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Psychosomatics: Toward An Understanding of Cardiovascular Disorders
NOVEMBER-DECEMBER 1973
VOLUME XIV - NUMBER 6
PSYCHOSOMATICS OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE
Psychosomatics: Toward An Understanding of Cardiovascular Disorders DAVID
L. KEEGAN, M.D.
INTRODUCTION
Since the time of Osler, speculation has strongly linked the cardiovascular system and the psyche.! Medicine, however, in the past didn't have the biophysiological or psychological sophistication to carry these ideas further. Although there were some significant psychological advances in the past twenty years in understanding this area, further advances in biochemistry were necessary to carry this research further. 2 Recent advances in the border-land between cardiology and psychiatry have led to interesting data which may in the future help to solve the dilemma and also help prevent significant morbidity and mortality from the present epidemic of cardiovascular disorders. This paper will review recent research information which will point up the need for continued expansion of cardiology and psychiatric liaison, both in the area of research and patient care. NEUROPHYSIOLOGY AND NEUROBIOCHEMISTRY
Recent developments in the biochemistry and physiology of the autonomic nervous system has helped to form some useful bridges b~ tween psychic phenomena and somatic physiology. The sympathetic nervous system relates to the cardiovasculature via Alpha and Beta receptors mediated by catecholamines, particularly norepinephrine. Through this mechanism, the chronotropic and inotropic cardiac effects, baroreceptor and peripheral resistance functions on the vasculature are mediated. Dr. Keegan is Assistant Professor of Psychiatry, University of Saskatchewan, University Hospital. Saskatoon, Sask., Canada. November-December, 1973
Catecholamines, either from the sympathetic division, adrenal medulla, or the heart itself, are active in both normal and pathological cardiovascular activity.3 A connection between catecholamine activity mediated through adenyl cyclase, cyclic A.M.P., and the cardiac contractile proteins has been postulated as a major functional entity.· Myocardial lesions and conduction defects secondary to catecholamine factors, particularly in the etiology of sudden cardiac death, have been theorized. G Emotional stress factors mediated through catecholamines and glucocorticoids lead to hypoxia which in coronary vascular disease may lead to disturbed conduction and to possiblearrythmias.6 Catecholamine induced arrythmias are being found increasingly in intensive care units during the post-myocardial infarction recovery period. Klein has postulated a connection between emotional factors, increased catecholamine levels particularly norepinephrine, arrythmias and reinfarction in a group of fourteen post infarct patients. He compared a group of seven patients with constant personnel through intensive care to regular nursing unit transition to a group of seven with different personnel, and interestingly found a lower incidence of distress, arrythmias and catecholamine levels in the former.? Catecholamines have also been implicated in many features of atherosclerosis and coronary vascular disease. Increased daytime norepinephrine levels have been correlated with significantly increased serum cholesterol, blood coagulability, free fatty acids, triglycerides, B/ A lipoprotein ratios.8,9 Along similar lines,
321
PSYCHOSOMATICS
Taggart and Carruthers, found a connection between emotions called "inter&al aggression", autonomic state measured by catecholamine levels and serum lipid biochemical levels. Norepinephrine levels are significantly elevated during the stress of an auto race while F.F.A. and triglycerides levels significantly elevated one hour after the test situation. 1o These multidimensional studies offer an interesting research approach and more studies of this type are needed in an attempt to link the biophysiological and psychosocial aspects. The parasympathetic division mediated through vagal, acetylcholine mechanisms has long been considered important in sudden death, particularly in such situations where people were considered to be "frightened to death" or in case of so-called "voodoo death". This has received increasing interest of late, and particularly Wolf has postulated a vagal bradycardia as a possible factor in sudden death and actually connects it to the physiological process of "giving up" the battle against overwhelming illness with depression or panic, thus evoking the same adaptive mechanism as the "diving reflex".ll CORONARY HEART DISEASE (C.H.D.)
