Mr. W, age 51, received an implantable cardioverter defibrillator (ICD) after a diagnosis of ventricular tachycardia. He has lived more than 2 years without an ICD discharge and had been functioning well.
One evening, while watching his favorite football team lose a close, intense game on television, Mr. W receives his first ICD “shock.” He becomes extremely anxious and immediately associates the shock with the anger and frustration he was feeling while watching the game. He also suspects he might have caused the shock by using the remote control to change channels when he realized his team would lose.
Anxiety, depression, and feeling a “loss of control” are common among ICD patients. Although the devices provide cardiac patients with a better quality of life than the use of antiarrhythmia drugs,1 ICD recipients may live in fear of receiving a powerful shock at any moment.
This article explains how to break the “fear of fear” cycle that causes ICD patients to avoid activities they associate with ICD activation. To help you preserve ICD patients’ functioning, we describe:
- common psychiatric symptoms in ICD recipients
- when and how to assess for ICD-related anxiety
- cognitive-behavioral and pharmacotherapeutic options.
A psychological jolt
An ICD acts to prevent sudden cardiac death (Box 1)2-7 when a patient develops a sustained, potentially life-threatening arrhythmia. The device restores normal cardiac rhythm by delivering high-energy electrical pulses (shocks) to the appropriate chamber in the patient’s heart (Box 2).
Patients usually perceive ICD shocks as painful and unpleasant, which can cause fear, anger, anxiety, helplessness, and depression.8-11 The ICD recipient’s cardiac status, history of psychiatric illness, and other factors increase the risk of experiencing these symptoms (Table 1).8,9
Undergoing the implantation of an ICD may cause patients to feel a loss of personal, social, and material resources. The higher the ICD recipient’s sense of loss of financial or physical well-being, the higher the risk of depression and anxiety.9
Inadequate social support, poor physical functioning, a
history of depression, and greater length of time
since ICD implantation also may contribute
to emotional distress.9
Besides having undergone cardiac surgery, patients with newly implanted ICDs face other stressors, including:
- expensive medical bills
- possible disability
- driving restrictions.
Patients’ personal relationships may become strained because of changes in their ability to maintain previous physical, social, and sexual activity. Depression or anxiety can cause patients to be withdrawn or irritable.
Some ICD recipients become concerned with body image because the silhouette of the device may be visible under the skin. After ICD implantation, patients may become more aware that they may experience life-threatening arrhythmias.
Finally—and perhaps most important to the patient and psychiatrist—a recipient might be constantly afraid that the device is about to deliver a shock.8
Sudden cardiac death: ICDs are first-line prevention
Sudden cardiac death (SCD)—one of the leading causes of mortality in the United States2,3—is an unexpected death from cardiac causes that occurs in ≤1 hour. Causes include ventricular tachycardia, ventricular fibrillation, and bradycardia. Most SCD victims have coronary artery disease.2
Each year approximately 330,000 people die from SCD outside a hospital or emergency department.2 The incidence increases with age and is higher in men than women and in African-Americans than Caucasians.3
Implantable cardioverter defibrillators (ICDs) are a first-line prophylactic therapy for patients at risk for SCD.4,5 Annual ICD implants increased by 11-fold from 1990 to 2000, and this trend continues as the U.S. population ages.6 ICDs prevent sudden cardiac death in >90% of cardiac rhythm disturbances.7
Table 1
5 risk factors for ICD-related psychiatric symptoms
| Age <50 years |
| Limited social support |
| Poor cardiac status |
| History of psychiatric illness |
| Receiving frequent ICD discharges |
| Source: References 8,9 |
Fear impairs functioning
Experiencing an ICD discharge can affect patients’ appraisal of their situation and impair functioning.
CASE CONTINUED: Anxiety leads to avoidance
After receiving the ICD shock, Mr. W stops watching his favorite teams on television. He later ceases viewing sporting events, and over the next several months stops watching television altogether.
Mr. W continues to experience severe anxiety and ruminates about potential shocks. He believes that as long as he avoids becoming “excited” he can reduce his risk of shock. He comes to believe that his avoidance accounts for the absence of subsequent shocks and therefore continues to alter his lifestyle. Mr. W begins to eliminate other behaviors, including sex and exercise, that he fears might induce an ICD shock.
Avoiding activities. After receiving a shock, patients often develop fear that causes them to avoid the activity they were doing when the discharge occurred. This classical conditioning process often leads patients to continually avoid the activity, which may reduce anxiety but is negatively reinforcing (operant conditioning).