Cases That Test Your Skills

Getting to the heart of his ‘shocking’ trauma

Current Psychiatry. 2007 June;6(6):84-90

References

1. Morris PL, Badger J, Chmielewski C, et al. Psychiatric morbidity following implantation of the automatic implantable cardioverter defibrillator. Psychosomatics 1991;32:58-64.

2. Conti JB, Sears SF, Jr. Understanding and managing the psychological impact of the ICD. Card Electrophysiol Rev 2001;5:128-32.

3. Pelletier D, Gallagher R, Mitten-Lewis S, et al. Australian implantable cardiac defibrillator recipients: quality-of-life issues. Int J Nursing Pract 2002;8:68-74.

4. Eads AS, Sears SF, Jr, Sotile WM, Conti JB. Supportive communication with implantable cardioverter defibrillator patients: seven principles to facilitate psychosocial adjustment. J Cardiopulm Rehab 2000;20:109-14.

5. Sola CL, Bostwick JM. Implantable cardioverter-defibrillators, induced anxiety, and quality of life. Mayo Clin Proc 2005;80:232-7.

6. Sears SF, Jr, Todaro JF, Lewis TS, et al. Examining the psychosocial impact of implantable cardioverter defibrillators: a literature review. Clin Cardiol 1999;22:481-9.

7. Goodman M, Hess B. Could implantable cardioverter defibrillators provide a human model supporting the learned helplessness theory of depression? Gen Hosp Psychiatry 1999;21:382-5.

8. Pauli P, Wiedemann G, Dengler W, et al. Anxiety in patients with an automatic implantable cardioverter defibrillator: what differentiates them from panic patients? Psychosom Med 1999;61:69-76.

9. Godemann F, Ahrens B, Behrens S, et al. Classic conditioning and dysfunctional cognitions in patients with panic disorder and agoraphobia treated with an implantable cardioverter/defibrillator. Psychosom Med 2001;63:231-8.

10. Irvine J, Dorian P, Baker B, et al. Quality of life in the Canadian Implantable Defibrillator Study (CIDS). Am Heart J 2002;144:282-9.

11. Dunbar SB, Warner CD, Purcell JA. Internal cardioverter defibrillator device discharge: experiences of patients and family members. Heart Lung 1993;22:494-501.

12. Bourke JP, Turkington D, Thomas G, et al. Florid psychopathology in patients receiving shocks from implanted cardioverter-defibrillators. Heart 1997;78:581-3.

13. Vlay SC, Olson LC, Fricchione GL, Friedman R. Anxiety and anger in patients with ventricular tachyarrhythmias: responses after automatic internal cardioverter defibrillator implantation. Pacing Clin Electrophysiol 1989;12:366-73.

14. Hamner M, Hunt N, Gee J, et al. PTSD and automatic implantable cardioverter defibrillators. Psychosomatics 1998;40:82-5.

15. Friccione GL, Vlay LC, Vlay SC. Cardiac psychiatry and the management of malignant ventricular arrhythmias with the internal cardioverter-defibrillator. Am Heart J 1994;128:1050-9.

16. Friccione GL, Vlay SC. Psychiatric aspects of the implantable cardioverter-defibrillator. In: Estes NAM, Menolis AS, Want PG, eds. Implantable cardioverter-defibrillators. A comprehensive textbook. New York: Marcel Dekker; 1994:405-23.

17. Kohn CS, Petrucci RJ, Baesser C, et al. The effect of psychological intervention on patients’ long-term adjustment to the ICD: a prospective study. Pacing Clin Electrophysiol 2000;23(4 pt 1):450-6.

18. Heller SS, Ormont MA, Lidagoster L, et al. Psychosocial outcome after ICD implantation: a current perspective. Pacing Clin Electrophysiol 1998;21:1207-15.

19. Fabian TJ, Schwartzman DS, Ujhelyi MR, et al. Decreasing pain and anxiety associated with patient-activated atrial shock: a placebo-controlled study of adjunctive sedation with oral triazolam. J Cardivasc Electrophysiol 2006;17:391-5.

20. Sala M, Coppa F, Cappucciati C, et al. Antidepressants: their effects on cardiac channels, QT prolongation and Torsade de Pointes. Curr Opin Investig Drugs 2006;7:256-63.

21. Swenson JR, Doucette S, Fergusson D. Adverse cardiovascular events in antidepressant trials involving high-risk patients: a systematic review of randomized trials. Can J Psychiatry 2006;51:923-9.

22. Pinski SL. Emergencies related to implantable cardioverter-defibrillators. Crit Care Med 2000;28(10 suppl):N174-N180.

23. Kuhl EA, Dixit NK, Walker RL, et al. Measurement of patient fears about implantable cardioverter defibrillator shock: an initial evaluation of the Florida Shock Anxiety Scale. Pacing Clin Electrophysiol 2006;29:614-18.

