Cardiac Device Patients’ Fears of Being Shocked Can Prevent Full Recovery, UAMS Audience Told
| Fear of being shocked is preventing many patients with implantable cardioverter defibrillators from making a true cardiac comeback, an expert on the psychological effects of cardiovascular disease told a UAMS audience June 17.
Samuel Sears, Ph.D., a professor in the departments of psychology and cardiovascular sciences at East Carolina University in Greenville, N.C., emphasized that cardiac doctors need to help patients trust the technology and overcome their fears while encouraging them to remain active.
Implanted in the chest below the collarbone, an implantable cardioverter defibrillator looks and works much like a pacemaker, but can send a low-energy shock that resets an abnormal heart rhythm back to normal. It can also send a discomforting, high-energy shock if an arrhythmia becomes so severe that the heart stops pumping.
Sears, a leading authority on the psychological care of cardioverter defibrillator patients, told an audience gathered both online and in a UAMS classroom about a patient in North Carolina who was an avid surfer.
Sears said that one day while surfing, the man received multiple inappropriate shocks from his device.
The man had no history of psychological problems, but after that experience developed such an intense fear of death that he became hypervigilant about the device malfunctioning again and developed an obsessive attentiveness to cardiac symptoms, which Sears called catastrophizing.
Sears said the patient suddenly began avoiding recreational activities, exercise and sex, and moved away from his beach community.
“So he had basically just shut it down and had disengaged from life,” Sears said.
Not only were those changes not necessary, studies show that patients who remain active after having a cardioverter defibrillator implanted tend to live longer, Sears said.
Samuel Sears discusses fears of being shocked and offers suggestions for doctors to help alleviate those fears.
He told the doctors in his audience, “There has to be some foresight, on your part, to be able to see a way for patients to overcome what they’ve been through.”
While a cardioverter defibrillator is a life-saving therapy — in fact “one of the most amazing innovations and inventions of our time” — the potential for anxiety and disengagement is high, Sears said.
In the North Carolina man’s case, he said, “We had to turn this into a safety-net kind of conversation, as opposed to a fear conversation.”
Sears emphasized the need for physicians “to reiterate our faith in the device, that the device is actually smart, and that while it was an inappropriate shock, it did what it was supposed to do from the standpoint of how it was programmed.”
Just in the past year, he said, the number of implanted cardioverter defibrillator patients who in the past 20 years could have expected to receive a shock as often as 40% of the time has fallen significantly. Now, just 4-6% of patients can expect to be shocked in any given year.
But despite improvements in technology, “there’s still fear, even though we’re at the best we’ve ever been. So, what are we doing here?” Sears asked his audience, which included cardiologists and cardiology fellows.
He said that as patients accumulate shocks or symptoms, they accumulate anxieties, moving from specific anxieties like “I’m afraid of exercise,” to a more general state of anxiety, to ultimately believing, “There’s nothing safe I can do.”
“If that is true, your comeback is stopped,” he said.
Sears suggested that cardiologists need to go beyond medical management to become more involved in managing their patients’ emotions and the roles they play in life, recognizing that many patients need help problem solving and decision making, as well as knowing how to contact their care team and otherwise access care.
“When we implant them, they’re a little bit anxious for three to six months, then get more confident,” he said. “Once they’ve been shocked, the anxiety seems to persist for almost two years without addressing in it some way.”
Sears said cardiac clinicians need to pay attention to try to recognize avoidance behavior in patients, as well as tendencies toward worst case scenario thinking.
“When patients say things that are exaggerated, they’re giving us a clue about their own adjustment process,” he told them. “There’s something they’re perceiving is more dangerous, than perhaps it is.”
He urged clinicians to also be on the lookout for patients who overuse technology, such as an Apple watch or even a blood pressure machine, as they tend to be hypervigilant, or unusually sensitive to their surroundings.
He also strongly advised physicians to validate their patients’ fears, but redirect attention to positive, proactive efforts to live life fully versus excessively watching for health problems.
“What never seems to work is dismissing, deflecting or denying emotions,” Sears said. “When somebody complains to you, validate. Say, ‘Well, I can see that’d be really annoying.’”
“We need to empathize, we need to validate and we have to help patients take the first step in the right direction. That’s it. We don’t have to become psychotherapists,” he said.
The message clinicians should be sending, Sears said, is ‘Let’s write a comeback story.’
“Anytime you incidentally catch that somebody really wants to do something, achieve something, you have the opportunity to ally yourself with them to achieve that goal: ‘You want to see your granddaughter’s wedding? I think if you follow what we’re doing together, we can make that happen,’” he said.
Sears said that after the North Carolina surfer underwent brief psycho-education sessions, he began re-engaging in life and learned how to manage stress. He even went back to the beach to start surfing again.
“When we help our patients achieve comebacks, we’ve created meaning,” he said.
In response to a question from Paul Mounsey, M.D., Ph.D., director of the UAMS Division of Cardiovascular Medicine, Sears said that about 15-20% of cardioverter defibrillator patients typically need psychological help to cope with an ICD.
Sears’ lecture, “Cardiac Comeback: Engaging Patients in the Recovery Process,” was sponsored by the UAMS College of Medicine and its Department of Internal Medicine.