UNC HOSPITALS CARDIAC REHAB PROGRAM CHAPEL HILL, NC
Turning Challenges Into Opportunities: From Surviving To Thriving
Janet Garvey Baradell, PhD, RN, CSBoard Certified, Psychiatric-Mental Health
Clinical Nurse Specialist
PSYCHOSOCIAL INTERVENTIONS
Screening tools
Psycho-education
Skills training
Social support
Individual meetings
Motivational interviewing
Referrals
Support group
Collaboration with health care providers
PSYCHOSOCIAL ASPECTS
OF HEART DISEASE FOR PATIENTS & FAMILIES:FROM SURVIVING TOTHRIVING
Janet Garvey Baradell, PhD, RN, CSBoard Certified,
Psychiatric-Mental HealthClinical Nurse Specialist
Adapted from Mayo Clinic .com
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OUTLINE
• What brings you to cardiac rehab?
• Impact of heart illness on you & your family
• Psychosocial risk factors
• Reducing your risk factors
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WHY ARE YOU HERE?
My doctor referred meMy spouse/family want me hereI want to prevent another heart eventI want to feel betterI want to reduce risk factorsI want to improve my quality of lifeI want to reduce stress
ILLNESS AND REHAB ARE STRESSFUL FOR EVERYONE IN THE FAMILY
YOU Crisis!
impact, turmoilresolution
Griefdenial, anger, bargaining,depression, acceptance
Guilt Face own mortality Fear/distrust body Stress
new demands, cost, time, role change: dependent, burden, powerless,role reversal
SPOUSE/PARTNER“Caregiver Strain “: many of the same feelings you
felt, plus hub of communication vigilant, protective role changes:
insecure about the future, new responsibilities, role reversal
Caregiver Strain IndexInconvenient, time consuming,
physically exhausting, disagreements about care, daily schedule, other family/work demands, etc.
CAREGIVER STRAIN INDEX (CSI)By M. Terry Sullivan, RN, MSW, MSN, CMC
Permission is hereby granted to reproduce this material for not-for-profit educational purposes only, providedThe Hartford Institute for Geriatric Nursing, Division of Nursing, New York University is cited as the source.
Available on the internet at www.hartfordign.org. E-mail notification of usage to: [email protected].
• Sleep is disturbed• Inconvenient• Physical strain• Confining• Family adjustments• Change in personal
plans
• Demands on my time• Emotional adjustments• Behavior is upsetting• Upset by changes from
his/her former self• Work adjustments• Financial strain• Feel overwhelmed
REACTIONS: FAMILY & FRIENDS
May be : helpful or disappointing clingy, withdrawn,
indifferent afraid
of what they don’t understand
to ask questions
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WHICH PSYCHOSOCIAL ISSUES ARE RELEVANT FOR HEART PATIENTS?
Smoking>PSYCHOSOCIAL RISK FACTORS>Hypertension>Obesity>Sedentary, etc.
Psychiatric ProblemsDepressionAnxiety
Personality TraitsType A Behavior PatternType D Behavior Pattern
Stress
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20-40% OF HEART PATIENTS WILL EXPERIENCE DEPRESSION OR ANXIETY
DepressionAnxiety
Neurologic Disorders
10-20%Cancer10-20%
Chronic Pain
40-60%
Heart Disease20-40%
Diabetes 10-20%
SubstanceDisorders
20-40%
www.apm.org/unutzger
PSYCHIATRIC PROBLEMSPozuelo, L. et al. 2009 Cleveland Clinic Journal Of Medicine. 76(1), 59-70. McGrady
A, McGinnis R, Badenhop D, Bentle M, Rajput M. Journal of Cardiopulmonary Rehabilitation and Prevention. 2009;29:358-364.
Depression and Anxiety reduce adherence to cardiac rehab
prescriptions
exercise, meds, nutrition, smoking cessation, stress management
increase the likelihood of not completing rehab
Over the last 2 weeks, how often have you been bothered by any of the following problems? (Circle your response.)
1. Little interest or pleasure in doing thing? 0 1 2 3
2. Feeling down, depressed, or hopeless? 0 1 2 3
3. Trouble falling or staying asleep, or sleeping too much?
0 1 2 3
4. Feeling tired or having little energy? 0 1 2 3
5. Poor appetite or overeating? 0 1 2 3
6. Feeling bad about yourself – or that you area failure or have let yourself or your family down?
0 1 2 3
7. Trouble concentrating on things, such as reading the newspaper or watching television?
0 1 2 3
8. Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?
