Emotional Problems in Patients with Angina Pectoris

Emotional Problems in Patients with Angina Pectoris MARTIN H. WENDKOS, M.D. and KURT WOLFF, M.D. • The concept that certain characteristic emotional conflicts may be closely intertwined with the development of angina pectoris cannot be considered to be especially new. Such a relationship has been proposed by a number of authors"; but heretofore, relatively little factual data have been presented to support this thesis. Accordingly, we undertook studies which sought to determine first, whether a representative group of anginal patients differed psychologically from a sample of non-anginal patients with rheumatic heart disease, and, second, the nature of the differences if, in fact, any were discernible. Moreover, unlike all previous investigations concerning the psychosomatic aspects of angina pectoris, ours constituted a collaborative effort by both a cardiologist and a psychoanalytically oriented psychiatrist. The data reported were derived from observations in 20 patients, of whom 13 represented cases of angina pectoris associated with arteriosclerotic coronary artery disease. In every instance, the diagnosis was established by the history and a characteristic ischemic ST segment change in an electrocardiogram obtained after a stressful procedure"o. The average age of the anginal patients was 49 and in the seven patients with rheumatic heart disease it was 42 years. nr. Wendkos is Hospital Cardiologist, Veterans Administration Hospital, CoateSVille, Pa., and Assistant Professor, Department of Psychiatry. Thomas Jefferson University School of Medicine, Philadelphia, Pa. Dr. Wolff is Associate Chief of Staff for Education, Veterans Administration Hospital, Coatesville, Pennsylvania, and Associate Professor Of Psychiatry, Jefferson Medical College, Philadelphia, Pa. Presented at the 15th Annual Scientific Meeting of the Academy of Psychosomatic Medicine, Miami Beach, Florida, December 1968. 334

The psychiatric investigation of these 20 patients consisted of intensive depth interviews which sought to explore especially their psychodynamics, to determine each patient's past behavior in relationship to parents, siblings, wife, teachers, and supervisors and also to establish the presence of any current environmental stresses. Particular attention was given to the period of toilet training, religious customs and sexual impulses. Further information was obtained from an extensive social service history and an evaluation of monthly progress notes made by the staff physician primarily responsible for the care of the patient in the hospital. Also, in some instances, psychologic testing was performed. Later, when all such data were collected and analyzed, it was found that a distinctive premorbid psychodynamic pattern seemingly could be identified in the anginal patients. Essentially, it consisted of a combination of unfulfilled oral needs, repressed hostility, a highly developed superego, and an exaggerated degree of compulsiveness. By contrast, it was found that the patients with rheumatic heart disease were passive and noncompulsive without unfulfilled oral needs. Their superego was moderately but not excessively strong and they were more relaxed than the patients with the anginal syndrome and they displayed fewer feelings of guilt. Moreover, on the basis of the information which we have collected, it would appear that unfulfilled oral needs were the foundation for the entire formulation of psychodynamic elements which characterized the personalities of the anginal patient. Therefore, the resentment, jealousy, anger, and hostility are conceived as a reaction to the lack of love and understanding from a mother or mother substitute or a reaction to the denial of such love and understanding because of the death or absence of such a parent. Volume

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It is also conceivable that the repressed hostility and compulsiveness in part were also due to the prominence of persistent anal traits in their psychosexual development. Moreover, because the repressed hostility was derived from feelings of deprivation and rejection it also can be blamed for the presence of a significant degree of inferiority feelings. In general, we found that the hostility was directed against other people, especially the nearest relatives. However, in some instances, it was directed against the person himself and therefore, proved to be self-destructive. The underlying hostility also favored a low tolerance for frustration and consequently the anginal patients symbolically could be considered to be persons who were "bursting from resentment". The highly developed superego or conscience in the anginal patients probably was derived from prolonged submission to strict and moralistic parents or from a continued exposure to rigid religious attitudes in the home environment during the early years of the life of the patient. This superego, we believe, was responsible for the repression of the hostile impulses derived from the unfulfilled oral needs. This repression, in turn, could readily explain the marked compulsiveness which also was such a conspicuous feature in the anginal patients, inasmuch as compulsive behavior is well recognized to be the usually socially acceptable substitute for underlying hostility and undesirable aggressive drives. Others, such as Roseman and Friedman 11 - J" have also emphasized the presence of compulsiveness in anginal patients but they have never specifically related it to the basic emotional conflicts which we have considered to be an important component of the psychopathology in such patients. However, despite an apparently successful penetration into the personalities of the patients we have examined, we believe th>lt the evidence we have collected still cannot justify too many interpretations regarding its significance. Thus, in our opinion, it would be premature to suggest, at this time, what position these personality traits should occupy in November-December, 1969

