Poster given at Verona Italy in June 2018

1. Is Abnormal Adult Attachment A Risk Factor In Takotsubo Cardiomyopathy?
F. Meissner MD, RDMS, RDCS1; C. Garza, JD, MD2; M. Escamilla, MD, PhD3
1TTUHSC Paul L. Foster School of Medicine, PGY-4 Child & Adolescent Psychiatry Fellow, El Paso TX
2TTUHSC Paul L. Foster School of Medicine, PGY-5 Child & Adolescent Psychiatry Fellow, El Paso TX
3TTUHSC Paul L. Foster School of Medicine, Director For Center of Emphasis- Neurosciences, El Paso TX
No Conflicts Of Interest
AIMS
‘
Takotsubo Cardiomyopathy, the most fascinating clinical entity in the evolving
field of behavioral cardiology demonstrates the exquisitely intertwined
responses and the physiological interdependence of the ‘head and the
heart’, was first described in Japan in 1990.1 The precise elucidation of the
cardiac and cellular pathophysiology of this condition is a field of intense
interest, however, psychological factors, other than a general appreciation
that ‘emotional triggers’ often precipitate this massive dysfunction of the ‘fight
or flight’ hyper-arousal response are poorly understood. We present two
cases of Takotsubo that illustrate that ‘A Grief Deferred’ via the defensive
emotional investment in symbolic transition objects may be a marker for
susceptibility to development of Takotsubo cardiac physiology when that
transitional object is lost, damaged, destroyed, or given up.
METHODS
Case history and analysis with simultaneous review of appropriate cardiology
studies. Focused literature research to determine the varieties and severity of
underlying psychological factors possibly associated with Takotsubo
Cardiomyopathy as a manifestation of pathological grieving. Development of a
conceptual model explaining delayed onset of Takotsubo physiology as seen
in our two cases.
RESULTS
Since the initial reports that strong emotions, particularly grief, could be a
precipitant for Takotsubo Cardiomyopathy; work on characterizing the
psychological profiles and psychological risk factors has been an ongoing
area of active research, e.g., Delmas et al2, has determined that
anxiodepressive disorders and chronic psychological stress are often
associated with the occurrence of Takotsubo Cardiomyopathy.
In our two cases, however, the timing of the events distant from the loss
illustrates that in certain instances of complicated grief, (in our lexicon) ‘A Grief
Deferred3’; acting via the agency of loss of a compensatory transitional object,
Takotsubo pathology can occur years distant from the patients initial loss of a
romantic and/or life partner.
In J. Bowlby’s magisterial volume, Loss4, he promulgated a model in which
absence of distress at loss, or apparent ‘detachment’ from grieving
represented a defensive reaction too loss that may eventually break down
and give rise to intense feelings of grief and sorrow.
Furthermore, romantic love has been conceptualized and demonstrated as an
attachment process5 analogous to infant attachment. Furthermore the rough
percentage and styles of attachment seems preserved across the temporal
and developmental lines separating childhood from adulthood, i.e., adults also
have been found to manifest so-called ‘secure’, ‘avoidant’, and ‘anxious/
ambivalent’ styles of attachment (as first described by Ainsworth6 In her
classical strange situation experiments). Subsequently Winnicott’s7 seminal
concept of transitional object has been shown to be generalizable to adults by
R.M Young.8
Utilizing a model first proposed by Kho, et al9, we have extended it to include
the cases in which abnormal adult attachments incorporate goal states that
represent emotional responses or non-acceptance responses incorporating
Takotsubo as both an immediate as well as delayed outcome of this model.
Grief, the process a bereaved individual goes through to assimilate loss after
the death of someone, is a very unique and individualized process. The
meaning-centered grief model conceptualized by Dezelic & Ghanoum10
integrates concepts from Logotherapy &
Existential Analysis and promises to
provide an overarching prophylactic
structure and existential framework for
dealing with death or loss of the love
object; thus increasing psychic
resilience - immunizing the suffering
lover from the risk of sudden cardiac
death through the dramatic Takotsubo
pathophysiology.
