Abstract
This study tested the effectiveness of integrated intervention program on Quality of life and personality type of Cardiovascular patients. 30 patients were randomly assigned to the intervention and control groups. Participants completed pretest scales and were reassessed after intervension. Findings revealed that the intervention group was significantly more Quality of life and fewer type D personality, which showed support for the effectiveness of the Cardiovascular disease specific psychotherapy. Furthermore, this method can be used with usual medical care in improvement in cardiovascular patients.
Keywords: Quality of life, personality, Cardiovascular Diseases, Psychotherapy
Introduction
Cardiovascular disease [CVDs] currently is one of the most common chronic disease and is becoming a leading reason of morbidity, mortality, and disability in the world (Ai et al., 2007). There are more than a few risk factors for Cardiovascular disease and Some of these risk factors, such as age, gender or family history, are un changeable (Guertin, Rocchi, Pelletier, Émond, & Lalande, 2015); However, research has confirmed the importance of psychological risk factors as independent risk factors in the incidence and prevalence of CVDs (Cornett & Simms, 2014). The most significant psychosocial factors are mental health as depression, anxiety, stress, quality of life and inappropriate personality types. These psychosocial risk factors show connection with CVDs, the onset of heart attack, the length of post-heart attack hospitalization and post-heart attack survival (Guertin et al., 2015). The presences of psychosocial risks factors have an impact on the development and the chances of recovery and of mortality after a cardiac event ( Scholl, Bots, & Peters, 2015).
Based on the model of health, desirable quality of life should encompass several physical, emotional, mental, social, spiritual and occupational dimensions (Zhang, Gallagher, & Neubeck, 2015), and according to the definition of the World Health Organization quality of life is “individual’s perception of own life considering the culture and value systems and its relationship to objectives, expectations, interests, standards, and individual’s life experiences” which includes physical health, psychological well-being, independence, satisfactory social relationships, and individual’s personal beliefs (Gholami et al., 2016). Accordingly, the quality of life is used as a criterion to assess the treatment results and the status of patients with physical and mental disorders (Houston, Hoch, Gabriner, Kirby, & Hoch, 2015).
Moreover, personality traits have been in association with physical and psychological health in cardiovascular patients. It seems that personality traits have significant effects on incidence and prevalence of CVDs (Batselé et al., 2016). Defining predisposing factors of diseases requires the study of personality traits (Borsoi et al., 2014). Given to personality structure, individuals show different behavior and emotions in dealing with stress (Howard & Hughes, 2013). So, D personality type is one of mediating factors in the relationship of health and stress (Bunevicius et al., 2013). researchers described two components of D personality type: negative affectivity (the tendency to experience negative emotions such as depressed mood, anxiety, anger, and hostility), and social inhibition (avoidance from potentially dangers in social interactions such as disconfirming by others) (Johan Denollet, 2005). Emotion inhibition in D personality type exposes people to health problems, including over tension, cardiovascular disease and mental disorders. Type D individuals may predispose to unhealthy behaviors like smoking, alcoholism, physical inactivation, and emotional stresses such as anxiety, depression and anger (Pedersen et al., 2006).
Large body of Studies have documented that improvement of quality of life and treatment of pathologic personality type reduces cardiac disease symptoms, and decreases patients’ morbidity and disabilities (Deek et al., 2016). Also, there is no comprehensive psychological intervention for cardiovascular diseases. Furthermore, we need to have comprehensive and multidimensional approach to chronic disease and we have to know that every disease needs their specific intervention which include all of risk factors. intervention without attention to all of risk factors could not lead to good improvement in patients. Due to the weakening nature of CVDs, the strategy for the treatment of these patients should take into account all facets of life, including social support, personality, stress and coping styles, emotional regulation, etc. The goal of the present study was the analysis of the efficacy of cardiovascular specific psychotherapy that was based on cognitive-behavioral therapy on patient’s quality of life and D personality type.