As our knowledge increases, it is obvious that the etiology of coronary heart disease and myocardial infarction must be re-evaluated. Distinct groups are being defined which were previously categorized together. These separate groups include (a) patients with risk factors of heredity, obesity, high serum cholesterol, low exercise, hypertension, excess cigarette smoking, and diabetes but no obvious E.K.G. evidence of disease, (b) patients with E.K.G. changes after exercise, (c) those with a history of angina but no infarct, (d) those with infarcts but no recurrent angina, (e) and the group who die suddenly and are usually thought to have cardiac electrical death. Certainly with such a diverse group of presentations, the question of multiple etiology and even distinct etiology becomes more important. Kannel emphasized the need for further investigation into predisposing factors so that preventive approaches could be expanded. 12 The search for other factors must include 3~
psychological and social phenomena which may potentiate the previously mentioned predisposing factors and may even be a fundamental importance in postulated catecholamine or vagal electrical death. To add to the growing perplexity of predisposing factors has been the finding of populations which fulfil the high risk criteria of coronary heart disease, and yet seem to have a lower incidence which suggests that certain protecting factors may exist and may be of a psychological etiology. The major relevant work in psychological understanding has been the attempt to define a coronary-prone behavior pattern (Coronaryprone Type A) through structured interview, observation and questionnaire. 13 In a prospective study this extreme behavior pattern has shown value in terms of predicting an increased incidence of coronary heart disease with associated biochemical and physiological alterations. 14 This behavior pattern shows high motor activity, forceful speech, time urgency, avoidance of free time and a drive toward competition and may correlate with finding a tense, frustrated, and perfectionistic person who plans relaxation and vacation time as much as he plans his work day. This Type A extreme pattern has been described in women, with similar biochemical findings and in 62 percent of sons of prospective study patients exhibiting the coronary-prone behavior pattern. III Other studies have related C.H.D. and raised cholesterol levels to a hyper-masculine drive and high depression scores on the M.M.P.I. and adherence to social norms, conscientiousness and selfcriticism on the C.P.I. (California Psychological Inventory.) 16·18 The chronically dissatisfied, striving, competitive behavior pattern described above may have a social correlate. It seems that people who strive and are competitive without success, unrelated to socioeconomic class and show socioeconomic mobility either up or down are more prone to develop C.H.D.lll.20 Personal dissatisfactions and losses were shown to be significant in a twin study where twins were discordant for coronary heart disease. In the twin with coronary heart disease, an increased incidence of life's dissatisfactions were found. 21 Parkes found that personal losses and discourVolUJQc XIV
CARDIOvASCULAR. DISORDERS-KEEGAN
agement surrounding the death of a spouse led to a significant increase in the incidence of death, within six months, from coronary heart disease in male widowers. 22 Job dissatisfactions, life changes and mobility are seen as important aspects of increased incidence of C.H.D. and although exact biochemical connections haven't been made a correlation was made between social and occupational stress periods in tax accountants and increased cholesterol levels and platelet stickiness.28-26 In larger cultural or societal terms, both psychosocial stressors and protectors may be important. Some cultures seem protected from C.H.D. although they stand high on the list of risk factors for C.H.D. Groups such as Italians, Negroes, and Indians in certain areas seem protected, possibly by cohesive, mutual cooperation, and non-competitive societies.21 .28 The combination of competitive social mores with family and personal d:ssatisfaction may lead certain cultures to be more vulnerable to C.H.D. with additive effects on other well-known C.H.D. risk factors. People with coronaryprone A behavior patterns, in a coronary-prone environment with a number of risk factors seem to have a greater incidence of C.H.D.29 HYPERTENSION
Many aspects of the hypertensive dilemma are being solved through the discovery of new etiological groups. Although the essential hypertensive group is diminishing, it still poses a significant problem and only recently has evidence arisen which may verify a role for emotional factors. Recent work has implicated emotional stress, catecholamines, baroreceptor and cardiac responses, in the development of hypertension. Mental stress of examinations has been correlated with increased catecholamine levels and a time limited elevation of blood pr~ssure. Labile hypertensives, who often later develop essential hypertension, tend to excrete more catecholamines at this time of emotional stress. 80 A correlation between psychosocial stimulation and confrontation in mice, has been highly correlated with permanent biosynthetic and metabolic increases in norepinephrine and epinephrine levels. Granted, these studies are November-December, 1973
