of Vasovagal Syncope?
F. GIADA1, I. SILVESTRI2, A. ROSSILLO1, M. MADALOSSO1, P.G. NICOTERA2, A. RAVIELE1
Introduction
Syncope is a very frequent clinical symptom. About 30% of the general popu- lation undergo one syncopal episode in their lifetime, while at least 3% faint more than once. In most cases, the aetiology of syncope is vasovagal [1].
Vasovagal syncope is generally a benign and isolated event which does not need specific interventions. However, some patients have frequent faint- ing fits, often associated with major trauma and severe impairment of quali- ty of life. The treatment of vasovagal syncope involves behavioural measures for all patients, drug therapy for those who are most symptomatic, and pace- maker implantation in a very limited and selected group of patients.
However, drug therapy has yielded disappointing results and, although pace- maker implantation seems to restore quality of life to a normal level and offer an attractive cost-effectiveness ratio, we have insufficiently compelling data on the real efficacy of cardiac pacing for the treatment of vasovagal syn- cope [1]. Thus, at the present time, treatment of patients with frequently recurrent vasovagal syncope still remains a controversial issue.
In this paper we will discuss the possible role of psychiatric and/or psy- chological interventions in the management of severe vasovagal fainters. We will analyse the relationship between vasovagal syncope and psychiatric dis- orders, how to perform psychiatric evaluation in subjects with syncope, and the data regarding the effects of psychiatric treatment on syncopal recur- rence.
1Division of Cardiology, Cardiovascular Department, Umberto I Hospital, Mestre- Venice, Italy ;2Division of Neurology, Umberto I Hospital, Mestre-Venice, Italy
Relationship Between Vasovagal Syncope and Psychiatric Disorders
Various factors seem to suggest an association between vasovagal syncope and psychological disturbances. Acute emotional stress or fear can facilitate and/or trigger vasovagal syncope [2, 3]; some psychiatric illnesses, such as anxiety and depression, may trigger vasovagal reactions [4]; after reassur- ance about the benign nature of their condition, vasovagal fainters have sig- nificantly fewer syncopal recurrences [5]; the only drug shown to be effica- cious in preventing vasovagal syncope in placebo-controlled studies is paroxetine, an inhibitor of serotonin re-uptake commonly used as an anti- depressant [6].
In the international literature, data about the prevalence of psychiatric disorders and the quality of life of patients suffering from vasovagal syncope are rather scanty and incomplete. Some studies have reported a high preva- lence of psychiatric disorders such as anxiety, depression, somatisation dis- orders, and alcoholism in patients with unexplained syncope [7–13].
Moreover, some authors have found that patients with recurrent syncope of various aetiologies also suffered a significant reduction in their quality of life in both the physical and the psychosocial domains [14–16]. The above- mentioned studies, however, include some bias and confounding factors:
poor homogeneity of the study population (enrolled patients had syncope of various origins, or were suffering from unexplained syncope); patients were very often affected by co-morbid conditions in addition to syncope (with the possibility that these concomitant illnesses may have affected the psycholog- ical profile and quality of life of the patients examined); lack a suitable con- trol group that is representative of the general population.
In a recently published study, we compared the psychological profile and quality of life in patients with severe vasovagal syncope confirmed by posi- tive tilt testing with full symptom reproduction and no concomitant associ- ated diseases, with those obtained in a control group made up of healthy sex- and age-matched subjects without syncope [17]. In this study we observed a higher prevalence of mild or moderate psychiatric disorders in patients with vasovagal syncope than in controls, especially with regard to anxiety, mood, and somatisation disorders. Moreover, we observed a marked reduction in all the quality of life scales in patients with vasovagal syncope in comparison with controls, and in patients with psychiatric disorders versus those with- out. Finally, the presence of psychiatric disorders constituted a potent risk factor for recurrence during follow-up.
As all the above-mentioned studies were case-controlled observational studies, no conclusion can be drawn as to whether the psychiatric disorders were the cause or the result of the recurrent syncopal episodes, or represent only a co-morbidity without any role in the pathogenesis of syncope.
Vasovagal syncope and psychiatric disorders may be linked through the serotonin pathway or, most probably, through input coming from the cortex to the brainstem, the site where the vasovagal reflex develops.
