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Pavan, Chiara (2008) Impianto di ICD (cardiodefibrillatore impiantabile) e sviluppo di sintomi psicici: uno studio prospettico su 66 pazienti. [Ph.D. thesis]

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Abstract (english)

Introduction
A high percentage of anxious and depressive symptoms have been observed in ICD (implantable cardioverter defribillator) recipients, due in particular to feelings of uncertainty and impotence induced by anticipation of potentially lethal arrhythmias.
Anxious and depressive type psychopathological symptoms have been found in 24-87% of patients, with 13-38% being anxiety spectrum disorders, including post-traumatic stress disorder. Many studies have identified a positive correlation between the experience of receiving a discharge and the development of psychopathological symptoms or disorders. This correlation can be attributed in part to the shock itself and in part to concern about the device malfunctioning, since the majority of patients consider the discharge to be lifesaving. It is not yet clear whether anxious and depressive type disorders are a direct consequence of ICD placement or were preexisting. It is therefore important to carry out prospective studies.
The objectives of our study were to assess the presence of psychiatric diagnoses and personality characteristics in candidates for implantation; to assess the risk of developing anxious and depressive symptoms by following up candidates at 6 months; and lastly to explore the impact of preexisting psychological characteristics on the risk of developing anxious and depressive disorders and on the number of discharges.
Materials and methods
From May 2006 to September 2008 we assessed 66 candidates for ICD implantation attending the Department of Cardiology of Padova University. Two patients declined to take part in the study and one patient was excluded from assessment because he was affected by a psychotic disorder.
The patients underwent a structured diagnostic interview and completed a few self-report questionnaires to assess the presence of mood disorders and anxiety (MINI), the presence of post traumatic symptoms (IES), the presence of D-type personality disorders (DS16), temperamental aspects (Attachment subscale of the TPQ), alexithymia (TAS-20) and perceived quality of social support (MPSS). ICD patients’ scores on the questionnaires were compared with a control group of 76 hypertensive patients without cardiopathy who completed the IES, DS16 and TPQ Attachment scales.
Results
At first assessment, a high prevalence of psychiatric disorders was observed in the ICD implantation candidates; only 30% of patients had no mood disorders, anxiety, or phobias. Scores on the “intrusive thoughts” and “hyperarousal symptoms” subscales of the IES, the “negative affectivity” subscales of the DS16, and the “difficulty identifying own feelings” (“Factor 1”) subscale of the TAS, were correlated with a diagnosis of anxious and depressive spectrum disorders.
A follow-up assessment was made on 57.5% of the sample six months after implantation. Among the subjects with no psychiatric symptoms at first evaluation (n=27), 8 developed sufficient psychiatric symptoms after ICD placement for a diagnosis of anxiety disorder and/or mood disorder. Logistic regression analysis to identify risk factors for the development of psychiatric disorders at follow up showed that device discharges did not have a direct role but that the presence of alexithymic characteristics (p=.04) did. However, the small size of this sample and the rarity of discharge events in the first 6 months after implantation did not permit assessment of the psychopathological effect of discharges on this group of patients.
Conversely, our study shows that the presence of psychiatric diagnoses at first assessment has a direct effect on the risk of discharges in the months following ICD placement. The diagnosis of generalized anxiety disorder (GAD) and the presence of lifetime major depression increased the risk of discharges or arrhythmias after implantation by 12 and 5.6 times, respectively.
Lastly, comparison of the test scores in the two considered groups (ICD patients and hypertensive patients) revealed statistically significant differences: the hypertensive group had significantly higher scores than the ICD group on the TPQ Attachment subscale (p=.00), indicating greater capacity for social attachment. In addition, the patients with hypertension without cardiopathy scored significantly higher on the “intrusive thoughts (p=.00) and “hyperarousal symptoms” (p=.00) subscales of the IES and total IES (p=.00).
Conclusions
The results confirm data on the high prevalence of psychiatric disorders in the cardiac population. In particular, the focus of these psychopathological characteristics is the tendency to perceive implantation as a stressful event and the psychiatric disorders are related to type D personality characteristics. The presence of a psychiatric diagnosis of GAD and/or lifetime depression at initial assessment was found to be associated with an elevated risk of receiving discharges or having arrhythmias.
Some initially psychologically “healthy” patients presented a psychiatric diagnosis at follow up. Compared to patients without a psychiatric diagnosis either before assessment or at follow-up, these subjects had greater difficulty in expressing their feelings and, in general, appeared to be more alexithymic. Hence difficulty in expressing own feelings is predictive of developing a psychiatric disorder at follow-up.
On comparing the ICD group and the hypertensive patients without cardiopathy, the hypertensive group presented more severe symptoms, particularly on the “intrusive” and “arousal” subscales, but also showed a temperament more inclined to seek help and support from significant others on the IES scale, suggesting a better reaction and adjustment to the condition compared to the “ICD group”.
Hence the importance of conducting psychoeducational type interventions to improve ability to adjust to a stressful event and the need to make an early psychological diagnosis in order to identify patients at higher risk of psychopathological complications.


