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Psychosocial Intervention for a Geriatric Patient to Address Fears Related to Implantable Cardioverter Defibrillator Discharges

Received July 14, 2003; accepted Aug. 14, 2003. From Stanford University School of Medicine, Palo Alto, Calif; and the Department of Clinical and Health Psychology and the Division of Cardiovascular Medicine, University of Florida, Gainesville. Address reprint requests to Dr. Urizar, Stanford Prevention Research Center, Stanford University School of Medicine, Hoover Pavilion, 211 Quarry Rd., Stanford, CA 94305-5705; urizar{at}stanford.edu (e-mail).

The efficacy of the implantable cardioverter defibrillator (ICD) in preventing sudden cardiac death is well described in the cardiovascular medicine literature.^1,2 Nonetheless, ICD patients and their families must cope with the challenges of recovering from and adjusting to life after ICD implantation. ICD-specific fears and symptoms of both anxiety^3,4 and depression^5,6 are quite common and appear to be more prevalent in ICD patients who experience a high frequency of defibrillator discharges.⁷ These psychological sequelae may be due to patients' misconceptions about the causes of dysrhythmia and ICD discharges, as well as perceived loss of control in daily functioning.⁸ For many patients, these misconceptions can lead to avoidance behaviors for fear of triggering an ICD discharge. As is found with young ICD recipients, ⁴ older ICD patients share common fears and concerns that include fear of unpredictable ICD discharge, device malfunction, and death.

Given the psychological sequelae experienced by some ICD recipients, cognitive behavior stress management interventions have been suggested as one treatment modality to aid in the management of ICD-specific fears, concerns, and psychosocial challenges. However, few studies have examined the efficacy of such interventions for ICD recipients experiencing distress and poor adjustment, especially for older ICD recipients (age 65 years and older). The following case presentation highlights the efficacy of an ICD-tailored psychosocial intervention in facilitating adjustment and addressing specific fears and concerns related to the ICD in an older patient.

Case Report

The patient is a 74-year-old, married, Caucasian male with a medical history of coronary artery disease, coronary thrombosis, an ejection fraction of 25%–30%, and recurrent monomorphic ventricular tachycardia for which an ICD was implanted in March 1994. After implantation, the patient experienced several shocks during a 2-year period and underwent a generator replacement in 1996. During this 2-year period, the patient did not report any symptoms of anxiety or depression. In January 1999, the patient received a second ICD replacement and also underwent radiofrequency ablation of his ventricular tachycardia in an attempt to alleviate his medical symptoms. In April 1999, the patient came to the emergency department with congestive heart failure and was noted to be hypotensive. The patient's hypotension was likely secondary to his medication (propafenone), which was discontinued. Three days later, the patient experienced two episodes of single ICD discharges while in the shower at home and one ICD discharge at the hospital. ICD interrogation (assessment of diagnostic information stored electronically in the ICD device) confirmed all discharges as appropriate. Antiarrhythmic medication was prescribed for the patient, and he was treated for heart failure. His medications included magnesium oxide, furosemide, warfarin, digoxin, potassium, lisinopril, magnesium sulfate, docusate, omeprazole, and simethicone. After his most recent hospitalization, he began to experience symptoms of anxiety, hyperarousal, and avoidance of certain activities (e.g., showering) because he believed they would trigger an ICD discharge. As a result of these symptoms, his cardiologist referred him for a psychological consultation.

At the time of the psychology consultation (approximately 2 months after his most recent hospitalization), the patient reported experiencing poor appetite, sleep disturbance, nervousness, feelings of helplessness, and excessive worry. He described feeling anxious and somewhat depressed during the past 4 months; however, he denied suicidal ideation. The patient often commented on having difficulty distinguishing symptoms related to heartburn from those related to arrhythmia, and this difficulty made him feel tense and on edge. He stated, "Every time I get heartburn, I'm afraid it's another shock coming on and I brace myself." The patient's wife indicated that her husband had become hypervigilant due to concerns of triggering a discharge of his ICD device. As a result, he would avoid engaging in activities of physical exertion, including driving or walking to visit friends, that he believed would induce an ICD discharge.

Psychological Assessment
Clinical evaluation revealed that the patient met the DSM-IV diagnostic criteria for specific phobia⁹ related to ICD discharges. The patient was subsequently referred for psychosocial treatment. Before beginning treatment, he completed a series of measures that assessed his level of anxiety (State-Trait Anxiety Inventory¹⁰ and Anxiety Sensitivity Index¹¹), depression (Beck Depression Inventory¹² and Cardiac Depression Scale¹³), quality of life (Medical Outcomes Study 12-Item Short-Form Health Survey¹⁴), and ICD-related avoidance behaviors (ICD Concerns Survey¹⁵) (refer to Table 1 for a summary and interpretation of the patient's scores). Informed consent was obtained from the patient to report the treatment results.

