PSYCHOLOGICAL ASSESSMENT POST-MI (myocardial infarction)
In the process of rehabilitation of patients post-MI there are many psychological variables (risk factors, consequences psychosocial) that influence the outcome of this process and must be evaluated to detect, in each case, such psychological problems that may adversely affect future health status and the patient's return to a fulfilling life after a heart attack. Once detected
specific problems can be improved, should be deepened within the framework of psychological intervention in its assessment, specifically and individually, through appropriate assessment techniques that allow the correct behavioral functional analysis of the problems identified and the subsequent implementation treatment programs suitable to each particular case.
not forget this unavoidable task-specific evaluation, then presents a review of the relevant aspects to consider in the psychological evaluation of coronary patients.
emotional impact assessment and their IM
consequences Assessment
initial emotional reaction
Several studies have devoted their attention to assessing the emotional state of individuals who have suffered an MI. The results indicate a high incidence of anxiety disorders and depression, characterized by the presence of fear of developing a new MI or death from cardiac causes of concern for health, disability, uncertainty about the future, irritability and guilt by premorbid behavior.
addition to anxiety and / or depression also described another pattern, apparently opposite, characterized by the denial of the importance of cardiac event and its consequences. In these cases, the assessment of levels of emotional deterioration in the early stages after MI, may show a situation of "false positive" resulting from an assessment by the patient, "inappropriately optimistic" of the situation, although variable has been cited as a good prognosis during the acute phase of illness, is, in fact risk a reaction medium and long term, to hinder, to a large extent, adherence to the therapeutic measures necessary for proper rehabilitation.
As can be seen, adverse emotional reactions post-IM resulting from the presence of dysfunctional cognitions, and the Most erroneous, about the importance of the disease and its consequences. In fact such emotional distress unrelated to the severity of the disease, but rather with the assessment that the subject makes his situation, regardless of the actual severity of the disorder.
Another important aspect regarding the emotional reaction is the presence of functional self-reported somatic symptoms (chest pain, fatigue) as these, when there are significant cardiologically may be an indicator of adverse emotional reaction. In this line, the frequency of somatic complaints closely correlated with the degree of emotional impairment as a result of the IM condition.
Therefore, proper evaluation of the emotional reaction should be considered:
IM psychosocial consequences are that, after leaving the hospital, the quantity and quality of activities performed by the patient is, in many cases, changed dramatically. These changes can be detrimental to the rehabilitation and therefore must be evaluated.
In this line, the behavior of post-MI patients has described as passive and dependent, decreasing their activity level and accompanied by feelings of dissatisfaction.
More specifically, the data refer to post-MI changes in social, recreational and sexual activity
Finally, we have attempted to identify factors that correlate with reductions in harmful activity and not justified from the medical point of view , identifying the patient's expectations about the likely impact of the attack and especially the presence of adverse emotional states during the early stages of convalescence.
also be taken into account in evaluating certain patients the presence of over-activity that, in some cases are evaluated as evidence of good progress of rehabilitation, when in fact can result from the denial of the disease and may be inadequate in the short term because your body is not ready, long-term because it impedes the realization of the changes necessary to avoid replay a lifestyle that has been the subject to the condition of a heart attack.
In this line is very important to clarify that the goal of cardiac rehabilitation is that the patient develop a healthy lifestyle, appropriate to their physical state at any time and aimed, in any case, a planned progression towards the recovery.
In short, this section should be considered:
This information is intended to determine, first, what did the patient pre-IM have to keep doing and should stop doing and, secondly, what activities do at present to be strengthened and to be reduced or eliminated.
initial emotional reaction
Several studies have devoted their attention to assessing the emotional state of individuals who have suffered an MI. The results indicate a high incidence of anxiety disorders and depression, characterized by the presence of fear of developing a new MI or death from cardiac causes of concern for health, disability, uncertainty about the future, irritability and guilt by premorbid behavior.
addition to anxiety and / or depression also described another pattern, apparently opposite, characterized by the denial of the importance of cardiac event and its consequences. In these cases, the assessment of levels of emotional deterioration in the early stages after MI, may show a situation of "false positive" resulting from an assessment by the patient, "inappropriately optimistic" of the situation, although variable has been cited as a good prognosis during the acute phase of illness, is, in fact risk a reaction medium and long term, to hinder, to a large extent, adherence to the therapeutic measures necessary for proper rehabilitation.
As can be seen, adverse emotional reactions post-IM resulting from the presence of dysfunctional cognitions, and the Most erroneous, about the importance of the disease and its consequences. In fact such emotional distress unrelated to the severity of the disease, but rather with the assessment that the subject makes his situation, regardless of the actual severity of the disorder.
Another important aspect regarding the emotional reaction is the presence of functional self-reported somatic symptoms (chest pain, fatigue) as these, when there are significant cardiologically may be an indicator of adverse emotional reaction. In this line, the frequency of somatic complaints closely correlated with the degree of emotional impairment as a result of the IM condition.
Therefore, proper evaluation of the emotional reaction should be considered:
- Assessment of anxiety and depression levels post-MI, the appropriateness of Anxiety and Depression Scales of Leeds. Assessment
- denial reactions to the IM: Scale of Awareness / Denial of Sanne et al.
- evaluation of beliefs and cognitions of the patient on IM, its risk factors and consequences: Knowledge Scale Lifestyle Heart and Heart Errors Scale, the Locus of Control Scale Health and subjective evaluation level of autonomy, capacity physical work capacity and general health status post-MI.
- Assessment by self-reports completed by the patient, functional somatic symptoms and the situations in which they arise. Assessment
IM psychosocial consequences are that, after leaving the hospital, the quantity and quality of activities performed by the patient is, in many cases, changed dramatically. These changes can be detrimental to the rehabilitation and therefore must be evaluated.
