Anxiety is a feeling that almost everybody has experienced. It is the feeling of nervousness, of apprehension, of internal shakiness, and it is commonly associated with unpleasant bodily sensations. It is experienced directly as fear, if related to a specific feared object, or generally as anxiety; an intense form is panic anxiety. In the thinking realm, anxiety can be expressed as worry, or disturbance of concentration. It can be felt in the muscles of the body as tension or restlessness, or in different bodily systems, such as butterflies in the stomach, diarrhea, dizziness, increased urination, and, in the context of this book, as chest pain, palpitations, shortness of breath and sweating.
Anxiety has a normal functionthat is, it signals a threat. Following a cardiac event, anxiety is common and normal in the early phases, from the lead-up to the event, through the aftermath and especially during emotional reaction, which is characteristic of the early recuperation phase. Anxiety is understandable, given the threat to the person in the recent past and especially in relation to the possibility of another event occurring. As recuperation becomes well established, anxiety will tend to settle down. This is closely related to the subsidence of physical symptoms.
In the early recuperation phase, the patient is typically going through emotional reaction, but, at the same time, physical symptoms, such as chest pain, palpitations, fatigue and shortness of breath, can be fairly prominent. As you will already have noticed, these are the same as, or very similar to, symptoms of anxiety. How is the individual to know which is which? Furthermore, as symptoms such as chest pain can represent a threat to the person, this, in itself, induces anxiety. With more anxiety comes more symptoms, and, presto!a vicious circle is born.
At this point, we must mention two forms of anxiety that are common, and contribute to this scenario. We emphasize that we are referring to a situation where the cardiologist has reassured the patient that the particular symptom does not pose a danger. The first form of anxiety, which some people experience more strongly than do others, is a tendency to worry excessively or, in fact, to become convinced that a serious medical event is going to occur. This is the only context in which the adjective "hypochondriacal" should be used. As we explained in Part One, "The Guide," it is quite understandable that a symptomatic person who has had a cardiac event might become overly concerned, but some do to excess.
The second case is that of pronounced bodily symptoms (such as palpitations, breathlessness, dizziness) in individuals with heart disease who are found to have a manifestation of panic anxiety or panic disorder. It must be made clear that, for these patients, panic itself does not have to be felt! It seems strange, but we are learning that what we call panic attacks can be expressed by the body alone, causing intense symptoms that the doctors often dismiss; but they are signs that there is something wrong. This situation is regrettable, because panic disorder is very treatable.
So, to reiterate, we have described the situation of a vicious circle of bodily symptoms and anxiety that often occur in the post-CAD patient, and which can occur more prominently in the case of persons with a hypochondriacal tendency and in those who are actually suffering panic attacks. However, these patients can also develop further heart problems, and need regular monitoring. If there is change in symptoms, they need to be reevaluated. We all know that even hypochondriacal patients can get ill!
In cases of normal anxiety, we expect a fluctuation and improvement over time. This is helped by being aware, and being able to reassure oneself, of the journey from event to recovery. It is one of the cardinal signs of rehabilitation, that emotional symptoms subside and are replaced by the upbeat tide of reconstruction. So, if the anxiety does not subside, but persistsand, obviously, if it worsens or becomes intolerable at any timeyou will need to consult a health-care professional. We will leave it to that person to determine what it is that is troubling you. Usually, such patients will have visited their doctors more often than others, and examination for complicating medical conditions will have been performed; in any case, medical evaluation must be obtained.
If the patient is deemed to be anxious, there are many strategies that can help. It is always important that the physician take the person seriously, in the sense of not dismissing the patient's complaints as "not real." If repeated visits have been a problem in the case of a truly hypochondriacal response, it is helpful to set up regular appointments with the doctor where concerns can be addressed and psychotherapy can be given.
If the patient is found to have panic anxiety, true panic attacks or panic disorder, there is more specific treatment given and the professional can be consulted about this.
For all patients, relaxation techniques are recommended. These are described below, but we are asking that they be formally taught, individually or in the group setting. In the case of a person who has prominent anxiety, we recommend an individualized approach. "Psychotherapy" refers to any "talking treatment." There will always be contexts in which the anxiety occurs, and an experienced psychotherapist can help to work through any problems that are associated with particular situations. Many patients are given tranquilizers in the hospital, and they request them when they are anxious on arrival home. The problem with these medications is twofold they can lose their effectiveness, and, if not, you have to keep taking them. If you suddenly stop tranquilizers, which you should not do, withdrawal effects can occur. A similar situation occurs with sleeping tablets, which are often in the same tranquilizer family. Medication may well be needed in the case of panic disorder, and this can be discussed more fully with your physician.
For anxiety that is well established and for panic disorder, a more rigorous type of psychotherapy, cognitive therapy (or cognitive behavior therapy, if there are associated behavioral issues), can be used. We will soon understand more clearly how patients recovering from a cardiac event will respond to such therapy, but it is likely that, in the future, modified forms of targeted cognitive therapy may be appropriate for such patients with mild panic disorder.
For most people, the anxiety will subside after a cardiac event and reassurance will be sufficient. What you should then do will depend on the progress that you have made, and also on your "vulnerability." There is good evidence that relaxation techniques can be helpful whatever your mood state, and we recommend them across the board; there are also other approaches to what you can do to deal with stress and help improve your CAD outcome.
Significant others, especially those closest to the patient, can naturally also experience the same type of anxiety as the patient, and may similarly require management, either self-taught or, if symptoms are prominent, more formal.