The Connectted Heart: Biopsychosocial Approaches to Cardiac Disease Presentation Kaiser Santa Rosa Cardiology
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This presentation explores the risk factors of heart disease and developing skills to address those risk factors. The presentation connects from biology to psychology and addresses life time risk.
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The Connectted Heart: Biopsychosocial Approaches to Cardiac Disease Presentation Kaiser Santa Rosa Cardiology
- 1. THE CONNECTED HEARTTHE CONNECTED HEART Treating the Whole PersonTreating the Whole Person B. Sue Stephenson,MD,B. Sue Stephenson,MD, Michael Changaris, Psy.D.Michael Changaris, Psy.D. Dorothy Mandel, Ph.D.Dorothy Mandel, Ph.D. Maureen Harrington, SEP. CMT.Maureen Harrington, SEP. CMT.
- 2. WHY?WHY? • Better outcomesBetter outcomes • Evidence-basedEvidence-based • Consumer demand/patient satisfactionConsumer demand/patient satisfaction
- 3. TOPICS • Non-traditional risk factors for CVD • Allostatic load • Mechanisms for increased risk • Interventions and resiliency • Consequences of CVD • Teach your patients about these factors • Foster healing relationship with patients (bidirectional) • Resources • Framework for placing future information
- 4. THETHE “OTHER”“OTHER” RISK FACTORSRISK FACTORS • DepressionDepression • Personality / Coping StylePersonality / Coping Style • Chronic stress /Chronic stress / “Burnout”“Burnout” • Chronic sleep deprivationChronic sleep deprivation • Post traumatic stress disorder (PTSD)Post traumatic stress disorder (PTSD) • Generalized anxiety disorder (GAD)Generalized anxiety disorder (GAD) • Chronic fatigue syndrome (CFS)Chronic fatigue syndrome (CFS) • Chronic pain/fibromyalgia (FM)Chronic pain/fibromyalgia (FM) • Socioeconomic status (SES) / Social FactorsSocioeconomic status (SES) / Social Factors
- 5. FOR INSTANCE:FOR INSTANCE: Mental Health and TheMental Health and The HeartHeart • Depression predicts all cause mortality includingDepression predicts all cause mortality including CVD.CVD. • Anxiety, phobic symptoms, low SES, work stressAnxiety, phobic symptoms, low SES, work stress predict CVD.predict CVD. • GAD is associated withGAD is associated with all cause mortalityall cause mortality • There is a strongThere is a strong association betweenassociation between PTSD and cardiovascular/pulmonary diseases.PTSD and cardiovascular/pulmonary diseases.
- 6. Time frame of risksTime frame of risks Across the LifespanAcross the Lifespan • In uteroIn utero • ChildhoodChildhood • Young adultYoung adult • AdultAdult • SeniorSenior
- 7. CONCEPT: Allostatic LoadCONCEPT: Allostatic Load • Allostatic load is a term used to describe theAllostatic load is a term used to describe the energetic cost of an organism needed toenergetic cost of an organism needed to maintain homeostasis.maintain homeostasis. • Under high- or chronic stress allostatic loadUnder high- or chronic stress allostatic load increases, reducing the bodyincreases, reducing the body’s ability to’s ability to engage its normal restorative processes.engage its normal restorative processes. • High allostatic load is a major pathway toHigh allostatic load is a major pathway to illness.illness.
- 8. Allostatic Load MeasurementAllostatic Load Measurement Allostatic load battery in CARDIA study: taps into ANS,Allostatic load battery in CARDIA study: taps into ANS, HPA, inflammation, metabolic fx, cardiovascular fxHPA, inflammation, metabolic fx, cardiovascular fx • 12hr overnight urine for norepinephrine, epinephrine,12hr overnight urine for norepinephrine, epinephrine, free cortisolfree cortisol • Saliva cortisol levelsSaliva cortisol levels • Blood: Total and HDL cholesterol, glycosylatedBlood: Total and HDL cholesterol, glycosylated hemoglobinhemoglobin • IL-6, CRP, fibrinogenIL-6, CRP, fibrinogen • Waist-hip ratioWaist-hip ratio • Systolic and diastolic BP - seated/restingSystolic and diastolic BP - seated/resting • Heart rate variabilityHeart rate variability
- 10. MECHANISMSMECHANISMS Pathways through which CVD can occur and throughPathways through which CVD can occur and through which emotional interventions can improve outcome…which emotional interventions can improve outcome… • InflammationInflammation • Cortisol: diurnal variation, etcCortisol: diurnal variation, etc • Oxytocin (OT)Oxytocin (OT) • ANS balance, heart rate variability (HRV)ANS balance, heart rate variability (HRV) • Platelet reactivity/activationPlatelet reactivity/activation • NONO • Others…Others…
- 11. Inflammatory Response Inflammatory Response CortisolCortisol OxytocinOxytocin ANS Balance And HRV ANS Balance And HRV Depression GAD PTSD Life StressCoping Style Adverse Childhood Events Personality Chronic Pain Social Support Poor Sleep Heart Disease
- 12. MECHANISMS: InflammationMECHANISMS: Inflammation • Inflammatory markers relate to prospectiveInflammatory markers relate to prospective cardiovascular risks. [1]cardiovascular risks. [1] • IL-6, IL-1, hs-CRP, NO, TNF–Alpha: all Related toIL-6, IL-1, hs-CRP, NO, TNF–Alpha: all Related to increased risk of CVD.increased risk of CVD. • Chronic work stress association with CVD (likelyChronic work stress association with CVD (likely mediated in part by acute inflammatory response).mediated in part by acute inflammatory response). • Relationship between depression and inflammatoryRelationship between depression and inflammatory response may be bi-directional.response may be bi-directional.