in mice but the findings may bridge a gap between measurable increases in blood pressure and catecholamine levels during emotional states in humans and a mechanism for development of the permanent chronic hypertensive state.81 Miller has added insights into the learning of cardiac and blood pressure changes in rats and has attempted to apply these to human studies. 32 This offers a learning prototype to the explanation of development of hypertension and to the vulnerability to increased blood pressure cardiac response under certain noxious stimuli. This knowledge has shaken the very roots of the so-called voluntary versus autonomic nervous system dichotomy in our western philosophy, and may at least be part of the long-awaited connection between psychological and somatic factors. Certainly it has given an increased understanding of hypertensive disorders,and has in theory advanced a rationale for treatment of these disorders via learning blood pressure lowering techniques.83,8-1 PSYCHOLOGICAL SEQUELAE OF CARDIOVASCULAR DISORDERS
Much recent work has been done through psychosomatic liaison in looking at the other end of the psychophysiological continuum, the psychological phenomena which are involved in post-coronary care treatment, post-cardiac surgery situations and the rehabilitative process involved in post-myocardial infarction and coronary heart disease. The response of the patient to intensive care units which involves anxiety, depression, denial, and dependency has been looked at closely.311 Increased assistance to the patients, staff, and the family has resulted in better psychological understanding. 36 Understanding the sensory isolation phenomenon in the recovery room and coronary care unit has been helpful in designing better facilities and making the staff much more aware of problems which may arise. The recommendation of better continuity of care from the coronary care unit to the general ward was led to some important questions and answers about the whole post-myocardial infarct period. The encouragement of less isolated monotonous units with external monitor set-ups has come through recent research efforts. Certainly better con323
PSYCliOSOMATIcS
.troiled and more evaluative studies are needed to find out just what the exact emotional factors are, and whether they are pathologic or a normal concomitant of the stress of cardiac surgery and/or acute myocardial infarction. Post-cardiac surgery psychoses including delirium have been studied, and at present, it would seem that this phenomenon is a combination of anaesthetic, anoxic effects combined with a somewhat predisposed personality and a stressful untherapeutic recovery room. 37 Certainly major factors in decreasing post-cardiac psychoses have been through shorter duration of surgery, improved perfusion on the heartlung machine and shorter duration of anaes· thesia. The rehabilitation of the post-myocardial infarct patient has been a rather neglected area of study from a specifically psycholog:cal point of view. However, with the realization of how poor the return to occupation figures are in some areas, an increasing effort is being made to look into these psychosocial issues. 38 The problems of continued anxiety, cardiac neuroses, chronic family and marital conflicts, mixed with severe dependency and depression point up the major task rehabilitation can be. 39 The use of family, group and spouse dynamics has been found useful in dealing with some problems. 40 The use of supervised exercise programs for coronary prevention and rehabilitation has also pointed up the possible importance of group and inter-actional dynamics in terms of assisting the coronary patient deal with cardiac anxieties and depressions, and a new sense of control over this life threat. The progress some patients have made through supervised exercise programs is remarkable and yet there is a dearth of psychosocial information in terms of understanding the possible group interaction and dynamics. 41 ,42 SUMMARY
We have emphasized some of the recent advances made through collaboration of cardiologists, psychiatrists, and basic scientists in the area of understanding the psychosocial links with cardiovascular disorders. It is of utmost importance to include further joint ventures in future research into the etiology and prevention 324
of sequelae for cardiovascular disorders. There is also a need for integrated psychosocial treatment and understanding of the cardiac patient via internists and family physicians. This approach which is the key to treatment in all patients, pays particularly rich dividends in the area of cardiovascular disorders. BIBLIOGRAPHY 1. Editorial, Heart Disease Prone: Aggressive Inpatient. J.AM.A., 203:28·29, February 12, 1968. 2. Reiser, Morton F.: Cardiovascular Disorders, in Comprehensive Textbook of Psychiatry, Freedman, Alfred M. and Kaplan, Harold I., Ed. Williams and Wilkins, Baltimore, 1967. 3. Editorial, Free Fatty Acids and Heart Attacks, Lancet, 843, April 24, 1971. 4. Editorial, Catecholamines and the Heart, Lancet, 1200, June 14, 1969. 5. Anderson, T.W.: Role of the Myocardium in the Modem Epidemic of Ischaemic Heart Disease, Lancet, 753·55, October 10, 1970. 6. Rub, W.: Emotionally Induced Disorders of Myocardial Metabolism, Function and Structure, Med. Counterpoint, 29·35, 1969. 