How to Perform Psychiatric Evaluation in Patients with Vasovagal Syncope
In patients with syncope psychiatric evaluation is generally performed by mean of a structured interview with a psychologist and/or specific question- naires. Among these, one of the most used is the Minnesota Multiphasic Personality Inventory-2 (MMPI-2) questionnaire. The MMPI-2 is a widely recognised instrument for assessing the psychological profile of adult sub- jects [18, 19]. Made up of over 500 items, the questionnaire uses specific scales to explore various aspects of the individual’s personality. After psychi- atric assessment, clinical diagnoses are formulated in accordance with the criteria of the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) [4]. Assessment of quality of life is generally by means of specific questionnaires. The Short-Form Health Survey (SF-36) questionnaire is an international standardised instrument for assessing the general state of health [20, 21]. It is often employed to evaluate the impact of syncope on the patient’s physical and psychological functions.
Effects of Psychiatric Treatment on Syncopal Recurrence
In the literature, data regarding the effects of psychiatric interventions in the treatment of patients with vasovagal syncope are rather limited, and consist mostly of single case reports or case series. In these small studies psy- chotherapy and/or pharmacotherapy were employed in patients with refrac- tory vasovagal syncope and in those with blood/injury phobia.
Vasovagal Syncope
Cognitive behavioural therapy, like biofeedback and relaxation, is used to teach patients to apply realistic and reassuring thoughts to physical symp- toms they see as alarming, with the aim of developing more adaptive beliefs about their ability to manage and cope with syncope, and to regain self- assurance in situations that provoke syncope. McGrady et al. undertook a randomised, controlled trial involving 22 patients with refractory vasovagal syncope [22]. They reported a significant reduction in syncopal recurrence in patients randomised to undergo biofeedback and relaxation therapy with respect to controls. The treatment was most effective in younger patients
whose syncope was associated with a strong psycho-physiological response.
Similar encouraging results were reported by Newton et al. in a case series of 9 patients with severe vasovagal syncope [23]. In this open label study, cogni- tive behavioural therapy resulted in a dramatic reduction of syncopal episodes.
Linzer et al. [8], in a open label study, used psychotherapy plus pharma- cotherapy to treat 11 patients with syncope of unknown origin and psychi- atric disorders, and obtained resolution of symptoms in the majority of patients. Kadri et al. [24] used clonazepam, a well-tolerated benzodiazepine, in 35 patients with refractory vasovagal syncope and anxiety or sleep disor- ders. In this non-randomised, non-placebo-controlled observational study, 83% of patients were free of syncopal recurrence during follow-up.
Blood/Injury Phobia
Blood/injury phobia is a common psychiatric disorder (2–4.5% of children and adults), in which fear can be triggered by seeing blood, by undergoing an invasive medical procedure, or by sustaining an injury. It is highly famil- ial, and is usually associated w ith vasovagal reaction and sy ncope.
Psychological deconditioning is considered the first choice therapy for this condition. During psychological deconditioning patients are exposed to pho- bic stimuli (such as the sight of blood) and taught to apply muscle tension.
They are generally also treated with cognitive behavioural therapy. Ost et al.
reported, during 1-year follow-up, an improvement in symptoms in 84–90%
of patients after one to five sessions of psychological deconditioning [25].
Similar good results were also reported in case series by Van Dijk et al. [26], Hellstrom et al. [27], and Marks [28].
Conclusions
Patients with recurrent vasovagal syncope frequently display mild to moder- ate psychiatric disorders, and the presence of psychiatric illness seem to pre- dict the risk of recurrence. Thus, in our opinion, psychiatric evaluation should be included in the clinical management of patients with severe vaso- vagal syncope, because it may be valuable in identifying which subjects are at high risk of recurrence and really need long-term treatment.
Psychiatric and psychological interventions seem to represent a promis- ing treatment, at least in patients with refractory vasovagal syncope and in those with blood/injury phobia. However, before becoming a first-line thera- py for most vasovagal fainters, the positive effects of psychiatric treatment need to be verified in larger, randomised and placebo-controlled trials.
