Me and My Heart

Self Identity and Recovery from a Coronary Event

Altnagelvin Hospital

Derry

Northern Ireland

Dr Don MacFarlane PhD., MB., MSc., MRCPsych., DPM

Take-Home Message

#1 and #2

Good: An aerobic exercise programme after

a coronary event improves (by a third)

survival, self confidence, level of function

and quality of life.

Bad: Adherence (a third) is poor even when

longer-term survival is at stake.

Take-Home Message #3

Education for those in recovery from

a coronary event needs to be

targeted at fatalistic self-beliefs that

contribute to avoidable self-

handicapping.

Part I

Risk Factors for Further Acute

Coronary Event

World Mortality Rankings

Amalgam of Coronary Disease, Hypertension, Impaired Glucose

Tolerance, Alcohol Abuse, Depression

“if you have one, you may have the lot”

Death rates per annum per 100k of

population

Former USSR 245-400

Horn of Africa 210-230

Himalayas 200-220

Middle East 160-175

Balkans 150-160

Subtropical Africa 50

West Africa 50

Pacific Islands 50

Mind the Gap

Hazard Ratios for Future Acute

Coronary Event (ACE)

Bad cholesterol x4

Current Smoking x3

Diabetes x3

Hypertension x 2.5

Depression x 2.5

Anxiety x 1.5

Exhaustion 2.5

Obesity x2.25

Hostility x3

Daily Fruit x 0.75

Exercise x0.75

All combined x 130

Life Stressors

• There will often have been a gradual

and cumulative build-up of stress over

years.

• A score of 300 on the Holmes -Rahe

Scale gives a 75 per cent prediction of

health breakdown in the near future.

Holmes – Rahe Scale

Death of spouse 100

Coronary Event 50

Reduced Lifestyle 50

Sexual Difficulties 40

Redundancy or Retirement 40

Loss of income 40

Mortgage difficulty 30

Social isolation 50

Part II

Cardiorehabilitation Findings

EUROASPIRE

(Kotseva, Wood, de Backer et al)

Noncompliance with target objectives

6 months after stents

• Smoking 18%

• BMI>25 82%

• BMI>30 35%

• Systolic BP>140 and/or

Diastolic BP>90 54%

• Inactivity Level 70%

• Cholesterol >4.5 46%

• Impaired Glucose 15%

Professor Carlo di Mario PhD FRCP

“The results are truly disappointing;

most patients do not hit one or more

targets that prolong life”.

ETICA Trial

(Belardinelli et al)

Comparison of exercisers with dropouts

• Quitting smoking 100%

• Improved physical 50%

• Improved Role 10%

• Improved Social 0%

• Improved Mental 50%

• Improved Wellbeing 25%

• Improved Pain 50%

• Improved ACE 100%

• Improved Restenosis 25%

GOSPEL Study

(Giannuzzi, Temporelli, Marchioli et al)

Longer Compliance with Life-Saving Lifestyle Measures

3 Years post ACE

• Smoking unchanged

• BMI>25 unchanged * (waist)

• Systolic BP and Diastolic BP unchanged

• Inactivity reduced to 50% from 70%

• Cholesterol level unchanged *

• Impaired Glucose Tolerance unchanged *

Heart and Soul Study

(Whooley and Schiller)

Comparison (%) of depressed and non-depressed

groups for smoking, drug noncompliance and

inactivity

0510152025303540

Depressed

Normal

Part Three

Missing Questions

Ego Threat

Vital Exhaustion

Allostasis (Stress)

Hostility

Self Identity

Insomnia

Vital Exhaustion

(Kop, Appels et al)

• Sense of Hazard

• Sense of Threat

• Liability

• Handicap

• Need to Awaken

• Need to Adapt

• Reduced Capacity

• Little Purpose

• Lack of Vitality

• Lack of Wholeness

Allostasis

(Doll et al)

• Stress

• Strain

• Tolerance

• Resilience

• Malleability

Hostility

(Smith, Ruiz et al)

• Physical (hitting out at)

• Verbal (giving off)

• Passive (sulking)

• Cynical (disapproving)

• Spousal (taking it out on)

• Controlling (not listening)

Personality

The Framingham Study identified Type A Personality as

pathogenic. Recent research points to Type D as perhaps

more predictive of cardiac outcome.

Type A Personality

Ambitious

Aggressive

Urgent

Competitive

Type D Personality

Isolating

Worried

Gloomy

Irritable

Reticent

Lacks confidence

Insomnia

(Schwartz et al)

• Falling asleep

• Staying asleep

• Feeling refreshed

• RR for all x 1.5

Self Identity

(Weinreich, Marcia et al)

• Diffused „What happened to me?‟

• Empathic „What have I become?‟

• Dissonant „Can I be bothered?‟

• Incongruent „Do I like how I am?‟

• Idealistic „What‟s the best I can expect?

‟

Ego Threat

Research into comorbid depression has not looked at

Ego-Threat as an integral but perhaps more important

component of depression as a contributory factor in

cardiac outcome.

Low Self Worth

Self Questioning

Self-punishment

Self-blame

Blaming Others

Hypersensitive

Loss of identity

Rage

Slow Suicide?

Failure to address or meet challenges and transition

induce emotional and behavioural paralysis.

Vegetative State

Foreshortening

Somatic Vigilance

Aimlessness

Irritability

Inability to express feelings

Part Four

Mediating Factors

Inflammatory Factors

Multiple inflammatory markers present in depression

attack the heart and induce heart failure.