Conclusions
1. Abnormal attachment, as manifested in the agency of an adulthood
invoked transitional object, is a risk factor for Takotsubo Cardiomyopathy if
that transitional object is subsequently lost, given up or destroyed.
2. Takotsubo pathophysiology can manifest many months distant to the
emotional loss that ultimately precipitated the Takotsubo episode.
A 57-year-old Hispanic female was the sole occupant of a T-bone
motor vehicle collision involving the car's mid-body position of her
SUV on level with her passenger door. Her vehicle was not spun by
the colliding vehicle, she was restrained by a seat belt, there was no
deployment of forward airbags, she denied any chest trauma and
deceleration forces were orthogonal to the anterior axis of the heart.
She self extracted on the scene. Immediately after leaving the vehicle,
she experienced severe (8-10/10) chest pain with associated severe
breathlessness. Her chest pain persisted unabated for 8 hrs post ED
evaluation. She had no conventional risk factors for CAD, however,
she had a right sided lumpectomy for Stage I Breast Cancer 5 years
prior to this event, and her adjunctive radiation therapy was not
oriented directly over the coronary arterial bed. She had NYHA
functional class I prior to this event. She had no history of thought
disorder, a questionable history of mild depression, no history of
substance use, no exposure to cardio toxic medications, no past
history of panic disorder or mitral valve prolapse. There was no family
history of thought disorder, depression, suicide or psychiatric
hospitalization. No family hx/o cardiomyopathy, premature CAD,
arrhythmia, or sudden cardiac death syndrome. She had no past
history of maladjustment in childhood. She worked as a Teacher’s
Aide and had divorced approximately one year previous to the
accident. She remained deeply in love with her estranged husband
who pressed her to agree to a divorce. She related that she was
overwhelmed with grief when she left her vehicle and saw the damage
to it, as the SUV, an anniversary present, two years distant from the
event, was the last remnant of her treasured marital life. She had kept
her grief in control by repression of her emotions of loss. Once the
material integrity of the SUV was breached, she had an instantaneous
outpouring of grief, rage against her husband, and ultimately fear for
her own life. After her chest pain relented, she had no significant
psychological sequelae and did not require antidepressant therapy,
responding well to the knowledge the her heart muscle damage was
transient.
Bay
A 61-year-old Caucasian female awoke at 3:00 AM approximately
5 hours after she left the home that she had just sold and which
she had shared for 30 years with her recently deceased husband
(died one year and three months previous to her hospitalization)
with persistent severe central chest pain and severe dyspnea.
Upon arrival in the ED, she was in severe heart failure and had
EKG evidence suggesting proximal LAD disease. Her maximal
troponin I measurement was 0.56 ng/ml and initial BNP 26.40 pg/
ml. She was intubated taken urgently to the cardiac catheterization
laboratory found to have normal coronary arteries and a LV gram
diagnostic of Apical Ballooning Syndrome with an estimated LVEF
of 10%. Because of a measured cardiac output of 1.6 L/min, an
intra-aortic balloon pump was inserted and an infusion of
Dobutamine begun. After 24 hours of inotropic and IABP support
her cardiac output returned to the normal range and she was
extubated. No other complications were experienced during this
hospitalization. She had a normal ejection fraction at follow up visit
one month after discharge. She had had no diagnosable
psychiatric illness prior to her Takotsubo Cardiomyopathy. She
reported an attenuated grief reaction with mild depersonalization
when her husband died and during his funeral preparations.
Case #1
Case #2
Modification of Attachment Grief Model of Kho et al6
Acute Echocardiography of case #1
Gated Sestamibi Image of Case #1
The Humanistic Model of Medicine -Extended
Pathophysological Aspects of Takotsubo Cardiomyopathy
Classical EKG of Stress
Induced Cardiomyopathy
Case #2
Diaastolic Dysfunction Case #2
Takotsubo Cardiomyopathy - A Structural Analogy
References
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Hypothesis ; Circulation Journal Vol.77, January 201
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10.https://www.drmariedezelic.com/meaning-centered-grief-model