- 13. MECHANISMS:MECHANISMS: Effects of Poor SleepEffects of Poor Sleep • High plasma IL6 and D-dimer levels. [5]High plasma IL6 and D-dimer levels. [5] • Increased evening cortisol levels. [10]Increased evening cortisol levels. [10] • Increased sympathetic nervous system activity.Increased sympathetic nervous system activity. [10][10] • Glucose intoleranceGlucose intolerance
- 14. MECHANISMS: MECHANISMS: Personality/Hostility Personality/Hostility • HostilityHostility is associatedis associated with increasedwith increased platelet reactivityplatelet reactivity (a key pathophysiologic pathway in the onset of (a key pathophysiologic pathway in the onset of CVD events). [15]CVD events). [15] • Antagonistic individualsAntagonistic individuals, especially those who, especially those who are manipulative and aggressive have are manipulative and aggressive have greatergreater increases inincreases in arterial thickeningarterial thickening. [19]. [19]
- 15. OT is a Cardiovascular Hormone • Synthesized in the heart and large vessels • OT receptors are found in all heart compartments and vasculature • Mediates ANP, BNP, and a variety of other cardiac regulatory processes. • Also involved in cognition, tolerance, adaptation and complex sexual and maternal behavior
- 16. Increased OT Promotes: • Natriuresis and blood pressure reduction through ANP/BNP modulation • Parasympathetic neuromodulation • Vasodilatation • Anti-inflammatory activity (Journal of the American Society of Hypertension Vol 2, Issue 5 318-325)
- 17. OT in Cardiac Healing OT infusion resulted in: • Diminished cell apoptosis and fibrotic deposits in the remote myocardium • Suppression of inflammation by reduction of neutrophils, macrophages and T lymphocyte • Decreased expression of proinflammatory cytokines, tumor necrosis factor-alpha ,and interleukin-6 • Promotion of transforming growth factor-beta • These results indicate that continuous OT delivery reduces inflammation and apoptosis in infarcted and remote myocardium, thus improving function in the injured heart. Basic Res Cardiol. 2010 Mar;105(2):205-18. Epub 2009 Dec 12.
- 18. OT: An Anti-Stress Effect • Exogenous oxytocin causes: • Lowered blood pressure • Decreased cortisol levels • Increased withdrawal latency (pain tolerance) • Increased release of vagally controlled gastrointestinal hormones (digestion) • Together, these effects form an anti-stress pattern. • Endogenously produced oxytocin induces similar effects.
- 19. Intervention-Social SupportIntervention-Social Support • Greater levels of perceived social supportGreater levels of perceived social support were associated with reducedwere associated with reduced catecholamine reactivity to acutecatecholamine reactivity to acute psychosocial stress.psychosocial stress.