Methods
Participants
The study population included all patients with CVDs referred to The Cardiovascular Research Center of Rasol-e-Akram hospital, Rasht, who meeting the inclusion criteria, were invited to participate. The inclusion criteria comprised of consent to participation, persian reading and writing ability, and lack of involvement in other similar programs and Psychiatric disorders. The diagnosis of cardiovascular disease was based on the: positive echocardiogram and having a history of heart failure for at least 6 months. This quasi-experimental study was conducted in 2015 on 30 patients with cardiovascular diseases who divided into two groups of intervention [N=15] and control [N=15]. Sample size was determined via Gpower software: [Effect size f²[V]=0.7, α err prop=0.05, Power [1-β err prop] =0.95, Number of groups=2, Response variables=2, Total sample size=30] (Faul, Erdfelder, Lang, & Buchner, 2007).
Intervention
In the present study, authors systematically reviewed all the paper in Iran which surveyed psychological risk factors of cardiovascular diseases. Based on systematic review, a cardiovascular disease psychotherapy designed. This psychotherapy includes all the psychological risk factors that based on systematic reviewe influence the incidence, onset, severity and progression of cardiovascular diseases. Considering the results of the previously conducted researches and the issue that the cardiovascular specific psychotherapy has not been designed in, we attempted to planning the cardiovascular specific psychotherapy. To do so, a literature review was performed searching www.ensani.ir, irandoc, www.nlai.ir, magiran, noormags, medlib, IranMedex, science direct, ncbi, Medline and PsycInfo. To identify the relevant studies, all titles and abstracts generated from the searches were reviewed by a reviewers. then, reviewers reevaluated 213 full articles. Finally,based on 88 articles, cardiovascular specific psychotherapy. sessions and contents of cardiovascular specific psychotherapy include: Session1: Review symptoms, Personal introduction; Understanding the role of psychological factors on cardiovascular diseases; determining goals of the treatment, therapy commitment; Sessions 2-3: Understanding type A, D and openness to experience, impact of personality on the expression, course, severity, and/or treatment response of a cardiovascular diseases; Sessions 4-5: Understanding hardiness and resiliency; Cognitive appraisals, Behavioral coping, Social resources and health-promoting behavior; Sessions 6-7: Short-term and long-term life goals and how to achieve realistic life and non-life goals; Healthy lifestyle, including physical activity, a healthy diet, avoiding excessive caffeine and alcohol, not smoking; Sessions 8-9: thoughts and behavior, the power of positive thoughts, identification of negative personal thoughts and turning them to positive ones, and identification of illogical thoughts; Sessions 10-11: Understanding coping styles and emotion regulation; Problem solving techniques, Training assertiveness and social skills; Sessions 12-13: Understanding spirituality; personal growth, self-actualization, relation to god, altruism, meaning and reinterpreting of disease, praying and the role of it o health; Sessions 14-15: Understanding social support; Negotiation, problem solving, problem identification and active listening, Tension reduction and relaxation technique; Improved social support; Sessions 16-17: Relaxation and how to use it, intimacy skills, Describe the cognitive model of depression, Explain cognitive-behavioral strategies
Sessions 18: termination; reviewing All treatment sessions and posttest. The cardiovascular specific psychotherapy has been created based on cognitive-behavioral therapy and in small group formats. The treatment plan is held in eighteen 2 hours’ sessions. Every session begins with welcoming members of the group and reviewing prior meetings [10 to 15 minutes]. At the end of each session, all participants review the session and practice the tasks of the week.
Measures
WHOQOL-BREF
To evaluate quality of life, we used the 26-item, self-report, short version of the World Health Organization Quality of Life instrument (Eker & Tüzün, 2004).This instrument provided us with a subjective quality of life assessment in four domains of physical (e.g., “How satisfied are you with your sleep?”), psychological (e.g., “How much do you enjoy life?”), social (e.g., “How satisfied are you with your personal relationships?”), and environment (e.g., “How satisfied are you with your access to health services?”). Data were reported on the total scores of the first three domains, as they were more relevant to the aims of this study (Skevington, Lotfy, O’Connell, & WHOQOL Group, 2004).
