THE CONNECTED HEARTTHE CONNECTED HEARTTreating the Whole PersonTreating the Whole Person

B. Sue Stephenson,MD, B. Sue Stephenson,MD, Michael Changaris, Psy.D. Michael Changaris, Psy.D.

Dorothy Mandel, Ph.D. Dorothy Mandel, Ph.D. Maureen Harrington, SEP. CMT.Maureen Harrington, SEP. CMT.

WHY?WHY?• Better outcomesBetter outcomes• Evidence-basedEvidence-based• Consumer demand/patient satisfactionConsumer demand/patient satisfaction

TOPICS• Non-traditional risk factors for CVD• Allostatic load• Mechanisms for increased risk• Interventions and resiliency • Consequences of CVD• Teach your patients about these factors• Foster healing relationship with patients

(bidirectional)• Resources• Framework for placing future information

THE THE ““OTHEROTHER”” RISK FACTORSRISK FACTORS• DepressionDepression

• Personality / Coping Style Personality / Coping Style

• Chronic stress / Chronic stress / ““BurnoutBurnout””

• Chronic sleep deprivationChronic sleep deprivation

• Post traumatic stress disorder (PTSD)Post traumatic stress disorder (PTSD)

• Generalized anxiety disorder (GAD) Generalized anxiety disorder (GAD)

• Chronic fatigue syndrome (CFS)Chronic fatigue syndrome (CFS)

• Chronic pain/fibromyalgia (FM)Chronic pain/fibromyalgia (FM)

• Socioeconomic status (SES) / Social FactorsSocioeconomic status (SES) / Social Factors

FOR INSTANCE: FOR INSTANCE: Mental Health and The Mental Health and The HeartHeart

• Depression predicts all cause mortality including CVD.Depression predicts all cause mortality including CVD.

• Anxiety, phobic symptoms, low SES, work stress Anxiety, phobic symptoms, low SES, work stress predict CVD.predict CVD.

• GAD is associated with GAD is associated with all cause mortalityall cause mortality

• There is a strong There is a strong association betweenassociation betweenPTSD and cardiovascular/pulmonary diseases. PTSD and cardiovascular/pulmonary diseases.

Time frame of risks Time frame of risks Across the LifespanAcross the Lifespan

• In uteroIn utero• ChildhoodChildhood• Young adultYoung adult• AdultAdult• SeniorSenior

CONCEPT: Allostatic LoadCONCEPT: Allostatic Load

• Allostatic load is a term used to describe the Allostatic load is a term used to describe the energetic cost of an organism needed to energetic cost of an organism needed to maintain homeostasis.maintain homeostasis.

• Under high- or chronic stress allostatic load Under high- or chronic stress allostatic load increases, reducing the bodyincreases, reducing the body’’s ability to s ability to engage its normal restorative processes. engage its normal restorative processes.

• High allostatic load is a major pathway to High allostatic load is a major pathway to illness. illness.

Allostatic Load MeasurementAllostatic Load Measurement

Allostatic load battery in CARDIA study: taps into ANS, Allostatic load battery in CARDIA study: taps into ANS, HPA, inflammation, metabolic fx, cardiovascular fxHPA, inflammation, metabolic fx, cardiovascular fx

• 12hr overnight urine for norepinephrine, epinephrine, free 12hr overnight urine for norepinephrine, epinephrine, free cortisol  cortisol  

• Saliva cortisol levels Saliva cortisol levels • Blood: Total and HDL cholesterol, glycosylated hemoglobinBlood: Total and HDL cholesterol, glycosylated hemoglobin• IL-6, CRP, fibrinogenIL-6, CRP, fibrinogen• Waist-hip ratio Waist-hip ratio • Systolic and diastolic BP - seated/restingSystolic and diastolic BP - seated/resting• Heart rate variabilityHeart rate variability

MECHANISMSMECHANISMS Pathways through which CVD can occur and through Pathways through which CVD can occur and through which emotional interventions can improve outcome…which emotional interventions can improve outcome…

• InflammationInflammation• Cortisol: diurnal variation, etcCortisol: diurnal variation, etc• Oxytocin (OT)Oxytocin (OT)• ANS balance, heart rate variability (HRV) ANS balance, heart rate variability (HRV) • Platelet reactivity/activationPlatelet reactivity/activation• NONO• Others…Others…

Inflammatory Response

Cortisol Oxytocin ANS BalanceAnd HRV

Depression

GAD PTSD Life StressCoping

Style

Adverse Childhood

Events

Personality

Chronic Pain

Social Support

Poor Sleep

Heart Disease

MECHANISMS: InflammationMECHANISMS: Inflammation• Inflammatory markers relate to prospective cardiovascular Inflammatory markers relate to prospective cardiovascular

risks. [1]risks. [1]

• IL-6, IL-1, hs-CRP, NO, TNF–Alpha: all Related to increased IL-6, IL-1, hs-CRP, NO, TNF–Alpha: all Related to increased risk of CVD.risk of CVD.