In this line, the behavior of post-MI patients has described as passive and dependent, decreasing their activity level and accompanied by feelings of dissatisfaction.
More specifically, the data refer to post-MI changes in social, recreational and sexual activity
Finally, we have attempted to identify factors that correlate with reductions in harmful activity and not justified from the medical point of view , identifying the patient's expectations about the likely impact of the attack and especially the presence of adverse emotional states during the early stages of convalescence.
also be taken into account in evaluating certain patients the presence of over-activity that, in some cases are evaluated as evidence of good progress of rehabilitation, when in fact can result from the denial of the disease and may be inadequate in the short term because your body is not ready, long-term because it impedes the realization of the changes necessary to avoid replay a lifestyle that has been the subject to the condition of a heart attack.
In this line is very important to clarify that the goal of cardiac rehabilitation is that the patient develop a healthy lifestyle, appropriate to their physical state at any time and aimed, in any case, a planned progression towards the recovery.
In short, this section should be considered:
- frequency and type of usual activities and social and leisure pre-IM.
- frequency and type of usual activities and social and leisure post-IM.
- In case of neglect of activities, reasons for leaving.
- overall satisfaction with social and leisure functioning post-MI.
- Cost / benefit of social activities and leisure.
- level reduction in sexual activity.
- subjective discomfort post-MI changes in usual activities.
- Expectations about the future in the field of business as usual. Reasons
- to which the patient attributes the changes in this area.
This information is intended to determine, first, what did the patient pre-IM have to keep doing and should stop doing and, secondly, what activities do at present to be strengthened and to be reduced or eliminated.
Assessment variables relevant to the rehabilitation work
On incorporation of the patient to work activity studies provide data that show great variability due mainly to the large number of factors involved in the rehabilitation of the patient about their work prior among which are medical, demographic, cultural and economic factors related to characteristics of their own work activity and psychological factors.
Leaving other considerations, since the goal of cardiac rehabilitation is a successful and healthy life for the patient, the psychological intervention in the area of work must address the achievement by the subject, taking into account the medical advice based on age, physical deterioration and the characteristics of the work done, the objective of developing the low or high activity to a level appropriate adequate personal satisfaction.
We describe the variables that have proved relevant in assessing the prognosis of occupational rehabilitation:
In summary, the assessment of post-MI patients should be considered with respect to relevant variables in the field of vocational rehabilitation:
This assessment, combined with medical information, should be sufficient to determine any deficiencies or excesses of activity present in the patient's behavior and the factors associated with work that may hinder the achievement of the objectives of cardiac rehabilitation.
On incorporation of the patient to work activity studies provide data that show great variability due mainly to the large number of factors involved in the rehabilitation of the patient about their work prior among which are medical, demographic, cultural and economic factors related to characteristics of their own work activity and psychological factors.
Leaving other considerations, since the goal of cardiac rehabilitation is a successful and healthy life for the patient, the psychological intervention in the area of work must address the achievement by the subject, taking into account the medical advice based on age, physical deterioration and the characteristics of the work done, the objective of developing the low or high activity to a level appropriate adequate personal satisfaction.
We describe the variables that have proved relevant in assessing the prognosis of occupational rehabilitation:
- subjects with anxiety and / or depression, both before and after MI, show rates of return to work 3 or 4 times less than do not exhibit such disorders.
- Certain patterns of coping in situations Stressful fit some results of vocational rehabilitation. Thus, post-MI patients assessed as Type A, before returning to their work prior to the attack, compared with post-MI patients classified as Type B.
- A third relevant variable appears to be the pessimistic expectations of patients about their future health status and their ability to return to work.
In summary, the assessment of post-MI patients should be considered with respect to relevant variables in the field of vocational rehabilitation:
- work activity level developed by the patient at the present time post-IM.
- Evaluation of the presence of anxiety, depression and denial of post-MI.
- expectations for future employment estimated by the patient.
- perception of work stress. Subjective discomfort
- changes in work activity post-MI.
This assessment, combined with medical information, should be sufficient to determine any deficiencies or excesses of activity present in the patient's behavior and the factors associated with work that may hinder the achievement of the objectives of cardiac rehabilitation.
relevant assessment of the family environment variables
Another study that may impair the rehabilitation process has been referred to the changes occurring in the family. Reactions have been reported anxiety and concern, especially the wives of the patients. Also noted, sometimes the presence of IM post-conflict between the patient and their families on issues related to adherence to the requirements of this care, and also changes in the behavior of relatives on the patient, behaviors typically consist of overprotection. Of interest is the assessment of social support to detect behaviors that support can be harnessed to benefit the patient and others that may impair their rehabilitation
summarize the information necessary for evaluation in the field of family functioning should include:
psychological assessment of coronary risk factors
Another study that may impair the rehabilitation process has been referred to the changes occurring in the family. Reactions have been reported anxiety and concern, especially the wives of the patients. Also noted, sometimes the presence of IM post-conflict between the patient and their families on issues related to adherence to the requirements of this care, and also changes in the behavior of relatives on the patient, behaviors typically consist of overprotection. Of interest is the assessment of social support to detect behaviors that support can be harnessed to benefit the patient and others that may impair their rehabilitation
summarize the information necessary for evaluation in the field of family functioning should include:
- changes noticed by the patient in the conduct of their families.
- discomfort / patient satisfaction with these changes.
- perceived stress level in the atmosphere.
- social support.
psychological assessment of coronary risk factors
The goals of cardiac rehabilitation include not only the infarcted patient's successful adaptation to the different areas of daily functioning, but also provide for reducing the risk of reinfarction. To this end, the psychological intervention should be directed also to the modification of behavior and personal risk factors, therefore, should be evaluated properly.
now considered the existence of three main coronary risk factors and older: hypertension, hypercholesterolemia and consumption of snuff. There are also other minor risk factors such as diabetes, excess weight and stress.