24. Sears SF, Shea JB, Conti JB. How to respond to an implantable cardioverter-defibrillator shock. Circulation 2005;111:380-2.

Clinical Point

Patients can become reclusive, fearing the ICD could discharge or malfunction at any time—such as while driving or in public

Whether quality of life diminishes as ICD firings become more frequent is uncertain.⁹ The Canadian Implantable Defibrillator Study (N=317) found greater quality of life improvements with ICD therapy than with amiodarone—200 to 400 mg/d maintenance therapy—but the improvements were lost in patients who experienced ≥5 shocks over 12 months.¹⁰ Pauli et al⁷ found misinterpretation of the reason for increasing shocks to be more emotionally destructive than shock frequency, however.

Detecting ICD maladjustment

Patients with ICD maladjustment typically show anticipatory anxiety and negative cognitive attributions, and many engage in fruitless maneuvers to prevent device firing.⁵ Nervousness, dizziness, weakness, and fear are common responses to shock by ICD.¹¹

Most patients with new-onset, post-ICD anxiety disorders have no pre-implant psychiatric history.¹² Only one trial assessing state and trait anxiety before and after ICD placement reported increased trait anxiety in some patients before implantation.¹³

HISTORY: Nights in the cornfield

During psychiatric evaluation, Mr. J reveals that his parents physically and emotionally abused him as a child. He says his father frequently beat him with farm tools, and sometimes the beatings were so severe that his parents kept him home from school to prevent teachers from noticing his bruises. He never received medical treatment for his injuries.

Clinical Point

Cognitive-behavioral therapy and participation in a peer support group might alleviate ICD-induced behavioral symptoms

The physical torture continued until high school when, Mr. J recalls, he became fast enough to escape his father’s grasp. “Some nights, I’d sleep in the cornfield,” he said.

For Mr. J, the inescapable threat of painful, unannounced ICD discharges has brought back the anticipatory terror and helplessness of his childhood. Just as he feared his father’s sudden rages, the specter of repeat ICD shocks now haunts him. He says he’d rather have the ICD removed and risk death from tachycardia than live another minute in fear.

The authors’ observations

Mr. J meets DSM-IV-TR criteria for PTSD. He associates ICD discharge with childhood abuse and experiences new-onset flashbacks, hyperarousal, and avoidance behavior.

To our knowledge, ICD shock-induced flashbacks to pre-implant trauma have not been reported, although some data associate ICDs with posttraumatic stress related to heart disease and treatment.^14-16 In one case series,¹⁴ patients showed:

cluster B re-experiencing symptoms (cognitive preoccupation with trauma or psychophysiologic reactivity to reminders of the ICD and heart disease)
cluster C avoidance symptoms (avoiding activities they thought might activate the ICD)
cluster D hyperarousal symptoms (insomnia, decreased concentration, hypervigilance, and irritability).

The authors’ observations

Treating comorbid anxiety or depression in ICD recipients is critical. A number of psychiatric interventions might alleviate behavioral and psychological effects of body-device interactions.

CBT. In a retrospective study¹⁷ of 36 ICD recipients, those who received 9 months of CBT reported decreased depression, anxiety, distress, and sexual problems compared with those who did not. Interestingly, more CBT-group patients (11 of 18) suffered ICD shocks than did controls (6 of 18).

Peer support groups. Out of 58 ICD recipients who answered a post-implant questionnaire, 23 (39%) attended a peer support group.¹⁸ Of these, 22 (96%) found the group helpful and were happier, less hostile, and more sociable after participating. Peer group participants also were more likely to return to work than nonparticipants.

Box

When a patient wants a life-preserving device deactivated

How would you handle a patient’s request to deactivate an implantable cardioverter-defibrillator (ICD) or other life-preserving device that is causing debilitating mental anguish? Physicians dealing with such requests will find themselves in an ethical wilderness.

Pinski²² offers guidelines in line with withdrawal of other life-extending technologies in terminally ill patients. “Deactivation of an ICD is appropriate when the device is believed to be prolonging patient suffering,” he writes, adding that preventing ICD shocks induced by frequent or agonal arrhythmias “will not only hasten but also permit a peaceful death.” Disabling the ICD function that responds to bradycardia will prevent agonal pacing and—as a result—shocks.

The literature, however, offers little guidance on responding to patient requests for ICD deactivation and few precedents on which to base such decisions for the terminally ill.

Even less guidance exists when mental illness resulting from ICD complications induces unbearable suffering. The underlying psychiatric condition should be optimally treated before clinicians entertain ICD removal. Mr. J, for example, decided to keep the implant once his crippling anxiety resolved and he was assured that his tachycardia finally was under control.

Psychotropics and psychotherapy. A small case series