For some individuals, the heart attack marks merely the onset

Heart attacks are transformative experiences, though one specific type can be especially distressing.

Spontaneous coronary artery dissection predominantly impacts women under 50 years of age. Frequently, they are active, non-smoking individuals with optimal cholesterol levels and standard blood pressure — in essence, the very individuals who are least likely to anticipate a cardiac crisis. The trauma associated with such an occurrence may elucidate why nearly 30 percent of survivors exhibit signs of medically induced post-traumatic stress disorder.

“Medically induced PTSD essentially refers to PTSD stemming from a sudden, devastating, life-threatening medical circumstance,” stated Christina Luberto, a clinical health psychologist within the Department of Psychiatry at Mass General Hospital/Harvard Medical School. “This actually represents about 7 percent of all PTSD diagnoses.”

Luberto is the founding director of the Mindful Living Center, a mental health initiative incorporated within the Mass General Women’s Heart Health Program. The Mindful Living Center stands among the limited programs nationally that merge psychological services directly with cardiovascular treatment for women.

“We assist survivors whose main presenting issue is the apprehension of recurrence,” she remarked. “They are frightened by the unpredictability and the chance that it may occur again.”

Despite its widespread nature, medically induced PTSD wasn’t officially acknowledged until the 1990s when the Diagnostic and Statistical Manual of Mental Disorders broadened its definition to encompass trauma from medical incidents. The criteria were later narrowed to sudden conditions, excluding chronic illnesses such as cancer or HIV. Studies have indicated that individuals with medically induced PTSD typically experience poorer recovery rates and an increased mortality risk compared to those without.

The symptoms associated with medically induced PTSD reflect those of PTSD from external traumas, Luberto explained: intrusive memories, heightened arousal, adverse shifts in mood or belief, and avoidance behaviors. However, significant distinctions exist.

“Individuals commonly associate PTSD with external incidents such as combat service. They may suffer from flashbacks and intrusive recollections. Their thoughts dwell on past events. They may circumvent certain situations, like gatherings with fireworks or loud sounds, and can manage to do so,” she noted. “In contrast, with medically induced PTSD, the risk isn’t confined to the past. You can’t evade the source of the ongoing threat, which is your own body.”

This reality renders survivors hyper-aware of physical sensations. Perspiration or an increased heart rate can provoke anxiety. Since exercise can replicate the sensations experienced during their heart attack, they may forgo physical activity — ironically, the precise action that could foster recovery and stave off future incidents. Others might neglect medications, skip medical appointments, or, on the contrary, excessively engage with the healthcare system, frequently contacting their providers.

“It’s a detrimental cycle. What I encounter is the forward-looking anxiety: ‘Will this happen again?’”

Christina Luberto

“There’s what we refer to as cognitive reactivity in response to bodily sensations. ‘Why am I sweating? Why is my heart racing? It might be the coffee, but perhaps not. Should I visit the hospital?’ And this stream of thought exacerbates physical symptoms of anxiety,” Luberto remarked. “It’s a harmful loop. What I hear is the future-oriented concern: ‘Is this going to happen once more?’”

Her studies illuminate how distressing thoughts can magnify. “Survivors begin to alter their perceptions about their bodies, and on some level, about the world. They think, ‘My body has failed me. This is destined to occur again. I am not secure.’”

The Mindful Living Center, inaugurated in October 2023, utilizes an adapted Mindfulness-Based Cognitive Therapy approach based on Luberto’s earlier NIH-supported research. In online group therapy sessions, patients confront the origin of their distress: their bodies.

“Mindfulness meditation draws attention inward, allowing individuals to observe their bodies without judgment, feeling sensations, recognizing where one can still feel secure or comfortable, and being capable of regulating focus to redirect attention away from the body if anxiety escalates.”

The outcomes thus far are promising. Since its inception, the Mindful Living Center has received 181 referrals and has treated 86 patients. Ninety percent of participants in the Mindfulness-Based Cognitive Therapy sessions noted enhancements in emotional well-being, and 75 percent indicated improvements in cardiac health.

“Stress and anxiety can yield considerable negative repercussions for patients, influencing their experiences of medical care and their capacity to take proactive measures to mitigate future incidents,” commented Amy Sarma, Cathy E. Minehan Endowed Chair in Cardiology at MGH and an assistant professor of medicine at Harvard Medical School. “Nonetheless, most cardiologists lack the resources to assist their patients as we do at Mass General Brigham. Our collaboration with Dr. Luberto in this distinctive initiative allows us to substantially enhance our patient care.”

Nandita Scott, Ellertson Family Endowed Chair in Cardiovascular Medicine and director of the Women’s Heart Health Program, emphasized the “extraordinary support” the mindfulness initiative has garnered from cardiology leadership at Mass General Brigham. “It is well-documented that mental wellness and cardiovascular results are intricately connected, yet few divisions would possess the foresight or resources to finance such a project,” she stated.

Luberto, who is also a senior faculty member at the MGH Health Promotion Resiliency Intervention Research Center and the MGH Benson-Henry Institute for Mind-Body Medicine, aspires to broaden the Mindful Living Center’s offerings to incorporate other evidence-based methodologies for handling medically induced PTSD. In a recent study conducted by UCLA doctoral student Corinne Meinhausen, with Luberto as co-author, researchers evaluated therapies ranging from traditional cognitive behavioral therapy to written exposure therapy, a concise five-session program where patients document detailed narratives of the traumatic occurrence. The lower dropout rates and positive initial outcomes associated with written exposure therapy make it an attractive choice, particularly for patients hesitant to commit to extended, more intensive treatments.

Luberto emphasized that physicians should be observant for PTSD indicators stemming from traumatic medical experiences. The American Heart Health Association advocates for depression screenings; she proposes including PTSD screenings for patients with spontaneous coronary artery dissection, as well as providing a clear treatment pathway. While little research exists on risk factors or the prevention of medically induced PTSD, compassionate care throughout hospitalization could prove beneficial, she remarked.

“There are trauma-informed care principles in mental healthcare overall that encompass providing patients with choices. Transparency is vital. Recognizing cultural and identity considerations is essential. Investigating whether this can mitigate risks is an important research avenue, but even if it doesn’t, it represents commendable care.”