0 1 2 3
9. Thoughts that you would be better off dead, or of hurting yourself in some way?
0 1 2 3
10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all _____ Somewhat difficult _____ Very difficult _____Extremely difficult______
PATIENT HEALTH QUESTIONNAIRE: Depression
Adapted from PRIMEMD, developed by Drs. R.L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. ©1999 Pfizer Inc. Used with permission by Dr. Kurt Kroenke, MD Nov. 15, 2009.
WNL (0-4) Mild (5-9)
Moderate (10-14)
Moderately severe (15-19)
Severe (20-27)
Over the last 2 weeks, how often have you been bothered by any of the following problems? (Circle your response.)
1. Feeling nervous, anxious or on edge 0 1 2 3
2. Not being able to stop or control worrying 0 1 2 3
3. Worrying too much about different things 0 1 2 3
4. Having trouble relaxing 0 1 2 3
5. Being so restless that it is hard to sit still 0 1 2 3
6. Becoming easily annoyed or irritable 0 1 2 3
7. Feeling afraid as if something awful might happen 0 1 2 3
8. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Not difficult at all _____ Somewhat difficult _____ Very difficult _____Extremely difficult______
PATIENT HEALTH QUESTIONNAIRE: Anxiety
Adapted from PRIMEMD, developed by Drs. R.L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. ©1999 Pfizer Inc. Used with permission by Dr. Kurt Kroenke, MD Nov. 15, 2009.
WNL (0-4) Mild (5-9)
Moderate (10-14)
Severe (15-21)
NO YES1. Do you ever drink alcohol (including beer or wine)? [ ]
[ ]
2. Have any of the following happened to you more than once in the last 6 months? NOYES
a. You drank alcohol even though a doctor suggested that you stop drinking because of a problem with your health [ ]
[ ] b. You drank alcohol, were high from alcohol, or hung over while you were working, going to school, or taking care of children or other responsibilities [ ] [ ] c. You missed or were late for work, school, or other activities because you were drinking or hung over [ ]
[ ] d. You had a problem getting along with other people while you were drinking [ ] [ ] e. You drove a car after having several drinks or after drinking too much [ ]
[ ]
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?
Not difficult at all _____ Somewhat difficult _____ Very difficult _____Extremely difficult______
PATIENT HEALTH QUESTIONNAIRE: Alcohol
Adapted from PRIMEMD, developed by Drs. R.L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. ©1999 Pfizer Inc. Used with permission by Dr. Kurt Kroenke, MD Nov. 15, 2009.
WNL (0)
"Yes" to any item 2 a -e
is suggestive of abuse
ADDITIONAL QUESTIONS
What is the most stressful thing in your life right now?__________________________________________________________________________________________________________________________________________________________________
NO YES
Are you taking any medicine for anxiety, depression or stress? [ ] [ ]
Are you seeing a pastor, therapist, counselor, or psychiatrist for psychotherapy or stress management? [ ] [ ]
Adapted from PRIMEMD, developed by Drs. R.L. Spitzer, Kurt Kroenke, and Janet B.W. Williams. ©1999 Pfizer Inc. Used with permission by Dr. Kurt Kroenke, MD Nov. 15, 2009.
Suicide Inquiry (use along with SAFE-T)http://www.stopasuicide.org/downloads/Sites/Docs/SAFE-T_One_Page_Final.pdf
I noticed that you answered "Yes" to question # 9 on the screening questionnaire regarding thoughts about ending your life. I am concerned about you.
• Ideation: Are you having these thoughts now? Have you had thoughts like this before? (If yes,) Tell me about that. How has your heart problem changed how you feel about living vs. dying?
• Plan: How did you think you might end your life? When did you plan to end your life?
Do you have _____ (whatever the means were – gun, drugs, hanging, knives)• Intent: How likely are you to carry out your plan to end your life? What might be some reasons to go on living?
family, friends, faith, pets, work, anyone who relies on this person, belief that things can get better, any significant relationship or person who cares about this person, including you How do you think this might affect your ______ (spouse, child, friend, etc.?) In my experience, this is a tragedy, very hard on those who love/care about you. I would be very sad if you ended your life…
I would be devastated.• Go to Risk Level/Intervention and follow guidelines for Level of Risk based on your
judgment.
