Management of emotional distress following a myocardial infarction: a qualitative content analysis

Management of emotional distress following a myocardial infarction: a qualitative content analysis Management of emotional distress following a myocardial infarction: a qualitative content analysis

Myocardial infarction is one of the leading causes of mortality and disability worldwide. Emotional distress, such as anxiety and depression, are common among myocardial infarction patients. The aim of this study was to investigate emotional reactions following myocardial infarction and to explore how myocardial infarction patients self-manage their emotional distress using the perspective of an explanatory behavioural model of depression and anxiety. Written testimonies from ninety-two myocardial infarction patients starting an internet-based cognitive behavioural therapy were analysed using qualitative content analysis with a mixed deductive and inductive approach. Six themes were identified. The first three highlight the emotional reactions post-myocardial infarction: Hypoarousal reactions and low mood; Hyperarousal reactions; and A changed sense of self and outlook on life. The following three themes describe strategies for managing emotional distress: Avoidance of potentially rewarding situations; Avoidance of heart relevant stimuli triggering anxiety; and Engaging in potentially positive activities and acceptance. The myocardial infarction experience may trigger emotional reactions, with a particular emphasis on heart-focused anxiety, depression and a shift in the perception of one's identity. Patients tend to manage emotional distress through social withdrawal and experiential avoidance which likely maintains the distress. Applying a behavioural model to the management of emotional distress following myocardial infarction is suited.

Introduction

Cardiovascular disease and its manifestation in cardiac events like myocardial infarction is relatively common and potentially lethal. Even though the prognosis after a myocardial infarction has greatly improved over the last decades, ischaemic heart disease was in twenty nineteen still among the leading causes of mortality and the top-ranked cause of disability among persons aged greater than fifty years worldwide. Many myocardial infarction patients experience emotional distress, such as anxiety and depression, after the event. Emotional distress post myocardial infarction is in turn a risk-factor for recurrent cardiac events and mortality. Psychological interventions in cardiovascular disease have been studied in several different cardiovascular disease patient populations, with different outcomes and various treatment content. Partly due to the heterogeneity of the study methods, the results have also varied.

In the present article we explore the application of a behavioural model on emotional distress after surviving a myocardial infarction. From a learning theory perspective, depression is best explained by Lewinsohn's behaviour model of depression, which in turn expands on the works of Ferster. According to learning theory depression is related to a lack of response-contingent positive reinforcement and, avoidant behaviour, such as social withdrawal, has a central role in both the origin and maintenance of depression. According to Lewinsohn's model, depression starts with a disruption in the normal behavioural pattern leading to a change in contingent positive reinforcement. A myocardial infarction can be such a disruption. The myocardial infarction may lead to withdrawal from formerly rewarding environments and behaviours due to low mood, fear, fatigue, physiological limitations or an altered financial or social situation. This can create a viscous cycle leading to a chronic state of low mood or depression. This theory of depression has been instrumental and forms the base of the well-used behavioural activation treatment approach where patients plan and do behaviours they once found reinforcing and that they do not do otherwise.

When it comes to anxiety, learning theory has been particularly influential and successful in generating effective exposure-based cognitive behavioural therapy-labelled treatments. These treatments can be traced back to Mowrer's two-factor theory. According to this theory, anxiety or fear is first coupled with stimuli through classical, or Pavlovian, conditioning. Thereafter avoidance of the conditioned stimuli is negatively reinforced through operant conditioning. As with the case of depression, this behavioural model for anxiety is also applicable in the cardiovascular disease context. In the myocardial infarction experience serving as the unconditioned stimuli fear and anxiety are coupled with several behaviours and environments related to the cardiac event, so-called heart focused anxiety, elevated heart rate, chest pain, being far from a hospital, stress, strenuous exercise etc. Heart focused anxiety has been defined as "excessive" and selective attention, fear and avoidance of cardiac related sensations and stimuli based on their perceived negative consequences for cardiac health. The coupling is maintained through the avoidance of these activities and situations, as this prevents corrective learning and habituation. Depending on the manifestations, diagnoses such as post-traumatic stress disorder, different phobias, generalized anxiety disorder or at least subclinical indications of the same, can also be expected after a myocardial infarction. When we refer to avoidance above, it is important to state that functionally it is the emotional experience that is being avoided. Certain strategies could facilitate experiential avoidance even when the conditioned stimuli is present. Experiential avoidance, such as withdrawal, rumination, distraction and safety behaviours, is thus important in the maintenance of both depression and anxiety. Avoidance of potentially rewarding activities may lead to, or maintain, depression, and avoidance of situations that elicit an anxious response may lead to, or maintain, anxiety. To illustrate this theory in the context of myocardial infarction,

we present a behavioural model of the development of depression and anxiety after a myocardial infarction based on learning theory. There are of course many factors, potentially influencing depression and anxiety after an event like a myocardial infarction. The focus here is on learning theory.

U-CARE Heart, which is the base of the present study, was a clinical trial aiming at treating depressed and anxious myocardial infarction patients with internet-based cognitive behavioural therapy. It included two hundred thirty-nine randomized participants and the intervention was not found to be more effective than standard care. The non-significant results were expected due to the low participant activity in the treatment. The low activity further highlights the question whether the needs were assessed properly and if the assumption of emotional reactions triggered by the myocardial infarction and maintained by experiential avoidance, in line with learning theory, was correct. Previous research indicates that avoidant coping strategies are fairly common among myocardial infarction patients. In this study, this was investigated further using qualitative analysis.