The heart is much more than a robotic mechanical pump that beats
72 times a minute or 100,000 times a day. Much more. It is intimately involved in our experience of life and works in harmony
with the rest of the body in regulation of our responses to the world around us. It begins to flutter by the sixth week of
pregnancy. Our hearts are first formed and the last beat signals the end of life. It punctuates our most important experiences;
when we graduate from school, when we get married, when we see our first child and when we sit at the bedside as someone we
love dies.
In his book Neurocardiology Dr. Andrew Armour describes the complex network of neurons, neurotransmitters and even hormones
with which the heart sends and receives signals to and from the brain and other parts of the body. In fact in 1983 the heart
was reclassified as an endocrine gland when it was discovered that it produces a hormone called atrial natriuretic factor
or ANF. This led cardiologist Dr. Mimi Guarneri to assert that “…the ten ounce heart is much more powerful than
we ever imagined—functioning as a sensory organ, hormone-producing gland, and information processing center.”
(Guineri, 2006, p157).
We tend to think of the heartbeat as being as rhythmic and regular
as what we see on an ECG readout. That is a much simplified signal and a product of the measurement method. Actually the heart
can vary greatly from moment to moment. By measuring heart-rate variability (HRV) researchers have been able to analyze how
the heart responds to stress and emotions. They have found that negative emotions like rage and frustration lead to increased
disorder and a chaotic HRV while positive emotions such as appreciation and love produce a coherent harmonic rhythm. And it
seems other organs in the body oscillate in synchronicity with the signals the heart sends out. One emergency cardiologist
who rode regularly with heart attack patients on the way to the hospital began to have them talk about the things they loved
the most and he watched the heart rate and blood pressure fall. All this more recent evidence about the heart led Dr. Guarneri
to say: “As a cardiologist, I know that low heart-rate variability can be as impotant as cholesterol levels.”
(Guineri, 2006, p169).
Since the heart is such an integral part of the emotional life
of all patients it should be no surprise that psychologists can play an important role in prevention and treatment of CHD.
Robert Allen, who is with Cornell Medical Center
and who authored Heart and Mind: The Practice
of Cardiac Psychology, points out that conditions or psychological characteristics which tend to elevate sympathetic
reactivity and arousal promote development of atherosclerosis and psychological intervention can be of great value. He concludes
his thorough review of the literature on possible psychological intervention with CHD by recommending these goals:
- Help the patient
learn to manage their anger
- Help reduce anxiety
through such methods as Benson’s relaxation response
- Help the patient
reduce risk factors like smoking, hyperlipidemia, obesity and a sedentary lifestyle
- Help the patient
develop resiliency to depression
- Provide emotional
support particularly after a major cardiac event such as a heart attack or bypass surgery
- Help the patient
strengthen social support
- Help the patient
deal with existential and spiritual issues by exploring their life and their
values
In my own experience with older adults the first two are the easiest
to introduce to my rounds in LTC and personally I think are of greatest value. Help the patient learn to better manage anger
and to attenuate the effects of anxiety and stress.
A study involving 774 older white men (average age 60) indicated
that high hostility levels were more predictive of developing coronary heart disease than risk factors like high cholesterol,
alcohol intake, cigarette smoking. Older men with the highest levels of hostility were at the greatest risk for developing
coronary heart disease independent of the effects of BMI (body mass index), waist-to-hip ratio, fasting blood-sugar levels,
triglcyride levels, and blood pressure.
In a series of studies carried out in Japan it was discovered that older Type A men, especially those with high hostility
levels, have weaker parasympathetic nervous systems than men with low hostility levels. An effective PNS can help counter
the effects of the SNS which results in the heart working less hard and lowering the risk for developing heart disease. This
suggests that combining anger management and relaxation training can be particularly effective as complementary interventions.