7. Klein, R.F.: Transfer from a Coronary Care Unit. Arch. Int. Med., 122: 104-108, August. 1968. 8. Friedman, M., Byers, S.O., Rosenman, R.H., Elevitch, F.R.: Coronary Prone Individuals: Some Biochemical Characteristics, J.AM.A., 212:6, May II, 1970. 9. Cleghorn, John M.: Psychosocial Influences on a Metabolic Process: The Psychophysiology of Lipid Mobilization, Canadian Psychiat. Assoc. J., 15:539-46, 1970. 10. Taggart, R., Carruthers, M.: Endogenous Hyperlipidemia Induced by Emotional Stress of Racing Driving, Lancet, 363-366, February 20, 1971. 11. Wolf, Stewart: The End of the Rope: The Role of the Brain in Cardiac Death, Canad. Med. Ass. J., 1022-1024, October 21, 1967. 12. Kannel, William B., Gordon, Tavia: Premature Mortality from Coronary Heart Disease, J.A.M.A., 215, 1617-1625, March 8, 1971. 13. Friedman, M.: Behavior Pattern and its Relationship to Coronary Artery Disease, Psychosomatics 8:4, 6·7, 1967. 14. Rosenman, R.H., Friedman, M., Jenkins, C.D. et al: Clinically Unrecognized Myocardial infarction in the Western Collaborative Study, A mer. J. Cardiol 19:776-782, 1967. 15. Bortner, R.W., Rosenman, R.H., Friedman, M.: . Familial Similarity in Pattern A Behavior; Father and Sons, J. Chronic Dis., 23:39-43, 1970. 16. Lovell, R.R.H., Vergbese, A.: Personality Traits Associated with Different Chest Pains Mter Myocardial Infarction. Brit. Med. J., Vol. 3, 327-31, 1969. Volume XIV
CARDIOVASCULAR DISORDERS-KEEGAN 17. Ostfeld, A.M., Lebovits, B.Z., Shekelle, R.B., Paul. 0.: The Relationship between Personality and Coronary Heart Disease. J. Chronic Dis., 17,265, 1964. 18. Jenkins, C. David, Hawes, C.G., Zyzowski, S.J., Rosenman, R.H.: Psychological Traits and Serum Lipids: 1. Findings from the California Psychological Inventory, Psycho$Om. Md. 2, 115-27, 1969. 19. Shekelle, R.B., Ostfeld, A.M., Paul, 0.: Social Status and Incidence of Coronary Heart Disease, J. Chronic Dis. 22, 381-94, 1969. 20. Bruhn, J.G., Chandler, B., et al: Social Aspects of C.H.D. in Two Adjacent Ethnically Different Communities, Amer. J. Pub. Heal/h, 56. 493, 1966. 21. Liljefors, I., Rahe, R.H.: An Identical Twin Study of Psychosocial factors in Coronary Heart Disease in Sweden. Psyc!losom, Med. 32, 523-42, 1970. 22. Parkes, C.M., Benjamin, B., Fitzgerald, R.B.: Broken Heart: A Statistical Study of Increased Mortality among Widowers, Brit. Med. J., 1:74043, 1969. 23. Jenkins, C. David: Psychological and Social PreCursors of Coronary Disease, New Engl. J. M. 284:307-17. February 11, 1971. 24. Friedman, M., Rosenman, R.H. et al: Changes in Serum Cholesterol and Blood Clotting time in Men Subjected to Cyclic Variation of Occupation Stress, Circulation, 17, 853, 1958. 25. Thomas. C.B.• Murphy, E.A.J.: Effects of Stress on Cholesterol levels. J. Chronic Dis. 8, 661, 1958. 26. Wyler, A.R.• Masuda, M.• Holmes. Thomas H.: Magnitude of Life Events and Seriousness of Illness, Psychosorn. Med., 2, March, 1971. 27. Stout, C., Morrow, J., Brandt. E., Wolf, S.: Low Incidence of Death from Myocardial Infarction in a Study of an Italian American Community in Pennsylvania, J.AM.A .• 845. 1964. 28. Sievers, M.L.: Myocardial Infarction Among Southwestern American Indians, Annals Int. Med., 67:800, 1967. 29. Caffrey, B.: Behavior Patterns and Personality Characteristics Related to Prevalence Rates of C.H.D. in American Monks. J. Chron. Dis.,
22:93, 1969. 30. Nestel, P.J.: Blood Pressure and Catecholamint Excretion after Mental Stress in labile Hypertensives. Lancet, 1:69294, 1969. 31. Henry. Jules P., Stephens. P.M., Axelrod, Julius, Mueller, Robert A.: Effect of Psychosocial Stimulation on Enzymes Involved in the Biosynthesis of Noradrenaline and Adrenaline. Psychosom. Med., 33:227-236. 1971. 32. Miller. Neal: Learning of Visceral and Glandular Responses. Science, 163:434-45. January 1969. 33. Shapiro. D., Tursky, B. et al: Effects of Feedback and Reinforcement on the Control of Human Systolic Blood P.-essure, Science, 163:588-90, 1969. 34. Weiss, T.• Engel, B.: Operant Conditioning of Heart Rate in Patients with Premature Ventricular contractions, Psychosom, Med., 33:4; July. 1971. 35. Wishnie, H.A., Hackett. Thomas P., Cassem, Ned H.: Psychological Hazards of Convalescence Following Myocardial Infarction, J.AM.A., 215: 1292·1296. February 22. 1971. 36. Keegan. David L.: The Coronary Patient: A Psychosocial Glimpse. Can. Farn. Phys., March, 1973. 37. Hiller. S.S., Frank. K.A. et al: Psychiatric Complications of Open Heart Surgery, New Engl. J. Med., 283, 1015-20. November 5, 1970. 38. Editorial. Return to work after Myocardial Infarction, Lancet, 591·92, September 11, 1971. 39. Skelton, M., Dominian, J.: Psychological Stress in Wives of Patients with Myocardial Infarction, Brit. Med. J., 2:101-103. 1973. 40. Adsett. C.A.• B,uhn, J.G.: Canad. Med. Assoc. J., 99:577. 1968. 41. Fisher, Stanley: Unmet Needs in Psychologoical Evaluation of Intervention Programs, Unpublished Manuscript, Airlie House Conference on Physical and Psychological Effects of Exercise Train· ing, Airlie, Va., April, 1972. (Personal communication.) 42. Friedman, Ernest H.. Hellerstein, Herman K.: Influence of Psychosocial Factors on Coronary Risk and Adaption to a Physical Fitness Program, Unpublished Manuscript. (Personal communication. )
It is always a silly thing to give advice-but to give good advice is absolutely fatal. Oscar Wilde