- 20. INTERVENTIONS
- 21. Adverse Childhood Events Adverse Childhood Events High Stress High Stress Depression PTSD GAD Depression PTSD GAD Poor Social Support Poor Social Support Poor Sleep Poor Sleep Increased Inflammatory Cytokines Increased Inflammatory Cytokines Low HRV Low HRV Low Oxytocin Low Oxytocin Low SES Low SES Poor Coping Skills Poor Coping Skills Elevated Cortisol Elevated Cortisol Psychotherapy Increased Control at Work Lower Life Stress Reduced Pain, Stress Increased Anti-inflamitory diet Physical Exercise Increased Emotion Regulation HRV Training Increased Sleep Increased Social Support And Social Skills Massage Touch Therapy Chocolate Yoga Thai Chi Increased Stress Management and Coping Skills Risk Factors Risk Factors Interventions Interventions
- 22. SOME SPECIFIC INTERVENTIONSSOME SPECIFIC INTERVENTIONS Touch therapyTouch therapy Yoga/Thai ChiYoga/Thai Chi Acupuncture/Chinese medicineAcupuncture/Chinese medicine Diet/dark chocolateDiet/dark chocolate Social Support/ Work HealthSocial Support/ Work Health Sleep regulationSleep regulation Counseling/ Therapy/Counseling/ Therapy/ Somatic Experiencing (SE)Somatic Experiencing (SE) MindfulnessMindfulness HRV TrainingHRV Training Soothing activitiesSoothing activities Increased heartfelt emotionsIncreased heartfelt emotions Healing relationship /CommunicationHealing relationship /Communication
- 23. INTERVENTIONS: HRV and ANSINTERVENTIONS: HRV and ANS BALANCEBALANCE • HRV provides a measure of relative activity andHRV provides a measure of relative activity and balance between the sympathetic andbalance between the sympathetic and parasympathetic branches of ANS.parasympathetic branches of ANS. • HRV is a measure of Allostatic Load.HRV is a measure of Allostatic Load. • HRV biofeedback and positive affect emotionalHRV biofeedback and positive affect emotional interventions can both help re-regulate HRV tointerventions can both help re-regulate HRV to more normative levels.more normative levels.
- 24. HRV: Methods of RegulationHRV: Methods of Regulation HRV can be regulated through:HRV can be regulated through: •• Breath training,Breath training, •• Bio-feedbackBio-feedback •• Emotion regulation skills training/ positive affectEmotion regulation skills training/ positive affect therapies.therapies. •• Inward attention/meditation.Inward attention/meditation. •• Tai Ch/ body awareness therapies.Tai Ch/ body awareness therapies.
- 25. Interventions: What helps increase OT production? • Caring words • Caring human to human contact/touch • Sensory safety and pleasure • Internal imagery/guided imagery • Emotions of love, caring, or appreciation can be triggered externally or generated internally. • Self generation of pleasant inner emotional states. • Social Engagement • Music • Intentionally induced positive affect (smile, etc)
- 26. CONSEQUENCES OF CVDCONSEQUENCES OF CVD • DepressionDepression • PTSDPTSD • Sleep disturbanceSleep disturbance • CognitionCognition • Increased stressIncreased stress and worryand worry • Changes inChanges in body systems thatbody systems that increase risks forincrease risks for CVD!CVD!
- 27. THERE ARE MANY WAYSTHERE ARE MANY WAYS DOCTORS CAN HELP…DOCTORS CAN HELP…
- 28. Doctor - Patient Relationship • Beginnings Matter: presence, eye contact, pacing, body language and tone of voice help determine whether your patient easily engages with you or feels guarded. • Social engagement reduces the stress response, increases oxytocin levels and as a result increases a person’s basic sense of safety. • Safety creates a sense of agency, empowerment, and increases the impact of the doctor/patient relationship. • Safety in social relationships increases the speed of wound healing and healing of heart tissue after surgery.
- 29. Relational Tools that Create Safety • Creating Social Bonds: Social bonds increase the impact of the doctor/patient relationship. STEPS: 1. Create Safety (eye contact – upper face working) 2. Approach Proximity (physical/ emotional closeness) 3. Establish Contact (physical/ emotional contact) • Self-Empowerment: Uses positive emotions to build on existing patient strengths. How: Identify successful coping, positive support, nurturing self care, and current strengths. This helps you get more mileage and impact when teaching new information.
- 30. Map for safe containment in clinical contact
- 31. What Signals Safety? • Your body talks: Your whole presence communicates safety. • High Vocal Prosody: Reduces stress through increased social engagement via changing tuning of inner ear. • Eye Contact: Reduces stress response. Exceptions: 1. type of eye contact within cultural norms 2. Follow patient’s lead (trauma). • Heart Face Connection: Core social engagement system. Seen in contact between mother and child. Can be evoked through face to face caring contact. • Environment Matters: Small amounts of physical beauty impacts health.
- 32. Resources: Kaiser • Health ed. classes: MBM, meditation, Yoga, stress reduction (catalog). • Psych dept: - Individual counseling, EMDR, etc. - Classes by referral within dept. after initial evaluation. • BMS consultation.
- 33. Kaiser resources, cont • Health education centers • Web-based tools • “tear sheet” • Possible women’s cardiac support group… and why not a men’s one also? You!