ACCESSING MENTAL HEALTH SERVICES
If psychotherapists are not available in your community, some suggestions are:
• To access public mental health services in each county, AS OF JANUARY 2011
http://www.ncdhhs.gov/mhddsas/lmedirectory.htm• Mental health providers – volunteer support group leader• Self help groups: AA, NA, AlAnon, OA, Depression and
Bipolar Support Groups, Compassionate Friends, Survivors of Suicide
• Online sites: Mayo Clinic, NIMH, http://www.mayoclinic.com/health/DiseasesIndex/DiseasesIndex http://www.nimh.nih.gov/index.shtml http://www.adaa.org/
• Meditation groups
PERSONALITY TRAITS: COPING STYLESRazzini et al., 2008
Personality TraitsType A (Angry) Behavior Pattern:
driven, perfectionist, multitask, time pressure/deadlines, competitive
hostile, critical and unhappy with othersType D (DISTRESSED) Behavior Pattern:
Negative emotions, like anger, in response to multiple situations and over time
social isolation to avoid experiencing negative emotions that arise in social interaction
Seen in 28% of coronary artery disease patients and 53% of hypertensive patients!!
Has a seven-fold increased risk of sudden, cardiac death
“STRESS”: LIFE EVENTSBaradell, J. Abbreviated Daily Hassles Scale. 1988; Lazarus & Folkman, 1984
Stress is anything that makes a demand on you:caused by internal or external demands
Internal Thoughts/Feelings – self generated pressure to return to work, provide care for others, be perfect, unrealistic expectations about time or effort necessary to recover or helplessness, hopelessness, despair
External stresses: time pressure /deadlines for work, school or family obligations, traffic, crime, weather
caused by positive or negative eventsPositive: births, weddings, graduations, pay raise,
promotion, new homeNegative: finances, work, marital conflicts, health problems,
death, divorce Accumulates over a lifetime
STRESSERSStress in America survey in
August by Harris Interactive for the American Psychological Association
The adults surveyed said that stress affected behavior and often had physical consequences:
• •31% say they skipped a meal.
• •40% say they overate or ate unhealthy foods.
• •44% say they lay awake at night.
http://www.usatoday.com/yourlife/health/medical/mentalhealth/2010-11-09-
apastress09_VA1_N.htmaccessed 11-10-10
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WHY ARE PSYCHOSOCIAL RISK FACTORS RISKY??? Pozuelo, et al., 2009; Razzini et al., 2008; Blumenthal, 2008; Jiang, 2008; Parissis et al.,
2007Carney, et al., 2004
Body seeks homeostasis: balance in level of arousal and relaxation
“Stress” activates the Fight or Flight Response: a defensive response that disrupts homeostasis
After stress subsides, relaxation restores homeostasis Not all stresses must induce Flight or Flight Response Chronic stress causes
hyper-arousal of the Sympathetic Nervous System, and
impairment of the Parasympathetic Nervous system to produce relaxation resulting in feeling “switched on” or “keyed up”
Stress contributes to the development of Coronary Artery Disease Endothelial Disease - a systemic disease that damages the lining of arteries
“FIGHT OR FLIGHT” RESPONSE Sympathetic Nervous System The Stress of Life (Selye, 1956, 1976, 1984)
Physical Impact Increases:
heart rate, BP, force of contraction rapid, shallow breathing blood sugar, triglycerides &
cholesterol sodium and water retention muscle tension clotting belly fat
Psychological Impact Alert Fearful Rapid thinking with impaired
memory Expect the worst Freeze
Sympathetic Nervous SystemBody reacts to stress by activating the HPA Axis:
Parasympathetic Nervous System: stimulation of Vagus nerve produces relaxation/homeostasis
PROGRESSION OF CADhttp://www.heartsite.com/html/cad.html
Normal coronary artery Fatty streaksFatty streaks begin to interfere with blood flow
Fibers encase fatty streakscreating plaque; inflammation
Ruptured plaque andclot formation
Clot continues to grow,blocking artery – Heart Attack
AN INFLAMMATORY PROCESS
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EFFECTIVE TREATMENTS FOR HEART PATIENTS
Pozuelo, et al., 2009; Blumenthal, 2008; Jiang, 2008; Manzoni, et al., 2008; Razzini et al., 2008; Parissis et al., 2007; Carney, et al., 2004
• Exercise: may be the most effective at reducing all risk factors, as well as, reducing depression
• Stress Management, including relaxation training or meditation: reverses “Fight or Flight”, may reduce inflammation, and platelet stickiness – all protective
• Antidepressants: SSRI’s citalopram (Celexa) and sertraline (Zoloft); mirtazapine (Remeron) was not effective in treatment of depression in heart patients
• Psychotherapy: effective in reducing depression and anxiety and improving quality of life , has not consistently shown reduced mortality
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Relaxation Training for Anxiety: A Ten-Years Systematic Review With Meta-Analysis
Gian Mauro Manzoni; Francesco Pagnini; Gianluca Castelnuovo; Enrico Molinari BMC Psychiatry. 2008; ©2008 Manzoni et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited.