The Recurrent Coronary Prevention Project (RCPP) was a 4.5 year
clinical trial aimed at reducing recurrent cardiac events in patients after they had one heart attack. One of the strategies
came to be known as the Hook. The goal was to create an immediate cognitive shift that would allow the patient to dampen arousal
and mobilize an alternative response. Patients rated the Hook as very valuable. A Hook is anything that might make the patient
angry. Hooks can include these thoughts:
· Involve
the perception that we have been victimized or harmed
· Involve
the belief that the provoking person meant to deliberately harm us
· Involve
the belief that the OTHER person was wrong and they should have behaved differently and that they were evil to harm us.
Hook themes include:
- People do not
pay enough attention to our needs; they do not care about us.
- People demand/expect
too much
- People are rude
or inconsiderate.
- People take advantage
or use us
- People are selfish;
they think only of themselves.
- People criticize,
shame, or disrespect us
- People are cruel
or mean.
- People are incompetent
or stupid.
- People are thoughtless
and irresponsible.
- People do not
help us.
- People are lazy
and refuse to do their share.
- People try to
control or manipulate us.
- People cause
us to have to wait.
It is suggested that the patient create a Hook Book. Each day
they review events and identify the Hooks, whether they bit the Hook or not. They should be specific about what was going
on when they began to notice that they were angry. What happened that gave pain or increase stress? What was the exact provocative
situation? What trigger thoughts (or themes) were going through their mind? On a scale of 0-100 how angry did they feel? What
did they do? What was the effect of their behavior on others? They share the Hook Book with the therapist.
Cardiac Psychologist Robert Allen teaches his patients a three
step anger management process:
- Identify your
hook, note it but DO NOT BITE IT. Do not express anger.
- Identify which
of the patients needs are not being met (e.g. respect or personal space)
- Find a way to
meet the need or decide to adjust to the fact that the need cannot be addressed.
By doing the Hook Book the patient learns to identify the most
common hooks. In therapy strategies can be developed to identify the underlying needs that are involved in the anger, learn
methods like deep breathing to dampen the arousal and then mobilize more constructive alternative ways to meet the need.
Dr. Herbert Benson, a Harvard cardiologist,
has made a study of the counterbalancing mechanisms of the body's stress reaction (Casey and Benson, 2004). He discovered that while the fight-or-flight response is part of the hard wired response to stress, there
is an opposite response, he called the relaxation response. The relaxation response
causes the body to calm itself. Metabolism decreases, heart rate decreases, blood pressure decreases, breathing rate decreases
and muscle tension decreases. Dr. Benson has discovered that the relaxation response
can be elicited by a number of techniques including:
- Diaphragmatic breathing
- Meditation
- Yoga
- Body scan exercise
- Mindfulness meditation
- Repetitive exercise
- Progressive muscle relaxation
- Imagery
- Repetitive prayer
There are the basic steps in learning to
elicit the relaxation response:
·
A mental focusing device, such as attending to breathing,
or repeating a word, phrase, prayer, sound, to help shift your mind from everyday worries. He suggest using the word ‘one’
or ‘calm’ as a device.
·
Tell the patient to gently direct the mind back to the mental or physical relaxation exercise when getting
caught up in a train of thought. It seems important to keep a passive attitude toward distractions.
The basic steps necessary to elicit the relaxation
response are:
Step 1:
Picking a focus word, phrase, image, or prayer.
Step 2:
Sitting quietly in a comfortable position.
Step 3:
Closing the eyes.
Step 4:
Relaxing muscles.
Step 5:
Breathing slowly and naturally repeating the focus word or phrase when exhaling.
Step 6:
It seems important to instruct the patient to not be critical of their ‘performance’ and when other thoughts
come to mind they should say: "Oh well," and gently return to the repetition.
Step 7:
Continue for ten to twenty minutes.
You may have your own well practiced methods
of doing anger management and relaxation training. While these two approaches have a lot of research support there is no reason
to think that your own variations will not be of significant value.
References
and recommended books:
Allen, R. Heart and Mind: The Practice of Cardiac Psychology, 1994, American
Psychological Association: Washington, DC.
Armour A. Neurocardiology, 1994, Oxford
University Press: USA.
Casey A. and Benson H. Mind Your Heart, 2004, Free Press: New York
Guarneri, M. The Heart Speaks, 2006, A Touchstone Book: New York