Abstract (italian)

Introduzione
Nei pazienti sottoposti ad impianto ICD (cardiodefibrillatore impiantabile) è stata osservata un’alta percentuale di sintomi ansiosi e depressivi, in relazione soprattutto al vissuto di precarietà e impotenza indotto dal verificarsi di aritmie potenzialmente letali.
Sintomi psicopatologici di tipo ansioso e depressivo sono stati rilevati nel 24-87% dei pazienti, con un 13-38% di disturbi dello spettro ansioso, tra cui il disturbo da stress post-traumatico. Da molti studi emerge una correlazione positiva tra gli episodi di scarica sperimentati e lo sviluppo di sintomi o disturbi psicopatologici. Tale correlazione andrebbe attribuita in parte all’esperienza della scarica in sé, in parte alla preoccupazione di malfunzionamento del dispositivo, essendo la scarica vissuta dalla maggior parte dei soggetti come un salva-vita. Non appare ancora chiaro se i disturbi di tipo ansioso e depressivo siano la diretta conseguenza dell’impianto o se siano preesistenti. A questo scopo è importante effettuare degli studi di tipo prospettico.
Gli obiettivi del nostro studio sono la valutazione della presenza di diagnosi psichiatriche e delle caratteristiche di personalità dei soggetti candidati all’impianto; valutare il rischio di sviluppare sintomi ansiosi e depressivi rivalutandoli a distanza di 6 mesi e infine esaminare l’impatto delle caratteristiche psicopatologiche pre-impianto sul rischio di sviluppare disturbi ansiosi e depressivi e sul numero di scariche.
Materiali e metodi
Da Maggio 2006 a Settembre 2008 sono stati valutati 66 pazienti candidati all’impianto ICD afferenti alla Clinica Cardiologia dell’Università di Padova. Due pazienti hanno rifiutato di partecipare allo studio e un paziente è stato escluso dalla valutazione perché affetto da disturbo psicotico.
I pazienti sono stati sottoposti ad un’intervista diagnostica strutturata e alla compilazione di alcuni questionari autosomministrati allo scopo di valutare la presenza di disturbi dell’umore e d’ansia (MINI), la presenza di sintomi post traumatici (IES), la presenza di personalità di tipo D (DS16), aspetti temperamentali (sottoscala attaccamento del TPQ), l’alessitimia (TAS-20) e la qualità del supporto sociale percepito (MPSS). Per quanto riguarda i punteggi ai questionari, i pazienti ICD sono stati confrontati con un gruppo di controllo di 76 ipertesi senza cardiopatia che hanno fatto IES, DS16 e TPQ attachment.
Risultati
Alla prima valutazione, nei pazienti candidati ad impianto ICD, è stata rilevata un’ alta prevalenza di disturbi psichiatrici; solo il 30% dei pazienti non avevano né disturbi dell’ umore, né di ansia, né fobie. Alla diagnosi di disturbi dello spettro ansioso e depressivo sono risultati correlati i punteggi delle sottoscale “pensieri intrusivi” e di “sintomi di iperattivazione” rilevati dalla IES, dell’ “affettività negativa” rilevata dalla DS16 e della “difficoltà ad identificare i propri sentimenti” (“Fattore 1”) della TAS.
La valutazione a 6 mesi di distanza dall’impianto è stata effettuata sul 57.5% del campione. Tra i soggetti asintomatici dal punto di vista psichiatrico alla prima valutazione (n=27), 8 hanno sviluppato, dopo l’impianto ICD, sintomi psichiatrici tali da essere inquadrati in una diagnosi di disturbo d’ansia e/o disturbo dell’umore. Una analisi di regressione logistica per individuare i fattori di rischio per lo sviluppo di disturbi psichici al follow-up, non ha dimostrato un ruolo diretto delle scariche del dispositivo, ma ha evidenziato come fattore di rischio la presenza di caratteristiche alessitimiche (p=.04). La scarsa numerosità di questo campione e la rarità degli eventi di scarica nei primi 6 mesi di follow-up impedisce però di valutare l’effetto psicopatologico delle scariche su questo gruppo di pazienti.