D personality type scale
This scale has been developed by Denollet in 1998 and consists of 14 items measuring negative affectivity (7 items) and social inhibition (7 items) (J. Denollet, 1998). Participants answer to each item on a 5-point Likert scale from 0 (false) to 4 (true). Scores range from 14 to 56. Cronbach’s α for negative affectivity and social inhibition subscales were reported 0.88 and 0.86 respectively, and concurrent validity of this scale with type A personality scale has been reported 0.63 (de Jonge et al., 2007).
Data analysis
All data appeared normally distributed, with no outliers. univariate analysis of covariance [ANCOVA] and Multivariate analysis of variance [MACNOVA] by SPSS software were used with pretest scores as the covariate to disclose the effects of treatments between the groups.
Results
The Mean and SD scores for D personality type and QOL and ite suscales are shown in table 1. Age of the participant’s sorts between 29 and 42 years with mean age 33.28±2.57 years. Gender distribution were 67% males and 33% were females. All the participants were married.
table 1: Mean ± SD of D personality type and QOL and ite suscales in experimental and control groups
Variable time Experiment Control
Mean ± SD Mean ± SD
D personality type Pre-test 21.67±2.10 18.25±2.67
Post-test 15.33±2.84 17.67±3.06
physical Pre-test 8.83±2.41 8.08±1.24
Post-test 10.67±1.67 9.33±1.15
psychological Pre-test 8.67±2.19 10.75±1.60
Post-test 13.50±1.17 11.75±1.60
Social Pre-test 12.50±2.15 12.50±1.68
Post-test 14.33±1.50 12.42±1.51
environment Pre-test 10.58±1.62 11.17±1.19
Post-test 13±1.28 13.58±1.16
Total QOL Pre-test 40.50±6.30 43.75±5.33
Pre-test 52.17±4.65 46.08±5.76
As seen in Table 1, the Mean±SD of D personality type and QOL and ite suscales at pre-test and post-test phase for the experimental and control groups are shown in table 1.
the MANCOVA [Multivariate Analysis of Covariance] statistical analysis was administered. This is because the pre-test data was co-variant, while the post-test data was variant, hence, the statistic is able to analysis the score differences of each dependent variable in Cardiovascular Specific Psychotherapy group and the control group.
In checking-out the status of QOL’ suscales based on the obtained data from the two groups, the MANCOVA showed significant difference in the mean score for QOL’ suscales between the two groups after the intervention [Box’s Test of Equality of Covariance Matrices= 7.188, p=0.835, Pillai’s Trace=0.744, F=10.89, P =0.00, Partial Eta Squared=0.744];
Table 2: The results of MANCOVA on the QOL’ suscales of two groups in the post-test
Variable SS df MS F Sig eta
physical 9.517 1 9.517 7.446 0.014 0.293
psychological 21.706 1 21.706 7.940 0.011 0.306
Social 29.396 1 29.396 15.260 0.001 0.459
environment 4.827 1 4.827 4.953 0.039 0.216
However according to Table 2, after carrying out the cardiovascular specific psychotherapy [CSP], the mean score for physical [F=7.44], psychological [F=7.94], Social [F=15.26], and environment [F=4.95] measured in posttest in the intervention group was significantly higher than that in the control group [P<0.05]. Based on the results, it can be concluded that the CSP has significant consequence on the main dependent variables which were the QOL’ suscales among the cardovascular patients.
