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PTSD and Automatic Implantable Cardioverter Defibrillators

Received April 4, 1998; revised July 6, 1997; accepted July 30, 1997. From the Department of Psychiatry, Medical University of South Carolina, Charleston; and the Ralph H. Johnson Veterans Affairs Medical Center (VAMC), Charleston, South Carolina. Address correspondence and reprint requests to Dr. Hamner, 116 Mental Health, VAMC, 109 Bee Street, Charleston, SC 19401.

Key Words: Case Report • Posttraumatic Stress Disorder (PTSD) • Defibrillator

Automatic implantable cardioverter defibrillators (AICDs) are indicated for patients with malignant ventricular arrhythmias that have been refractory to medical management. AICDs have been used in more than 34,000 patients with refractory arrhythmias.¹ AICDs monitor for arrhythmias and deliver an electric shock to the heart for cardioversion or defibrillation if a ventricular tachycardia or fibrillation occurs. These shocks may be uncomfortable or disturbing to patients. Psychiatric syndromes, including anxiety and depression, have been described in patients with AICDs, with important implications for clinical management.² In addition to contributing to decreased psychosocial functioning, anxiety and depressive symptoms may increase risk for recurrent arrhythmias in AICD patients.³ Moreover, quality of life is more likely to be significantly lower in patients with comorbid anxiety and depression.⁴

Although literature reports on psychiatric sequelae of AICDs have documented a high occurrence of depressive and anxiety syndromes, to our knowledge there has been relatively limited mention of posttraumatic stress disorder (PTSD) per se in association with AICDs. Fricchione and colleagues⁵ noted that in some severe cases, a PTSD episode characterized by reliving of traumatic events (in this case arrhythmias, resuscitation, and defibrillator shocks) through flashbacks or nightmares may develop. Patients may make major efforts to avoid similar situations, occasionally resulting in physiological hyperarousal. The possible occurrence of PTSD features is also noted in a review of psychiatric aspects of AICDs.⁶ Systematic assessment of PTSD symptoms has not, to our knowledge, been reported.

The heart disease and/or activation of the AICD may meet criteria for a psychologically traumatic stressor,⁷ and some case reports in the literature suggest PTSD symptoms, for example, cognitive preoccupation with the trauma or psychological or physiological reactivity on exposure to reminders of the AICD and heart disease (DSM-IV PTSD Cluster B: reexperiencing symptoms); avoidance of activities or situations that may activate the AICD (Cluster C: avoidance symptoms); and a variety of increased arousal symptoms, for example, insomnia, difficulty concentrating, hypervigilance, irritability (Cluster D: increased arousal symptoms). Furthermore, the discomfort or shock associated with AICD activation, and in some patients the associated constriction of activities, is reminiscent of the animal model of learned helplessness, which has been advanced as a model for human PTSD.

The following patients all met criteria for PTSD based on DSM-IV. Identifying PTSD in AICD patients may be important in determining who is at risk for developing psychiatric symptoms; helping with treatment interventions (based on strategies found useful in other trauma populations); and enhancing our theoretical understanding of the interactions among heart disease, AICDs, and psychological stress.

Case Reports

Case 1. Mr. A. is a 51-year-old, married, retired salesman, with ischemic cardiomyopathy and AICD, who presented for heart transplant evaluation. Important psychiatric history included the onset of severe anxiety following rampant defibrillation in January 1997, when his AICD had discharged close to 50 times in the span of 90 minutes. He reported the subsequent development of severe anxiety and fear of defibrillator discharge. He was preoccupied with thoughts of the AICD discharging. He experienced about 12 discrete episodes of tachycardia/palpitations accompanied by heightened psychic anxiety, muscular tension, the feeling of needing to get to an open area (e.g., out of a car), and fear of dying. Avoidance of being alone ensued and was accompanied by irritability and preoccupation with and fear of death. He developed insomnia. He began drinking alcohol at night to calm down and sleep. The intrusive thoughts of the AICD, avoidance of situations or activities, and increased arousal symptoms were all consistent with a diagnosis of PTSD based on DSM-IV criteria. His internist added fluoxetine (20 mg/day) to his standing medication regimen, which included amitriptyline (75 mg/day at bedtime), lorazepam (2 mg/day), amiodarone, potassium, digoxin, aspirin, and atenolol. At the time of initial psychiatric interview, he had been taking fluoxetine for about 4 weeks. Both he and his wife reported a remarkable improvement of his symptoms as well as cessation of drinking. He underwent successful cardiac transplantation (which included removal of the AICD) and for several months has maintained his improvement off both fluoxetine and amitriptyline, which had been discontinued after transplantation.

