How we adapt after a heart attack may depend on what we believe this diagnosis means

25 Oct

by Carolyn Thomas    @HeartSisters

There are at least 12 commonly used measurement tools available to the medical profession that look at how patients navigate “the search for meaning in chronic illness”. Clinical tools like the Psychosocial Adjustment To Illness Inventory or the Meaning of Illness Questionnaire have been used on cancer and AIDS patients, as well as others living with chronic disease. But a 2008 study found, alas, that limiting factors in the success of these tools included “the infrequent use of some of the instruments clinically or in research.”

I can’t help but wonder why these readily available assessment tools are not being administered routinely to patients who have been freshly diagnosed with heart disease – a serious medical crisis that begs to be examined for its influence on our “psychosocial adjustment” to it. I’ve only recently learned about these tools, more than two years after my own heart attack.

This lack of medical attention to the profound psychological impact of a cardiac event is significant. As Dr. Gilles Dupuis of the Université du Québec and the Montreal Heart Institute reported in the the Canadian Journal of Cardiology, post-traumatic stress disorder following heart attack is a largely under-diagnosed and unrecognized phenomenon that can actually put survivors at risk of another attack.

Back in 1997, an Oregon study reported in the Journal of Acute and Critical Care did look at the meaning of illness for women with coronary heart disease. Researchers found that meaning actually evolved over time in a process they called seeking understanding.

At the onset of symptoms, the women survivors in the study described three early responses:

  • 1. denial
  • 2. acknowledging
  • 3. being scared

The women also described four additional themes that emerged after obtaining medical attention:

  • 4. naming the illness
  • 5. seriousness of illness
  • 6. comparing self with others
  • 7. causality

Researchers concluded that a patient’s process of seeking understanding contributes to how health care professionals can assess the decision-making behaviours and lifestyle choices of women living with coronary heart disease.

About 10 years ago, a Russian study also looked at heart patients using a number of psychosocial coping strategy assessment tools. They identified four cardiac conditions, any one of which substantially increased the negative subjective meaning of the disease for patients.  I had two of these.  They are:

  • 1. the onset of heart disease in midlife (younger than 65 years) with its subsequent fast progression including high incidence of recurrent coronary events and/or congestive heart failure
  • 2. “typical” and protracted angina pectoris (chest pain)
  • 3. cardiac arrhythmias (irregular heart beats) accompanying persistent high heart rate and defying any self-care

An early pioneer in the development of these coping strategy assessment tools was the late Dr. Zbigniew Lipowski of the University of Toronto, who identified eight categories of meaning that capture how patients respond to stressful events like a serious disease diagnosis. He wrote in the Canadian Medical Association Journal in 1983:

“Medical educators have emphasized the need for physicians to acquire the skills to deal with psychological aspects of patient care and to evaluate patients’ psychosocial reactions to physical illness.”

Dr. Lipowski also listed three general types of reaction to illness based on:

  • the personal meaning of illness
  • emotional responses to illness
  • modes of coping with illness

Considerable research using these psychosocial assessment tools on patients diagnosed with serious illness has been done. One interesting study reported in the Journal of Clinical Nursing on the use of these tools on hospital in-patients (55% of them women, mean age 37) found that 47% of the patients studied had poor adjustment scores.

Researchers found that psychosocial adjustment to their illness was affected by a number of important factors:

  • having children
  • anxiety
  • depression
  • locus of control
  • perceived social support
  • information level about their illness and its treatment
  • tendency towards escape-avoidance behaviours
  • planned problem solving
  • positive re-appraisal

Researchers concluded that physical illness is indeed an important stress factor, adding:

“In providing medical help, a number of factors should be taken into consideration, including how the patient perceives the  illness, the impact the illness has on the patient’s life, and a determination of the degree of depression being experienced by the patient.”

In a 2009 German study, 387 cancer patients (81% with breast cancer) were asked to complete Interpretation of Illness Questionnaires (IIQ) based on the eight categories used by Dr. Lipowski to assign meaning to their diagnosis. Patients were asked to rank their responses to the statement “I regard my illness as …”

  • 1.  as a challenge – a life situation that consists of multiple tasks that must be mastered
  • 2.  as an enemy – like an invasion of harmful forces that have entered your body and your life
  • 3.  as a punishment being delivered justly or unjustly for your lack of perfection
  • 4.  as a sign of weakness
  • 5.  as a relief from your typical life stresses
  • 6.  as a strategy to use in trying to get more nurturing attention from the family and the rest of the world
  • 7.  as an irreparable loss of valuable aspects of life
  • 8.  as an opportunity for growth and development

Researchers correlated the eight items on this questionnaire with health-related quality of life, anxiety/depression, fatigue, life satisfaction, and adaptive coping strategies. Their conclusions:

  • Patients who know they are in a progressive state of disease will interpret their illness more negatively than positively.
  • Health is a changing continuum, and patients have to adapt their strategies to changing situations. These strategies and also their interpretations of disease may change during the course of illness.
  • Changing negative illness interpretations and depressive/avoidance coping by means of an intervention and encouraging social support by means of patient support groups may improve quality of life.

study from the University of Miami identified differences between certain illness-coping behaviours such as:

  • ‘resignation/acceptance’ (accepting the fact that a stressful life event like a serious disease diagnosis has occurred and is real)
  • ‘focus on and venting of emotions’ (increased awareness of one’s emotional distress, along with a tendency to ventilate or discharge those feelings)

Another study out of the University of Texas looked at the consequences of denial in those diagnosed with serious illness, and at the differences between ‘active’ and ‘avoidance’ coping strategies. First they identified risk factors (negative life events like a serious disease diagnosis) and resistance factors (qualities that could help mitigate risk factors, such as self-confidence, an easygoing disposition, family support). Patients with ‘active coping strategies‘ tried to change either the nature of the risk factor/stressor itself (living with the disease) or how they thought about it. In contrast, those with ‘avoidance coping strategies‘ tried to prevent a direct confrontation with the stressor, a reaction that researchers found could lead to substance abuse or depression. Significantly, they identified avoidance as a psychological risk factor or marker for adverse response to a serious illness diagnosis.

