Psychological Risks of Coronary Bypass Su rgery

Psychological Risks of Coronary Bypass Su rgery

Psychological Risks of Coronary Bypass Surgery JUNE B. PIMM and JOSEPH R. FEIST Pimm Consultants Miami, Florida With contributions by Franklin H. Foote Catherine J. Green Sally Kolitz Parry B. Larsen Theodore Millon Kathie Roy PLENUM PRESS NEW YORK AND LONDON

Library of Congress Cataloging in Publication Data Pimm, June B., 1927- Psychological risks of coronary bypass surgery. Includes bibliographical references and index. 1. Aortocoronary bypass-complications and sequelae. 2. Aortocoronary bypass Psychological aspects. 3. Sick-Psychology. 4. Crisis intervention (Psychiatry) 1. Feist, Joseph R., 1947-. II. Title. [DNLM: 1. Aortocoronary Bypass-adverse effects. 2. Aortocoronary Bypass - psychology. 3. Coronary Disease. 4. Crisis Intervention. 5. Patient Education-methods. WG 169 P644p] RD598.P48 1984 617'.412 84-8424 ISBN-13: 978-1-4612-9695-9 DOl: 10.1007/978-1-4613-2735-6 e-isbn-13: 978-1-4613-2735-6 1984 Plenum Press, New York Softcover reprint of the hardcover 1st edition 1984 A Division of Plenum Publishing Corporation 233 Spring Street, New York, N.Y. 10013 All rights reserved No part of this book may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, microfilming, recording, or otherwise, without written permission from the Publisher

To Matthew

Contri butors Joseph R. Feist, Pimm Consultants, 2699 S. Bayshore Drive, Miami, Florida Franklin H. Foote, Department of Psychology, University of Miami, Coral Gables, Florida Catherine J. Green, Department of Psychology, University of Miami, Coral Gables, Florida Sally Kolitz, Department of Psychology, University of Miami, Coral Gables, Florida Parry B. Larsen, Department of Surgery, University of Miami, Coral Gables, Florida Theodore Millon, Department of Psychology, University of Miami, Coral Gables, Florida June B. Pimm, Pimm Consultants, 2699 S. Bayshore Drive, Miami, Florida Kathie Roy, Cardiovascular and Thoracic Surgery Associates, Suite 207, 1150 N.W. 14th Street, Miami, Florida vii

Foreword Heart surgery is still a relatively recent advance in medical technology. The first open-heart procedure was closure of an atrial septal defect in a child at the University of Minnesota Hospital in 1953. This issued in a life-saving advance, the use of which has expanded enormously to include treatment of many areas of cardiac disease. Not unexpectedly, surgical techniques allowed through the use of the heart-lung machine (open-heart surgery) came to be applied in 1967 to the major killer of Americans, namely, coronary artery disease. This operation, known as coronary artery bypass, has become one of the most common surgical operations. Coronary artery disease, with the possibility of total incapacitation or sudden death from a heart attack, can alter severely the personality of the patient. Corrective surgery can sometimes intensify rather than ameliorate a patient's fears. To the surgeon, occupied by increasing numbers of patients, there is not time enough to give the preoperative attention that might be helpful. Also, the surgeon and cardiologist are limited in their ability to recognize those patients near the breaking point. The research outlined in these chapters by Drs. Pimm, Feist, and their associates is welcomed by cardiologists and cardiac surgeons. It provides insight into what appears to be reliable recognition of those patients likely to have an adversely affected mental status by coronary bypass surgery and "crisis intervention" to avert this effect and allow the complete benefit of returning the patient to a normal life. Clinical Professor of Surgery University of Miami School of Medicine Chairman, Department of Cardiovascular and Pulmonary Disease Northridge General Hospital Ft. Lauderdale, Florida JAMES R. JUDE ix

