PTSD and Automatic Implantable Cardioverter Defibrillators

Received April 4, 1997; revised July 6, 1997; accepted July 30, 1997. From the Department of Psychiatry, Medical University of South Carolina, Charleston; and the Ralph H. Johnson Veterans Affairs Medical Center (VAMC), Charleston, South Carolina. Address correspondence and reprint requests to Dr. Hamner, 116 Mental Health, VAMC, 109 Bee Street, Charleston, SC 19401. Copyright 1999 The Academy of Psychosomatic Medicine. Automatic implantable cardioverter defibrillators (AICDs) are indicated for patients with malignant ventricular arrhythmias that have been refractory to medical management. AICDs have been used in more than 34,000 patients with refractory arrhythmias. AICDsmonitor for arrhythmias and deliver an electric shock to the heart for cardioversion or defibrillation if a ventricular tachycardia or fibrillation occurs. These shocks may be uncomfortable or disturbing to patients. Psychiatric syndromes, including anxiety and depression, have been described in patients with AICDs, with important implications for clinical management. In addition to contributing to decreased psychosocial functioning, anxiety and depressive symptoms may increase risk for recurrent arrhythmias in AICD patients. Moreover, quality of life is more likely to be significantly lower in patients with comorbid anxiety and depression. Although literature reports on psychiatric sequelae of AICDs have documented a high occurrence of depressive and anxiety syndromes, to our knowledge there has been relatively limited mention of posttraumatic stress disorder (PTSD) per se in association with AICDs. Fricchione and colleagues noted that in some severe cases, a PTSD episode characterized by reliving of traumatic events (in this case arrhythmias, resuscitation, and defibrillator shocks) through flashbacks or nightmares may develop. Patients may make major efforts to avoid similar situations, occasionally resulting in physiological hyperarousal. The possible occurrence of PTSD features is also noted in a review of psychiatric aspects of AICDs. Systematic assessment of PTSD symptoms has not, to our knowledge, been reported. The heart disease and/or activation of the AICD may meet criteria for a psychologically traumatic stressor, and some case reports in the literature suggest PTSD symptoms, for example, cognitive preoccupation with the trauma or psychological or physiological reactivity on exposure to reminders of the AICD and heart disease (DSM-IV PTSD Cluster B: reexperiencing symptoms); avoidance of activities or situations that may activate the AICD (Cluster C: avoidance symptoms); and a variety of increased arousal symptoms, for example, insomnia, difficulty concentrating, hypervigilance, irritability (Cluster D: increased arousal symptoms). Furthermore, the discomfort or shock associated with AICD activation, and in some patients the associated constriction of activities, is reminiscent of the animal model of learned helplessness, which has been advanced as a model for human PTSD. The following patients all met criteria for PTSD based on DSM-IV. Identifying PTSD in AICD patients may be important in determining who is at risk for developing psychiatric symptoms; helping with treatment interventions (based on strategies found useful in other trauma populations); and enhancing our theoretical understanding of the interactions among heart disease, AICDs, and psychological stress.