Table 3: The results of ANCOVA on the total scores of Quality of life and D personality type in the post-test
Variable SS df MS F Sig eta
Total QOL 213.814 1 213.814 18.271 0.003 0.465
D personality type 56.505 1 56.505 7.097 0.015 0.253
However according to Table 3, after carrying out the cardiovascular specific psychotherapy [CSP], the mean score for Total QOL [F=18.271] and D personality type [F=7.097] measured in posttest in the intervention group was significantly higher and lower respectively, than that in the control group [P<0.05]. Based on the results, it can be concluded that the CSP has significant consequence on the main dependent variables which were the Quality of life and D personality type among the participants. According to Table 2 and 3, the cardiovascular specific psychotherapy [CSP] have significant effects on post-test scores (P<05); considering the eta squared, we can say that 29%, 30%, 45%, 21%, 46% and 25% changes of Physical domain, of psychological, of Social, of environment, of Total QOL and of D personality type respectively are due to the effect of cardiovascular specific psychotherapy [CSP] in experimental condition.
Discussion
The results displayed that CSP, improved Quality of life and D personality type in the intervention group. our findings are consistent with the results of similar studies such as (Athilingam, Edwards, Valdes, Ji, & Guglin, 2015; Lundgren et al., 2015) confirming the effectiveness of psychological interventions in reducing the psychological and somatic symptoms in cardiovascular patients. The CSP is based on the cognitive behavioral theory and is a therapy procedure which combines the cognitive processes and behavioral tactics to achieve cognitive and behavioral alterations in cardiovascular patients. People undergoing such a training plan learn to understand thoughts, feelings and bodily sensations as passing events in the mind rather than self-evident truths or aspects of the self. By this approach, the skills learned from CSP help people recognize and disengage themselves from habitual dysfunctional cognitive routines, which in turn protect them against future risks of experiencing psychopathology. The CSP thus providing new cognitive and behavioral coping skills which may lead to success in overcoming internal and external stresses. CSP presupposes correction of automatic catastrophic thoughts that worsen anxiety symptoms and fear, anticipatory anxiety, and predispose to avoidances. Through tactics to relieve anxiety [diaphragmatic breathing and muscle relaxation], cognitive changes and interoceptive exposures, the patients are more able to be exposed to avoided situations and, therefore, improve their quality of life, overcoming everyday life stressors and anxieties and dependence on relatives, which account for a major impairment in daily activities, often reaching the level of disability (Hannesdottir & Ollendick, 2007). According to The CSP, anxiety arise from distorted and catastrophic interpretations of bodily symptoms. CSP of anxiety is based on the cognitive behavioral theory that the disorder stems from constant perceptions of the world as a dangerous place, resulting in a process of maladaptive and habitual interactions among cognitive, behavioral, and physiological response systems. Maladaptive cognitive responses include a pre-attentive bias to threat cues (Batelaan, ten Have, van Balkom, Tuithof, & de Graaf, 2014; Lee, Choi, Yum, Yu, & Chair, 2016).
it can be stated that CSP have cognitive and behavioral skills and even some mechanisms of this plan programs serve to target emotion dysregulation. For example, relaxation exercise is often used to help reduce a patient’s biological reaction to anxiety. Since relaxation allows cardiovascular patient to modify their biological arousal, it may serve as an emotion regulation strategy, thus it decreases the excitement. The CSP decreases negative cognitive coping in cardiovascular patients and increases effective coping after treatment. Cognitive coping is another valuable psychological construct that in some studies reported to be effective in prevention and treatment of anxiety disorders and is correlated with depression and sadness (Gallo et al., 2014). Maladaptive or excessive uses of negative cognitive tactics contribute to the progress and perseverance of anxiety. The CSP focus on modifying the cognitive [e.g., maladaptive thinking patterns] and behavioral [type A, D personality, emotional coping style, …] and helps cardiovascular patients to identify somatic aspects of stress, anxiety and depression and to develop a plan, as well, to cope with stress, anxiety and depression provoking situations. patients put on the skills in real-life situations to gain mastery over their stress, anxiety and depression, while there is Results of the several study revealed that anxious patients demonstrated greater intensity and frequency of negative cognitive and emotional responses. These patients had less ability in evaluating negative emotional situations and more reliance in emotion regulation strategies, in which the risk of functional impairment and intense negative emotion is increased. Furthermore, these