Me and My Heart: Self Identity and Recovery from a Coronary Event
1. Me and My Heart
Self Identity and Recovery from a Coronary Event
Altnagelvin Hospital
Derry
Northern Ireland
Dr Don MacFarlane PhD., MB., MSc., MRCPsych., DPM
2. Take-Home Message
#1 and #2
Good: An aerobic exercise programme after
a coronary event improves (by a third)
survival, self confidence, level of function
and quality of life.
Bad: Adherence (a third) is poor even when
longer-term survival is at stake.
3. Take-Home Message #3
Education for those in recovery from
a coronary event needs to be
targeted at fatalistic self-beliefs that
contribute to avoidable self-
handicapping.
5. World Mortality Rankings
Amalgam of Coronary Disease, Hypertension, Impaired Glucose
Tolerance, Alcohol Abuse, Depression
“if you have one, you may have the lot”
Death rates per annum per 100k of
population
Former USSR 245-400
Horn of Africa 210-230
Himalayas 200-220
Middle East 160-175
Balkans 150-160
Subtropical Africa 50
West Africa 50
Pacific Islands 50
6. Mind the Gap
Hazard Ratios for Future Acute
Coronary Event (ACE)
Bad cholesterol x4
Current Smoking x3
Diabetes x3
Hypertension x 2.5
Depression x 2.5
Anxiety x 1.5
Exhaustion 2.5
Obesity x2.25
Hostility x3
Daily Fruit x 0.75
Exercise x0.75
All combined x 130
7. Life Stressors
• There will often have been a gradual
and cumulative build-up of stress over
years.
• A score of 300 on the Holmes -Rahe
Scale gives a 75 per cent prediction of
health breakdown in the near future.
8. Holmes – Rahe Scale
Death of spouse 100
Coronary Event 50
Reduced Lifestyle 50
Sexual Difficulties 40
Redundancy or Retirement 40
Loss of income 40
Mortgage difficulty 30
Social isolation 50
11. Professor Carlo di Mario PhD FRCP
“The results are truly disappointing;
most patients do not hit one or more
targets that prolong life”.
12. ETICA Trial
(Belardinelli et al)
Comparison of exercisers with dropouts
• Quitting smoking 100%
• Improved physical 50%
• Improved Role 10%
• Improved Social 0%
• Improved Mental 50%
• Improved Wellbeing 25%
• Improved Pain 50%
• Improved ACE 100%
• Improved Restenosis 25%
13. GOSPEL Study
(Giannuzzi, Temporelli, Marchioli et al)
Longer Compliance with Life-Saving Lifestyle Measures
3 Years post ACE
• Smoking unchanged
• BMI>25 unchanged * (waist)
• Systolic BP and Diastolic BP unchanged
• Inactivity reduced to 50% from 70%
• Cholesterol level unchanged *
• Impaired Glucose Tolerance unchanged *
14. Heart and Soul Study
(Whooley and Schiller)
Comparison (%) of depressed and non-depressed
groups for smoking, drug noncompliance and
inactivity
0
5
10
15
20
25
30
35
40
Depressed
Normal
16. Vital Exhaustion
(Kop, Appels et al)
• Sense of Hazard
• Sense of Threat
• Liability
• Handicap
• Need to Awaken
• Need to Adapt
• Reduced Capacity
• Little Purpose
• Lack of Vitality
• Lack of Wholeness
18. Hostility
(Smith, Ruiz et al)
• Physical (hitting out at)
• Verbal (giving off)
• Passive (sulking)
• Cynical (disapproving)
• Spousal (taking it out on)
• Controlling (not listening)
19. Personality
The Framingham Study identified Type A Personality as
pathogenic. Recent research points to Type D as perhaps
more predictive of cardiac outcome.
Type A Personality
Ambitious
Aggressive
Urgent
Competitive
Type D Personality
Isolating
Worried
Gloomy
Irritable
Reticent
Lacks confidence
21. Self Identity
(Weinreich, Marcia et al)
• Diffused „What happened to me?‟
• Empathic „What have I become?‟
• Dissonant „Can I be bothered?‟
• Incongruent „Do I like how I am?‟
• Idealistic „What‟s the best I can expect?
22. Ego Threat
Research into comorbid depression has not looked at
Ego-Threat as an integral but perhaps more important
component of depression as a contributory factor in
cardiac outcome.
Low Self Worth
Self Questioning
Self-punishment
Self-blame
Blaming Others
Hypersensitive
Loss of identity
Rage
23. Slow Suicide?
Failure to address or meet challenges and transition
induce emotional and behavioural paralysis.
Vegetative State
Foreshortening
Somatic Vigilance
Aimlessness
Irritability
Inability to express feelings
25. Inflammatory Factors
Multiple inflammatory markers present in depression
attack the heart and induce heart failure.
• The damaged lining of blood vessels releases
interleukin and C-reactive protein.
