Emotional stress as a factor in ventricular arrhythmias

PATRICK T. DONLON, M.D. ARNOLD MEADOW, Ph.D. EZRA AMSTERDAM, M.D.

Emotional stress as a factor in ventricular arrhythmias Clinical evidence suggests that in some cases psychologic stress may be a more potent factor than exercise in precipitating pathologic cardiac effects. An experiment designed to test this hypothesis with one patient is described. The data suggest the importance of a more careful evaluation of the differential cardiac effects of emotional factors and physical exercise when outlining a treatment plan for coronary patients.

ABSTRACT:

Although several cases attempting to demonstrate the relationship between emotional stress and ventricular arrhythmias have been reported in the literature, there are relatively few data on the relationship between emotional and physical stress as precipitating factors in pathologic cardiac functioning.1,2 The case we describe suggests that psychologic stress can sometimes function as a more important factor than physical activity in precipitating pathologic cardiac events. Following recovery from a coronary occlusion, our patient demonstrated a normal tolerance for

physical activity but experienced ventricular arrhythmias and angina during periods of severe emotional distress. In addition to the comparison of psychologic and physical stress factors, the present study differs from many previous ones in that it employed an experimental method to evaluate the cardiac effects of pleasurable as opposed to emotionally painful stimuli. Case history Physical condition: The patient, a 38-year-old, tall, slender, twicemarried engineer, was hospitalized for treatment of acute myocardial

Dr. Donlon is associate clinical professor ofpsychiatry, Dr. Meadow is professor of psychiatry, and Dr. Amsterdam is associate professor of cardiology, at the School of Medicine, University of California at Davis. Reprint requests to Dr. Donlon. 2252 45th Street, Sacramento, CA 95817. APRIL 1979· VOL 20 • NO 4

infarction. Previous cardiovascular symptoms were denied and, although he suffered from chronic anxiety, his general health was considered excellent. He did not smoke, and alcohol use was minimal. His family history revealed a questionable myocardial infarct in his 82-year-old father some 15 years previously; but his 69-yearold mother was well. There is no history of heart disease in any of his three siblings. Hours after severe anterior chest pains awakened him from sleep, the patient was hospitalized. The prior week had been very hectic for him, and had included problems with his supervisor over a contract deadline, rejection by a girl friend, and marital friction. Initial findings included blood pressure, 130/80; pulse, 100 and regular; and respiration, 14. The ECG revealed ST-segment elevation, T-wave inversion in leads II, III, and VI, and aVF. The physical examination was within normal limits. His heart rate was regular with no gallop. The white blood count was 10,000, with a hematocrit 233

Stress factors in arrhythmias

of 41. A chest film revealed his heart to be of normal size and the pulmonary parenchyma to be clear of infiltrates. Enzymatic changes included an SGOT of 120, a CPK of 99, and an LDH of 660. The hospital course was unremarkable. The following week his CPK was 16, his SGOTwas 6, and his SGPT was 9. His diagnosis at discharge on day 14 was "acute inferior wall myocardial infarction." He was discharged on diazep?m and nitroglycerin and two weeks later returned to work. Emotional state: Six weeks after the infarct, the patient sought psychiatric care because he felt that emotional factors might provoke another "heart attack." On examination, there was no history of previous psychiatric treatment or borderline or psychotic functioning. He described himself as hard working, overly honest, but full of guilt, and unable to express feelings. He stated that his present marriage had been prompted by an unplanned pregnancy ten years earlier to a woman he had dated only briefly. He had consented to marry out of guilt and a sense of obligation; however, the marriage became emotionally unsatisfactory, and he found his wife's developing alcoholism disgusting. Their only child died from congenital heart disease at age two. Another presenting complaint was his professional relationship with his supervisor, whom he found critical, guilt-provoking, and frustrating with respect to his own career aspirations. Although the patient often worked 60 hours a week, his over-all performance did not meet with his supervisor's approval, and attempts to increase work productivity went unrewarded. APRIL 1979 • VOL 20 • NO 4

Initial mental status examination: There was no evidence of a thinking disorder. His intelligence was above average. He dressed neatly and was well-mannered. His affect was over-controlled, yet his thought content was appropriate. Recent and remote memories were unimpaired. Most apparent were a high level of anxiety and tension, isolation of affect, and moderately depressed mood. The psychiatric diagnosis was that he had an obsessive personality with reactive depression and anxiety. Observations during psychotherapy: In therapy, it was soon evident that his concerns were associated with extreme states of apprehension and tension. During one therapy session, when discussing an incident involving his supervisor, he developed anterior chest pain which was relieved by nitroglycerin. The previous day his supervisor had found fault with a major engineering proposal that the patient was finishing. At the time, the patient responded with withdrawal and politeness, but when he recalled the episode in therapy, he responded with signs of marked subjective distress (tension, unsteady yet controlled angry voice, sweating, strained facial expression, rapid respiration, and pallor); it was then that he developed the anterior chest pain. In addition, the patient described periods of friction at home; these periods were also associated with similar symptoms and, at times, with anginal pain, also relieved by nitroglycerin. Initially, he de-emphasized the relationship between emotional stress and cardiovascular symptoms, and took his prescribed medication infrequently, feeling that he could handle his social and work relationships without it.