patients perceived themselves as less able to manage the emotionally provocative situations successfully. They displayed more dysregulated management [i.e., culturally inappropriate emotional expression] and less adaptive coping across experiences of anger, sadness, and worry compared with the healthy peoples (Cuffee, Ogedegbe, Williams, Ogedegbe, & Schoenthaler, 2014). Incorrect breathing patterns lead to hyperventilation and biological symptoms resulting from significant increase in blood oxygenation: dizziness and tachycardia. Muscle tension also plays a role in increasing anxiety and may also cause somatic reactions such as pain. These sensations can be reduced using appropriate breathing methods and muscle relaxation (Jerath, Crawford, Barnes, & Harden, 2015). Diaphragmatic breathing is a method that uses abdominal muscles for respiratory control. Progressive muscle relaxation is an exercise involving practice of tension and relaxation of the main muscle groups. Both techniques [relaxation and abdominal breathing] can be practiced in sequence or independently, especially in situations in which there is anticipatory anxiety. Distorted and catastrophic interpretations of physical sensations of stress and anxiety are common in cardiovascular patients, as well as patient’s beliefs about hopelessness and inability to manage anxiety and stress (Golbidi, Frisbee, & Laher, 2015). Cognitive therapy aims at restructuring such catastrophic thoughts. To do so, it is important for the patient to know the basic assumptions of the cognitive model and cognitive therapy: that thoughts influence emotions and behavior. In treatment, patients are asked to treat their thoughts as hypotheses or “guesses” about the world. Training is given in identifying overlearned [“automatic”] catastrophic thoughts linked to stress, anxiety and depression (Doering et al., 2013).
our study and the other noted research suggest that a healthy life style such as greater levels of physical activity, avoidance of smoking, maintenance of a healthy weight range, and light to moderate alcohol consumption all could be prevent by CSP. patients who are mentally in a more optimal situation have more motivations to carry out health-promoting behaviors. This mental health is reinforced by being with family and having intimate relations with its mem¬bers and effects patient’s spiritual health. CVs patients who have the assistance of social support have a higher quality of life and are less vulnerable if they ex¬perience negative incidents. Continuing connected specially having significant communications, which are high in quality is a fixed predictor for the quality of life.
cardiovascular disease specific psychotherapy [CSP] is designed to help cardiovascula patients avoid habitual negative thoughts, emotions and behavioral patterns. Instead, increased awareness and acceptance are seen as allowing for new ways to respond and cope with different situations both in relation to oneself and the wider world. In the CSP, Mindfulness training has been linked to the changes in those areas of the brain which are responsible for affect regulation and stress impulses reactions; in turn, these changes influence body functions such as breathing, heart rate and immune function. Thus, as a result of CSP, the participants presumably acquired the skills to disengage themselves from ruminative thoughts and images that confer some protection against future stressful situations and subsequent stress, anxiety and depression.
On the other hand, considering the relationship between body and mind as well as physical and mental health of individuals affected by their beliefs, expectations and perceptions of life quality and satisfaction in their lives, many diseases are placed in the category of psychosomatic diseases. The emergence of psychosomatic disorders requires that psychological factors and physical symptoms are linked with each other simultaneously. In many areas, health psychology has found its exceptional role mixing its information and practice into traditional medicine. Nowadays psychological factors are considered as strong and independent risk factors for chronic disease, but usually are not recognized in the clinical practice. For better clinical relevance psychosocial, behavioral and medical risk factors can be assigned a point value based on the strength of the research relevance, thus all the risk ratings could be administered in a clinical design. Clinical practice should be lean towards multidisciplinary care models and recognize the evidence of the benefits of comprehensive patient care. And now, we introduce cardiovascular disease specific psychotherapy [CSP] to health psychologist to take it in their clinical health intervension for cardiovascular patients. The present research had some limitations; The fact that the data were collected through self-reporting tools is another weak point in the current study. It would be advisable that behavioral objective indicators with semi-structured interviews be employed in this field of research. our sample population was only one hospital. Therefore, we can’t generalize the results to other populations.