the hierarchy of risk factors which are generally thought to predispose to the development of angina pectoris. Surely, to do so, on the basis of the relatively small body of data we have assembled up to now, would be presumptuous and unwarranted. On the other hand, it is likely that the findings we have described can even presently be of some use as guideposts for those physicians who are charged with the responsibility of caring for anginal patients. Undoubtedly, an understanding of the prevailing emotional conflicts we have discussed should give the attending physician an insight which should assist him to more successfully cope with the manifold problems peculiar to the person who is handicapped by angina pectoris. This means that, in recognition of the underlying hostility in his patient, the physician who, of necessity, is cast in the role of a parent surrogate, should be careful never to act in an overly authoritative manner, lest he intensify the patient's existing anger and thereby worsen the anginal state. It also means the physician should encourage the patient to verbalize his hostilities and, if he deems it to be necessary, arrange that the patient receive definitive psychotherapy. Selective psychoactive agents presumably can also be helpful in this respect. In addition, our observations should make the attending physician realize that the prominent place of unfulfilled orality needs in the psychopathology associated with angin9 pectoris cannot go unheeded. For this rea')')n, he should be prepared to deal appropriately with the increased hostility, along with all its adverse responses when he interdicts the smoking habit and limits the patient's food intake. Moreover, certain forms of exercise properly should be perceived as socially acceptable outlets for the displacement of aggressive drives and underlying hostility and, therefore, it would seem to be therapeutically unsound to recommend that the anginal patient discontinue such activities. Admittedly, it would seem logical to impose such restrictions because the angina is provoked by effort, but it 335

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must also be recognized that the compulsive anginal patient who must restrict such long established living habits will suffer not only from the precordial pain related to myocardial hypoxia but also will suffer from the anguish engendered by such a well meaning but ill-advised proscription. Again, such a prohibition dictated by the authoritative father figure can only result in even more resentment and consequently in a worsening of the anginal state. Fortunately, because the anginal patient can be freed from the pain of physical effort if he merely places under his tongue a suitable nitrate preparation before he undertakes any prescribed form of physical activity, full use should be made of this particular property of the drug. Various nitrate compounds can be employed for this purpose, but the one we have found most effective is isosorbide dinitrate, which differs from other nitrates because it not only begins to act rapidly but also because it has a long duration of action" REPRESENTATIVE CASES

Case No.1: J.V. was studied in April and May of 1967. His anginal symptoms first appeared in 1958 when he was 36 years of age and since then he has repeatedly experienced episodes of chest pain. Psychiatric evaluation revealed that he was born in the United States, and that his parents were European who had emigrated from Austria. Both parents were Greek Gatholics; the father was intensely religious and a regular attendant at church. The patient was raised at home along with three sisters and two brothers, all of whom, except for one sister, were older. The patient described the father as stern and autocratic who beat him frequently with a broomstick to punish him for minor forms of misbehavior. When the patient was 12 years of age, the father died. Thereafter, the mother, who was rigid and demanding. assumed full charge of the family. As he grew up in this family setting, the patient never developed a close attachment either to his mother or to his siblings. As an adult, he has seen his brothers and sisters infrequently. He attributed this circumstance to the preoccupation of his siblings with their own families since they have married. He completed hhigh school at the age of 18 and then entered the Navy during World War II, servect for three years as a pharmacist's mate and then received an honorable discharge. Following his return to civilian life, he enrolled in a nurse's

