Psychological implications and management for patients with implantable cardioverter defibrillators

The implantation of an implantable cardioverter defibrillator (ICD) device poses numerous psychosocial challenges, which have been shown to significantly influence functional outcomes in this population. Therefore, the optimisation of medical therapy and provision of psychological support is key to managing the patient’s biopsychosocial functioning, write Elizabeth Banwell, Katie Murray and Stephen Gunning, clinical psychologists at Imperial College Healthcare NHS Trust, London, UK for Cardiac Rhythm News.

A crucial aspect in the self-care for patients with an ICD is learning to live with the unique psychosocial demands of the device, along with the demands of their condition. Patients with ICDs are at risk of psychosocial distress due to various factors, including: the diagnosis and management of a potentially life-threatening cardiac rhythm condition; reliance on a device; an altered sense of self especially regarding aesthetics and functional capabilities; as well as living with the potential for shock and mortality.¹

It is estimated that 13-46% of ICD recipients experience clinically significant anxiety disorders and 24-46% experience depression.² Furthermore, there is increasing evidence supporting a link between psychological vulnerability and risk of ventricular tachyarrhythmias and mortality in ICD patients.³ Therefore, the optimisation of medical therapy and provision of psychological support is key to managing the patient’s biopsychosocial functioning.⁴

Several intra-individual factors, as well as the timing and stage of diagnosis or treatment may influence psychological functioning. Risk factors for psychological distress include: younger ICD recipients (<50 years) possibly due to impact on lifespan stages and being an “age inappropriate illness”; women; shock history; poor understanding of the device and condition; psychological history; and severe medical comorbidities.⁵ Type D personality- typified by increased negative emotions and inhibition-is another emerging risk factor, research has indicated that Type D personality was the strongest predictor of depression, over ICD concerns and comorbidities, three months post-implantation.⁶

Pre implant concerns may include: concerns related to the implant procedure; the impact on future physical abilities, risk of shock, resuming sexual relationships, self-identity and meaning of the need for implant.

Post implant concerns may include the above, in addition to: pain from wound site; adjustment to physical routine (adhering to medical guidelines, particularly whilst leads settle and wound site heals); body image concerns; potential impact on work and family roles; anxiety about potential for receiving a shock; and post shock management and adjustment. Common concerns for younger patients may also include family planning and the desire to resume competitive sports. Anxiety is common within this population, with ICD related fears being particularly pervasive.⁷

Patients may believe a certain activity ‘caused’, or is likely to cause an ICD shock, and therefore ‘avoid’ subsequent shocks by evading such activity, which has negative implications for psychological and physical well-being. This avoidance may be precipitated and maintained by shock history, and/or catastrophic interpretation of physiological symptoms.⁷

Frequent assessment of psychological concerns is important within this population pre- and post-implantation, and throughout medical follow-up, and can be especially pertinent after a shock.⁸ Patients may be reluctant to disclose, or not identify difficulties as psychological in origin, so impaired functioning may be a clue to underlying psychological difficulties, eg. a patient who reported they had stopped working, which turned out was due to fear of setting off their device.⁸ ICD specific screening measures can identify ICD related concerns and targets for intervention, such as the ICD Concerns (ICDC) Questionnaire.^8,9 Additionally, general measures of distress, such as the Hospital Anxiety and Depression Scale (HADS) can help to identify broader concerns.^8,10 Patients receiving ICD shocks should also be screened and monitored for symptoms of post-traumatic stress, using the Impact of Events Scale (IES-R)¹¹ and Type D personality, using the Type D Scale (DS14).¹²

Psychological support can be provided from various sources, including the medical multidisciplinary team, spouse/family, as well as formal psychological intervention. Identification of spouse/family anxiety may help to optimise adjustment and management; eg. inclusion in ICD education to identify and address misconceptions regarding the device and ensure understanding of the shock management plan.⁵ Education may also help to normalise emotional reactions to ICD therapy and which aspects may lead to distress.

Psychological therapy may be warranted if the patient is experiencing anxiety and/or depression relating to the device, which is impacting their functioning and quality of life. Cognitive behavioural therapy is evidenced within an ICD population.⁴ This therapy commonly includes: developing tolerance of uncertainty; cognitive restructuring, to identify and alter maladaptive thoughts; relaxation training, to reduce the vicious cycle of physiological and cognitive responses to anxiety; and activity scheduling, to gradually increase previously avoided activities.^4,5,7

Therapy can also include the development of a ‘shock plan’ and planning post-shock coping strategies, such as using relaxation exercises and cognitive restructuring to identify and challenge maladaptive beliefs and behaviours eg. inappropriate or excessive avoidance of activities regarded as shock triggers.¹³

Within our clinical practice we also focus therapeutically on exploring the patient’s self-identity and the idiosyncratic meanings associated with living with an ICD. This aids identification of problematic beliefs, such as ‘I had better avoid excitement in case it causes a shock’. Having a psychologist within a multidisciplinary team is important to consult and liaise with colleagues regarding ICD management guidelines and settings to incorporate realistic goals into therapy and identify and reduce development and persistence of maladaptive illness perceptions and behaviours.

References

1. Vasquez L D et al, PACE 2010; 33:1131-1140
2. Sears S F et al, Pacing Clin Electrophysiology 1999; 22:1831-1834
3. Pederson S S et al, Expert Review of Medical Devices 2012; 9(4):377-388
4. Kirian K, Sears S F and DeAntonio (2012). Sudden Cardiac Arrest: A biopsychosocial approach to patient management of ventricular fibrillation and implantable cardioverter defibrillators. In Dornelas, E. A. (ed.) Stress proof the heart: Behavioural interventions for cardiac patients. Springer Science and Business Media.
5. Sears S F et al, Journal of Cardiovascular Electrophysiology 2009; 1-8
6. Pederson S et al, American Journal of Cardiology 2011; 108(1): 69-74
7. Sears S F et al, Heart 2002; 87:488-493
8. Gibson D P et al, Current Psychiatry 2007; 6(9):17-28
9. Frizelle D et al, British Journal of Health Psychology 2006; 11:293-301
10. Zigmond A S et al, Acta Psychyitra Scandinavia 1983; 67(6):361-370
11. Weiss D S (2007). The Impact of Events Scale-Revised. In Wilson, J P and Keane, T M (Eds) Assessing Psychological Trauma and PTSD: a practitioner’s handbook (2^nd edition, p 168-189). New York: Guildofrd Press
12. Braunschweig F et al, Europace 2010; 12:1673-90
13. Sears S F et al, Circulation 2005; 111:380-382

Elizabeth Banwell, Katie Murray and Stephen Gunning are clinical psychologists at Imperial College Healthcare NHS Trust, London, UK