Cardiac-disease-induced PTSD (CDI-PTSD): A systematic review

Highlights

• CDI-PTSD is both conceptually and empirically a valid diagnostic entity.

• CDI-PTSD prevalence is highly dependent on the assessment tool used.

• There is a lack of knowledge in the field regarding diagnoses other than acute coronary syndrome.

• There is a lack of information regarding CDI-PTSD among patients' caregivers.

• There is a lack of data regarding therapeutic interventions for CDI-PTSD.

Abstract

The goal of the current systematic review was to provide an overview of the findings in the field of Cardiac-Disease-Induced Posttraumatic Stress Disorder (CDI-PTSD) in order to establish CDI-PTSD as a valid diagnostic entity for a wide spectrum of cardiac diseases and related medical procedures. In accordance with PRISMA guidelines, we conducted a systematic electronic literature search. Of the 3202 citations identified, 150 studies meeting the selection criteria were reviewed. Our main findings were that the prevalence of CDI-PTSD ranged between 0% and 38% (averaging at 12%) and was highly dependent on the assessment tool used. The most consistent risk factors are of a psychological nature (e.g., pre-morbid distress). The consequences of CDI-PTSD range from psychosocial difficulties to lack of adherence and heightened mortality rates. Much inconsistency in the field was found with regard to patients who present with diagnoses other than acute coronary syndrome (e.g., cardiac arrest) and who undergo potentially traumatic medical procedures (e.g., defibrillator implantation). Yet the current review seems to strengthen the conceptualization of CDI-PTSD as a valid diagnostic entity, at least with regard to acute cardiac events.

Introduction

Cardiovascular disease (CVD) is a leading cause of death worldwide (Centers for Disease Control and Prevention, 2016). The number of non-institutionalized adults with diagnosed heart disease in the United States alone is 26.6 million (Blackwell, Lucas, & Clarke, 2014), of whom more than 17 million survived an acute coronary event (Edmondson, 2014).

Among cardiac diseases, the most frequent type is ischemic heart disease (IHD), which is precipitated by coronary artery disease (CAD). CAD causes diminished blood flow to the myocardium (Walker & Lorimer, 2004). When the myocardium receives insufficient blood supply it can result in myocardial ischemia, leading to acute coronary syndrome [ACS; i.e., myocardial infarction (MI) and unstable angina (UA)] and even sudden cardiac arrest (SCA). The most common treatments are catheterization (PTA: percutaneous transluminal angioplasty or PCI: percutaneous coronary intervention); heart surgery (CABG: coronary artery bypass graft); and implantation of a pacemaker or ICD (implantable cardioverter defibrillator)¹ (Falvo, 2014).

Among life-threatening illnesses, cardiac events – and especially ACS – seem to consist of unique traumatizing characteristics. Among these features are the abruptness of the event, the concrete danger of death, and the patients' intense sense of loss of control and helplessness during the event (Kutz, Shabtai, Solomon, Neumann, & David, 1994). Alonzo (2000) adds that the intrusive experience of the treatments – such as coronary surgery, angioplasty, angiography, pacemaker implantation, stress testing and even the side effects of medications – can also be potentially traumatic events leading to the development of posttraumatic stress disorder (PTSD). In addition, although survival rates from cardiac disease are growing, it is still perceived as a significant threat to one's life. Consequently, it gives rise to intense emotional reactions such as fear or anxiety (of dying or recurrence), anger, sadness, and grief (Fisher & Collins, 2012) as well as PTSD.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) defines posttraumatic stress disorder (PTSD) as a trauma- and stressor-related disorder precipitated by a traumatic event and characterized by symptoms of re-experiencing the trauma, avoidance, negative cognitions and mood, and arousal, which cause significant distress and functional impairment. The diagnosis of PTSD requires at least one month of continuous symptoms following exposure to a traumatic event. Posttraumatic stress symptoms experienced within the first month of the traumatic event are classified as acute stress disorder (ASD), which presents with a similar clinical picture characterized by intrusion, negative mood, dissociation, avoidance, and arousal (APA, 2013). The inclusion in the fourth edition of the DSM (DSM-IV; APA, 1994) of a life-threatening disease as a potentially traumatic event that might trigger the onset of PTSD prompted a new area of research that pointed to the emergence of PTSD in the aftermath of a cardiac event.

The first evidence of CDI-PTSD was reported by Kutz, Garb, and David (1988), who presented four cases of patients who developed posttraumatic symptoms after a myocardial infarction. Since then, the issue of CDI-PTSD has attracted a great deal of attention, and many studies have examined its prevalence, stability and risk factors as well as its psychological and physiological consequences. The results of these studies have been summarized in review papers and one meta-analysis (e.g., Edmondson, 2014, Edmondson et al., 2012, Edmondson et al., 2012, Gander and von Känel, 2006, Spindler and Pedersen, 2005, Tedstone and Tarrier, 2003).

Yet alongside the growth of research in this area, a contrary trend –which questions the classification of a life-threatening illness as a traumatic event – has begun to emerge. This opposing perspective has been most vigorously manifested in the reservation added to the recent revision of the DSM (DSM-5; APA, 2013) which states that “a life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event” (DSM-5; APA, 2013, p. 274) which qualifies as a Criterion A for PTSD. As some illnesses and medical procedures may be considered stressors rather than “traumatizers,” the DSM-5 indicates that the distress they evoke should be diagnosed as an adjustment disorder (DSM-5; APA, 2013) rather than as PTSD.

This position calls into question the validity of the CDI-PTSD diagnosis. Therefore, the main goal of the current review is to establish the validity of this diagnostic entity for a wide spectrum of cardiac diseases and related medical procedures, as well as to pinpoint CDI-PTSD's unique characteristics. In order to achieve these goals, the accumulated empirical evidence regarding CDI-PTSD was examined and compared with the features of PTSD resulting from “traditional” Criterion A events. This comparison of observable data enabled the detection of whether the empirical findings accumulated thus far in the field of CDI-PTSD create a convincing enough “nomological net” (Cronbach & Meehl, 1955) for CDI-PTSD to be accurately regarded as a diagnostic entity. Finally, based on the knowledge from other research fields of trauma and illness, an additional aim was to identify topics which are missing from the existing research in the field.

In this review we cover a wide range of cardiac-related-diseases and procedures: myocardial infarction (MI), coronary artery bypass graft (CABG), implantable cardioverter defibrillator (ICD), cardiovascular disease (CVD), coronary artery disease (CAD), acute coronary syndrome (ACS), heart transplantation (HT) cardiac arrest and heart failure. This review includes all of the publications of empirical studies and reviews that we could find on the subject: the first one dating from the year 1988 (Kutz et al., 1988) and the last one from the end of the calendar year 2015. Our review covers relevant issues related to CDI-PTSD, including frequency, stability over time, risk factors, psychological and physiological reactions, psychological interventions, and the experience of patients' family members.