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training school and, since completing his studies, worked as a nurse on the staff of a hospital in the Veterans Administration. He stated that he liked his job very much, that he was very conscientious in performing his nursing duties, and that he became very angry and resentful whenever his nursing supervisor criticized any aspect of his perfcrmancc. Howevel'. he never became involved in any physical altercations with his supervisors or peers. except 'on one occasion. He also admitted that he tends to become angry easily. especially whenever he feels frustrated, when he makes a mistake at work. or when he feels that he might not be able to continue working. While the patient was serVing in the Navy during World War II, his mother developed coronary heart disease and diabetes mellitus. TheRe complications were responsible for a prolonged, disabling illness. Ten years afterward. when the patient was 29 years of age, his mother died from complications ensuing from the arteriosclerotic heart disease. The patient never married. but he has had occasional heterosexual experiences with prostitutes and others. He never considered marriage because. in his view. he had never met a girl who attracted him sufficiently. He admitted that, in spite of his cardiac illness, he has been smoking cigarettes regularly and has been drinking beer and whiskey frequently, but he denied any bouts of alcoholic intoxication. and his drinking habits have never interfered with his ability to function adequately on his job. As a result of his excessive food intake, he became somewhat obese. He recalled that he weighed 240 pounds when his cardiac symptoms first developed in 1958. Since then, by dietary restriction. he lost approximately 40 pounds. He always enjoyed sports; however swimming was the only sport in which he ever participated to any extent. Other pleasures included traveling and gambling. He never was an introverted individual and always preferred being in the company of others. Although he generally socialized satisfactorily, he never developed any close personal friendships. His physical symptoms were typical of angina pectoris. So far as he could recall. the episodes of chest pain almost always were provoked either by physical effort or by some type of angergenerating situation. The physical examination, while he was being studied at the hospital, did not disclose any significant abnormalities. However. findings in his electrocardiogram were unequivocally those associated with the anginal phase of ischemic heart disease. The noteworthy electrocardiographic change was an ST segment dip follOWing completion of the customary amount of measured exercise performed during a standard Treadmill stress test and the prevention of Volume X

EMOTIONAL PROBLEMS WITH ANGINA-WENDKOS AND WOLFF this "ischemic" effect when the same test was performed following sublingual administration of 10 mg. of isosorbide dinitrate. Thus, on the basis of the foregoing information, it is evident that, in a psychodynamic sense, the patient was an orally deprived person (h'story of overeating, enjoying alcoholic beverages, and smoking). Apparently, too, he did not obtain enough love and understanding from his mother, and, obviously, no mother figure had entered his present life to fulfill his oral needs. Evidently, also, his superego was highly developed, pre_ sumably as a result of the strong religious atmosphere in the household in which he was reared. His work record demonstrated that he was a per_ fectionist who took his work very seriously (compulsive personality). Finally, it can be concluded that he was suffering from a great deal of re_ pressed hostility and sexual inhibition, the latter being ascribable to the influence of his parents, both of whom were rigid and deeply religious. Case No.2: L.A.B. was born in a rural community in Pennsylvania in 1917 and never had any serious physical problems until he developed an attack of tonsillitis at the age of 26 while assigned to military duty in one of the Pacific islands during World War II. At that time he also developed migratory polyarthritis, and studies in the hospital confirmed the diagnosis of acute rheumatic fever. FollOWing recovery from this illness he was discharged from military service and was granted a service-connected disability pension. Nevertheless, after his return to civilian life, he was able to obtain employment as a nursing assistant at a Veterans Administration Hospital. He worked fairly steadily at this job without experiencing any symptoms until 1964, when he noted fatigue and dyspnea on exertion. Digitalis therapy was prescribed and his symptoms improved. Repeated physical examinations, radiologic studies and electrocardiographic examinations, have confirmed the presence of a rheumatic cardiac lesion with mitral stenosis, mitral regurgitation, and a minimal degree of aortic regurgitation. Cardiac surgery has been advised but the patient has been unwilling to accept the suggestion, inasmuch as his symptoms, in his opinion, were not sufficiently severe. He has never experienced any chest pain and electrocardiographic studies following measured exercise have not indicated the presence of any coronary insufficiency. The following facts were gleaned during the psychiatric interview: Both his parents are still alive. His father is 80 years of age and his mother is 82. Both are apparently in fairly satisfactory physical condition despite their advanced years. His home life during his childhood was a happy one. There is still a closeness to both of his parents and to his siblings as well. He has one brothNovember-Decembel', 1969

