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.

¹² attributes reduction of ICD-induced anxiety to combination individual psychotherapy and unspecified dosages of benzodiazepines. Two patients also received adjunctive fluoxetine or paroxetine, dosages unspecified.

In a double-blind, placebo-controlled crossover study, implantable atrial defibrillator recipients reported decreased pain and anxiety while taking the short-acting benzodiazepine triazolam, 0.375 mg, before patient-activated shock.¹⁹

We recommend trying a combination regimen that acts acutely and subacutely. A long-acting benzodiazepine such as clonazepam can calm acute, overwhelming anxiety, and a selective serotonin reuptake inhibitor (SSRI) such as fluoxetine or paroxetine can help manage chronic depressive and generalized anxiety symptoms.

SSRIs are relatively benign but more research on their cardiac safety is needed.^20,21 Tricyclic antidepressants, which prolong cardiac conduction, should be avoided.

In addition to psychotropics, concomitant psychotherapy can reduce chronic symptoms.

The authors’ observations

Clinical Point

Try a psychotropic combination that offers acute and subacute treatment for severe ICD-induced anxiety or depression

Requests for ICD removal because of intolerability pose an ethical dilemma (Box).²² Is increased life expectancy resulting from heart-implant technology worth the diminished quality of life stemming from iatrogenic psychopathology? Mr. J felt it was not, but we wanted to try to resolve his crippling anxiety before making a recommendation.

Preparing patients for ICD problems. Anxiety after an ICD shock and the dread of repeat shocks are normal; the goal is to prevent that anxiety from destroying quality of life.

As with Mr. J, many ICD recipients are emotionally unprepared for device-related complications. Most cardiologists do not screen patients for pre-existing anxiety before ICD placement, nor do many adequately address ICD-induced anxiety once the device has been placed.

Psychological screening before implantation can help detect and manage preexisting anxiety disorders. Small-scale evaluations have used anxiety scales to continuously measure anxiety before and after ICD placement.^13,23

Increased patient education on how ICDs work can help patients decide whether to proceed with implantation and tolerate discharges should they occur. Psychological screening and brief, routine communication between providers and patients about psychosocial issues can help patients adjust and identify those who need extended psychological services.⁴

Clinical Point

Increased patient education and communication with providers can help ICD recipients cope with shocks should they occur

To cope with ICD discharges, encourage patients to:

develop a plan for how a shock would be handled
perform relaxation exercises immediately after the shock
resume activities they were involved with when the shock occurred to prevent avoidance.²⁴

Large, randomized, prospective studies using validated, structured interview tools could help clarify the nature of psychopathology induced by ICD and other technological innovations and evaluate interventions.

TREATMENT: Third attempt

The cardiology team discontinues flecainide and performs a third radioablation, which eradicates ectopic ventricular activity.

Acting on the psychiatry consult team’s advice, Mr. J is transferred to the inpatient mood disorders unit to aggressively treat his PTSD. He undergoes 4 days of intensive CBT designed to explore the connection between his response to the discharges and his father’s abuse. We prescribe clonazepam, 0.5 mg bid, to reduce Mr. J’s agitation and anxiety, and recommend outpatient counseling to help manage his stress—particularly his anxious response to stimuli that remind him of the ICD discharge.

Mr. J is discharged after 12 days in the cardiac and psychiatric units. He has no suicidal thoughts, his sadness has decreased, and his energy, concentration, sleep, and outlook on his future have improved. He also is resolving relationship issues with his partner.

As Mr. J’s anxiety declines and he is increasingly reassured that his arrhythmias are under control, he decides to keep the ICD. His function gradually improves with continued cardiac rehabilitation, although he does not continue psychotherapy.

Related resources

Stutts LA, Cross NJ, Conti JB, Sears SF. Examination of research trends on patient factors in patients with implantable cardioverter defibrillators. Clin Cardiol 2007;30:64-8.
Sears SF, Shea JB, Conti JB. How to respond to an implantable cardioverter-defibrillator shock. Circulation 2005;111;380-2. http://circ.ahajournals.org/cgi/reprint/111/23/e380.
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. www.psychosomaticmedicine.org/cgi/reprint/61/1/69.

Drug brand names

Amiodarone • Cordarone
Clonazepam • Klonopin
Flecainide • Tambocor
Fluoxetine • Prozac
Paroxetine • Paxil
Sotalol • Betapace
Triazolam • Halcion, others

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.