral medical intervention designed to enhance and prolong life.⁴ Although CBT is mentioned in most articles addressing the psychiatric management of patients with AICDs, no detailed account of its specific application or effectiveness has been reported. We will describe the psychological reaction and comprehensive case management of a client with an AICD.

Case Report

Client: The client is a 36-year-old white, married woman who was diagnosed with right-ventricular dysplasia. An AICD was implanted in March 1995 as a "safety net" for the continued regimen of medication, sotalol (120 mg po bid). Subsequent to implantation, the client experienced one episode of six or seven defibrillator shocks in April 1995 while walking to work. Shortly after this incident, she began to experience symptoms of hyperarousal, flashbacks of the jolts, nightmares, and agoraphobic avoidance, all of which slowly tapered off within 3 weeks. In addition, she began to experience somatic symptoms of dizziness, fatigue, and nausea, not due to the arrhythmia.

In July 1995, the client had an episode of pacing therapy while walking her children in the park. This episode triggered her panic attacks as well as the return of her agoraphobia and generalized anxiety symptoms. Prior to the start of her CBT, her cardiologist had been prescribing alprazolam (0.25mg prn) for her anxiety, and her gastroenterologist was prescribing zolpiden (0.5mg prn) for sleep. The client reported only occasional use of either medication. In addition to her anxiety symptoms, the client began experiencing feelings of depression linked to her heart condition in April 1995 shortly after receiving the implant.

Measures: The client's anxiety and depressive diagnoses were made through a two-session administration of the Anxiety Disorders Interview Schedule⁵ as well as the completion of the Marks and Mathews Fear Questionnaire,⁶ the Body Sensations Questionnaire,⁷ the Agoraphobic Cognitions Questionnaire,⁸ the Mobility Inventory for Agoraphobia,⁸ and the Beck Depression Inventory.⁹ Her symptoms remained unchanged over the course of the two intake sessions. The client was diagnosed, in accordance with DSM-IV¹⁰ criteria, with panic disorder with agoraphobia, major depressive disorder, and posttraumatic stress disorder in remission stemming from a rape 14 years earlier.

Treatment: Treatment was conceptualized as a traditional cognitive–behavioral psychotherapy designed to focus on the client's anxiety symptoms as well as to monitor and address her level of depression.¹¹ This current therapy was considered to be one component of a multidimensional approach that included medication management, couples interventions, and a referral to an appropriate medical support group. Her therapy was conducted for 8 weekly sessions, tapering down to 7 sessions over the course of the following 10 months. The client requested a psychiatric evaluation after the 12th session and was prescribed nefazodone (100 mg po bid). Her dosage was increased to 150 mg po bid after 1 month and was increased to and maintained at 200 mg po bid after 2 additional months.

Treatment began with education about panic and the impact of her heart condition on her symptoms. Her cardiologist was consulted in the early stages of therapy to assist in differentiating normal symptoms of recovery such as fatigue from symptoms of panic and depression. With the approval of her cardiologist, the client's physical panic symptoms were addressed through an interoceptive exposure purposely encouraging hyperventilation, which is a common component of her regular AICD checkups. Diaphragmatic breathing retraining and an audiotaped progressive muscle-relaxation exercise were taught as relaxation techniques to cope with the physical symptoms of anxiety. The client reported that she learned to recognize and differentiate the sensation of the onset of tachycardia from panic sensations, and to then stop and perform relaxation exercises, rather than to rush to a safe place before attempting such coping responses. In this manner, she felt better able to avoid a more serious attack of tachycardia.

Cognitive challenging of her catastrophic thoughts was taught, focusing on her primary concern that the defibrillator would fail to function successfully in an emergency. This intervention primarily involved reinterpreting the AICD firings as positive, lifesaving occurrences rather than life-threatening shocks.

The final stage of therapy focused on the client's daily stresses and moods. Some strategies to manage worries, especially at times when she was trying to fall asleep, were suggested, including delaying worry, setting a daily worry time, distraction, and implementing the relaxation techniques.¹² The client's husband attended one early therapy session to share in the education process, learn basic ways to coach his wife through active coping with the panic symptoms, and to help family members adjust to the client's recovery. The client eventually joined an AICD recipient support group at the hospital, where she had received her implant as her CBT was tapering off.

Results: The results of the pre- and posttreatment clinical measures are presented in Table 1. Both the client's anxiety and depression scores evidenced clinically meaningful drops after treatment and remained decreased at the 3-month follow-up. Additional decreases in symptomatology occurred after the activation of medication for the 6-month and 1-year follow-ups, although the stress of relocating her family resulted in a minor increase in depression at the 1-year follow-up. The client was determined to be in remission for both panic disorder with agoraphobia and major depressive disorder by the therapist and psychiatrist at the termination of treatment.

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Table 1

Discussion

We describe the treatment of a woman diagnosed with panic disorder with agoraphobia and major depressive disorder during the first year of her adjustment to the AICD. In many ways, this therapy was similar to that of clients with panic disorder whose fears of heart attacks during panic are unfounded. Although the treatment team was initially cautious about the hyperventilation exercise, consultation with the client's cardiologist allowed this component of the treatment. In terms of the cognitive component to the therapy, rather than rely on the argument that panic attacks do not result in heart attacks, the client relied more on "accepting her health condition" and reframing the AICD as a beneficial safety net while adjusting to its "normal" functioning. Differentiating panic symptoms from cardiac symptoms and using relaxation methods to cope with both were also important.

Given the high incidence of psychiatric morbidity in response to AICD implantation, psychoeducation provided proactively within a multidisciplinary team approach would seem to be an essential component in enhancing an individual's adjustment to the procedure. Although the literature in this area has begun to explore the psychological adjustment to the AICD, there exists a lack of specified therapeutic strategies to target this growing population. While the case study design is limited in its generalizability and power to determine active therapeutic agents, it is a valuable first step in defining specific interventions for the effective management of the AICD recipient. Additional experimental research strategies comparing presurgical educational and/or cognitive–behavioral interventions for clients would lend more direct support to the importance of psychological interventions in aiding their adjustment to the process. Given the increased complexity of medical intervention to prolong life in a variety of illnesses, the further development and application of CBT treatments to enhance quality of life are warranted.

ACKNOWLEDGMENTS

This work was supported, in part, by a grant from the National Institute of Mental Health (Grant No. 42545) and funds from the Department of Psychiatry's practice plan.

ACKNOWLEDGMENTS

The authors thank Noelle Langan, M.D., Department of Cardiology, Mount Sinai Medical Center, for her input concerning the treatment and management of AICD recipients as well as Ramaswamy Viswanathan, M.D., for providing excellent medication management.

REFERENCES

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