PSYCHOSOCIAL ASPECT OF

CORONARY HEART DISEASE

Dr. Fazeela Moghal
Assistant Professor
Psychiatry Department
Dow Medical College
 Lecture Overview
• Primary risk factors for coronary heart disease
• Role of psychosocial risk factors
– Hostility and type A behavior
– Depression and anxiety
– Psychosocial work characteristics
– Social network structure and quality of social support
• Psychosocial consequences of CHD
• Psychosocial Interventions
• Psychological factors cause or exacerbate
many physical disorders the most common
of which is coronary heart disease (CHD)
• Around 80% of deaths with CHD occurred
in low and middle-income countries.
• The primary risk factors for CHD include
– an unhealthy diet
– physical inactivity and
– smoking.
• The increasing prevalence therefore,
reflects changes towards
– imbalanced nutrition including high
consumption of saturated fats and refined
carbohydrates
– reduced physical activity and
– increased tobacco consumption.
 Role of psychosocial factors in
causing CHD
• Psychosocial factor:
– psychological phenomena that relates to the
social environment and both, in turn
contribute to patho-physiological changes
• Ongoing psychological processes and
social events might be perceived as
‘stressful’ beyond a certain point.
• When that happens, these could affect the
bodily systems and contribute towards
health difficulties
• Hemingway & Marmot (1999) described
three interrelated pathways to explain the
causal association between psychosocial
factors and CHD:
1. psychosocial factors may affect health
related behaviors
2. psychosocial factors may cause direct acute
or chronic patho-physiological changes
3. access to and quality of medical care may be
influenced by social factor
• There are four psychosocial factors clearly
contributing towards CHD
– Hostility and type A behavior
– Depression and anxiety
– Psychosocial work characteristics
– Social network structure and quality of social
support
 Hostility and type A behavior
Type A behavior pattern characterized by
• Competitive behavior
• Potential for hostility
• Pronounced impatience
• Extreme ambition
• Of its major components, hostility has
received the most attention.
• Hostility is a broad psychological concept
that includes anger, cynicism, and mistrust.
• Multiple patho-physiological mechanisms
have been suggested by which hostility
may be linked to CHD.
• It is associated with unhealthy lifestyle
behaviors including
– Smoking
– Poor diet
– Obesity
– Alcoholism
• These individuals are also more likely to
manifest other psychosocial factors associated
with CHD such as social isolation
• Other possible mechanisms include
– Higher heart rate and blood pressure levels
– Hypercortisolemia (high cortisol)
– High levels of circulating catecholamines
– Diminished vagal modulation of heart function
– Increased platelet reactivity
 Depression and anxiety
• Depression and anxiety are well defined
common mental illnesses
• Depression and anxiety can be caused or
can also be common consequence of
CHD
• The relationship between depression and
CHD is more complex than is the case for
other psychosocial factors.
• Depression and heart disease could share
common antecedents
• Like other psychosocial factors
responsible for CHD, depression is also
associated with unhealthy lifestyle
behaviors such as smoking and poor
compliance with medical advice.
• Direct pathophysiological effects of depression
involve at least three mechanisms.
– First, depression is accompanied by
hypercortisolemia.
– Second, depressed individuals may develop
significant impairments in platelet function. The
combination of hypercortisolemia and enhanced
platelet function cause atherogenic changes.
– In addition, reduced heart rate and impaired vagal
control is reported among depressed patients which
may increase the chances of arrhythmias
• Unlike the difficulty in measuring type A
behavior, standardized instruments are
available to measure depression.
• This helps in detecting the condition easily,
thus making it an essential component of
overall preventive plan for heart disease
 Psychosocial work
characteristics
• ‘Stressful jobs’ contribute towards causing
coronary heart disease
• People on jobs characterized by low
control over work and high conflicting
demands might be highly strained.
• An imbalance between the effort at work
and rewards received predicts cardiac
events and has been correlated with
progression of carotid atherosclerosis
 Social network structure and
quality of social support
• Social support has a quantitative as well as a
qualitative dimension.
• The quantitative dimension includes the
presence of family members, partner status
(living alone, marital status, and /or marital
disruption), number of friends, and the extent of
one’s “social network.”
• The qualitative dimension of one’s social support
system is based on the amount of perceived
emotional support and opportunity to confide.
• Social support also plays a major role in
recovery from cardiac events and long
term prognosis
• Social support also influences the extent
to which individuals engage in high-risk
behavior such as smoking and unhealthy
dietary habits
 Psychosocial consequences of
CHD
Immediate reactions
• A heart attack not just threatens life but, as
‘metaphorically, as well as physiologically,
the heart is crucial to one’s identity and
social function’.
• A whole range of emotional reactions are
considered ‘normal’ in such circumstances.
These include aspects of shock, fear,
anger, guilt, sadness and grief.
• Sometimes, patients find it hard to adapt
psychologically to the drastically changed life
conditions. They cope with the immense distress
associated with it by using different defense
mechanisms
• These include
– denial of the disease
– regression to an earlier more childlike form of
behavior
– projection of their hostile feelings onto staff and family
members
Long term consequences
• Some patients might have persistent
psychological consequences.
• The incidence of depression after
myocardial infarction is 15-30% mostly in
the first month after the event
• Depression is associated with adverse
outcome of CHD including chances of
another coronary event and increased
mortality
• Depressed patients are known to adhere
poorly to advised behavior and life style
changes contributing to poor prognosis
• Medication adherence and cardiac
rehabilitation, routine screening and
prompt treatment of depression is highly
recommended
• Other psychological consequences include
generalized anxiety, pervasive fear and
post-traumatic stress reactions.
Effect on families
• Increase in household chores and other
responsibilities
• Families tend to become over protective
and discourage the patient from resuming
complete responsibility.
• Ongoing interpersonal difficulties or marital
discord might cause stressful situation
leading to re-infarction
 Psychosocial interventions for
CHD
• Following CHD, action needs to be taken
to reduce mortality and the risk of
subsequent cardiac events.
• The management plan, therefore, includes
drug treatments, psychological
interventions and behavioral changes
• Health education is an integral component
of any treatment plan.
• Patients should have an explanation of the
nature of their health problem and the
solutions in their own language using
simple words and avoiding medical jargon
• The socioeconomic condition of the
patients should be carefully assessed
Psychological and behavioral interventions
may include;
• Lifestyle changes
• Diet changes and weight reduction
• Physical activity
• Changes at work
• Psychotherapy
• Treatment of depression