November-December, 1973
325
VOLUME XIV - NUMBER 6
PSYCHOSOMATICS OFFICIAL JOURNAL OF THE ACADEMY OF PSYCHOSOMATIC MEDICINE
Psychosomatics: Toward An Understanding of Cardiovascular Disorders DAVID
L. KEEGAN, M.D.
INTRODUCTION
Since the time of Osler, speculation has strongly linked the cardiovascular system and the psyche.! Medicine, however, in the past didn't have the biophysiological or psychological sophistication to carry these ideas further. Although there were some significant psychological advances in the past twenty years in understanding this area, further advances in biochemistry were necessary to carry this research further. 2 Recent advances in the border-land between cardiology and psychiatry have led to interesting data which may in the future help to solve the dilemma and also help prevent significant morbidity and mortality from the present epidemic of cardiovascular disorders. This paper will review recent research information which will point up the need for continued expansion of cardiology and psychiatric liaison, both in the area of research and patient care. NEUROPHYSIOLOGY AND NEUROBIOCHEMISTRY
Recent developments in the biochemistry and physiology of the autonomic nervous system has helped to form some useful bridges b~ tween psychic phenomena and somatic physiology. The sympathetic nervous system relates to the cardiovasculature via Alpha and Beta receptors mediated by catecholamines, particularly norepinephrine. Through this mechanism, the chronotropic and inotropic cardiac effects, baroreceptor and peripheral resistance functions on the vasculature are mediated. Dr. Keegan is Assistant Professor of Psychiatry, University of Saskatchewan, University Hospital. Saskatoon, Sask., Canada. November-December, 1973
Catecholamines, either from the sympathetic division, adrenal medulla, or the heart itself, are active in both normal and pathological cardiovascular activity.3 A connection between catecholamine activity mediated through adenyl cyclase, cyclic A.M.P., and the cardiac contractile proteins has been postulated as a major functional entity.· Myocardial lesions and conduction defects secondary to catecholamine factors, particularly in the etiology of sudden cardiac death, have been theorized. G Emotional stress factors mediated through catecholamines and glucocorticoids lead to hypoxia which in coronary vascular disease may lead to disturbed conduction and to possiblearrythmias.6 Catecholamine induced arrythmias are being found increasingly in intensive care units during the post-myocardial infarction recovery period. Klein has postulated a connection between emotional factors, increased catecholamine levels particularly norepinephrine, arrythmias and reinfarction in a group of fourteen post infarct patients. He compared a group of seven patients with constant personnel through intensive care to regular nursing unit transition to a group of seven with different personnel, and interestingly found a lower incidence of distress, arrythmias and catecholamine levels in the former.? Catecholamines have also been implicated in many features of atherosclerosis and coronary vascular disease. Increased daytime norepinephrine levels have been correlated with significantly increased serum cholesterol, blood coagulability, free fatty acids, triglycerides, B/ A lipoprotein ratios.8,9 Along similar lines,
321
PSYCHOSOMATICS
Taggart and Carruthers, found a connection between emotions called "inter&al aggression", autonomic state measured by catecholamine levels and serum lipid biochemical levels. Norepinephrine levels are significantly elevated during the stress of an auto race while F.F.A. and triglycerides levels significantly elevated one hour after the test situation. 1o These multidimensional studies offer an interesting research approach and more studies of this type are needed in an attempt to link the biophysiological and psychosocial aspects. The parasympathetic division mediated through vagal, acetylcholine mechanisms has long been considered important in sudden death, particularly in such situations where people were considered to be "frightened to death" or in case of so-called "voodoo death". This has received increasing interest of late, and particularly Wolf has postulated a vagal bradycardia as a possible factor in sudden death and actually connects it to the physiological process of "giving up" the battle against overwhelming illness with depression or panic, thus evoking the same adaptive mechanism as the "diving reflex".ll CORONARY HEART DISEASE (C.H.D.)