When all the above risk factors are taken together, do not provide a complete explanation of cardiac risk, suggesting the existence of other risk factors not yet identified, which should be taken into account. Focusing on the variables
strictly psychological, which are coronary risk factors, they could be classified into:
- stressful environmental stimuli.
- personal characteristics.
- behavioral habits.
- emotional disorders.
vulnerability assessment and stress coping skills
environmental demands for its intensity and / or frequency should be considered, potentially at least as highly stressful, are coronary risk factors. And it seems that stress, both acute and chronic is among the main factors proposed as precipitants of reinfarction and sudden cardiac death.
Based on these data and taking into account the influence in determining the presence of stress, situational demands on the one hand, and other personal characteristics should be assessed vulnerability and stress coping skills and lifestyle and the usual demands to be exposed to the patient (family, work ...)
In this line, you should evaluate the vulnerability to stress and coping skills. To this end, the initial assessment of post-MI patient can include, for its utility, brevity and simplicity, the inventory of items on Vulnerability to Stress and Coping Skills proposed by Beech and must also charge the patient the embodiment, at least for a week, a daily activity that allows an overview of the life style he developed.
environmental demands for its intensity and / or frequency should be considered, potentially at least as highly stressful, are coronary risk factors. And it seems that stress, both acute and chronic is among the main factors proposed as precipitants of reinfarction and sudden cardiac death.
Based on these data and taking into account the influence in determining the presence of stress, situational demands on the one hand, and other personal characteristics should be assessed vulnerability and stress coping skills and lifestyle and the usual demands to be exposed to the patient (family, work ...)
In this line, you should evaluate the vulnerability to stress and coping skills. To this end, the initial assessment of post-MI patient can include, for its utility, brevity and simplicity, the inventory of items on Vulnerability to Stress and Coping Skills proposed by Beech and must also charge the patient the embodiment, at least for a week, a daily activity that allows an overview of the life style he developed.
Assessment of personal characteristics relevant
The possibility that individual differences in coping style in different situations, play an important role in the degree of vulnerability to disease of coronary artery disease has led to attempt to identify patterns of behaviors that may be risk factors for this disease.
Rosenman and Friedman, based on the observation of coronary patients, suggested a set of behavioral characteristics that seemed to define how the behavior of these patients, behavior pattern called Type-A.
described the PCTA characterized by:
Statistical analysis of the results has led to the identification of three major factors: competitiveness, impatience and hostility fifth recital as the main defining components of TABP.
Recently, the validity of the concept of TABP and its precise relationship with increased coronary risk has been questioned.
The inconsistency in results regarding the relationship between the presence of TABP and increased coronary risk has led some to suggest the possibility that only certain PAAT damaging elements, oriented the research interest, from this idea, in search of the toxic components of TABP.
The research has been directed exclusively to the study of hostility and coronary risk factor and again studies have yielded conflicting results.
Finally, the involvement of PCTA in increasing coronary risk has also been studied regarding the risk of mortality and recurrence of disease manifestations cardioisquémica in subjects who have already suffered a first MI. In this sense it seems that the solution to the question remains open and that more data is required.
In summary, although some general trends appear to influence behavior in coronary heart health, determining which specific patterns of behavior and how they exert such influence remains today in question and future research is the need to clarify these terms.
seems that may be of interest to evaluate the tendency of patients to feelings and expressions of hostility and the manifestation of behavioral characteristics of TABP for the following reasons. Although the relationships between these behaviors and coronary risk are not set accurately, should be alert to patients with these characteristics, either to take them as a starting and / or to guide the therapist's own performance.
In this line, it may be useful to include in the protocol for initial patient assessment scales infarcted evaluating these personal characteristics, being particularly suited, by virtue of its brevity and simplicity, the scale of the SCL-90 hostility and listing Feature type proposed by Beech. It is unusual instruments but the justification of its recommendation lies in the objective clinical evaluation proposal. This is for an initial exploration of the presence of certain patient characteristics, which then will be to identify and evaluate concretely for modification. Moreover, the choice responds to the need for economy of time and effort for the patient, at the expense of which would, without doubt, the use of more sophisticated assessment tools that, without providing more relevant information for the purposes pursued, may jeopardize such important issues as the motivation for intervention.
The possibility that individual differences in coping style in different situations, play an important role in the degree of vulnerability to disease of coronary artery disease has led to attempt to identify patterns of behaviors that may be risk factors for this disease.
Rosenman and Friedman, based on the observation of coronary patients, suggested a set of behavioral characteristics that seemed to define how the behavior of these patients, behavior pattern called Type-A.
described the PCTA characterized by:
- intense and sustained effort aimed at achieving self-selected targets and usually poorly defined.
- High inclination towards competitiveness.
- Persistent desire for recognition and prestige.
- constant involvement in multiple and diverse activities.
- habitual propensity to accelerating the realization of diverse activities, and Special
- alert level physically and mentally.
Statistical analysis of the results has led to the identification of three major factors: competitiveness, impatience and hostility fifth recital as the main defining components of TABP.
Recently, the validity of the concept of TABP and its precise relationship with increased coronary risk has been questioned.
The inconsistency in results regarding the relationship between the presence of TABP and increased coronary risk has led some to suggest the possibility that only certain PAAT damaging elements, oriented the research interest, from this idea, in search of the toxic components of TABP.
The research has been directed exclusively to the study of hostility and coronary risk factor and again studies have yielded conflicting results.
Finally, the involvement of PCTA in increasing coronary risk has also been studied regarding the risk of mortality and recurrence of disease manifestations cardioisquémica in subjects who have already suffered a first MI. In this sense it seems that the solution to the question remains open and that more data is required.