• The damaged lining of blood vessels releases

interleukin and C-reactive protein.

• Depression can also be caused by these inflammatory

factors.

• Depression, even without coronary disease, has these

factors present.

• A vicious circle can perpetuate coronary spasm as well

as depression.

Pathophysiology

• Platelet Aggregation

• Heart-Rate Variability

• Cardiac Output

• Ejection Fraction

• Parasympathetic imbalance

• Sarcomere Production

Part Five

Beneficial Factors

The Best Medicine

Regular and testing aerobic exercise has a marked and

beneficial effect upon cardiac output, stroke volume,

ejection fraction, rhythm and blood pressure.

(Ray Squires, Mayo Clinic)

• exercise will reduce depression and adverse

cardiac events over a two year period by a

quarter.

• 40% of maximum capacity in the first stage of

cardiorehab is the correct ratio for benefit versus

strain on the recovering heart.

Optimal Exercise

Warning: An exercise programme can be dangerous

unless initiated under the correct cardiorehab

supervision.

• 3 sessions per week

• 45 minutes per session

• 80% of HRmax (maximum heart rate)

• 6-10 months adherence or more

• 60% off HMD (Hamilton Depression Scale)

ENRICHD Behaviour

(Berkman, Blumenthal, Burg et al)

Study Showed that Lifestyle Measures in Control Group

were as effective as treatment with antidepressants or CBT

Proper Sleep

Socialise

Problem Sharing

Optimism

Kindness

Eating Right

Setting Goals

Exercise

Psychological Factors Aiding

Cardiac Recovery

Buzzwords

Some factors are likely to have an effect on cardiac

outcome

• Commitment

• Optimism

• Sociotropy

• Avoidance of avoidance

• Autonomy

• Goals

Take Optimism !

Giltay, Zitman, Hoekstra et al

(with some gender-bias apparent, optimism protects

against cardiovascular events from late middle-age)

Optimism Test

An Optimism Score based upon the MacNew and

Coping Style Instruments can do for screening.

Rubber Band Time

• There‟s a shadow hanging over me

• I‟m only half the man I used to be

• All my troubles seemed so far away

• Now it looks as though they‟re here to

stay

“On the Third Blast, Don‟t Panic”

• Take a deep breath

• Think on something else

• Do some yoga

• Give a hand

• Have a chat

• Go for a walk

• Write it down

• Treat yourself

• Make something

Identity and Cardiac Outcomes

• Threats to identity leave a person less ill-

equipped

• Change is hard if poorly visualised

• Identity, emotions and actions should be in

tune

• Value systems should be easily accessible

„One man in his time has many parts‟

Role is the aspect of identity that has to do with outworking

of behaviours and obligations that are in keeping with that

identity (Bales).

• Role Validity

• Role Overload

• Role Inadequacy

• Role Security

• Role Conflict

• Role Misfit

• Role Ambiguity

PROCESS OF CHANGE

Challenges and Transitions

Adapted from Erik Erikson

Throughout the lifespan, challenges present and represent

which have to be negotiated for successful transition and

which may otherwise be termed as „crises‟.

• Capable v. Helpless

• Reflective v. Instinctual

• Adventurous v. Avoidant

• Persistent v. Quitting

• Affectionate v. Detached

• Trusting v. Disbelieving

„Here and Now‟ Anxiety

„Here and Now‟ Depression

Cycles of Change

Cycles of change show periods of action preceded by

reflection or moratorium

Interpretation

Commitment

Planning

Support

Growth

Denial

Giving Off

Giving Up

Drinking

Levers of Change

(adapted from Prosci‟s ADKAR)

Knowledge

Desire

Awareness

Acceptance

Ability

Efficacy

Motivation

Control

Reinforcement

Facsimile of Self Entities

Worrying about

Symptoms

0 Ignoring symptoms

Me as I am now -4 to -1 0 1 to 4

Me as I will be -4 to -1 0 1 to 4

Me feeling good -4 to -1 0 1 to 4

Me when I was fit -4 to -1 0 1 to 4

Me with family -4 to -1 0 1 to 4

Me when depressed -4 to -1 0 1 to 4

Me in rehab -4 to -1 0 1 to 4

Facsimile of Self Views

-4 to -1 0 1 to 4

Doing everything I can 0 Making excuses to drop out

Enjoying all the attention 0 Resenting being fussed over

Blotting it out of my mind 0 Problem is always there

Keeps going whatever 0 Gives up too easily

Feels as capable as ever 0 Feels a nuisance to all

Using good advice 0 Wearing cloth ears

Expects to die early 0 Will live a full lifespan

Self as Context

• The Wise Mind

(Socrates)

• The Big Picture

(Socrates)

• Realism (Aristotle)

• Awareness (Hume)

• The Zone (Voltaire)

• Pragmatism (Hegel)

• Coping (Spinoza)

• Goals (Pascal)

• Perspective (Carson)

Some Self Scripts

Aristotle – strive for the best, accept no less.

Augustine – there is always a better perspective

Epicure – there is no afterlife, make the most of now

Plato – find your guiding light

Kant – every act has consequences

Heidegger – find meaning but within not from around

James – find what works, not what pleases

Need Therapy?

Modalities that are suited to those in

recovery from an ACE are TA, CAT,

ACT, IPT and CBT

THE END

http://cardiorehab.wordpress.com