As our knowledge increases, it is obvious that the etiology of coronary heart disease and myocardial infarction must be re-evaluated. Distinct groups are being defined which were previously categorized together. These separate groups include (a) patients with risk factors of heredity, obesity, high serum cholesterol, low exercise, hypertension, excess cigarette smoking, and diabetes but no obvious E.K.G. evidence of disease, (b) patients with E.K.G. changes after exercise, (c) those with a history of angina but no infarct, (d) those with infarcts but no recurrent angina, (e) and the group who die suddenly and are usually thought to have cardiac electrical death. Certainly with such a diverse group of presentations, the question of multiple etiology and even distinct etiology becomes more important. Kannel emphasized the need for further investigation into predisposing factors so that preventive approaches could be expanded. 12 The search for other factors must include 3~
psychological and social phenomena which may potentiate the previously mentioned predisposing factors and may even be a fundamental importance in postulated catecholamine or vagal electrical death. To add to the growing perplexity of predisposing factors has been the finding of populations which fulfil the high risk criteria of coronary heart disease, and yet seem to have a lower incidence which suggests that certain protecting factors may exist and may be of a psychological etiology. The major relevant work in psychological understanding has been the attempt to define a coronary-prone behavior pattern (Coronaryprone Type A) through structured interview, observation and questionnaire. 13 In a prospective study this extreme behavior pattern has shown value in terms of predicting an increased incidence of coronary heart disease with associated biochemical and physiological alterations. 14 This behavior pattern shows high motor activity, forceful speech, time urgency, avoidance of free time and a drive toward competition and may correlate with finding a tense, frustrated, and perfectionistic person who plans relaxation and vacation time as much as he plans his work day. This Type A extreme pattern has been described in women, with similar biochemical findings and in 62 percent of sons of prospective study patients exhibiting the coronary-prone behavior pattern. III Other studies have related C.H.D. and raised cholesterol levels to a hyper-masculine drive and high depression scores on the M.M.P.I. and adherence to social norms, conscientiousness and selfcriticism on the C.P.I. (California Psychological Inventory.) 16·18 The chronically dissatisfied, striving, competitive behavior pattern described above may have a social correlate. It seems that people who strive and are competitive without success, unrelated to socioeconomic class and show socioeconomic mobility either up or down are more prone to develop C.H.D.lll.20 Personal dissatisfactions and losses were shown to be significant in a twin study where twins were discordant for coronary heart disease. In the twin with coronary heart disease, an increased incidence of life's dissatisfactions were found. 21 Parkes found that personal losses and discourVolUJQc XIV
CARDIOvASCULAR. DISORDERS-KEEGAN
agement surrounding the death of a spouse led to a significant increase in the incidence of death, within six months, from coronary heart disease in male widowers. 22 Job dissatisfactions, life changes and mobility are seen as important aspects of increased incidence of C.H.D. and although exact biochemical connections haven't been made a correlation was made between social and occupational stress periods in tax accountants and increased cholesterol levels and platelet stickiness.28-26 In larger cultural or societal terms, both psychosocial stressors and protectors may be important. Some cultures seem protected from C.H.D. although they stand high on the list of risk factors for C.H.D. Groups such as Italians, Negroes, and Indians in certain areas seem protected, possibly by cohesive, mutual cooperation, and non-competitive societies.21 .28 The combination of competitive social mores with family and personal d:ssatisfaction may lead certain cultures to be more vulnerable to C.H.D. with additive effects on other well-known C.H.D. risk factors. People with coronaryprone A behavior patterns, in a coronary-prone environment with a number of risk factors seem to have a greater incidence of C.H.D.29 HYPERTENSION
Many aspects of the hypertensive dilemma are being solved through the discovery of new etiological groups. Although the essential hypertensive group is diminishing, it still poses a significant problem and only recently has evidence arisen which may verify a role for emotional factors. Recent work has implicated emotional stress, catecholamines, baroreceptor and cardiac responses, in the development of hypertension. Mental stress of examinations has been correlated with increased catecholamine levels and a time limited elevation of blood pr~ssure. Labile hypertensives, who often later develop essential hypertension, tend to excrete more catecholamines at this time of emotional stress. 80 A correlation between psychosocial stimulation and confrontation in mice, has been highly correlated with permanent biosynthetic and metabolic increases in norepinephrine and epinephrine levels. Granted, these studies are November-December, 1973