In contrast to his reaction to psychologic situations, he stated that he repeatedly engaged in strenuous physical activities that he found to be very relaxing and not associated with cardiovascular symptoms. For example, within the year following his infarct, he learned to ski, frequently backpacked into the high mountains, and helped farm friends do heavy labor, such as throwing bales and cutting wood. Although his anterior chest pain was typical of angina pectoris with its localization and radiation into his left shoulder, it was atypical in origin because it was associated only with emotional stress and was absent even during heavy physical exertion. This atypical history led us to initiate a more extensive workup and documentation since clinically, additional data were necessary to establish a realistic plan for the patient in order to advise him about the possible limitations of physical exercise and emotional experience. Also, we assumed that if the patient's verbal report of differing reactions to psychologic and physical stress could be verified by objective data, then the impetus would be provided to investigate similar reactions in other patients to prevent similar morbidity. The patient gave his written informed consent to participate in the following diagnostic evaluation, after the risk and possible benefits were explained. Metbod In the cardiology laboratory, a continuous electrocardiogram (ECG) and arterial blood pressure were monitored by a cardiologist while the patient was interviewed by a psychiatrist and a psychologist. During the hour-long interview, the 237

Stress factors in arrhythmias

patient was asked to discuss various themes, based on previous clinical data judged by the interviewers to be either emotionally arousing, relatively neutral, or pleasurable. Both the interview and subsequent maximal graded treadmill exercise tests were recorded on video film. The ECG and blood-pressure tracings data were subsequently superimposed on the film, in order to facilitate later analysis. Prior to the data analysis, the filmed interview was divided into 62 one-minute segments. Two independent raters carefully reviewed the film and made global ratings about the degree of emotional stress. The psychologic classification was based not only on the stimulus introduced (discussion of a fishing trip, marriage, work experience), but also on the subject's global reaction (expressive movements, content, emotional response) to the material discussed. The global one-minute ratings were divided into four categories: very stressful, mildly stressful, mildly relaxed, and very relaxed. Subsequent to the psychologic ratings, the ventricular ectopic beats (VEBs) and other ECG patterns were similarly divided into oneminute segments. Accordingly, the physiologic data could later be collated with the psychologic ratings for analysis. The Thematic Apperception Test (TAT) was administered to the patient to assist him with diagnostic formulation. Coronary angiography was not performed. Results The reliability of the global ratings given by the two raters was calculated to be .90. At no period was the patient rated mildly relaxed, although when he evaluated the film 238

I

Table-Number of Yentrlcul~r Ectopic Beats (YEBs) During Psychiatric Interview

VEBs/min 5 or more Less than 5 Total minutes

.

"

~

Very relaxed

Mildly relaxed

3 6

0 0 0

9

Mildly Very Total stressful stressful minutes

18 8 26

21 6 27

42 20 62

l

l

p

later, he considered his relaxed periods to be subjectively more "mild" than "marked." We selected 5 VEBs per minute as suggesting significant pathology. The Table lists the number of oneminute segments per category for VEB frequencies of 5 or more and less than 5 per minute. Data in the Table indicate that a larger number of 5 or more VEBs per minute occurred in the "mild" and "marked" stress groups as compared with the "very relaxed" and "mildly relaxed" stress groups. Relatively little difference in this respect is shown between the "mild" and the "marked" stress categories. A chisquare analysis indicates that the observed differences are significant at the 5% level. The periods of stress were clinically associated with pallor, sweating, tension, anxiety, drawing of facial musculature, mild tremor, and rigid isolation of affect. Emotions ranged from feelings of grief and depression over his son's death, disgust and guilt concerning his wife, to hostility and agitation when discussing the supervisor. Periods of relaxation were associated with greater animation, smiling, absence of "fight-flight" autonomic response, and more frequent invitations for input from the