Al contrario, il nostro studio dimostra la presenza di un effetto diretto della presenza di diagnosi psichiatriche alla prima valutazione sul rischio di scariche nei mesi successivi all’impianto ICD. La diagnosi di Disturbo d’ansia generalizzato (DAG) e la presenza di depressione maggiore lifetime aumentano rispettivamente di 12 volte e di 5.6 volte il rischio di avere scariche o aritmie dopo l’intervento di impianto.
Confrontando infine i tests nei due gruppi considerati (pazienti ICD e pazienti ipertesi) emergono delle differenze statisticamente significative: il gruppo ipertesi presenta rispetto al gruppo ICD punteggi significativamente più alti alla sottoscala Attachment della TPQ (p=.00), che indica una maggiore capacità di attaccamento sociale. Inoltre, i pazienti con ipertensione senza cardiopatia riportano punteggi significativamente più alti alle sottoscale “pensieri intrusivi” (p=.00) e “sintomi di iperattivazione” (p=.00) della IES e alla IES totale (p=.00).
Conclusioni
I risultati confermano i dati sull’alta prevalenza di disturbi psichiatrici nella popolazione con patologia cardiaca. In particolare le caratteristiche psicopatologiche si concentrano sulla predisposizione a percepire l’ impianto come evento stressante ed i disturbi psichiatrici sono legati a caratteristiche di personalità di tipo D. E’ emerso che la presenza di una diagnosi psichiatrica di DAG e /o di depressione lifetime alla prima valutazione si associa ad un aumentato rischio di avere scariche o aritmie.
Alcuni pazienti, inizialmente “sani” dal punto di vista psicologico, presentano una diagnosi psichiatrica al follow-up. Tali soggetti, rispetto ai pazienti senza diagnosi psichiatrica né alla prima valutazione né al follow-up, presentano una maggiore difficoltà ad esprimere i propri sentimenti e, in generale, appaiono maggiormente alessitimici. Quindi la difficoltà ad esprimere i propri sentimenti è predittiva dello sviluppo di un disturbo psichiatrico al follow-up.
Per quanto riguarda il confronto tra gruppo ICD e gruppo pazienti ipertesi senza cardiopatia, alla scala IES, in particolare alle sottoscale “intrusivi” e “attivazione”, il “gruppo ipertesi” manifesta una sintomatologia più grave, ma alla sottoscala attachment della TPQ, tale gruppo presenta un temperamento più incline a chiedere aiuto ed a appoggiarsi a figure significative dimostrando cosi di reagire in modo migliore e più adattivo alla malattia rispetto al “gruppo ICD”.
Da qui l’importanza di condurre degli interventi di tipo psicoeducativo per migliorare la capacità di adattamento ad un evento stressante e la necessità di una diagnosi psicologica precoce al fine di identificare i pazienti a maggior rischio di complicazioni psicopatologiche

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EPrint type:Ph.D. thesis
Tutor:Santonastaso, Paolo
Supervisor:Favaro, Angela
Ph.D. course:Ciclo 21 > Scuole per il 21simo ciclo > SCIENZE MEDICHE, CLINICHE E SPERIMENTALI > NEUROSCIENZE
Data di deposito della tesi:28 January 2009
Anno di Pubblicazione:December 2008
Key Words:ICD, Psicopatologia, shocks, Disturbo post-traumatico da stress
Settori scientifico-disciplinari MIUR:Area 06 - Scienze mediche > MED/25 Pschiatria
Struttura di riferimento:Dipartimenti > Dipartimento di Neuroscienze
Codice ID:1522
Depositato il:28 Jan 2009
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