Case 2. Mr. B. is a 55-year-old man in the flooring business who was active and healthy until a myocardial infarction (MI), which occurred in December 1996. His post-MI course was complicated by ventricular arrhythmia, which led to the placement of an AICD several weeks after his MI. Over the following 6 months, he developed debilitating anxiety and overwhelming fear that his AICD would fire. At the time of psychiatric evaluation, his chief complaints were insomnia and pervasive anxiety that he attributed to the experience of being defibrillated twice. He described a remote history of panic attacks that he had successfully managed without specific intervention. The first AICD discharge took place when his heart rate exceeded threshold during exercise stress testing. In May 1997, the second firing occurred at his home, the morning after a significant altercation with his adult son. His anxiety was characterized by persistent worry and thoughts about the AICD discharging, sleep disturbance, diminished capacity to focus, and irritability. He made a point to distinguish this experience from panic attacks that he had experienced earlier in adulthood. (He received no formal treatment for those panic attacks, which were not accompanied by significant avoidance and which spontaneously remitted.) Fear of AICD firing led to avoidance of physically and emotionally strenuous situations and to compulsive checking of his pulse and blood pressure. His symptoms were consistent with PTSD by DSM-IV criteria. Initial treatment with alprazolam (12 mg/day) was briefly effective but was complicated by diminishing effect and rebound anxiety. After psychiatric evaluation, he began a trial of paroxetine (titrating from 10 mg to 20 mg/day over 3 days). He was gradually switched from alprazolam (1.5 mg/day) to clonazepam (1.5 mg/day). Additionally, he used twice-monthly psychotherapy to address the meaning of his cardiac disease and treatment and its impact on his interpersonal and professional life. Anxiety symptoms improved significantly, and he began to reclaim his active life-style.

Case 3. Mr. C. is a 47-year-old man whose status was post-AICD implantation for refractory ventricular arrhythmia 1 year before our evaluation. Psychiatric consultation was requested because of his anxiety about activities of daily living that might precipitate AICD firing. His medical history was remarkable for coronary artery disease, ventricular tachycardia, hypertension, hypercholesterolemia, and type 2 diabetes mellitus. He had a remote history of possible alcohol abuse but denied alcohol use for at least 1 year before our evaluation. He had no other psychiatric history before AICD implantation and also had no family history of psychiatric disorder. He was preoccupied with thoughts of the AICD when he had any physical symptoms and avoided activities that could increase his heart rate and/or remind him of the AICD (e.g., walking, sexual activity, yardwork). He acknowledged irritability, insomnia, gastrointestinal distress ("my stomach turning"), and heart palpitations associated with thoughts or reminders of the AICD. These symptoms were consistent with DSM-IV PTSD. Initiation of treatment with an antidepressant (paroxetine) and supportive psychotherapy was recommended.

Discussion

These cases illustrate the potential for developing PTSD secondary to AICDs. Two of the cases also suggest that relatively straightforward treatment, including antidepressant pharmacotherapy and individual psychotherapy, may help most symptoms and improve adaptive functioning. Further study is needed to define the incidence of PTSD and other psychiatric diagnoses in the AICD population.

A number of other cases in the literature also describe possible PTSD symptoms, although not specifically identified as such. For example, "Despite having a functional AICD, she developed disabling anxiety about the possibility of recurrent arrhythmia and sudden death as well as the possibility of AICD discharge or failure. Consequently, a phobic-type reluctance to resume her former life-style set in, which severely limited her activities."²

By using a semistructured interview, Morris et al.⁸ reported that 30% of patients in their series of 20 AICD patients had a transient psychiatric disorder and 20% had a major psychiatric disorder. Diagnoses, based on DSM-III-R, included adjustment disorder in six patients, major depression in three patients, and panic disorder in one patient. None of their series had PTSD, but it is not clear whether the interview used specific questions for PTSD phenomena. To our knowledge, this is the only study using DSM diagnostic criteria in the AICD population.