interviewers-almost in a sense of comradeship. In contrast, the patient's physiologic response during the four stages tested on the exercise treadmill was unremarkable. He considered the treadmill as a physical challenge and appeared relaxed during the exercise. He demonstrated adequate cardiac compensation during exercise with a paucity of VEBs. Serial ECGs and vital sign patterns showed that significant pathology was absent. The TAT analysis revealed an obsessive-compulsive personality with conflicts in many areas, including aggression, sexuality, rejection, retaliation, and work. A strong sense of right and wrong and a desire for perfection were present, as were feelings of guilt. In addition, the protocols revealed the patient's entangled relationships with his wife, mother, supervisor, and father. Discussion This case documents a relationship between stressful emotional states and cardiac symptoms in a man who demonstrated normal tolerance to physical exercise. Ventricular ectopic beats are commonly found in asymptomatic people whose coronary angiograPSYCHOSOMATICS

phy is normal and thus, in some individuals, may be innocuous. During continuous monitoring, Calvert et aP found VEBs in 62% of 283 overtly healthy middle-aged ambulatory men in contrast to nearly 85% of patients with coronary heart disease. Evidence suggests, however, that VEBs-especially those with high frequency, which are mUltifocal, paired, or present at low exercise rates-increase the risk of sudden death. Continuous cardiac monitoring of hospitalized patients who experience sudden death demonstrates4 that death is most commonly preceded by arrhythmias, especially ventricular fibrillation; these, in turn, are normally preceded by VEBs. Previous case studiesS-8 have indicated that emotional stress can precipitate YEBs, that it can precipitate ventricular arrhythmias, and that these may sometimes produce sudden death. Recently, Bruhn and associates9 and Lynch lO have reported the increased risk of serious arrhythmias occurring during periods of emotional turmoil in the coronary care unit (CCU) in comparison with quieter, less confused settings. Taggert and associates found ectopic beats in continuously monitored ECGs of persons without heart disease driving in routine traffic, II and in public speakers. 12 The correlation between emotional stress and ventricular arrhythmias has also been studied in animals. Corbalan 13 reports cardiac arrhythmias that developed after psychologic stress and arrhythmias that became more marked following coronary occlusion. Johansson 14 reports severe acute cardiopathy in all their laboratory animals, with a 13% occurrence of sudden death APRIL 1979 • VOL 20 • NO 4

resulting from severe stresses. A control group remained healthy. Although our patient did not ex,. perience ST- and T-wave changes or angina suggestive of coronary anoxia in our study, it is probable from his history and the data from his therapy sessions that the periods of subjective distress followed by angina were analogous to the increased VEBs produced by the emotionally painful stimuli of our experiment. Similarly, exercise tolerance on the treadmill confirmed his report of a healthy cardiovascular response to physical activity. Thus, our laboratory data are consistent with the history of ECG changes and anginal pains associated with emotional stress, but not with exercise. The present data thus indicate several facts: Angina pains are reported by a patient in situations of emotional stress; one such episode was observed by the therapist in a psychotherapy session; increased VEBs and other ECG abnormalities were associated with the presence of emotional tension in this clinical investigation; and the history of normal tolerance for exercise was confirmed by treadmill monitoring. Thus we conclude that, for our patient, at least, emotional events can precipitate dangerous cardiac effects, but tolerance to physical exercise may be quite normal, perhaps because it is subjectively experienced as relaxation. The data suggest the hypothesis that emotional determinants can produce arrhythmias resulting in anginal pain, though the precise mechanisms producing the arrhythmias remain unclear. We hypothesize that other individuals with YEBs, with or without coronary heart disease, may be at higher risk for ventricular fibrilla-

tion than is presently considered. Further research is required to document more precisely the incidence and psychobiology of this relationship. From a clinical viewpoint, the data suggest that physicians should attempt to make a separate assessment of the possible differential effects of psychologic stress and physical exercise in each patient suffering from cardiovascular heart disease or in those presenting with VEBs. Patients at risk for developing cardiac complications from emotional events possibly can be identified by history, through an interview of the sort described in this report, or through continued observations in places such as the CCU. Various therapies (psychotherapies, relaxation techniques, anxiolytic and antiarrhythmic drugs) could be investigated to establish their differing outcomes and safety. An individual similar to our patient may be encouraged to do a relatively greater amount of physical exercise, but steps should be taken to reduce his or her sensitivity to emotional provocation. Conversely, some patients may exhibit pathologic reactions to minimal physical stress but remain imperturbable during psychologic situations that are traumatic to others. Such an etiologic assessment and appropriate treatment might reduce the incidence of VEBs occurring in patients suffering from cardiac disease. 0

REFERENCES 1. Lown B, Temte JV, Reich P, et al: Basis for recurring ventricular fibrillation in the absence of coronary heart disease and its management, N Engl J Med 294:623-629, 1976. 2. LynCh JJ, Paskewitz DA, Gimbel KS, ef al: Psychological aspects of cardiac arrhythmias, Am Heart J 93:645-657,1977. 3. Calvert A, Lown B, Gorlin R: Ventricular premature beats and anatomically defined coro-