References
1. Brignole M, Alboni P, Benditt DG et al (2004) Guidelines on management (diagno- sis and treatment) of syncope – update 2004. Europace 6:467–537
2. Schmidt RT (1975) Personality and fainting. J Psychosom Res 19:21–25
3. Sledge WH (1978) Antecedent psychological factors in the onset of vasovagal syn- cope. Psychosom Med 40:568–579
4. American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th ed (DSM-IV). American Psychiatric Association, Washington DC, p 20
5. Sheldon R, Rose S, Flanagan P et al (1996) Risk factors for syncope recurrence after a positive tilt-table test in patients with syncope. Circulation 93:973–981
6. Di Girolamo E, Di Iorio C, Sabatini P et al (1999) Effects of paroxetine hydrochlori- de, a selective serotonin re-uptake inhibitor, on refractory vasovagal syncope: a randomized, double-blind, placebo-controlled study. J Am Coll Cardiol 33:1227–1230
7. Kapoor WN, Fortunato M, Hanusa BH et al (1995) Psychiatric illnesses in patients with syncope. Am J Med 99:505–512
8. Linzer M, Felder A, Hackel A et al (1990) Psychiatric syncope: a new look at an old disease. Psychosomatics 31:181–188
9. Koenig D, Linzer M, Pontinen M et al (1992) Syncope in young adults: evidence for combined medical and psychiatric approach. J Intern Med 232:169–176
10. Kouakam C, Lacroix D, Baux P et al (1996) Anxiety neurosis and unexplained syn- cope of presumed vaso-vagal origin. Arch Mal Coeur 89:1247–1254
11. Cohen TJ, Thayapran N, Ibrahim B et al (2000) An association between anxiety and neurocardiogenic syncope during head-up tilt table testing. Pacing Clin Electrophysiol 23:837–841
12. Ventura R, Maas R, Ruppel R et al (2001) Psychiatric conditions in patients with recurrent unexplained syncope. Europace 3:311–316
13. Kouakam C, Lacroix D, Klug D et al (2002) Prevalence and prognostic significance of psychiatric disorders in patients evaluated for recurrent unexplained syncope.
Am J Cardiol 89:530–535
14. Linzer M, Pontinen M, Gold DT et al (1991) Impairment of physical and psychoso- cial function in recurrent syncope. J Clin Epidemiol 44:1037–1043
15. Linzer M, Gold DT, Pontinen M et al (1994) Recurrent syncope as a chronic disease:
preliminary validation of a disease-specific measure of functional impairment. J Gen Intern Med 9:181–185
16. Rose MS, Koshman ML, Spreng S et al (2000) The relationship between health-rela- ted quality of life and frequency of spells in patients with syncope. J Clin Epidemiol 53:1209–1216
17. Giada F, Silvestri I, Rossillo A et al (2005) Psychiatric profile, quality of life and risk of syncopal recurrence in patients with tilt-induced vasovagal syncope. Europace (in press in press)
18. Butcher JN, Dahlstrom GW, Graham JR (1989) MMPI-2 manual for administration and scoring. University of Minnesota Press, Minneapolis, p 81
19. Pancheri P, Sirigatti S (1995) MMPI-2 Minnesota Multiphase Personality Inventory-2 manual. Italian adaptation. OS (Organizzazioni Speciali), Florence, Italy, p 34
20. Ware JE, Sherbourne CD (1992) The MOS 36-Item Short-Form Health Survey (SF- 36): I. Conceptual framework and item selection. Med Care 30:473–483
21. Mc-Horney CA, Ware JE, Raczek AE (1993) The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care 31:247–263
22. McGrady AV, Kern-Buell C, Bush E et al (2003) Biofeedback-assisted relaxation the- rapy in neurocardiogenic syncope: a pilot study. Appl Psychophysiol Biofeedback 28:183–192
23. Newton JL, Kenny RA, Baker CR (2003) Cognitive behavioural therapy as potential treatment for vasovagal/neurocardiogenic syncope – a pilot study. Europace 5:299–301
24. Kadri NN, Hee TT, Rovang KS et al (1999) Efficacy and safety of clonazepam in refractory neurally mediated syncope. Pacing Clin Electrophysiol 22:307–314 25. Ost LG, Hellstrom K, Kaver A (1992) One versus five sessions of exposure in the
treatment of injection phobia. Behav Res Ther 23:263–282
26. Van Dijk N, Velzeboer SCJM, Destree-Vonk A et al (2001) Psychological treatment of malignant vasovagal syncope due to blood phobia. Pacing Clin Electrophysiol 24:122–124
27. Hellstrom K, Fellenius J, Ost LG (1996) One versus five sessions of applied tension in the treatment of blood phobia. Behav Res Ther 34:101–112
28. Marks I (1988) Blood–injury phobia: a review. Am J Psychiatry 145:1207–1213