In a 2005 study, Dutch researchers found that younger patients used active coping strategies significantly more often and they perceived more internal control over the cause of their disease.  In contrast, older patients used religious coping and religious control more frequently at all assessments. In both groups, like the Texas study’s findings, avoidance coping was associated with more depressive symptoms and a worse quality of life.

And a 2003 University of Manitoba study of over 1,000 Canadian women with breast cancer showed that patients who were assessed using the eight categories of meaning described what breast cancer meant in their lives in several ways:

  • the majority (57%) chose ‘challenge’
  • a minority described breast cancer as providing ‘something of value’ (28%)
  • 8% chose ‘enemy’
  • 4% chose ‘irreparable loss’

At follow-up assessment three years later, the women who had ascribed a negative meaning of illness with choices such as ‘enemy’ or ‘loss’ had significantly higher levels of depression and anxiety, and poorer quality of life than women who had indicated a comparatively positive meaning like ‘challenge’ or ‘value’.

Overall, among the many possible ways humans cope with disease, two general strategies can be distinguished:

  • problem-solving (do something active to avoid stressful circumstances)
  • emotion-focused (try to regulate the emotional consequences of stressful or potentially stressful events)

See also:


8 Responses to “How we adapt after a heart attack may depend on what we believe this diagnosis means”

  1. Ronnie November 12, 2010 at 3:18 pm #

    After my double bypass in 2007, I started off as a #1, 2, 3 , 4, and 7 – the lowest experiences in life.
    Many assume patients can bounce back depending only on the severity of the heart muscle damage — but this list is right on the money in explaining the wide range of possible scenarios and reasons why we react the way we do. THANK YOU for this.

    Liked by 1 person

  2. Remo November 4, 2010 at 3:23 am #

    …”why these readily available assessment tools are not being administered routinely to patients who have survived a heart attack – a serious medical crisis that begs to be examined for its influence on our “psychosocial adjustment” to it…”

    AMEN! Why indeed? We HAVE these tools available yet they are not routinely part of cardiac discharge planning?!?!

    Liked by 1 person

  3. Dr. Stephen Parker October 26, 2010 at 10:55 pm #

    Wow Carolyn. Lots of information about one of the most important issues facing heart patients — the emotional/psychological/coping side, apart from the medical facts.

    One of my pet peeves related to the problems associated with being diagnosed with a progressive disease that was mentioned in your post is the almost standard diagnosis of “Stage 1 Heart Failure” after a heart attack that has left some sort of damage.

    I was depressed for weeks thinking my heart was failing, in spite of the fact that nothing had changed except the diagnosis. How about classifying it as “Stage 1 Heart Survival” (and being given a CD with Gloria Gaynor’s “I Will Survive” at the same time?)

    Liked by 1 person

  4. Doc Connect October 26, 2010 at 1:07 am #

    Post-surgery care is a subject that is not explored sufficiently. I love this article because it touched the very essentials, and helps to understand this issue.

    Liked by 1 person

  5. Mary October 25, 2010 at 8:06 am #

    Carolyn, I think this is SPOT ON.

    It’s absolutely the best, or at least in the top 3 columns you’ve ever done. I heartily and completely agree.

    There is one area that I wonder if the assessments capture; looping back toward those with ongoing, perceived life threatening pain, which cannot be completely treated, if regardless of if the person is younger or older, and particularly if there is PTSD present, the assessment of the PATIENT ascribing a negative quality of life.. is understandable.

    To consider otherwise is what I would consider “blaming the victim”. Although it is very desirable to modify the perception and experience both for the the patient and the medical practitioner, sometimes it is simply a condition that cannot be veiled with drugs or behavioral mods.

    I do agree, that until proper assessment is understood through use of assessment tools, and all treatments and modifications applied, one should not assess that outcome.

    Liked by 1 person

  6. New Allie October 25, 2010 at 7:48 am #

    Great article Carolyn and I love the new look!

    Interesting that after twenty months and so many doctors, I’ve never been asked once by any of them how I was coping, much less answered any such questions.

    I even had the “tools,” with a background not only in medicine but a second career in ministry. I’d not only been one who daily meditated, but taught how. I cannot imagine anyone coping less well than I did! I knew the why and how, I was simply too shell shocked to help myself.

    PTSD indeed – and on a multitude of levels. I believe I’m finally through the darkest emotional fog of it, but it has been a difficult and painful journey.

    Thanks for shedding the light. I wish every doctor out there was required to read it.

    Liked by 1 person

  7. Ben Waugh October 25, 2010 at 5:00 am #

    I found your blog on Google and just added you to my Google News Reader. Keep up the good work on this important cardiac info. Look forward to reading more from you in the future.

    Liked by 1 person


  1. Stress Page - October 25, 2010

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