In summary, although some general trends appear to influence behavior in coronary heart health, determining which specific patterns of behavior and how they exert such influence remains today in question and future research is the need to clarify these terms.
seems that may be of interest to evaluate the tendency of patients to feelings and expressions of hostility and the manifestation of behavioral characteristics of TABP for the following reasons. Although the relationships between these behaviors and coronary risk are not set accurately, should be alert to patients with these characteristics, either to take them as a starting and / or to guide the therapist's own performance.
In this line, it may be useful to include in the protocol for initial patient assessment scales infarcted evaluating these personal characteristics, being particularly suited, by virtue of its brevity and simplicity, the scale of the SCL-90 hostility and listing Feature type proposed by Beech. It is unusual instruments but the justification of its recommendation lies in the objective clinical evaluation proposal. This is for an initial exploration of the presence of certain patient characteristics, which then will be to identify and evaluate concretely for modification. Moreover, the choice responds to the need for economy of time and effort for the patient, at the expense of which would, without doubt, the use of more sophisticated assessment tools that, without providing more relevant information for the purposes pursued, may jeopardize such important issues as the motivation for intervention.
Assessment of coronary risk behavioral habits
Within this category identify those habitual behaviors whose presence has been associated with increased likelihood of suffering from ischemic heart disease as those which, not being present in the repertoire of the subject increase, also the risk of disease. In this line, three behavioral habits are considered risk factors: two for excess: the consumption of snuff and certain dietary habits, and one flaw: the lack of physical exercise.
Numerous studies, both prospective and retrospective have confirmed clear evidence of the association between the consumption of snuff and the condition of the disease. In addition, cigarette consumption has also been found associated with a worse prognosis. In fact, rates of recurrence and death among post-MI subjects who continue to smoke are at least twice those of to abandon this habit.
regard to dietary habits, the apparent increase in coronary heart disease has coincided with major changes in food, especially the increase in calories from fat, total calories increased, the increase in refined sugars and reducing consumption carbohydrate, and a decrease in dietary fiber. The consumption of cholesterol in the diet is considered today as the main coronary risk factor, whose relationship with coronary heart disease is clear. Obesity also appears to be associated with deterioration of heart health.
As for exercise. Early works made in the 40 and 50, and suggested that there might be a connection between physical activity levels and protection against mortality cardioisquémico disorder. These early data have been confirmed. The results suggest that physically active individuals have a lower risk of developing the disease than less active people.
These data underscore the need to assess the patient's behavior regarding smoking behavior, eating behavior and exercise behavior. In this sense, we must bear in mind that the goal of psychological intervention in post-MI patients is not always the elimination of these behaviors, is more this is not normal. On the contrary, there may be three situations: in some cases can obviously harmful habits such were not present in the behavioral repertoire, in others, these unhealthy behaviors may have been very common, distinguishing, in this case, patients continue to show these behaviors post-MI, and must be eliminated, and secondly, and perhaps most often, patients after infarction have been able to leave harmful habits, but with a high probability of relapse, should lead to the strengthening intervention subject's current status, reducing vulnerability to relapse.
Therefore, the evaluation post-initial IM standard coronary risk behaviors (snuff, diet and sedentary lifestyle) should include:
This assessment should be considered as a starting point to detect, at first, areas that should be subject to intervention, so that once identified the particular problems of each patient, we can deepen their evaluation using the proper functional analysis of each of the behaviors to change.
PSYCHOLOGICAL INTERVENTION POST-IM
Within this category identify those habitual behaviors whose presence has been associated with increased likelihood of suffering from ischemic heart disease as those which, not being present in the repertoire of the subject increase, also the risk of disease. In this line, three behavioral habits are considered risk factors: two for excess: the consumption of snuff and certain dietary habits, and one flaw: the lack of physical exercise.
Numerous studies, both prospective and retrospective have confirmed clear evidence of the association between the consumption of snuff and the condition of the disease. In addition, cigarette consumption has also been found associated with a worse prognosis. In fact, rates of recurrence and death among post-MI subjects who continue to smoke are at least twice those of to abandon this habit.
regard to dietary habits, the apparent increase in coronary heart disease has coincided with major changes in food, especially the increase in calories from fat, total calories increased, the increase in refined sugars and reducing consumption carbohydrate, and a decrease in dietary fiber. The consumption of cholesterol in the diet is considered today as the main coronary risk factor, whose relationship with coronary heart disease is clear. Obesity also appears to be associated with deterioration of heart health.
As for exercise. Early works made in the 40 and 50, and suggested that there might be a connection between physical activity levels and protection against mortality cardioisquémico disorder. These early data have been confirmed. The results suggest that physically active individuals have a lower risk of developing the disease than less active people.
These data underscore the need to assess the patient's behavior regarding smoking behavior, eating behavior and exercise behavior. In this sense, we must bear in mind that the goal of psychological intervention in post-MI patients is not always the elimination of these behaviors, is more this is not normal. On the contrary, there may be three situations: in some cases can obviously harmful habits such were not present in the behavioral repertoire, in others, these unhealthy behaviors may have been very common, distinguishing, in this case, patients continue to show these behaviors post-MI, and must be eliminated, and secondly, and perhaps most often, patients after infarction have been able to leave harmful habits, but with a high probability of relapse, should lead to the strengthening intervention subject's current status, reducing vulnerability to relapse.
Therefore, the evaluation post-initial IM standard coronary risk behaviors (snuff, diet and sedentary lifestyle) should include:
- dietary habits, consumption of snuff and regular physical activity pre-IM. Level of compliance
- post-MI prescriptions regarding risk behaviors.
- subjective discomfort rating for tracking prescriptions.
This assessment should be considered as a starting point to detect, at first, areas that should be subject to intervention, so that once identified the particular problems of each patient, we can deepen their evaluation using the proper functional analysis of each of the behaviors to change.