er and three sisters; the patient is the youngest in the family. He was never treated too strictly nor too leniently. There was no trouble, while in school and never any punishment by either his parents or his teachers. He married when he was 30 years of age; in every respect his marriage is a happy one. There are two children with whom he has a most satisfactory relationship. He has never had any serious arguments with his wife; he is sexually well adjusted and has had no conflicts with members of his wife's family. His wife is cooperative and contributing to the support of the famly by working as a nursing assistant. She is aware of his physical limitations and tries to be as considerate as possible. He has never indUlged in the use of alcohol to excess, never ate excessively, and has always been able to retain his slender body build without difficulty. There never were any serious emotional problems, nor did he find it necessary to consult a psychiatrist. So far as he could recall, there have been no psychiatric illnesses in his family. He does not smoke, enjoys television, socializes well with h's neighbors and has many friends. Although he is not overly religious he attends church regularly. He takes a fairly active interest in sports, but, since he has been incapacitated by his heart condition, his interest has been limited to that of a spectator. He enjoys helping his wife with the cleaning at home; both of them share many entertaining experiences together. He is not inclined to complain about his lot in life. The shortcomings and eccentricities of other people are treated with tolerance rather than anger. Before developing symptoms indicative of reduced myocardial reserve, he customarily smoked about half a pack of cigarettes a day; s'nce the onset of cardiac symptoms he has stopped smoking and has not found it particularly difficult to do so. The psychodynamics of this patient suggest fulfilled oral needs due to the fact that he had a happy childhood and was loved by both parents and, after his marriage, by his wife. He had no cause for resentment or hostility and was well adjusted during childhood and adult life, accepting his physical handicaps with a philosophic and relaxed attitude. There was no special ambition or compulsive drive at any time and he manifested a rather passive and "resigned attitude". His superego appeared to be in fairly good equilibrium at all times, and it could not be considered as very strong or remarkable. The fast that he was able to discontinue smoking without difficulty indicated that his oral needs were fulfilled.

REFERENOES 1. Wolfe, T.P.: Dynamic aspects of cardiovascular symptomatology, Amer. J. Psychiat.,

91, 563, 1934. 331

PSYCHOSOMATICS 2. Menninger, K.A. and Menninger, W.C.: Psychoanalytic observations in cardiac disorders, Ame1'. Heart J., 11, 10, 1936. 3. Arlow, J.A. : Identification mechanisms in coronary occlusion, Psychosom. Med., 7, 195, 1945. 4. Arlow, J.A.: Anxiety patterns in angina pectoris. Psychosom. Mcd., 14, 461, 19152. 5. Ostfeld, A.M., Lebovits, B.Z. and Shekelle, RB.: A prospective study of the relationshiP between personality and coronary heart disease. J. Chronic Dis., 17, 265, 1964. 6. Ibrahim, M.A.: Personality traits and coronary heart disease, J, Chronic Dis., 19, 255, 1966. 7. Mattingly, T.W.: The post-exercise electrocardiogram: Its value in the diagnosis of coronary arterial disE!ase, Amer. J. Cardiology, 9, 439, 1962. 8. Robb, G.P. and Marks, H.H.: The post-exercise electrocardiogram in the detection of coronary disease: A long-term evaluation,

Trallsact. of the Assoc. of the Life Ills. Med. Directors Of Amer., 45, 81, 1962.

9. Wendkos, M.H.: Stress tests and the evalUation of anti-anginal drugs, J. Amer. Geriat. Soc., 15, 908, 1967. 10. Wendkos, M.H.: The anti-anginal effect of rapidly-acting nitrates in subjects with ergotinduced angina, Amer. J. Med. Sci., 253, 39, 1967. 11. Friedman, M. and Rosenman, R.H.: Association of specific overt behavior pattern with blood and cardiovascular findings, JAMA, 169, 1286, 1959. 12. Rosenman, RH.: The role of personality and behavior patterns in the genesis of coronary heart disease, J. Amer. Women's Med. Assoc., 20, 161, 1965. 13. Rosenman, RH., Friedman, M., Straus, R, Wurm, M., Jenkins, C.D., and Messinger, H.B.: Coronary heart disease in the Western collaborative group study: A follow-up experience of two years, JAMA, 195, 86, 1966.

The actual, the threatened, or the anticipated loss of a relationship is the key stress that evokes the psychodynamic cycle of events leading to the mobilization of depression with its suicidal potentiality... Death (of a parent, spouse, or close friend) is experienced unconsciously by the survivor as a deliberate abandonment .and is intensely resented. The hostility is clinically Observable in irrational criticism of medical care dUring the terminal disease of the lost one, or irrational criticism of the self with feelings of guilt for not doing enough... Quoted JAMA, Feb. 14, 1966

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