Thomas P. Hackett

Factors contributing to delay in responding to the signs and symptoms of acute myocardial infarction

Abstract The delay time between the onset of symptoms and arrival at a medical facility for examination was studied in 100 randomly selected patients who had been admitted to a coronary care unit with a diagnosis of suspected or proved acute myocardial infarction. 1. 1. The delay time did not differ significantly between private and ward patients. In general, the patient with coronary symptoms was apt to respond sooner than later. These patients who delayed 5 or 6 hours could easily have delayed 48 hours or longer. The half-time for reaching medical aid was 3.9 hours. 2. 2. There was no significant relation between delay and age, sex, history of previous myocardial infarctions, socioeconomic scores and presenting symptoms. 3. 3. The time of delay tended to diminish as the subjective severity of the symptoms mounted. However, there was no relation between the severity of the disease, as measured by the Peel score, and the time of delay. 4. 4. There was a significant relation between the source of the symptom and delay. Thus, patients who recognized their heart as causing the symptom sought help sooner than those who displaced the cause to other organ systems. Patients who interpreted the symptom solely in terms of excluding the heart as causal delayed the longest. 5. 5. The role of a second person in initiating the decision to seek help was significant. For the largest, number of patients, a family member made the decision. Spouses appeared to be less successful in reducing delay than friends or associates. The most influential person in reducing delay in our series was an unrelated friend or stranger who was not associated with the patients work. 6. 6. Physicians caused or contributed to patient delay in 12 per cent of our cases. They rationalized the delay along the same lines as the patient. Other organ systems were blamed or the pain was minimized by calling it angina. Since referral to the hospital was a simple matter, no adequate reason can be given for the procrastination of these doctors. 7. 7. The defense of denial is commonly used by the patient with coronary disease to control anxiety. The finding that no significant relation could be established between denial and delay in our data is explained. Denial was found to be significantly related to symptom displacement and the influence of another person on delay. Those patients who denied minimally recognized the heart as the source of trouble and did not require outside help to seek the advice of a physician. Patients whose denial was major displaced the source of trouble from the heart to other organ systems and tended to put off consulting a physician until someone else urged them to do so.

Components of type A, hostility, and anger-in: further relationships to angiographic findings.

In a previous study of patients undergoing angiography at Duke University Medical Center, we reported that of all components of the Type A behavior pattern (TABP), only Potential for Hostility and Anger-In were significantly associated with extent of coronary artery disease (CAD). The present study was undertaken to replicate these findings using a different patient population. Tape-recorded structured interviews from 125 angiography patients at Massachusetts General Hospital were blind scored using the component scoring system employed in the Duke study. The results confirmed our previous findings. Global TABP was completely unrelated to extent of CAD, while Potential for Hostility and Anger-In were significant independent predictors of disease severity. These findings argue for a reconceptualization of the manner in which the TABP is defined and assessed.

Patient delay in cancer.

Abstract Analysis was made of psychosocial factors influencing the amount of elapsed time between the first sign or symptom of cancer and the search for medical help in 563 patients. Delay remained...

Predilection to death. Death and dying as a psychiatric problem.

&NA; A series of five unusual surgical patients is reported in which “predilection” to death was a prominent part of the clinical picture. The common characteristic of these predilection patients is that each anticipated his death at the time of admission. With the exception of a mentally ill woman, they were neither anxious nor significantly depressed. All expressed the conviction that death would occur within a short time, except for a young girl who serenely anticipated death without openly referring to it. The conviction of death was invariably accompanied by an expectation of being killed by another. Predilection patients may be readily distinguished from preoperative patients with high anticipatory anxiety, depressed patients, suicidal patients, and those rare patients who correctly prognosticate their own deaths and demonstrate no significant lesions at autopsy. Two men died unexpectedly in the course of convalescence. Three women patients were not only expecting to die but were expected to die because of malignant disease. However, in one woman, the disease had apparently been arrested for 28 yr. Relapse and metastatic lesions did not occur in another patient until after a young man with the same disease had succumbed. A third woman, suffering both from severe mental illness and incurable cancer, became alarmed shortly before death when a palliative procedure threatened to prolong her unhappy life. Death held more appeal for these patients than did life because it promised either reunion with lost love, resolution of long conflict, or respite from anguish. Each patient was emotionally isolated during the final admission. Their “loneliness” was of several different kinds; one man was a semi‐vagrant who had never known emotional intimacy; another man had exiled himself from his family; one woman had suffered successive deaths of her husband and members of her family; another woman had repudiated all but the most formal relationships throughout her life; a young girl had not only lost a close friend by death but was deserted by her physicians and family, who were so concerned that they could not come to terms with her certain death. Study of the predilection patients has led to an evaluation of the care of the dying patient in general, particularly from the viewpoint of the paradoxical attitudes towards death that are conventionally assumed. The application of psychodynamic principles to the concept of death and the process of dying is based on the hypothesis of the appropriate death. An appropriate death is one that recognizes the inevitability of personal death as a fulfillment of life. It satisfies four conditions: conflict reduction, compatibility with ego ideals; continuity of personal relations with the living and the already dead; and consummation of phantasies. In short, the circumstances of an appropriate death are the opposite of those in which a patient would commit suicide. The conditions of an appropriate death have been derived from the distinction between impersonal, interpersonal, and intrapersonal death. The fear of dying is not the same as the fear of death. The dying process has psychological counterparts in primary anxiety, the sense of imminent disintegration; the fear of death. it has been shown, is a death phobia, indirectly related to “rational” fears. Appropriate death is an aspect of euthanasia‐‐death without suffering‐‐for patients whose death is imminent. However, the conventional concept of euthanasia as the hastening of the death of incurably ill patients is the antithesis of the appropriate attitude towards death which psychiatric intervention advocates. In conventional euthanasia, the patients personality is ignored; in the proposal of therapeutic dissociation of the patient from the disease, the personality in its unique dignity is enhanced. Various practical recommendations for implementing the appropriate death are presented, but no intervention is possible without frankly facing the imminence of death with the patient. Evidence has been presented to indicate that this is usually more difficult for the doctor than for the patient. Tacitly to impose silence, denial, deception, and isolation upon the dying patient may itself cause suffering and bring about bereavement of the dying, a state of premortem loneliness, emotional abandonment, and withdrawn interest that the survivors impose upon the dying. Examples are cited in which altered interpersonal relationships provide the prodromal intimations of approaching death. Instead of viewing death as a failure beyond his competence, the physician can extend his care and help his dying patient to achieve an appropriate emotional world in which to die.