PSYCHOLOGICAL INTERVENTION POST-IM
Needs and objectives
Many of the problems of rehabilitation of coronary patients are associated with failure in the initial dominance of post-MI situation itself, leading to adverse emotional reactions that limit the capabilities of patient to respond in an effective and healthy.
On the other hand, the general objectives of the psychologist's work in this area should focus primarily on reducing the emotional impact of heart disease and achieve a realistic assessment by the patient, the impact of heart attack, for then focus on the rehabilitation process, focusing, more specifically the behavioral modification of coronary risk factors and to foster the best conditions to ensure future adherence to healthy behaviors and improve coping skills and stress management of patients, performing all adjustments considered necessary its daily operations in order to make it as successful and healthy as possible.
analyze these broad objectives and specific goals:
Reduction emotional impact caused by myocardial
attention to the patient's emotional reaction after infarction should be considered a priority area in the early stages psychological intervention. Successful treatment of these difficulties as well as specific benefits, will facilitate the work to be done later in other areas. Suffering a
IM can be assumed, and indeed seems to occur so highly stressful circumstances, to whose management requires a considerable level of coping skills.
physiological manifestations of stress (increased heart rate, blood pressure) not only pose a risk to health, but also tend to be interpreted by the patient as manifestations of physical deterioration caused by IM. For its part, the cognitive manifestations, especially alarmist analysis of the situation, often created on the subject a state of psychological disability that prevents a large extent, the recovery of normal activity level before the cardiac event, and similarly, the analysis "falsely optimistic" shown by subjects react by denying the disease difficult to achieve the changes necessary for proper rehabilitation.
In summary, compared to the overall goal of reducing the emotional impact, the psychologist should be addressed, firstly, the possible modification of irrational cognitions, considering both the catastrophic thoughts like those overly optimistic and on the other hand, to achieve a healthy level of activity in these early stages of the recovery process.
Achieving these objectives will in the short term, increase wellbeing, while the long term, to facilitate the establishment of these conditions favorable psychological help to cope with the changes required for reinstatement, in healthy conditions, the different areas of normal operation, since many of the factors of poor prognosis in rehabilitation after a stroke, are related, in large part, to failure in the initial management of emotional impact caused by the stroke.
attention to the patient's emotional reaction after infarction should be considered a priority area in the early stages psychological intervention. Successful treatment of these difficulties as well as specific benefits, will facilitate the work to be done later in other areas. Suffering a
IM can be assumed, and indeed seems to occur so highly stressful circumstances, to whose management requires a considerable level of coping skills.
physiological manifestations of stress (increased heart rate, blood pressure) not only pose a risk to health, but also tend to be interpreted by the patient as manifestations of physical deterioration caused by IM. For its part, the cognitive manifestations, especially alarmist analysis of the situation, often created on the subject a state of psychological disability that prevents a large extent, the recovery of normal activity level before the cardiac event, and similarly, the analysis "falsely optimistic" shown by subjects react by denying the disease difficult to achieve the changes necessary for proper rehabilitation.
In summary, compared to the overall goal of reducing the emotional impact, the psychologist should be addressed, firstly, the possible modification of irrational cognitions, considering both the catastrophic thoughts like those overly optimistic and on the other hand, to achieve a healthy level of activity in these early stages of the recovery process.
Achieving these objectives will in the short term, increase wellbeing, while the long term, to facilitate the establishment of these conditions favorable psychological help to cope with the changes required for reinstatement, in healthy conditions, the different areas of normal operation, since many of the factors of poor prognosis in rehabilitation after a stroke, are related, in large part, to failure in the initial management of emotional impact caused by the stroke.
Decrease risk of new episodes of myocardial
As regards the objective of preventing further occurrences of IM, the psychological intervention should focus their attention on behavioral patterns that constitute coronary risk factors, as well as patient training strategies coping and stress management.
In short, about changing habitual behaviors that constitute coronary risk factors, work will lead to the weakening of existing harmful habits, establishing in its place more adequate, and achieving long-term maintenance of both behaviors healthy routine in place, as those others, present at first post-MI but with a high likelihood of relapse subsequently.
Another area of \u200b\u200bsignificant intervention in preventing new episodes of stroke, is the training of patients with stress coping skills.
In this direction, the psychologist will be to reduce the vulnerability of individuals to stress-provoking situations, increasing their coping skills. This intervention is aimed to train the subjects to resume their usual activities at work, sexual, social, etc. prior to cardiac event in healthy conditions.
As regards the objective of preventing further occurrences of IM, the psychological intervention should focus their attention on behavioral patterns that constitute coronary risk factors, as well as patient training strategies coping and stress management.
In short, about changing habitual behaviors that constitute coronary risk factors, work will lead to the weakening of existing harmful habits, establishing in its place more adequate, and achieving long-term maintenance of both behaviors healthy routine in place, as those others, present at first post-MI but with a high likelihood of relapse subsequently.
Another area of \u200b\u200bsignificant intervention in preventing new episodes of stroke, is the training of patients with stress coping skills.
In this direction, the psychologist will be to reduce the vulnerability of individuals to stress-provoking situations, increasing their coping skills. This intervention is aimed to train the subjects to resume their usual activities at work, sexual, social, etc. prior to cardiac event in healthy conditions.
psychological intervention programs in cardiac rehabilitation: the nature and effectiveness
The term cardiac rehabilitation programs have been referring to, since the 50's he began to apply under that name, mainly based interventions Early mobilization of patients post-MI, through systematic programs of physical exercise. These programs seem to have shown a significant contribution to the decline in mortality, however, have proved insufficient to achieve other objectives of rehabilitation.
recognition failure of Cardiac Rehabilitation programs based on exercise for the purpose of a comprehensive rehabilitation (not just physical but also psychological and social) led to some attempts at intervention and applied by non-specialists in psychological issues, aimed at achieving adequate overall recovery of the patient and, likewise, some attempts to implement specific psychological techniques focusing on changing specific aspects related to problems of rehabilitation of heart attack patients.
discuss these issues:
Education Programs and psychological counseling
A review of studies conducted in the 80's helped to confirm that the therapeutic approaches is most widely used programs in order consisted of psychological counseling and educational programs.