• Chronic work stress association with CVD (likely mediated in Chronic work stress association with CVD (likely mediated in part by acute inflammatory response).part by acute inflammatory response).

• Relationship between depression and inflammatory response Relationship between depression and inflammatory response may be bi-directional. may be bi-directional.

MECHANISMS: MECHANISMS: Effects of Poor SleepEffects of Poor Sleep

• High plasma IL6 and D-dimer levels. [5] High plasma IL6 and D-dimer levels. [5]

• Increased evening cortisol levels. [10] Increased evening cortisol levels. [10]

• Increased sympathetic nervous system activity. Increased sympathetic nervous system activity. [10] [10]

• Glucose intoleranceGlucose intolerance

MECHANISMS:MECHANISMS:

Personality/HostilityPersonality/Hostility

• HostilityHostility is associated is associated

with increased with increased platelet reactivity platelet reactivity

(a key pathophysiologic pathway in the onset of (a key pathophysiologic pathway in the onset of

CVD events). [15] CVD events). [15]

• Antagonistic individualsAntagonistic individuals, especially those who , especially those who

are manipulative and aggressive haveare manipulative and aggressive have greater greater

increases in increases in arterial thickeningarterial thickening. [19]. [19]

OT is a Cardiovascular Hormone

• Synthesized in the heart and large vessels

• OT receptors are found in all heart compartments and vasculature • Mediates ANP, BNP, and a variety of other cardiac

regulatory processes.

• Also involved in cognition, tolerance, adaptation and complex sexual and maternal behavior

Increased OT Promotes:

• Natriuresis and blood pressure reduction through ANP/BNP modulation• Parasympathetic neuromodulation• Vasodilatation• Anti-inflammatory activity

(Journal of the American Society of Hypertension Vol 2, Issue 5 318-325)

OT in Cardiac HealingOT infusion resulted in:• Diminished cell apoptosis and fibrotic deposits in the

remote myocardium

• Suppression of inflammation by reduction of neutrophils, macrophages and T lymphocyte

• Decreased expression of proinflammatory cytokines, tumor necrosis factor-alpha ,and interleukin-6

• Promotion of transforming growth factor-beta

• These results indicate that continuous OT delivery reduces inflammation and apoptosis in infarcted and remote myocardium, thus improving function in the injured heart. Basic Res Cardiol. 2010 Mar;105(2):205-18. Epub 2009 Dec 12.

OT: An Anti-Stress Effect• Exogenous oxytocin causes: • Lowered blood pressure • Decreased cortisol levels • Increased withdrawal latency (pain tolerance) • Increased release of vagally controlled gastrointestinal hormones

(digestion)

• Together, these effects form an anti-stress pattern.

• Endogenously produced oxytocin induces similar effects.

Intervention-Social SupportIntervention-Social Support

• Greater levels of perceived social support Greater levels of perceived social support were associated with reduced were associated with reduced catecholamine reactivity to acute catecholamine reactivity to acute psychosocial stress. psychosocial stress.

INTERVENTIONS

Adverse Childhood Events

High Stress

Depression PTSD GAD

Poor Social

Support

Poor Sleep

IncreasedInflammator

yCytokines

Low HRV

Low Oxytocin

Low SES

Poor Coping Skills

Elevated

Cortisol

Psychotherapy

Increased Control at

Work

Lower Life Stress

Reduced Pain, StressIncreased

Anti-inflamitory diet

Physical Exercise

Increased Emotion

Regulation

HRV Training

Increased Sleep

Increased Social

SupportAnd Social

Skills

MassageTouch TherapyChocolate Yoga

Thai Chi

Increased Stress Management and

Coping Skills

Risk Factors Interventions

SOME SPECIFIC INTERVENTIONSSOME SPECIFIC INTERVENTIONS

Touch therapyTouch therapy Yoga/Thai ChiYoga/Thai Chi Acupuncture/Chinese medicineAcupuncture/Chinese medicine Diet/dark chocolateDiet/dark chocolate Social Support/ Work Health Social Support/ Work Health Sleep regulationSleep regulation Counseling/ Therapy/Counseling/ Therapy/

Somatic Experiencing (SE)Somatic Experiencing (SE) MindfulnessMindfulness HRV TrainingHRV Training Soothing activitiesSoothing activities Increased heartfelt emotionsIncreased heartfelt emotions Healing relationship /CommunicationHealing relationship /Communication

INTERVENTIONS: HRV and ANS INTERVENTIONS: HRV and ANS BALANCEBALANCE

• HRV provides a measure of relative activity and HRV provides a measure of relative activity and balance between the sympathetic and balance between the sympathetic and parasympathetic branches of ANS.parasympathetic branches of ANS.

• HRV is a measure of Allostatic Load.HRV is a measure of Allostatic Load.

• HRV biofeedback and positive affect emotional HRV biofeedback and positive affect emotional interventions can both help re-regulate HRV to interventions can both help re-regulate HRV to more normative levels.more normative levels.