A review of 18 published studies that address psychiatric symptoms and quality of life suggested that the majority of AICD patients have at least some anxiety and/or depressive symptoms with associated reduction in level of functioning and quality of life, although most are satisfied to have the AICD.⁹ As an example of these studies, Vlay et al.³ administered several questionnaires before and after AICD implantation to eight patients and found increased anxiety and anger. Only a minority of studies suggested that AICD implantation might have a more minimal psychological impact. For example, Pycha et al.¹⁰ reported a relatively low incidence of depression and anxiety, and Keren et al.¹¹ reported that AICD activation had minimal effect on anxiety and depression. Two studies more recently published (not addressed in the aforementioned review) also investigate the quality-of-life issues and psychological adjustment. Chevalier et al.⁴ administered structured clinical ratings (i.e., Hamilton Anxiety Scale, Beck Depression Inventory, and a quality-of-life scale) to 32 AICD patients. Quality of life was negatively correlated with anxiety and depressive symptoms. Hermann et al.¹² reported that psychological distress correlated with the number of AICD challenges in their study of 70 consecutive AICD patients. Psychological distress was measured by using a standardized self-assessment. A subgroup of patients in their study had high psychological stress, lower quality of life, and frequent AICD discharges. Neither of these studies reported PTSD or other specific psychiatric diagnoses. As Gallagher et al.¹⁹ note, however, "most [AICD] recipients are anxious about the unpredictable onset and effect of the shock and use a variety of strategies such as lifestyle change to reduce their anxiety and feel some control." Conceivably, some of these patients develop essentially a learned helplessness, manifest as PTSD or other anxiety or depressive syndromes. The occurrence of learned helplessness may be more plausible based on the fact that about two-thirds of AICD patients have no warning signs or symptoms that a shock will occur.¹³ The unpredictability of AICD discharges is associated with increased psychological stress^9,14 and with psychiatric illness.⁸

The animal model of learned helplessness is based on the observation that animals exposed to repeated, uncontrollable, or unpredictable aversive stimuli (e.g., electric footshock or feared swimming) from which they cannot escape eventually seem to "give up." The animals often appear listless, "anxious," or irritable; have decreased interaction with other animals; lose weight; and have difficulty learning new behaviors. This animal syndrome responds to antidepressants (and has long been used for testing novel putative antidepressant agents); ^15,16 however, this syndrome may have better applicability as a model for PTSD.¹⁶ Biological changes associated with learned helplessness include dysregulation of endogenous opioid peptide, noradrenergic, dopaminergic, and serotonergic function.

Many biological changes observed in these stressed animals have been reported in PTSD.¹⁷ Noradrenergic dysregulation associated with psychological, pharmacological, and physical stressors has also been described in PTSD patients.^18–20 Persistent noradrenergic dysfunction could be one link between psychiatric symptoms and risk for recurrent cardiac symptoms. If so, this would especially highlight the importance of recognition and treatment of PTSD and other psychiatric syndromes. Heart disease itself may also precipitate or exacerbate PTSD.^21–23

Two of our patients benefited from antidepressant medications and anxiolytics, both mainstays in the treatment of PTSD.²⁴ In other trauma populations, individual psychotherapy and group therapy may also be a beneficial strategy that allows peers to share commonality of experience and coping strategies, and has proven beneficial for certain PTSD populations (e.g., veterans, crime victims). Specialized cognitive–behavioral psychotherapies are also useful in other PTSD populations. To our knowledge, the effectiveness of psychotherapy and/or psychopharmacologic treatments has not been systematically investigated for AICD patients with psychiatric syndromes.

Cardiologists and consulting psychiatrists should be aware of the potential for PTSD to develop in association with AICD implantation as well as from the primary heart disease. Establishing the diagnosis of PTSD if present (or other psychiatric disorders by using DSM-IV diagnostic criteria if appropriate) may better guide treatment interventions. Further research is needed to better determine the incidence of PTSD and other psychiatric syndromes, potential risk factors, and refine treatment interventions for these AICD patients.

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