The former consist of discussion, usually in groups, between patient / s and therapist about problems arising as a result of suffering a heart attack, including also frequently a component information related to coronary heart disease, risk factors and consequences.
The latter consist only in providing information on various aspects related to the disease and the rehabilitation process.
In the 90's the situation has not changed substantially, and studies that have attempted to verify the effectiveness of educational programs and psychological counseling in achieving the objectives of cardiac rehabilitation have yielded mixed results, but in any case limited as appear to indicate the most recent reviews on the subject.
The form of psychological assistance usually given to people who have suffered an MI, is far from what can be considered a psychological intervention. Among the major shortcomings of these traditional psychological intervention should be noted:
First, intervention is a "nonspecific", ie no specific therapeutic techniques are used, but on the contrary, without even evaluating, in each case, what are these problems, attempt to "support" the sick, in a vague, allowing you to express your concerns and "encouraging" to overcome, by providing objective information on the impact of stroke that, medically, would be expected.
is true that one of the problems is the presence of catastrophic ideas about the impact of the disease in their daily functioning. In this sense, the traditional intervention can serve, at least on occasion, to correct misconceptions about their patient's recovery. However, generally these catastrophic ideas are not simply errors due to lack of information, but a manifestation of the negative impact of disease on the patient's emotional state for which an amendment is needed specialized care to overcome emotional problems.
Moreover, given the nature of this intervention, the most common is that it takes place in a group, to be implemented by non-specialists and follow a standardized program. All these circumstances seem to be, also serious deficiencies in care traditionally given to the subjects.
In short, the traditional psychological intervention appears to be of little use due to nonspecific therapeutic components included therein and the inadequacy of the procedures used to carry out, not previously assessed the specific problems of each individual , performing in a group without discriminating the different needs presented by patients, adjusting to a standardized program unchanged from one patient to another and being applied by unskilled personnel.
A review of studies conducted in the 80's helped to confirm that the therapeutic approaches is most widely used programs in order consisted of psychological counseling and educational programs.
The former consist of discussion, usually in groups, between patient / s and therapist about problems arising as a result of suffering a heart attack, including also frequently a component information related to coronary heart disease, risk factors and consequences.
The latter consist only in providing information on various aspects related to the disease and the rehabilitation process.
In the 90's the situation has not changed substantially, and studies that have attempted to verify the effectiveness of educational programs and psychological counseling in achieving the objectives of cardiac rehabilitation have yielded mixed results, but in any case limited as appear to indicate the most recent reviews on the subject.
The form of psychological assistance usually given to people who have suffered an MI, is far from what can be considered a psychological intervention. Among the major shortcomings of these traditional psychological intervention should be noted:
First, intervention is a "nonspecific", ie no specific therapeutic techniques are used, but on the contrary, without even evaluating, in each case, what are these problems, attempt to "support" the sick, in a vague, allowing you to express your concerns and "encouraging" to overcome, by providing objective information on the impact of stroke that, medically, would be expected.
is true that one of the problems is the presence of catastrophic ideas about the impact of the disease in their daily functioning. In this sense, the traditional intervention can serve, at least on occasion, to correct misconceptions about their patient's recovery. However, generally these catastrophic ideas are not simply errors due to lack of information, but a manifestation of the negative impact of disease on the patient's emotional state for which an amendment is needed specialized care to overcome emotional problems.
Moreover, given the nature of this intervention, the most common is that it takes place in a group, to be implemented by non-specialists and follow a standardized program. All these circumstances seem to be, also serious deficiencies in care traditionally given to the subjects.
In short, the traditional psychological intervention appears to be of little use due to nonspecific therapeutic components included therein and the inadequacy of the procedures used to carry out, not previously assessed the specific problems of each individual , performing in a group without discriminating the different needs presented by patients, adjusting to a standardized program unchanged from one patient to another and being applied by unskilled personnel.
Using specific techniques of behavior modification
addition to more traditional surgery, described, have also been carried out, although to a lesser extent, studies on the effectiveness of intervention programs in which specific techniques were applied behavior modification, including techniques such as relaxation training or cognitive-behavioral strategies different . Such intervention
than largely, many of the shortcomings outlined above, apply proven techniques and, at times, is done individually, adjusting the treatment to the characteristics of the patients also more frequently are applied by psychologists.
These programs have been effective to increase skills the patient coping with stressful situations in his life, to change behaviors characteristic of Type A behavior pattern and to reduce the degree of tension experienced after stroke.
However, this is a very limited intervention that serves a targeted manner to certain problems in the infarcted patient.
In any case, such programs has led, in particular, exclusively to provide the patient with skills that allow you to better cope with difficult or threatening situations, and although these new skills can have a positive impact on the recovery process, usually be common for successful rehabilitation intervention required broader and, especially, held for this purpose to intervene directly, through specific therapeutic actions in the overall process of rehabilitation, rather than focusing on a particular parcel of it.
addition to more traditional surgery, described, have also been carried out, although to a lesser extent, studies on the effectiveness of intervention programs in which specific techniques were applied behavior modification, including techniques such as relaxation training or cognitive-behavioral strategies different . Such intervention
than largely, many of the shortcomings outlined above, apply proven techniques and, at times, is done individually, adjusting the treatment to the characteristics of the patients also more frequently are applied by psychologists.
These programs have been effective to increase skills the patient coping with stressful situations in his life, to change behaviors characteristic of Type A behavior pattern and to reduce the degree of tension experienced after stroke.