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Stress factors in arrhythmias

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nary heart disease. Am J Cardio/39:627-633, 1977 Lown B, Wolf M: Approaches to sudden death from coronary heart disease. Circulation 44:130-142,1971 Weiss S: Instantaneous "physiologic" death. N Engl J Med 223:793,1940 Duncan CH, Stevenson IP, Ripley HS: Life situahons, emohons and paroxysmal auricular arrhythmias. Psychosom Med 12:23-37, 1950 Stevenson IP, Duncan CH, Wolf S, et al: Lite situations, emotions and extrasystole. Psy-

chosom Med 11:257-272,1949. 8. Katz LN, Winton SS, Megibow RS: Psychosomatic aspects of cardiac arrhythmias: A physiological dynamic approach. Ann Intern Med 27261-274, 1947. 9. Bruhn JG, Thurman AE Jr, Chandler BC, et al: Patients' reactions to death in a coronary care unit. J Psychosom Res 14:65-70, 1970. 10. Lynch J, Thomas S, Mills M, etal: The effect of human contact in coronary care patients. J Nerv Ment Dis 158:88-99,1974. 11. Taggert P, Gibbon D, Somerville W: Some effects of motor car driVing on the normal and

abnormal heart. Brit Med J 4: 130-134, 1969. 12. Taggert P, Carruthers M, Somerville W: EKG, plasma catecholamines, and lipids, and their modification by oxprenolol when speaking before an audience. Lancet 2:341-346, 1973. 13 Corbalan R, Verrier R, Lown B: Psychological stress and ventricular arrhythmias during myocardial infarchon in the conscious dog. Am J Cardio/34:692-696, 1974. 14. Johansson G, Jonsson L. Lannek N, et al: Severe stress cardiopathy in pigs. Am Heart J 87:451-457,1974

the MMPI occurs in physically healthy individuals over age 60. The authors should, I feel, have defined what they mean by high and low MMPI scores. If, as they say, "data revealed that the T scores tended to be within the nonpathologic range," Figure 2 must be grossly inaccurate. I would also have appreciated a better explanation of the Tennessee Self Concept Scale (TSCS), together with references to its validation. G. F. Bigwood, M.D. Lahey Clinic Boston

to send Dr. Bigwood a copy of this chart with an explanation. With regard to the L scores on the M M PI, Dr. Bigwood apparently has failed to note that the population as a whole scored somewhat lower than the other disability groups reported (low back pain and multiple sclerosis). The pulmonary group scored slightly lower than our arthritic population. It is interesting that scales I, 2, and 3 of the MMPI are elevated in physically healthy individuals over age 60. However, I would be interested in Dr. Bigwood's definition of "physically healthy." It may be that those individuals over 60 who were examined do not perceive themselves as healthy; but of course, this is pure conjecture. I agree with Dr. Bigwood that this study probably could have been more scientific if we were able to control for all the variables. However, when one does clinical research in a hospital setting that requires the assistance of many people, sticking to rigid experimental techniques can be extremely difficult. Philip Spergel, Ed.D. Moss Rehabilitation Hospital Philadelphia

LETTERS Rheumatoid personality To the Editor: In reading Spergel, Ehrlich, and Glass's article "The rheumatoid arthritic personality: A psychodiagnostic myth" (PSYCHOSOMATICS 19(2):79-86, 1978), I welcomed their emphasis and c1arifi~ cation of what most of us have been accepting in everyday hospital psychiatry for some years. However, I was unable to be sure they had effectively proven their point. I have no faith at all in averaged MMPI profiles unless the maximal degree of variation from the mean is indicated for each scale. From these profiles one could expect a high degree of psychopathology. I note that according to Figure 2, the average L score for males was 71, and the average F score was 72. For females, the average L score was 75, average F score, 74. In my clinical work, this kind of score gives me a concern about validity. With a compact patient group of only 46, it would have been easy to reproduce the computer sheet so that those interested in the article could see if the information contained therein fitted the conclusions advanced by the authors. I must also mention that elevation above 70 of scales I, 2, and 3 of 240

Dr. Spergel replies: Dr. Bigwood states that our article emphasized and clarified what has been accepted in everyday hospital psychiatry for some years; the purpose of research is to attempt to validate clinical impressions. The statistical techniques, particularly the hierarchal cluster analysis used to analyze the data of the TSCS, are quite sophisticated and are also quite significant. Unfortunately, the figure demonstrating the hierarchal cluster analysis on the TSCS was not reproduced in this article. However, I would be happy

PSYCHOSOMATICS