HRV: Methods of RegulationHRV: Methods of Regulation

HRV can be regulated through: HRV can be regulated through: • • Breath training, Breath training, • • Bio-feedback Bio-feedback • • Emotion regulation skills training/ positive affect therapies. Emotion regulation skills training/ positive affect therapies. • • Inward attention/meditation.Inward attention/meditation.• • Tai Ch/ body awareness therapies. Tai Ch/ body awareness therapies.

Interventions: What helps increase OT production?

• Caring words• Caring human to human contact/touch• Sensory safety and pleasure• Internal imagery/guided imagery• Emotions of love, caring, or appreciation can be

triggered externally or generated internally.• Self generation of pleasant inner emotional states. • Social Engagement • Music• Intentionally induced positive affect (smile, etc)

CONSEQUENCES OF CVDCONSEQUENCES OF CVD

• DepressionDepression• PTSDPTSD• Sleep disturbanceSleep disturbance• CognitionCognition• Increased stressIncreased stress

and worryand worry• Changes in Changes in

body systems thatbody systems thatincrease risks for increase risks for CVD!CVD!

THERE ARE MANY WAYS THERE ARE MANY WAYS DOCTORS CAN HELP…DOCTORS CAN HELP…

Doctor - Patient Relationship

• Beginnings Matter: presence, eye contact, pacing, body language and tone of voice help determine whether your patient easily engages with you or feels guarded.

• Social engagement reduces the stress response, increases oxytocin levels and as a result increases a person’s basic sense of safety.

• Safety creates a sense of agency, empowerment, and increases the impact of the doctor/patient relationship.

• Safety in social relationships increases the speed of wound healing and healing of heart tissue after surgery.

Relational Tools that Create Safety• Creating Social Bonds: Social bonds increase the impact of the

doctor/patient relationship.

STEPS: 1. Create Safety (eye contact – upper face working) 2. Approach Proximity (physical/ emotional closeness)3. Establish Contact (physical/ emotional contact)

• Self-Empowerment: Uses positive emotions to build on existing patient strengths.

How: Identify successful coping, positive support, nurturing self care,and current strengths. This helps you get more mileage and impact when teaching new information.

Map for safe containment in clinical contact

What Signals Safety?• Your body talks: Your whole presence communicates safety.

• High Vocal Prosody: Reduces stress through increased social engagement via changing tuning of inner ear.

• Eye Contact: Reduces stress response. Exceptions: 1. type of eye contact within cultural norms 2. Follow patient’s lead (trauma).

• Heart Face Connection: Core social engagement system. Seen in contact between mother and child. Can be evoked through face to face caring contact.

• Environment Matters: Small amounts of physical beauty impacts health.

Resources: Kaiser

• Health ed. classes: MBM, meditation, Yoga, stress reduction (catalog).

• Psych dept: - Individual counseling, EMDR, etc. - Classes by referral within dept.

after initial evaluation.

• BMS consultation.

Kaiser resources, cont

• Health education centers

• Web-based tools

• “tear sheet”

• Possible women’s cardiac support group… and why not a men’s one also?

You!

Thoughts?Questions?Comments?

• From “OT is a cardiovascular hormone:• (Brazilian Journal of Medical and Biological Research

2000, 33:625-633)

Intervention-Life Style ChangesIntervention-Life Style Changes

• Active and fulfilling non-work-time behaviors Active and fulfilling non-work-time behaviors maximize recovery from work strain. [21] maximize recovery from work strain. [21]

• Good sleep hygieneGood sleep hygiene

• Cultivating pleasure, passion, positive affect, Cultivating pleasure, passion, positive affect, nurturing relationships, nurturing relationships,

and spiritual support..and spiritual support..

The Physician Healer• Healing involves full care, involving

anyone, including the patient, their physician, family, friends, community, and all resources.

• It doesn’t take more time, especially in the long run.

• Physicians: Relationships with patients are transformative relationships.

Depression, ANS and Depression, ANS and Medication ConsiderationsMedication Considerations

• Patients with MDD display autonomic dysfunction Patients with MDD display autonomic dysfunction SNRI and to a lesser degree SSRI exacerbate this SNRI and to a lesser degree SSRI exacerbate this dysregulation. [24]dysregulation. [24]

• Choosing a medication that has less effect on the Choosing a medication that has less effect on the ANS could lead to better outcomes in cardiac patients. ANS could lead to better outcomes in cardiac patients.

• Emotion regulation therapies can be a viable mode of Emotion regulation therapies can be a viable mode of assistance (CBT, DBT and others). assistance (CBT, DBT and others).

Positive Social

Interactions

Oxytocin Release

Early Childhood

Experiences

Effective Emotional Regulation

Oxytocin Release

Sustained Reduction in

Stress (CORT)

LONG TERM HEALTH

Poor Social Interactions

Less Oxytocin Release

Adverse Early Childhood

Experiences

Ineffective Emotional Regulation

Less Oxytocin Release

Poor Stress Modulation

Hyperactivity (CORT) POOR

LONG TERM HEALTH AND CVD