• Depression can also be caused by these inflammatory
factors.
• Depression, even without coronary disease, has these
factors present.
• A vicious circle can perpetuate coronary spasm as well
as depression.
28. The Best Medicine
Regular and testing aerobic exercise has a marked and
beneficial effect upon cardiac output, stroke volume,
ejection fraction, rhythm and blood pressure.
(Ray Squires, Mayo Clinic)
• exercise will reduce depression and adverse
cardiac events over a two year period by a
quarter.
• 40% of maximum capacity in the first stage of
cardiorehab is the correct ratio for benefit versus
strain on the recovering heart.
29. Optimal Exercise
Warning: An exercise programme can be dangerous
unless initiated under the correct cardiorehab
supervision.
• 3 sessions per week
• 45 minutes per session
• 80% of HRmax (maximum heart rate)
• 6-10 months adherence or more
• 60% off HMD (Hamilton Depression Scale)
30. ENRICHD Behaviour
(Berkman, Blumenthal, Burg et al)
Study Showed that Lifestyle Measures in Control Group
were as effective as treatment with antidepressants or CBT
Proper Sleep
Socialise
Problem Sharing
Optimism
Kindness
Eating Right
Setting Goals
Exercise
33. Buzzwords
Some factors are likely to have an effect on cardiac
outcome
• Commitment
• Optimism
• Sociotropy
• Avoidance of avoidance
• Autonomy
• Goals
34. Take Optimism !
Giltay, Zitman, Hoekstra et al
(with some gender-bias apparent, optimism protects
against cardiovascular events from late middle-age)
35. Optimism Test
An Optimism Score based upon the MacNew and
Coping Style Instruments can do for screening.
36. Rubber Band Time
• There‟s a shadow hanging over me
• I‟m only half the man I used to be
• All my troubles seemed so far away
• Now it looks as though they‟re here to
stay
37. “On the Third Blast, Don‟t Panic”
• Take a deep breath
• Think on something else
• Do some yoga
• Give a hand
• Have a chat
• Go for a walk
• Write it down
• Treat yourself
• Make something
38. Identity and Cardiac Outcomes
• Threats to identity leave a person less ill-
equipped
• Change is hard if poorly visualised
• Identity, emotions and actions should be in
tune
• Value systems should be easily accessible
39. „One man in his time has many parts‟
Role is the aspect of identity that has to do with outworking
of behaviours and obligations that are in keeping with that
identity (Bales).
• Role Validity
• Role Overload
• Role Inadequacy
• Role Security
• Role Conflict
• Role Misfit
• Role Ambiguity
41. Challenges and Transitions
Adapted from Erik Erikson
Throughout the lifespan, challenges present and represent
which have to be negotiated for successful transition and
which may otherwise be termed as „crises‟.
• Capable v. Helpless
• Reflective v. Instinctual
• Adventurous v. Avoidant
• Persistent v. Quitting
• Affectionate v. Detached
• Trusting v. Disbelieving
44. Cycles of Change
Cycles of change show periods of action preceded by
reflection or moratorium
Interpretation
Commitment
Planning
Support
Growth
Denial
Giving Off
Giving Up
Drinking
45. Levers of Change
(adapted from Prosci‟s ADKAR)
Knowledge
Desire
Awareness
Acceptance
Ability
Efficacy
Motivation
Control
Reinforcement
46. Facsimile of Self Entities
Worrying about
Symptoms
0 Ignoring symptoms
Me as I am now -4 to -1 0 1 to 4
Me as I will be -4 to -1 0 1 to 4
Me feeling good -4 to -1 0 1 to 4
Me when I was fit -4 to -1 0 1 to 4
Me with family -4 to -1 0 1 to 4
Me when depressed -4 to -1 0 1 to 4
Me in rehab -4 to -1 0 1 to 4
47. Facsimile of Self Views
-4 to -1 0 1 to 4
Doing everything I can 0 Making excuses to drop out
Enjoying all the attention 0 Resenting being fussed over
Blotting it out of my mind 0 Problem is always there
Keeps going whatever 0 Gives up too easily
Feels as capable as ever 0 Feels a nuisance to all
Using good advice 0 Wearing cloth ears
Expects to die early 0 Will live a full lifespan
48. Self as Context
• The Wise Mind
(Socrates)
• The Big Picture
(Socrates)
• Realism (Aristotle)
• Awareness (Hume)
• The Zone (Voltaire)
• Pragmatism (Hegel)
• Coping (Spinoza)
• Goals (Pascal)
• Perspective (Carson)
49. Some Self Scripts
Aristotle – strive for the best, accept no less.
Augustine – there is always a better perspective
Epicure – there is no afterlife, make the most of now
Plato – find your guiding light
Kant – every act has consequences
Heidegger – find meaning but within not from around
James – find what works, not what pleases
