Harvard Heart Letter

When heart disease turns traumatic

Post-traumatic stress disorder doesn't single out combat veterans. It can also afflict those battling heart disease.

As soldiers return from Iraq and Afghanistan, post-traumatic stress disorder is in the news again. Much has been learned about this condition since its current name was coined during the Vietnam War (see "What's in a name?"). One thing we've come to realize is that post-traumatic stress disorder (PTSD) isn't limited to soldiers, victims of a terrorist attack, or witnesses of a horrifying event. It can also appear after heart trouble, major surgery, or diagnosis of a serious illness such as cancer or AIDS.

What's in a name?

Although the term post-traumatic stress disorder has only been around since the 1970s, the reality of it has been with us since before the beginning of civilization. Early humans attacked by animals or brutalized by their own kind probably developed it. Achilles, the Greek warrior at the center of Homer's Iliad, may have had it. During the Civil War it was called "nostalgia" or "soldier's heart"; in World War I, it was "shell shock." "Combat neurosis" and "battle fatigue" were the preferred terms during World War II and the Korean War. By the late 1970s it had evolved into post-traumatic stress disorder. Today it is disorder 309.81 in the Diagnostic and Statistical Manual of Mental Disorders IV, the bible of psychiatric diagnoses.

Imagine collapsing in the mall because your heart suddenly stops beating. The next thing you know, you're jolted back to life by a shock from a defibrillator and rushed to a hospital. That's traumatic. So is a stroke, a searing-pain-in-the-chest kind of heart attack, or open-heart surgery. The more out of the blue the event, the more traumatic it can be.

A small but growing body of research shows that the consequences of heart disease or procedures for treating it can trigger post-traumatic stress disorder. Not only does it cause emotional and psychological distress, but it may slow recovery from a heart attack, stroke, or surgery, and hasten the progression of heart disease.

What is PTSD?

In a nutshell, post-traumatic stress disorder is a lasting and exaggerated reaction to a terrifying or life-threatening event. It makes you feel like you are living through the event over and over again. PTSD shows itself in three main ways:

  • Re-experiencing. People with PTSD mentally relive the triggering trauma in daytime flashbacks, nightmares, or inescapable thoughts about the event. Sights, sounds, smells, or other stimuli can bring the event to life.

  • Avoidance. People with PTSD tend to avoid people, places, thoughts, feelings, and activities that remind them of the trauma. They get less enjoyment out of family, friends, work, and play, and they often become numb to both positive and negative feelings.

  • Arousal. People with PTSD are constantly on guard against danger. They have trouble falling asleep or staying asleep. They tend to be irritable and have trouble concentrating. And they startle easily.

These symptoms arise from the brain's circuits for instantly responding to potentially life-threatening situations.

Traumatic events, such as engaging in hand-to-hand combat, witnessing a bombing, or having a heart attack, set off the same immediate responses in the brain. Danger warnings from the senses streak into the brain and are shunted into two circuits. One feeds straight into the amygdala, an almond-shaped structure deep in the brain that coordinates the fear response. The amygdala is responsible for immediately marshaling all the body's systems to fight or to flee. It also activates the hippocampus, which helps the brain form vivid, emotional memories. Creating memories like this is actually a good survival strategy. It might, for example, have put a hunter or gatherer on high alert without much conscious thought when nearing an area where he or she saw a fellow traveler attacked.

The second circuit is routed to the cortex, the part of the brain that handles data processing and analysis. The cortex confirms the danger, figures out what is causing it, and determines how best to respond. Once the danger has passed, the cortex sends an all-clear message even as it continues to process the event and its aftermath. The anterior cingulate cortex seems to be involved in responding to fear.

People with PTSD create memories of a traumatic event that are stronger, more vivid, and more easily recalled than normal. An overreactive amygdala may be partly to blame. Malfunctions in the hippocampus and the anterior cingulate cortex, both of which help keep the amygdala in check, may also contribute to PTSD.

PTSD and the brain

Three areas of the brain — the amygdala, hippocampus, and the anterior cingulate cortex — appear to play key roles in the development of PTSD.

PTSD and the heart

After a heart attack, sudden cardiac arrest, or stroke, almost everyone has some post-traumatic stress. "These are big shocks to the system and the psyche that often require a massive readjustment to who you are and what you have been doing," says Leonard Doerfler, a psychologist who has been studying the links between heart disease and PTSD since the mid-1980s.