in mice but the findings may bridge a gap between measurable increases in blood pressure and catecholamine levels during emotional states in humans and a mechanism for development of the permanent chronic hypertensive state.81 Miller has added insights into the learning of cardiac and blood pressure changes in rats and has attempted to apply these to human studies. 32 This offers a learning prototype to the explanation of development of hypertension and to the vulnerability to increased blood pressure cardiac response under certain noxious stimuli. This knowledge has shaken the very roots of the so-called voluntary versus autonomic nervous system dichotomy in our western philosophy, and may at least be part of the long-awaited connection between psychological and somatic factors. Certainly it has given an increased understanding of hypertensive disorders,and has in theory advanced a rationale for treatment of these disorders via learning blood pressure lowering techniques.83,8-1 PSYCHOLOGICAL SEQUELAE OF CARDIOVASCULAR DISORDERS
Much recent work has been done through psychosomatic liaison in looking at the other end of the psychophysiological continuum, the psychological phenomena which are involved in post-coronary care treatment, post-cardiac surgery situations and the rehabilitative process involved in post-myocardial infarction and coronary heart disease. The response of the patient to intensive care units which involves anxiety, depression, denial, and dependency has been looked at closely.311 Increased assistance to the patients, staff, and the family has resulted in better psychological understanding. 36 Understanding the sensory isolation phenomenon in the recovery room and coronary care unit has been helpful in designing better facilities and making the staff much more aware of problems which may arise. The recommendation of better continuity of care from the coronary care unit to the general ward was led to some important questions and answers about the whole post-myocardial infarct period. The encouragement of less isolated monotonous units with external monitor set-ups has come through recent research efforts. Certainly better con323
PSYCliOSOMATIcS
.troiled and more evaluative studies are needed to find out just what the exact emotional factors are, and whether they are pathologic or a normal concomitant of the stress of cardiac surgery and/or acute myocardial infarction. Post-cardiac surgery psychoses including delirium have been studied, and at present, it would seem that this phenomenon is a combination of anaesthetic, anoxic effects combined with a somewhat predisposed personality and a stressful untherapeutic recovery room. 37 Certainly major factors in decreasing post-cardiac psychoses have been through shorter duration of surgery, improved perfusion on the heartlung machine and shorter duration of anaes· thesia. The rehabilitation of the post-myocardial infarct patient has been a rather neglected area of study from a specifically psycholog:cal point of view. However, with the realization of how poor the return to occupation figures are in some areas, an increasing effort is being made to look into these psychosocial issues. 38 The problems of continued anxiety, cardiac neuroses, chronic family and marital conflicts, mixed with severe dependency and depression point up the major task rehabilitation can be. 39 The use of family, group and spouse dynamics has been found useful in dealing with some problems. 40 The use of supervised exercise programs for coronary prevention and rehabilitation has also pointed up the possible importance of group and inter-actional dynamics in terms of assisting the coronary patient deal with cardiac anxieties and depressions, and a new sense of control over this life threat. The progress some patients have made through supervised exercise programs is remarkable and yet there is a dearth of psychosocial information in terms of understanding the possible group interaction and dynamics. 41 ,42 SUMMARY
We have emphasized some of the recent advances made through collaboration of cardiologists, psychiatrists, and basic scientists in the area of understanding the psychosocial links with cardiovascular disorders. It is of utmost importance to include further joint ventures in future research into the etiology and prevention 324
of sequelae for cardiovascular disorders. There is also a need for integrated psychosocial treatment and understanding of the cardiac patient via internists and family physicians. This approach which is the key to treatment in all patients, pays particularly rich dividends in the area of cardiovascular disorders. BIBLIOGRAPHY 1. Editorial, Heart Disease Prone: Aggressive Inpatient. J.AM.A., 203:28·29, February 12, 1968. 2. Reiser, Morton F.: Cardiovascular Disorders, in Comprehensive Textbook of Psychiatry, Freedman, Alfred M. and Kaplan, Harold I., Ed. Williams and Wilkins, Baltimore, 1967. 3. Editorial, Free Fatty Acids and Heart Attacks, Lancet, 843, April 24, 1971. 4. Editorial, Catecholamines and the Heart, Lancet, 1200, June 14, 1969. 5. Anderson, T.W.: Role of the Myocardium in the Modem Epidemic of Ischaemic Heart Disease, Lancet, 753·55, October 10, 1970. 6. Rub, W.: Emotionally Induced Disorders of Myocardial Metabolism, Function and Structure, Med. Counterpoint, 29·35, 1969. 