Type A personality and extent of coronary atherosclerosis

The relation between type A personality and the extent of coronary artery disease was studied in 109 patients who underwent selective coronary angiography. Type A personality as measured with the Jenkins Activity Survey was not correlated with the extent of coronary artery disease as assessed from the number of vessels with 50 percent or greater narrowing of diameter.

Psychological Management of the Myocardial Infarction Patient

The acute coronary experience is divided into three parts. In the first, the pre-hospital phase, attention is devoted to the widespread phenomenon of patient delay. Evidence is given to indicate that the source of delay is entirely psychological and centers around the inability to decide whether or not to seek help. The second part, or hospital phase, describes the response of the patient to the various aspects of the coronary care unit, including monitoring, false alarms, witnessing and sustaining a cardiac arrest. The third phase, the post-hospital convalescence, centers on the principal psychological problem of this period, depression. Its causes, manifestations, and methods of management are discussed.

Predicting cardiac morbidity based on risk factors and coronary angiographic findings

A cohort of 189 men was followed up for 1 year after performance of coronary angiography and determination of risk factors to ascertain which risk factors or clinical and laboratory findings could aid in predicting the patients who would have a substantial cardiac morbid event. Data on clinical signs and symptoms, psychosocial assessments, angiographic findings and presence of standard risk factors for coronary artery disease were collected in each case. Twenty-five percent of the men experienced a substantial cardiac morbid event (hospitalization, myocardial infarction, resuscitation or death). With or without inclusion of the patients who underwent surgery, discriminant analysis equations were successful in predicting morbidity on the basis of risk factor data. For the whole sample such analysis was significant at p < 0.00005 and accurately predicting the fate of 78 percent of the subjects. With exclusion of the surgically treated patients, the discriminant analysis accurately predicted future morbidity 83 percent of the time (p < 0.0001). The following risk factors for increased morbidity were common to both analyses: severity of angina, history of myocardial infarction, family history of heart disease, fatigue and absence of type A behavior.

The risk of type a mediated coronary artery disease in different populations.

&NA; Using angiographic evidence of coronary artery disease, we have examined whether certain populations were particularly susceptible for risk engendered by Type A personality. Two hundred three men were studied with the Jenkins Activity Surveys; 103 of them were also studied with the Rosenman semistructured interview. The extent of vessel disease was found unrelated to Type A in each of the three ethnic groups studied—Irish Catholic, Italian Catholic, and white Anglo‐Saxon Protestant. Likewise, no relationship between Type A and vessel disease was discerned in high depressed, low depressed, high stressed, or low stressed individuals. Finally, we examined whether cardiac symptomatology could affect any relationship found between Type A personality and vessel disease. No significant relationship was discerned in patients who had experienced or had not experienced a myocardial infarction or in patients with mild, moderate, or severe exertional angina.

The amytal interview: history and current uses.

Abstract The Amytal interviews usefulness is limited and its use is not specific for any particular psychiatric condition. Used properly in particular cases, however, the technique may be of extraordinary value. The history of its use is reviewed and current indications and contraindications are summarized.

White-collar and blue-collar responses to heart attack

Abstract This study investigates the influence of socioeconomic factors on the responses of patients to acute myocardial infarction. Patients were divided socioeconomically in two ways: by their ward assignment and by socioeconomic status scores (SES Score). In this way prior socioeconomic differences (SES score) could be contrasted with differences arising in the two treatment settings (ward vs private). There was no significant differences in anxiety, depression or fear of death between the groups. Patients from each group were undermedicated for pain, anxiety and insomia—undermedication for insomia was significantly greater for ward patients. At discharge only 30% of the entire population received tranquilizers. A significantly greater number of white collar patients had sleeping medication prescribed. In comparison with the white collar group, blue collar patients(1) found the equipment more frightening, (2) knew less about it, (3) blamed their heart for monitor artifacts, (4) knew less about the process of cardiac repair, (5) avoided asking questions about the future, (6) displayed more regressive behavior and (7) were less able to recall their doctors name. Most of these differences can be explained by faulty communication between the patient and his caretakers. White collar patients probably enjoy a greater exchange of information.