According to the Centers for Disease Control, one person in the U.S. dies every 36 seconds from cardiovascular disease (CVD). And heart disease is the leading cause of death for men and women of most racial and ethnic groups.

Obviously, this is a huge challenge for cardiologists. But cardiologists aren’t the only ones working to slow the encroachment of these deadly diseases. The psychotherapy community is also getting involved through a field known as psychocardiology. Researchers in this area are interested in understanding how psychological factors, such as depression, anxiety, stress disorders and substance abuse, contribute to CVD and vice versa.
 

For example, a study in the European Heart Journal by Sripal Bangalore and colleagues found that individuals with a history of CVD are more likely to experience symptoms of depression than those without such a history. Conversely, the risk of developing CVD increases by as much as 65% in individuals with depression. And in those who are already being treated for heart diseases, psychological problems can cause further complications. All of this suggests a deep, bi-directional connection between the heart and the brain.

Let’s consider what therapists need to know to put this information into practice.

What we Know About the Brain-Heart Connection

We’re only just beginning to understand the deep connection between the heart and the brain. We know, for instance, that psychological stress can put extra strain on our hearts. When our bodies are in “flight-or-flight” mode, our blood pressure increases and our brains release adrenaline, along with other chemicals that can cause our hearts to spasm.

Although these physiological changes can help us survive immediate threats to our lives, when we spend most of our time in “flight-or-flight” mode, as is the case with most of our patients, the odds of developing heart disease greatly increase. In fact, one large scale study by Salim Yusuf and his team which involved 25,000 participants in 52 countries, found that psychological factors accounted for about 30% of heart attacks and strokes.

 

One explanation for the increase here is that stress hormones can cause damage to our hearts when constantly released into our bloodstreams over long periods of time. Additionally, mental stress increases inflammation of the brain and the heart, which can also lead to further complications.

The Need for New Interventions

Stress Management
Armed with the information above, many psychocardiologists are focused on stress management. The hope here is that cardiac patients who learn how to better manage stress through behavioral change will not only improve their symptoms of depression, but will also see improvements in their heart symptoms.

Such findings suggest that stress management training administered by therapists and psychologists would be beneficial for every cardiac rehabilitation patient. And when compared to the cost of other interventions, like angioplasty or bypass surgery, stress management is quite cost efficient.

Improved Quality of Life
Other psychocardiologists look for ways to improve quality of life. Yes, many heart patients end up with depression after surgery or other medical treatment for cardiovascular disease. And yes, depressed people often don't exercise, eat well, or take their medications. But there may also be physiological connections between CVD and depression.

Because we know that cognitive behavioral therapy combined with talk therapy can effectively reduce depression and anxiety, there is reason to believe these interventions can also reduce levels of stress hormones, decrease elevated heart rates, and calm hyper-active responses to physical stressors.

Challenges Remain
Unfortunately, while acceptance of psychocardiology is growing among the medical community, there are still challenges. For one thing, it’s difficult to get insurance companies to pay for any cardiac rehabilitation, let alone adding a psychological component. And with hospital stays getting shorter in the U.S., there’s little hope for inpatient rehabilitation and outpatient rehabilitation tends to focus on physical therapy, since insurance refuses to pay for other services.

However, none of the above has to get in the way of therapists’ treating their own patients, inquiring about heart disease symptoms, and making them aware of the heart-brain connection. Additionally, we all need to look for ways to treat the whole patient and to partner with cardiologists or other clinicians to ensure that our patients receive the best care possible.

Case Application

Jeffrey, a 48-year-old male with symptoms of depression, was referred to my office by his cardiologist for an evaluation. Jeffrey presented with both anxiety and depressive symptoms. His symptoms of depression had been present for nine months. Jeffrey was an avid cyclist who had recently suffered a myocardial infarction (MI) that required a cardiac catheterization, medication management and a cardiac rehabilitation program. Even though Jeffrey recovered from the MI, it left him with damage to his heart muscle, and he was advised by his cardiologist to continue to exercise but that he must also “slow it down.” This meant that Jeffrey could no longer ride with his buddies, something he used to look forward to all week long, since they rode at a level that would cause too much strain on his heart.

Even though Jeffrey was given clearance by his cardiologist to ride again, over the past nine months he had been struggling to get started. Jeffrey was becoming increasingly anxious that riding would put too much strain on his heart and possibly cause another cardiac event to occur. He worried about what would happen to his wife and two children if he had another MI and did not survive. He would ruminate over the possibility of never being able to keep up with his cycling buddies, a group that he had been riding with for over ten years.

The worry was starting to negatively impact Jeffrey. He now had low energy during the day, no motivation to exercise or join his family and friends in weekend activities, difficulty concentrating at work, poor sleep, weight gain, and feeling “down” on most days.
After taking Jeffrey’s medical and psychological history, I explained the mind-body connection, the concept of psychocardiology, and the comorbidity between psychiatric disorders and heart diseases. I also explained the bi-directional relationship between the heart and mind and how his heart problems were negatively impacting his mental health state, and that by working with him to help his mood, he would feel better physically.

To alleviate some of his anxiety and to highlight his body–mind connection, I incorporated breathing exercises and other relaxation techniques, such as guided imagery and body scanning to reduce stress and muscle tension. Body scanning is like meditation; it enabled Jeffrey to get in touch with his physical symptoms and their meaning. Jeffrey started to realize that cycling was a coping mechanism that he used to alleviate his anxiety and that now he needed to discover new methods. He identified his all-or-nothing thinking, e.g., “If I cannot ride my bicycle a certain way, I would consider myself a failure.” In sessions we addressed how this rigid thinking made it difficult to recover when something unexpected occurs.

CBT exercises helped Jeffrey explain the link between cognitions (beliefs that he would never be able to keep up with his riding buddies) and emotions (fear, failure) and safety (he may have another MI and not survive this time). Cognitive restructuring helped to identify old and new stressors, understand what response they trigger, and find alternative responses. During sessions, Jeffrey identified and processed the negative feelings that surfaced during his forced time away from riding. To increase self-confidence and reduce anxiety, measurable, realistic, performance-based goals were developed and monitored in each session.

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Jeffrey’s unexpected cardiac event resulted in an immediate imbalance and disruption to his life. The inability for him to continue cycling was devastating and hindered his recovery process and negatively impacted his mental health. Jeffrey’s deeper understanding of the role psychological well-being played in his physical functioning resulted in greater motivation to work on his mental and physical health. The collaboration between two specialties, cardiology and mental health, enabled Jeffrey to have his psychological and physical needs managed simultaneously.
 

File under: The Art of Psychotherapy, Musings and Reflections