- 38. • From “OT is a cardiovascular hormone: • (Brazilian Journal of Medical and Biological Research 2000, 33:625-633)
- 39. Intervention-Life Style ChangesIntervention-Life Style Changes • Active and fulfilling non-work-time behaviorsActive and fulfilling non-work-time behaviors maximize recovery from work strain. [21]maximize recovery from work strain. [21] • Good sleep hygieneGood sleep hygiene • Cultivating pleasure, passion, positive affect,Cultivating pleasure, passion, positive affect, nurturing relationships,nurturing relationships, and spiritual support..and spiritual support..
- 40. The Physician Healer • Healing involves full care, involving anyone, including the patient, their physician, family, friends, community, and all resources. • It doesn’t take more time, especially in the long run. • Physicians: Relationships with patients are transformative relationships.
- 41. Depression, ANS andDepression, ANS and Medication ConsiderationsMedication Considerations • Patients with MDD display autonomicPatients with MDD display autonomic dysfunction SNRI and to a lesser degree SSRIdysfunction SNRI and to a lesser degree SSRI exacerbate this dysregulation. [24]exacerbate this dysregulation. [24] • Choosing a medication that has less effect onChoosing a medication that has less effect on the ANS could lead to better outcomes inthe ANS could lead to better outcomes in cardiac patients.cardiac patients. • Emotion regulation therapies can be a viableEmotion regulation therapies can be a viable mode of assistance (CBT, DBT and others).mode of assistance (CBT, DBT and others).
- 43. Poor Social Interactions Less Oxytocin Release Less Oxytocin Release Adverse Early Childhood Experiences Ineffective Emotional Regulation Less Oxytocin Release Less Oxytocin Release Poor Stress Modulation Hyperactivity (CORT) Poor Stress Modulation Hyperactivity (CORT) POOR LONG TERM HEALTH AND CVD POOR LONG TERM HEALTH AND CVD
Editor's Notes
- The main point here is that stress an the sequelai of it’s physiological pathways are a common factor in all of these conditions and they are all documented risk factors for MI and CVD. We could have listed many citations here but chose to include some in your bibliography to expidite time.
- Prenatal and birth influences set stress response patterns that can persist throughout the lifespan until resolved. Minimizing stressors and downregulating the stress response during these periods is most preventive and cost effective. (Barker reseach citations might be included here) Childhood stress disorders are on the rise and suggest different forms of intervention than adult. We will be focusing primarily on interventions that can help downregulate the stress response in adults though the science behind these interventions is applicable in various forms across the lifespan.
- Would be great for Sue to speak on this one ie to define it and speak of some of the possible screening tools.And then to say that suggestions for interventions to decrease allostatic load are coming.
- These are some of the identified mechanisms through which stress dysregulates physiology. They are also the same mechanisms through which the hormones associated with positive affect can downregulate the stress response. (Can we include a concise exemplary cited statement on each one of these?? Ie we have HRV and OT covered but not the rest- I think we or I may have eliminated some of these)
- Relate to anti-inflammatory hormones and emotional counterpart
- Antagonistic individuals, especially those who are manipulative and aggressive have greater increases in arterial thickening. Can lowering hostility lower risk?
- These are all regulatory processes.
- Some Specifics- OT infusion resulted in: Diminished cell apoptosis and fibrotic deposits in the remote myocardium Suppression of inflammation by reduction of neutrophils, macrophages and T lymphocyte Decreased expression of proinflammatory cytokines tumor necrosis factor-alpha and interleukin-6; promotion of transforming growth factor-beta These results indicate that continuous OT delivery reduces inflammation and apoptosis in infarcted and remote myocardium, thus improving function in the injured heart. Basic Res Cardiol. 2010 Mar;105(2):205-18. Epub 2009 Dec 12.
- These pathways are also indicative of the effects of social support.
- A warm smile and a kind word can be powerful forms of social support.
- Somatic therapies involve both touch and increased awareness of physical sensations and are based on the intenetion of increasing pleasurable sensation. Touch itself helps regulate parasympathetic balance. Therapy that increases access to positive affect increases parasympathetic activation, improves HRV, increases oxytocin production, and facilitates social support. We’ll talk more about the mechanisms through which these therapies improve outcomes.
- HRV training via simple handheld personal biofeedback devices and emotion focused guided imagry exercises are available to the public through the Institute of HeartMath as a cost effective intervention
- Pleasure, nurture, nature, social support, compassion, touch are all associated with positive affect and with better HRV, and increased oxytocin production. Encouraging positive affect is a cost effective intervention.
- Because the consequences of CAD can mimic the causal risks, similar emotional screening strategies and similar interventions can be significantly beneficial in reducing these consequences and increasing both patient comfort and health outcomes.
- In summary….. I think would be great for Sue to due summary part.