7. Klein, R.F.: Transfer from a Coronary Care Unit. Arch. Int. Med., 122: 104-108, August. 1968. 8. Friedman, M., Byers, S.O., Rosenman, R.H., Elevitch, F.R.: Coronary Prone Individuals: Some Biochemical Characteristics, J.AM.A., 212:6, May II, 1970. 9. Cleghorn, John M.: Psychosocial Influences on a Metabolic Process: The Psychophysiology of Lipid Mobilization, Canadian Psychiat. Assoc. J., 15:539-46, 1970. 10. Taggart, R., Carruthers, M.: Endogenous Hyperlipidemia Induced by Emotional Stress of Racing Driving, Lancet, 363-366, February 20, 1971. 11. Wolf, Stewart: The End of the Rope: The Role of the Brain in Cardiac Death, Canad. Med. Ass. J., 1022-1024, October 21, 1967. 12. Kannel, William B., Gordon, Tavia: Premature Mortality from Coronary Heart Disease, J.A.M.A., 215, 1617-1625, March 8, 1971. 13. Friedman, M.: Behavior Pattern and its Relationship to Coronary Artery Disease, Psychosomatics 8:4, 6·7, 1967. 14. Rosenman, R.H., Friedman, M., Jenkins, C.D. et al: Clinically Unrecognized Myocardial infarction in the Western Collaborative Study, A mer. J. Cardiol 19:776-782, 1967. 15. Bortner, R.W., Rosenman, R.H., Friedman, M.: . Familial Similarity in Pattern A Behavior; Father and Sons, J. Chronic Dis., 23:39-43, 1970. 16. Lovell, R.R.H., Vergbese, A.: Personality Traits Associated with Different Chest Pains Mter Myocardial Infarction. Brit. Med. J., Vol. 3, 327-31, 1969. Volume XIV
CARDIOVASCULAR DISORDERS-KEEGAN 17. Ostfeld, A.M., Lebovits, B.Z., Shekelle, R.B., Paul. 0.: The Relationship between Personality and Coronary Heart Disease. J. Chronic Dis., 17,265, 1964. 18. Jenkins, C. David, Hawes, C.G., Zyzowski, S.J., Rosenman, R.H.: Psychological Traits and Serum Lipids: 1. Findings from the California Psychological Inventory, Psycho$Om. Md. 2, 115-27, 1969. 19. Shekelle, R.B., Ostfeld, A.M., Paul, 0.: Social Status and Incidence of Coronary Heart Disease, J. Chronic Dis. 22, 381-94, 1969. 20. Bruhn, J.G., Chandler, B., et al: Social Aspects of C.H.D. in Two Adjacent Ethnically Different Communities, Amer. J. Pub. Heal/h, 56. 493, 1966. 21. Liljefors, I., Rahe, R.H.: An Identical Twin Study of Psychosocial factors in Coronary Heart Disease in Sweden. Psyc!losom, Med. 32, 523-42, 1970. 22. Parkes, C.M., Benjamin, B., Fitzgerald, R.B.: Broken Heart: A Statistical Study of Increased Mortality among Widowers, Brit. Med. J., 1:74043, 1969. 23. Jenkins, C. David: Psychological and Social PreCursors of Coronary Disease, New Engl. J. M. 284:307-17. February 11, 1971. 24. Friedman, M., Rosenman, R.H. et al: Changes in Serum Cholesterol and Blood Clotting time in Men Subjected to Cyclic Variation of Occupation Stress, Circulation, 17, 853, 1958. 25. Thomas. C.B.• Murphy, E.A.J.: Effects of Stress on Cholesterol levels. J. Chronic Dis. 8, 661, 1958. 26. Wyler, A.R.• Masuda, M.• Holmes. Thomas H.: Magnitude of Life Events and Seriousness of Illness, Psychosorn. Med., 2, March, 1971. 27. Stout, C., Morrow, J., Brandt. E., Wolf, S.: Low Incidence of Death from Myocardial Infarction in a Study of an Italian American Community in Pennsylvania, J.AM.A .• 845. 1964. 28. Sievers, M.L.: Myocardial Infarction Among Southwestern American Indians, Annals Int. Med., 67:800, 1967. 29. Caffrey, B.: Behavior Patterns and Personality Characteristics Related to Prevalence Rates of C.H.D. in American Monks. J. Chron. Dis.,
22:93, 1969. 30. Nestel, P.J.: Blood Pressure and Catecholamint Excretion after Mental Stress in labile Hypertensives. Lancet, 1:69294, 1969. 31. Henry. Jules P., Stephens. P.M., Axelrod, Julius, Mueller, Robert A.: Effect of Psychosocial Stimulation on Enzymes Involved in the Biosynthesis of Noradrenaline and Adrenaline. Psychosom. Med., 33:227-236. 1971. 32. Miller. Neal: Learning of Visceral and Glandular Responses. Science, 163:434-45. January 1969. 33. Shapiro. D., Tursky, B. et al: Effects of Feedback and Reinforcement on the Control of Human Systolic Blood P.-essure, Science, 163:588-90, 1969. 34. Weiss, T.• Engel, B.: Operant Conditioning of Heart Rate in Patients with Premature Ventricular contractions, Psychosom, Med., 33:4; July. 1971. 35. Wishnie, H.A., Hackett. Thomas P., Cassem, Ned H.: Psychological Hazards of Convalescence Following Myocardial Infarction, J.AM.A., 215: 1292·1296. February 22. 1971. 36. Keegan. David L.: The Coronary Patient: A Psychosocial Glimpse. Can. Farn. Phys., March, 1973. 37. Hiller. S.S., Frank. K.A. et al: Psychiatric Complications of Open Heart Surgery, New Engl. J. Med., 283, 1015-20. November 5, 1970. 38. Editorial. Return to work after Myocardial Infarction, Lancet, 591·92, September 11, 1971. 39. Skelton, M., Dominian, J.: Psychological Stress in Wives of Patients with Myocardial Infarction, Brit. Med. J., 2:101-103. 1973. 40. Adsett. C.A.• B,uhn, J.G.: Canad. Med. Assoc. J., 99:577. 1968. 41. Fisher, Stanley: Unmet Needs in Psychologoical Evaluation of Intervention Programs, Unpublished Manuscript, Airlie House Conference on Physical and Psychological Effects of Exercise Train· ing, Airlie, Va., April, 1972. (Personal communication.) 42. Friedman, Ernest H.. Hellerstein, Herman K.: Influence of Psychosocial Factors on Coronary Risk and Adaption to a Physical Fitness Program, Unpublished Manuscript. (Personal communication. )
It is always a silly thing to give advice-but to give good advice is absolutely fatal. Oscar Wilde
November-December, 1973
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