Most people recover and readjust, drawing on a combination of inner strength, faith, and family or other support. Indeed, for some people a heart attack or stroke sounds a wake-up call to take stock and make positive changes in their relationships and for their health. Others slide toward depression. Somewhere between 5% and 10% of heart attack survivors develop symptoms of PTSD. It has also been seen in people after a stroke, a heart transplant or other major heart surgery, and implantation or firing of a cardioverter/defibrillator.

One of the special problems of heart-related PTSD is that the trauma comes from within. "The knowledge that your body betrayed you once, and could very well do it again, has some heart attack survivors walking on eggshells," says Doerfler, a professor of psychology at Assumption College in Worcester, Mass. These people are constantly on the alert for a racing heart, shortness of breath, sweating, or other signs that preceded their heart attacks. The trouble is, these are also normal responses to physical activity, a traffic jam, or even a hot, humid day.

Interestingly, the severity of PTSD isn't related to the severity of the heart attack or other traumatic event. Even a minor stroke can kick off major PTSD.

People with heart-related PTSD may go to great lengths to avoid reminders. Some stop climbing stairs, making love, gardening, or doing other activities that make the heart beat faster. Some stop taking aspirin and other medications because doing this reminds them of their heart attack.

PTSD takes a toll on the body as well as the mind and relationships. Cutting back on physical activity and not taking important medications can set the stage for another heart attack or stroke. Chronic activation of the fight-or-flight response may increase blood pressure or cause potentially deadly heart rhythms. It may also spur atherosclerosis, the process that leads to cholesterol-clogged arteries and often culminates in a heart attack or stroke.

Coping with PTSD

It's perfectly normal to feel anxious or down in the dumps for a while after a heart attack, stroke, or open-heart surgery. So how would you know if you or a loved one had PTSD? Think about these four questions:

  • Do you find yourself thinking about the traumatic event even when you don't want to, or have nightmares about it?

  • Do you go out of your way to avoid situations, thoughts, or feelings that remind you of it?

  • Do you feel constantly on alert, or find yourself getting startled easily?

  • Are you feeling detached from family, friends, or other loved ones, or avoiding people or activities that used to give you pleasure?

Answering yes to three or four of these should prompt a talk with a doctor or counselor about being evaluated for PTSD or depression.

Treating PTSD usually starts with something called cognitive behavioral therapy. This type of talk therapy aims to help a person come to terms with a traumatic event by conjuring up memories of it in a safe situation. While stressful at first, this reimagining can gradually show that the memory itself isn't harmful. It also helps tie together the traumatic memory and the emotions it spawned. This makes it easier to file away the memory as something that happened in the past, and not something that is still happening.

Reconnecting with people, interests, and activities is another goal of therapy. This improves mental and physical activity as well as social connections, all of which are good for the mind and the heart.

In addition to talk therapy, some people benefit from taking an antidepressant in the selective serotonin reuptake inhibitor family. Two of these — paroxetine (Paxil, generics) and sertraline (Zoloft, generics) — have been specifically approved for treating PTSD. It's likely that the others in this group — fluvoxamine (Luvox, generics), fluoxetine (Prozac, generics), and citalopram (Celexa, Lexapro, generics) — also work.

One of the cruel ironies of heart-related PTSD is that the symptoms often appear when recovery is well under way. Recognizing the signs of PTSD (and depression), realizing they aren't just "in your mind," and getting help will be good for your heart, your health, and your life.

More information and further reading

The booklet "Post-Traumatic Stress Disorder, A Real Illness" is available from the National Institute of Mental Health by calling 866-615-6464 (toll free) or online at www.nimh.nih.gov/healthinformation/ptsdmenu.cfm.

The Anxiety Disorders Association of America offers information and support for people with PTSD as well as family and friends: 240-485-1001 or www.adaa.org.

Two books by Boston psychiatrist Jonathan Shay — Achilles in Vietnam: Combat Trauma and the Undoing of Character (Scribner, 1995) and Odysseus in America: Combat Trauma and the Trials of Homecoming (Scribner, 2003) — draw striking parallels between the experiences of American soldiers and warriors from ancient Greece