However, this is a very limited intervention that serves a targeted manner to certain problems in the infarcted patient.
In any case, such programs has led, in particular, exclusively to provide the patient with skills that allow you to better cope with difficult or threatening situations, and although these new skills can have a positive impact on the recovery process, usually be common for successful rehabilitation intervention required broader and, especially, held for this purpose to intervene directly, through specific therapeutic actions in the overall process of rehabilitation, rather than focusing on a particular parcel of it.
Multidimensional Intervention Program Post-Im
In view of the figures in general psychological intervention usually done in post-MI patients, there seems to be underused resource that could provide specialized psychological work in this field. Therefore, in recent years we have developed a model that, given the objective of process overall rehabilitation, using specific therapeutic techniques proven for the solution of specific psychological problems, in each case, hinder the achievement of this general objective.
This intervention model, called Multidimensional Intervention Program Post-IM (Good and Buceta) assumes, as intervention targets those discussed.
In view of the figures in general psychological intervention usually done in post-MI patients, there seems to be underused resource that could provide specialized psychological work in this field. Therefore, in recent years we have developed a model that, given the objective of process overall rehabilitation, using specific therapeutic techniques proven for the solution of specific psychological problems, in each case, hinder the achievement of this general objective.
This intervention model, called Multidimensional Intervention Program Post-IM (Good and Buceta) assumes, as intervention targets those discussed.
a) Initial assessment and delineation of individual objectives.
comprehensive patient assessment on all relevant aspects to determine what are the specific objectives to be achieved and what are the priority areas of intervention to achieve them.
should be an assessment of the subject's cognitions about the implications, short and long term, the development of stroke in later life, as well as the level and type of activities undertaken by the patient at this early stage after episode of stroke.
also be collected information about risk behaviors (snuff, diet and exercise), both at present and in the time before suffering a heart attack, paying specific attention to the circumstances in the past, may have been responsible for the appearance and / or maintenance of these behaviors.
Finally, assessment should consider the coping skills and trends in patient functioning in various areas of daily life.
As a first step in this evaluation process uses the Initial Assessment Interview for Post-MI Patient. From this overview, should be conducted for each problem, a behavioral assessment on time, interspersed this evaluation more specifically, at appropriate times in the course of the intervention.
This evaluation process should allow the original definition of individual goals, obviously, vary considerably from patient to patient. However, in summary, in table 8.1. can find an outline of possible objectives that must address the intervention programs.
comprehensive patient assessment on all relevant aspects to determine what are the specific objectives to be achieved and what are the priority areas of intervention to achieve them.
should be an assessment of the subject's cognitions about the implications, short and long term, the development of stroke in later life, as well as the level and type of activities undertaken by the patient at this early stage after episode of stroke.
also be collected information about risk behaviors (snuff, diet and exercise), both at present and in the time before suffering a heart attack, paying specific attention to the circumstances in the past, may have been responsible for the appearance and / or maintenance of these behaviors.
Finally, assessment should consider the coping skills and trends in patient functioning in various areas of daily life.
As a first step in this evaluation process uses the Initial Assessment Interview for Post-MI Patient. From this overview, should be conducted for each problem, a behavioral assessment on time, interspersed this evaluation more specifically, at appropriate times in the course of the intervention.
This evaluation process should allow the original definition of individual goals, obviously, vary considerably from patient to patient. However, in summary, in table 8.1. can find an outline of possible objectives that must address the intervention programs.
b) Design of the treatment plan and initial explanation to the patient.
Once defined the objectives to be achieved in each case, could be designed, according to them, the initial treatment plan for their achievement. It is of crucial importance
explaining the objectives and general action plan for their achievement, so that the patient is clear about what is to be achieved, what benefits they pose for him these achievements and outline work to be done to achieve them.
The understanding of the patient to the goals and benefits arising from them, should serve to increase their motivation. To successfully overcome this situation and achieve the changes required to perform effectively, the psychologist can help with specific techniques for each problem, to be carried out progressively, the various tasks that allow you to resume a normal life under favorable conditions.
This increased the patient's motivation for therapy, combined with the knowledge and acceptance of the system of work to be carried out, should serve to ensure the appropriate involvement of the subject in a process that requires intervention, inevitably, their active participation in order to achieve a successful outcome.
Once defined the objectives to be achieved in each case, could be designed, according to them, the initial treatment plan for their achievement. It is of crucial importance
explaining the objectives and general action plan for their achievement, so that the patient is clear about what is to be achieved, what benefits they pose for him these achievements and outline work to be done to achieve them.
The understanding of the patient to the goals and benefits arising from them, should serve to increase their motivation. To successfully overcome this situation and achieve the changes required to perform effectively, the psychologist can help with specific techniques for each problem, to be carried out progressively, the various tasks that allow you to resume a normal life under favorable conditions.
This increased the patient's motivation for therapy, combined with the knowledge and acceptance of the system of work to be carried out, should serve to ensure the appropriate involvement of the subject in a process that requires intervention, inevitably, their active participation in order to achieve a successful outcome.
c) Implementation of the program.
Once the initial assessment, defined goals, designed the general plan of action and explained to the patient the above, you can start to apply the treatment. The techniques vary depending on the issues to be decided in each case, however it is worth noting some general aspects of interest.
First, the patient training in strategies that have been defined as a loss, you must answer a proper functional analysis of behavior and should be addressed to achieve specific skills related to their usual environment.
Closely linked with this, is of paramount importance throughout the treatment process, an evaluation is ongoing. This refers to the need to observe progressively over the implementation of treatment strategies, the effect they may be causing, in order to correct possible errors in the initial therapeutic approach, or take advantage of the gains which can leave making for the further development of the intervention.
