June 1st, 2014

“Stress Proof the Heart: Behavioral Interventions for Cardiac Patients”

“Stress Proof the Heart: Behavioral Interventions for Cardiac Patients”

Edited by Ellen A. Dornelas

Springer Science + Business Media

New York, N.Y., 2012

 Book essential for clinicians working with cardiac patients

Reviewed by Paul Efthim, Ph.D.

About 15 years ago, I began working with heart patients at a local hospital. They were a fascinating but varied group: people who had recently experienced a heart attack, bypass surgery, catheterization, valve replacement or installation of a defibrillator or pacemaker. Without exception, all were struggling with depression, anxiety or both.

Being new to this population, I consulted the literature and was dismayed at the lack of clinical guidance on the psychological care of heart patients. I sought input from colleagues and medical staff at the hospital’s cardiac rehab program. They helped me put together a short-term group intervention that combined talk therapy with stress management instruction.

On the whole, patients loved it. They hungered to talk about the experience of being a cardiac patient with others who knew it from the inside. It was a no-brainer to put people with life-threatening conditions together in groups. However, there were a lot of technical, medical and existential matters that I needed to learn in order to work effectively. Most of that learning took place on the job by listening to patients’ stories.

Fortunately, the field of behavioral cardiology has expanded over the past two decades. A leading figure is Connecticut-based psychologist Ellen Dornelas, Ph.D., director of Behavioral Health Programs at Hartford Hospital. She recently published an impressive edited volume, “Stress Proof the Heart,” which gathers the latest clinical research on what works.

This volume boasts an international, cross-disciplinary group of contributors. Three other Connecticut psychologists – Yale faculty members Carrie Lukens, Dicle Turkoglu and Matthew Burg – wrote a chapter on stress management. Other contributors hail from South Korea, Italy, Canada, Switzerland, Ireland, Austria and the Netherlands.

Dornelas divides the book’s 17 chapters into two sections. Chapters focus on a particular condition such as coping with arrhythmia, atrial fibrillation, heart failure, heart transplantation, surviving cardiac arrest and living with an implantable defibrillator.

The second section of the book focuses on intervention strategies such as stress management, meditation, yoga, the role of job stress and over commitment, smoking cessation, exercise, and sleep problems.

One interesting recent development in the field is a new take on personality factors. Previous research had suggested that Type A traits (anger, hostility, impatience, competitiveness) are associated with increased risk for cardiovascular disease. However, more recent findings show that a much better predictor is the “distressed” personality pattern (Type D) characterized by proneness to negative emotions (such as dysphoria, anxiety, and irritability) along with social inhibition, which involves the inhibition of emotional expression to avoid disapproval by others.

The book devotes an entire chapter to reviewing the research on the Type D concept, pointing out both its promise and how much remains poorly understood.

Another striking fact is the high prevalence of sleep disorders (between 33 and 66 percent) in the cardiac population. Sleep apnea patients, for example, see a significant reduction in cardiac mortality and morbidity if they are compliant with treatment. Thus, the lengthy chapter on sleep disorders is required reading for any health psychologist.

Dornelas closes the book with a chapter that examines integrative treatment models and looks at how behavioral, cognitive and psychodynamic approaches each have something to offer. She places current developments in historical context and lays out a research agenda for the future.

The contributors mostly but not always succeed in their effort to balance science with practical guidance for the clinician; some chapters in the first section are overly academic. I wanted to see more attention to patients with pacemakers as well as more work on group treatment and models for integrating psychological treatment into cardiac rehabilitation programs, which are the single most powerful point of entry into a patient’s mental life following a cardiac event.

Some of the most useful sections include case examples and descriptions of patient experience coping with their conditions. More vignettes and direct quotations that convey the phenomenological quality of living with cardiovascular disease would have added more texture.

In sum, “Stress Proof the Heart” is absolutely essential reading for any clinician working with this population in any setting.

Paul Efthim, Ph.D. is a licensed psychologist in private practice in Brookline, Mass. He holds a faculty appointment at the Boston Institute for Psychotherapy and is a candidate at the Massachusetts Institute for Psychoanalysis.

By Paul Efthim PhD

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