• Progressive relaxation and meditation are effective in reducing anxiety (ES: Progressive Relaxation=.8 and meditation=.7, high effect)
• Homework practice improves effectiveness
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RELAXATION – RESTORES HOMEOSTASISby stimulating the Parasympathetic Nervous System
Diaphragmatic Breathing
Passive MindProgressive
Muscle Relaxation
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RELAXATION CD5 Tracks With Instructions:• Mindful Breathing - 3 minutes
Practice Mindful Breathing several times a day: mid-morning and mid-afternoon and anytime you notice negative emotions like anger or impatience; feel “fight/flight/freeze” sensations or notice rapid thinking or negative thinking (judging self or others, replaying an event, worrying about a future event, creating a story in your head about a future event – as if it were TRUE)
• Progressive Relaxation and Mindfulness MeditationPractice twice a day for 2 weeks, using 1 of these tracks, then once a day – morning practice seems most beneficial– Mindful Relaxation with Imagery - 9 minutes– Progressive Relaxation - 12 minutes– Progressive Relaxation -13 minutes– Mindfulness Meditation – 20 minutes
Mindfulness Meditation classes: Program on Integrative Medicine @ UNC-Chapel Hill: http://pim.med.unc.edu/ or call 966-8586
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STRESS MANAGEMENT STRATEGIESSTRESS MANAGEMENT STRATEGIES An Active Partnership for the Health of Your Heart (AHA & ASA)An Active Partnership for the Health of Your Heart (AHA & ASA) https://www.krames.com/OA_HTML/ActivePartnership.html#TabTop
Consider priorities Avoid unnecessary stress:
do I own it? Adapt
change the way you think or feel to reduce your suffering; get socially involved; Job redesign, transfer, or change; family communication, compromise, negotiate
Accept things you can’t change
acceptance doesn’t mean agreement
Self Actualization: lack of prejudice, creative, spontaneous, acceptance of reality, problem solving
Esteem: confidence, achievement, self respect;
respect of others
Love/Belonging: family, friends, sexuality
Security: physical and emotional safety; job/school;
adequate finances; family and social connections; organize to meet priorities; home
maintenance
Physiological: smoking cessation; exercise 5-6 times a
week for 45-60 minutes; practice daily relaxation or meditation; sleep; medications;
nutrition & alcohol
Goal: MET level ≥ 8
(Maslow adapted)
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ANGER MANAGEMENT
ANGER KILLS!
Count to 10, Breathe Think before you act – what am I angry
about? Talk it out – seated, no raised voices;
say what the problem is & how you feel; ask for what you want; compromise
If you aren’t able talk it out, get away & cool off; then, get back together
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ALCOHOL GUIDELINES
IF YOU DRINK: Men: up to 2 drinks per day Women: 1 drink per day 1 Drink = 1 oz hard liquor;
4-5 oz wine (about ½ cup); 12 oz beer
WHY? interacts with medications:
eliminating them more rapidly or slowly increases risk of bleeding causes or worsens fatigue, insomnia, anxiety & depression
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SOCIAL SUPPORTCompanions and Lovers
Sexual relations, with a committedpartner allows you to feel “normal” Ask your doctor when it’s safe Orgasm is within 80% THRR To reduce workload:
non-cardiac spouse on top use side-lying or seated positions 2 hrs after meal
When in doubt about sexual function, try it out – in private
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SOCIAL SUPPORT
Health
care
teamCardiac
Rehab
Cardiac Survivors
Support Group
Volunteering
Grocery
Store
Senior
Center
Church
Exercise
Group Garden
Club
Meditation
Group
Pets
AA
OA
NA
Prayer
Group
Parents
Siblings
Neighbors
Coworkers
Friends
Spouse
Children
You
HELPFUL REFERENCESFull Catastrophe Living. 1990, Jon Kabat Zinn. PhD.
Dr. Dean Ornish’s Program for Reversing Heart Disease. 1990, Dean Ornish, MD.
10 Simple Solutions to Stress: How to Tame Tension & Start Enjoying Your Life. 2007, Claire M. Wheeler, MD, PhD.
Instant Calm: Over 100 Easy-to-Use Techniques for Relaxing Mind and Body. 1995, Paul Wilson.
Motivational Interviewing: Preparing People for Change, 2nd ed. 2002, William Miller, PhD and Stephen Rollnick, PhD.
Motivational Interviewing in Health Settings: A Review. Britt, E. Hudson, S. Blampied, N. Patient Education and Counseling, 53 (2004) 147-155.(full text was online)