Preface This book is the result of a personal experience that triggered the idea for a major research study. Approximately five years ago, I encountered a middle-aged couple playing golf. The man appeared strong and muscular and played his first shot with the skill of an experienced athlete. However, as he prepared to hit the ball, his wife turned to me and said fearfully, "I hope he hits a good shot. He has just recovered from heart surgery and is still so depressed; I feel inadequate to help him." I had just returned from meetings at Harvard University with Gerald Caplan, who had talked of the psychological consequences of normal life crises, and it seemed to me that the experience of coronary bypass surgery, even if successful, could leave someone with an unresolved emotional problem. Caplan proposed "crisis intervention" as a suitable approach for helping individuals in these circumstances, and it occurred to me that it could be helpful for heart surgery patients. I discussed my thoughts with several heart surgeons and was surprised by their immediate interest. Psychological complications, particularly depression, had been a source of worry to many of them. What followed was the initiation of a long-term research study intended to evaluate the effectiveness of crisis intervention with male coronary bypass patients. Four years later this book describes the project and tells what happened to these patients during the three years after surgery. Recently someone asked me if our book was completed. Upon hearing my affirmative reply, a stranger asked about its subject and I explained that it dealt with the psychological risks of coronary bypass surgery. To my amazement and delight, this stranger assured me that there was no problem with adverse psychological effects of this procedure if it was carried out at our local hospital. She described her experience when the husband of a close friend underwent surgery at one of the project's two participating institutions. Without knowing that she was describing our study, she glowingly outlined the many ways in which her friends had been helped and supported throughout the expexi

xii PREFACE rience. For us, none of the enclosed tables of outcome statistics that underline the helpfulness of this approach can equal this unsolicited testimonial from a naive observer. We hope the reader will be equally persuaded that coronary bypass surgery can result in successful outcome, both physically and psychologically. JUNE B. PIMM

Acknowledgments It is impossible to know where to begin in acknowledging help in conducting a study of these dimensions. In the beginning our thanks go to the surgeons and cardiologists whose initial interest prompted us to attempt the research. They are James Jude, University of Miami School of Medicine; James Hirschman, Mercy Hospital; Jack Davis, South Miami Hospital; Ernest Traad and John Lister, the Miami Heart Institute; and, with special thanks, Jerry Stolzenburg, the Miami Heart Institute, whose continued interest and support has been indispensable. We are grateful to the National Heart Association, Miami Chapter, for providing funds for the first year of the research and in particular to James Margolis, chairman of their research committee, who provided suggestions for amending the research design. The Miami Heart Institute made it possible for us to continue the study by providing further funding administered through the office of their capable research director Jeff Raines. Dr. Raines's support for the project, and his belief that the research had merit, has been a key factor in making this book possible. We thank the patients, the surgeons, and the staffs of the Miami Heart Institute and South Miami Hospital, where the study was carried out. We are particularly indebted to the following surgeons of the Miami Heart Institute: Thomas Gentsch, Parry B. Larsen, Ernest Traad, Malcolm Dorman, and Paul DeWitt. Special thanks go to Dr. Jude, who insisted that we watch him perform a coronary bypass operation before we began our research. We received invaluable help from University of Miami graduate student assistants Randy Levine, Ron Genellen, and Ken Johnson. We are also indebted to William Kurtines of Florida International University for help with statistical strategies and advice, as well as suggestions for methodology and presentation of results. Thanks also go to our counselors, Sally Kolitz and Judy Wolfe, who actually met with the patients and their families and provided the supportive counseling which this book is all about. Later, Robin Stillwell xiii

xiv ACKNOWLEDGMENTS provided invaluable insights into the welfare of the patients whom she interviewed 3 years after surgery. Her dedication to the task was remarkable, and her insight into the psychological well-being of each family was formidable. We also gratefully acknowledge the cooperation of wives of our patients who took the time to respond to interviews and fill out questionnaires. Editorial comments were provided by Robert and Matthew Pimm, whose continued enthusiasm for the writing of the book helped in no small way. Finally, there is no way to express enough thanks to the two women without whom the book would not have been completed: Dolly Lauderdale, our secretary, who typed and revised endless pages, and Agnes Woodward, who volunteered to collect reference material by searching the contents of libraries in two countries. Each in her own way showed enthusiasm, dedication, and loyalty to the project to a truly remarkable degree.