As already noted, the success of treatment depends largely on the motivation and active involvement of the patient. Such reasoning should be cared for, well, for example at a particular time of the intervention, it may seem advantageous for the patient to a self-registration, but although this information may seem interesting, the therapist should assess the overall convenience of ordering such tasks as we must consider that the effort required to obtain information, perhaps not a priority, can negatively affect your level of motivation.
Finally, since in most cases, the patient is trained in various skills and change behaviors that seem to impede the smooth development of the recovery process post-MI intervention programs include a number of behavioral and cognitive strategies are a complex treatment package. In this sense, it is important to perform a therapeutic efforts aimed at achieving more favorable interaction between the various components of the treatment program, taking advantage, wherever possible, the gains are obtained in some areas of work for the benefit of others.
not forget that this complex procedure of applying the treatment must be applied by a trained professional, ie, a psychologist with the appropriate experience and training in this area.
As regards these specific therapeutic techniques included in intervention programs, obviously vary from case to case, however, to provide an overview will make a brief summary of the different areas of intervention and therapeutic possibilities of behavior modification in each, dividing in a) techniques for the reduction of the initial emotional impact of Post-MI, b) techniques for reducing coronary risk:
therapeutic techniques for reducing the emotional impact
Post-MI treatment programs include the application of cognitive strategies for behavioral modification of dysfunctional cognitions and planning systematic activities to do at this early stage, allowing one hand, adjusting the level of initial activity of the patient and, secondly, to contribute to the modification of dysfunctional cognitions if, as in the line proposed by Beck, the planned activities are used as behavioral experiments to provide empirical data to support more rational cognitions about the impact of stroke.
In this line, using self-registration sheets daily activities is very helpful to develop an understanding by the patient of the inadequacy of their business and benefits of rethinking and modification, to plan specific objectives change in this area and, finally, to evaluate more objectively and realistically changes as they occur.
therapeutic strategies that can be used to meet the objectives of this first phase of the rehabilitation program are: a) transmission of relevant information, b) Beck's cognitive therapy and c) systematic planning of activities
therapeutic techniques for reducing coronary risk
respect to the appropriate intervention for behavioral change habits that are risk factors for coronary patient information on risk behaviors, self-observation and self-registration of behaviors that are intended to modify the application of strategies such as stimulus control, time schedule or planning objectives, are some of the alternative therapies that offer behavior modification to solve the problems that arise in this area.
As regards the possible need to increase patients' abilities to handle stressful situations and achieve a healthy work style, techniques such as stress inoculation, cognitive restructuring and rational programming time can be useful tools.
Once the initial assessment, defined goals, designed the general plan of action and explained to the patient the above, you can start to apply the treatment. The techniques vary depending on the issues to be decided in each case, however it is worth noting some general aspects of interest.
First, the patient training in strategies that have been defined as a loss, you must answer a proper functional analysis of behavior and should be addressed to achieve specific skills related to their usual environment.
Closely linked with this, is of paramount importance throughout the treatment process, an evaluation is ongoing. This refers to the need to observe progressively over the implementation of treatment strategies, the effect they may be causing, in order to correct possible errors in the initial therapeutic approach, or take advantage of the gains which can leave making for the further development of the intervention.
As already noted, the success of treatment depends largely on the motivation and active involvement of the patient. Such reasoning should be cared for, well, for example at a particular time of the intervention, it may seem advantageous for the patient to a self-registration, but although this information may seem interesting, the therapist should assess the overall convenience of ordering such tasks as we must consider that the effort required to obtain information, perhaps not a priority, can negatively affect your level of motivation.
Finally, since in most cases, the patient is trained in various skills and change behaviors that seem to impede the smooth development of the recovery process post-MI intervention programs include a number of behavioral and cognitive strategies are a complex treatment package. In this sense, it is important to perform a therapeutic efforts aimed at achieving more favorable interaction between the various components of the treatment program, taking advantage, wherever possible, the gains are obtained in some areas of work for the benefit of others.
not forget that this complex procedure of applying the treatment must be applied by a trained professional, ie, a psychologist with the appropriate experience and training in this area.
As regards these specific therapeutic techniques included in intervention programs, obviously vary from case to case, however, to provide an overview will make a brief summary of the different areas of intervention and therapeutic possibilities of behavior modification in each, dividing in a) techniques for the reduction of the initial emotional impact of Post-MI, b) techniques for reducing coronary risk:
therapeutic techniques for reducing the emotional impact
Post-MI treatment programs include the application of cognitive strategies for behavioral modification of dysfunctional cognitions and planning systematic activities to do at this early stage, allowing one hand, adjusting the level of initial activity of the patient and, secondly, to contribute to the modification of dysfunctional cognitions if, as in the line proposed by Beck, the planned activities are used as behavioral experiments to provide empirical data to support more rational cognitions about the impact of stroke.
In this line, using self-registration sheets daily activities is very helpful to develop an understanding by the patient of the inadequacy of their business and benefits of rethinking and modification, to plan specific objectives change in this area and, finally, to evaluate more objectively and realistically changes as they occur.
therapeutic strategies that can be used to meet the objectives of this first phase of the rehabilitation program are: a) transmission of relevant information, b) Beck's cognitive therapy and c) systematic planning of activities
therapeutic techniques for reducing coronary risk
respect to the appropriate intervention for behavioral change habits that are risk factors for coronary patient information on risk behaviors, self-observation and self-registration of behaviors that are intended to modify the application of strategies such as stimulus control, time schedule or planning objectives, are some of the alternative therapies that offer behavior modification to solve the problems that arise in this area.
As regards the possible need to increase patients' abilities to handle stressful situations and achieve a healthy work style, techniques such as stress inoculation, cognitive restructuring and rational programming time can be useful tools.
d) Results Application of multidimensional intervention program Post-Im.
Although obviously requires further investigation, the efficacy data obtained so far can be considered encouraging
Although obviously requires further investigation, the efficacy data obtained so far can be considered encouraging
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