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TABLE 1. Scores on Outcome Measures Before and After a Psychosocial Intervention for an Elderly Patient With Specific Phobia Related to Implantable Cardioverter Defibrillator (ICD) Discharges and Normative Scores for Healthy Subjects and Cardiac Disease Patients

Psychosocial Intervention
A cognitive behavior stress management intervention was used to facilitate the patient's goals of adjusting to living with the ICD and resuming a full range of physical and social activities. Topics covered in the intervention were adapted from a treatment manual tailored for health care providers treating ICD recipients¹⁶ and were based on standard cognitive behavior and stress management treatment strategies.

The cognitive behavior stress management intervention was conducted on an outpatient basis and comprised five weekly sessions, with a 1-month follow-up appointment. The first session consisted of psychoeducation about how ICDs function. The patient had reported feeling nervous about engaging in any form of exercise for fear of increasing his heart rate and causing his ICD device to discharge; therefore, psychoeducation was used to enhance the patient's understanding of how the device worked and help dispel any misconceptions and fears about the ICD. The second and third sessions consisted of instruction in stress management techniques, such as diaphragmatic breathing, that the patient could use to manage his anxiety. Over time, he reported that these techniques helped him take a more proactive approach to coping with his anxiety by recognizing when he was panicking (e.g., bracing for possible ICD discharge) and differentiating these symptoms from those of tachycardia. In the fourth and fifth sessions, the patient was instructed in how to promote his self-efficacy by identifying and reframing cognitive distortions, such as, "I should have done something to prevent that ICD shock. Maybe if I had been more calm, it wouldn't have happened." Intervention exercises consisted of facilitating optimistic beliefs and interpretations about the ICD (e.g., viewing the ICD as a life-saving device) that would help the patient to shift his attention from worrying about future ICD discharges to resuming activities of daily living. A sixth session was conducted to address any remaining concerns of the patient and to develop a plan for response in the event the patient experienced another ICD discharge.

Results of the pre- and post-intervention clinical assessment measures are presented in Table 1. At baseline, the patient's level of anxiety (as measured by the State-Trait Anxiety Inventory) and depression (as measured by the Beck Depression Inventory and the Cardiac Depression Scale) were within normal limits.^10,12,13 However, the patient demonstrated greater reactivity to his anxiety (as measured by the Anxiety Sensitivity Index), compared to a healthy normative group,¹¹ and lower emotional quality of life (as measured by the 12-Item Short-Form Health Survey), compared to other cardiac patient populations.¹⁴ After treatment, the patient evidenced a clinically significant decline in levels of anxiety (as measured by the State-Trait Anxiety Inventory and the Anxiety Sensitivity Index), depression (as measured by the Cardiac Depression Scale), and avoidance behaviors (as measured by the ICD Concerns Survey) and an overall improvement in emotional quality of life (as measured by the 12-Item Short-Form Health Survey). A 1-month follow-up examination revealed no subsequent ICD discharges.

Discussion

This case study examined whether a 6-week cognitive behavior stress management intervention would be effective in reducing levels of distress in an older ICD recipient with a diagnosis of specific phobia related to ICD discharges. Post-intervention results demonstrated a clinically significant decline in symptoms of depression and anxiety, improved emotional quality of life, and a reduction in ICD-related avoidance behaviors.

It is intriguing that the patient developed a phobia after his second ICD implantation and not the first, despite experiencing multiple ICD discharges after both implantations. Although the occurrence of ICD discharges has been associated with increased symptoms of anxiety after implantation, recent studies have suggested that this phenomenon may be related to a set of "catastrophic cognitions" present in a subset of ICD recipients.^17,18 Experiencing an ICD storm ( three discharges) alone may not predict a distress reaction; however, the experience may prompt catastrophic cognitions and feelings of helplessness, leading to symptoms of anxiety and depression. In the case presented here, the patient tended to have negative interpretations of somatic symptoms (e.g., heartburn) and heightened fear of sudden death, prompted by his most recent ICD discharges. If older patients can be helped during the course of treatment to view the ICD as a "life-saving device" rather than a "life-debilitating device," fewer patients may interpret ICD discharges as being their fault or as a marker of poor health. In this case, the patient was ultimately able to engage in fewer avoidance behaviors and resume activities of daily living.

Psychosocial adjustment to ICD therapy in older ICD recipients is an area that needs to be carefully examined, given that the majority of ICD recipients are age 65 years and older¹⁶ and that the prevalence of symptoms of anxiety and depression in this patient group ranges from 13% to 38%.⁴ The use of ICD therapy as a mode of arrhythmia management is expected to increase in older adults with heart disease as sudden cardiac death (due to ventricular fibrillation or sustained ventricular tachycardia) becomes a more common risk in this population.¹⁹

Although the treatment outcomes presented in this case study are those for one older ICD recipient, similar results have been reported for other ICD patient populations at the individual^20,21 and group²² level. Given the overall benefits demonstrated in reducing levels of distress and enhancing the adjustment of ICD patients, systematic studies are needed to examine psychosocial interventions for older ICD recipients and investigate optimal treatment strategies for this patient population. The results of this case study suggest that psychosocial interventions can be developed to supplement the medical management of these patients and optimize the health outcomes of all ICD recipients.

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