Contents CHAPTER 1 Introduction and Overview 1 June B. Pimm References... 5 SECTION I: CORONARY BYPASS SURGERY: MEDICAL, NURSING, AND CHAPTER 2 PSYCHOLOGICAL FACTORS Coronary Heart Disease: Etiology, Diagnosis, and Surgical Treatment... 9 Parry B. Larsen Cause and Prevention of Coronary Heart Disease... 9 Clinical Picture... 10 Diagnosis and Selection of Patients for Surgery... 11 Preparation of the Patient for Surgery... 13 The Operation... 14 Immediate Results... 15 Postoperative Results... 18 References... 19 CHAPTER 3 Coronary Bypass Surgery: The Role of the Patient-Educator 21 Kathie Roy Introduction Specific Functions of the Patient-Educator xv 21 22

xvi CONTENTS Before Surgery... 23 Initial Preoperative Period... 24 Preparation for Discharge... 28 Reference... 31 CHAPTER 4 The Millon Behavioral Health Inventory: Its Utilization in Assessment and Management of the Coronary Bypass Patient 33 Catherine J. Green and Theodore Millon Search for Relevant Psychological Dimensions in Physical Health... 31 Construction of the Millon Behavioral Health Inventory... 36 The Use of the MBHI with Coronary Bypass Patients... 38 The Management of Phillip R.... 40 Postoperative Course and Long-Term Follow-up... 42 The Case of James N.... 43 Postoperative Course and Long-Term Follow-up... 45 The Treatment of George C.... 46 Postoperative Course and Long-Term Follow-up... 49 Summary... 49 References... 49 SECTION II: TECHNIQUES FOR WORKING WITH THE CORONARY BYPASS PATIENT CHAPTER 5 Crisis Intervention and Coronary Bypass Surgery Sally Kolitz and June B. Pimm 55 Introduction to Crisis Intervention... 55 Crisis Intervention Applied in Coronary Bypass Cases... 61 Medical Stages of Coronary Bypass Surgery... 62 Preoperative Stage... 62 After Surgery... 63 Psychological Stages of Heart Surgery Patients... 64 Before Surgery... 64 In the Surgical Intensive Care Unit... 66

CONTENTS xvii After Intensive Care... 66 After Discharge... 67 Counseling and Assessment... 68 Before Surgery... 68 In the Surgical Intensive Care Unit... 70 After Intensive Care... 70 Preparation for Discharge and Postdischarge Counseling... 71 Prerequisites, Training, and Supervision of the Counselor... 72 References... 73 SECTION III: RESEARCH ON CRISIS INTERVENTION AND CORONARY BYPASS SURGERY CHAPTER 6 Crisis Intervention and Coronary Bypass Patients: Patient Characteristics, Methodology, and Research Design... 77 joseph R. Feist The Patients.... Medical Description Research Procedure Evaluation Methods References.... 78 80 82 85 90 CHAPTER 7 Crisis Intervention and Coronary Bypass Patients: Outcome and Research Predictions... 91 Franklin H. Foote Overview of Outcome and Predictions... 91 Equivalency of Treatment and Control Groups before Surgery. 93 Depression Outcome... 94 Predicting the Benefit of Crisis Intervention Counseling... 100 Using This Analysis: Tough Way... 101 Using This Analysis: Easy Way... 102 Millon Behavioral Health Inventory and Depression following Coronary Bypass Surgery... lo4

xviii CONTENTS Time and Treatment Effects on Psychological Measures Other than Depression... 109 Pretesting Effects... 115 References... 116 Appendix A: Presurgical Interaction with Depression Outcome. 117 Appendix B: Presurgical Variables Predictive of Depression... 153 Reference... 158 Appendix C: Correlations between the MBHI and Other Measures... 159 CHAPTER 8 Depression, Crisis Intervention, and Coronary Bypass Surgery. 165 June B. Pimm Depression in Heart Attack Victims... 165 Intervention Studies... 168 Intervention Studies with Heart Surgery Patients... 172 Crisis Intervention and Heart Surgery Patients... 174 Measurement of Depression... 174 Theories of Depression... 175 Denial and Depression... 178 Behavioral Definitions of Depression... 183 Case Histories... 185 Patient A (Control Group)... 185 Patient B (Treatment Group)... 187 References... 188 CHAPTER 9 The Psychology of Coronary Bypass Patients... 195 June B. Pimm Stress... 196 Recent Life Events... 199 Life Events and Coronary Bypass Patients... 201 Locus of Control... 202 Type A... 206 Measurement of Type A Behavior... 207 Relationship of Type A to Coronary Heart Disease... 207

CONTENTS xix Type A and the Sympathetic Nervous System... 209 Psychological Variables and Their Relationship to Medical Variables... 215 SCL-90 R... 215 Patient Selection for Crisis Intervention... 215 Case Histories... 216 Patient X (Treatment Group)... 216 Patient Y (Control Group)... 218 References... 220 CHAPTER 10 Conclusions and Recommendations... 225 June B. Pimm INDEX... 227