Cognitive behavioral (CB) disease management programs were developed to help people with chronic back pain and have an extensive evidence base in that role. The same methods are now being adapted for use in other chronic illnesses.1Using the example of angina, this chapter will explain how these techniques can be applied in cardiac rehabilitation (CR) and concludes with a brief description of such a program.
The Cognitive Hypothesis
Our thoughts and beliefs about an illness lead us to choose how to behave. Therefore, to understand patients’ behavior we have to examine their beliefs – to help them change their behavior we may have to encourage them to change some beliefs. For example, many people with angina believe that each “attack” leads to further damage to their heart. Quite reasonably they stop doing any activ- ity likely to lead to angina and become inactive and physically deconditioned, an unhelpful reac- tion. Changing that specific belief is associated with patients becoming more active. Another common example is the belief that heart problems are caused by too much stress, worry, or overwork.
Again the sensible action appears to be to avoid:
any kind of exciting or “stressful” situations;
sexual intercourse; promotion at work; playing with grandchildren, and so on. It is clear that this can lead to a failure to rehabilitate and, if too many pleasures are abandoned, a depressed and anxious patient and spouse. These beliefs have been called
“cardiac misconceptions” and the effect they have
on recovery following a myocardial infarction (MI) was first shown more than 15 years ago2and more recently in angina.3
Cognitive and Behavioral – Both Are Required
It is important to educate people to understand that these beliefs are wrong and how they can be harmful. A simple method in a CR program is to ask patients to complete a questionnaire of common “cardiac misconceptions” as a group
“quiz” and to then discuss each of the answers, pointing out how these beliefs have led people into trouble in the past. We have developed question- naires for this purpose (available on request). The most essential things to discover are: what the patient thinks has caused the problem; what is likely to happen next with the illness; how much control they think they can exert on the illness and how they should best respond to protect their health. If conducted in the right manner, as a dis- cussion rather than a lecture, most patients will find this a useful and rewarding exercise.
Important as it is, educating patients and their partners about wrong beliefs will not usually be sufficient to produce lasting behavior change. This is where the “behavioral” part of CB becomes important. CB programs use principles derived from “behavioral psychology” to help people develop new habits. The first law of behavioral psychology is that “behavior that is rewarded increases in frequency.” A powerful behavioral strategy derived from this is to arrange for
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Cognitive Behavioral Rehabilitation for Angina
Robert J. Lewin
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41. Cognitive Behavioral Rehabilitation for Angina 339
rewards to be given as soon as possible after a person has practiced a desired behavior. Self- recording of success in a task is a simple but effec- tive way to do this. Patients set goals and work up through these in small steps, “ticking off the boxes” as they progress. A facilitator reviews the progress with the goals at regular times, also con- gratulating (rewarding) the patient. In a group program reporting these successes to the whole group is a powerful added reward for many people. The steps should always be set by the patient and be small to allow for many rewards.
Each small step forward builds further confidence that the person can succeed (technically often called “self-efficacy”) and makes it more likely that the they will attempt the next step. Deliber- ately building up “self-efficacy” in this way is a common element of CB treatments. A number of the other common techniques used in CB based programs have recently been summarized in a review by Michael Von Korff.1
The Relationship Between the Lesion and Disability
CB programs started because it was obvious that the amount of disability shown by a patient often had little or no relationship to the amount of damage to their back. There was little or no con- nection between the impairment (the lesion) and the disability (pain, functional capacity, anxiety, etc.). This is also true in cardiac illness.4,5 For example, the degree to which angina interferes with a patient’s daily life is not related to the extent of atheroma in their arteries. From a CB perspec- tive this lack of association is to be expected because having a lot of mistaken beliefs, known as “cardiac misconceptions,” is associated with increased disability but not with impairment. If the patient does not believe the angina miscon- ception that every further attack of angina is damaging them, they are much more likely to stay active even if this sometimes causes angina.
This repeated ischemic challenge can lead to an increase in the blood flow through capillaries to the ischemic area, lowering the threshold for angina. This has been shown experimentally by deliberately encouraging patients to exercise despite angina.6The opposite is also likely. If the
patient thinks that every attack is a “mini-heart attack” and restricts their activity level, the thresh- old at which they experience angina will fall. In both cases the correlation between the extent of atheroma and exercise tolerance will become weaker. It is known that psychological and per- sonality factors are related to the amount of dis- ability and symptoms reported by a person with angina.4
Psychological Factors in the Production of Angina
Herberden named angina after the “choking sen- sation of fear” it produces and most patients will agree that it is a very frightening sensation. As many as 50% of ischemic episodes may be trig- gered by emotion rather than exertion.7 This is most likely the result of raised autonomic drive leading to vasoconstriction; emotionally induced hyperventilation may also be involved. We teach patients a rapid relaxation technique to use if they feel angina starting.
Evidence for the CB Approach
A trial of a specially developed Angina Manage- ment Programme conducted by our group (described below) produced at 12 months: a 72%
reduction in self-reported disability (Sickness Impact Profile); a 70% reduction in episodes of angina (30% reported no angina); a 65% reduc- tion in the use of nitrates; a 57% improvement in exercise tolerance and a 30% increase in time to 1 mm ST depression.8We have translated aspects of this program into a patient-held workbook, home-based program that can be administered by a healthcare worker who has completed a brief distance learning intervention, the Angina Plan (www.anginaplan.org.uk). It is currently being used by CR programs in the UK in a number of ways: in a group format, in brief clinic visits, or though repeated phone contacts. In a randomized controlled trial we compared it to a “usual prac- tice” 40-minute angina advice clinic for newly diagnosed patients. At 6 months the patients who had used the Angina Plan reported 43% fewer episodes of angina, fewer physical limitations
340 R.J. Lewin
(Seattle Angina Questionnaire), and a lower level of anxiety and depression. They were also more likely to report having changed their diet and increased their daily walking.9This replicated the success of an earlier CB program for post-MI patients, the Heart Manual,10 a rehabilitation method also now widely used in CR in the United Kingdom.
Protocol for a Group CB CR Program for Angina
Goal Setting and Pacing (40–60 Minutes for a Group of 8–10 People)
Patients select some activities that they have had to cut back on or give up but would like to get back to. These are their “goals.” Walking is chosen by most patients, gardening, hobbies, sports and social activities are all popular choices. A “base- line” level for each activity, one that will not produce any symptoms and that they agree they can practice every day even if it is “a bad day,” is set in individual discussion with each patient.
It may be that initially they can only do a few minutes of an activity; this does not matter, in fact the lower the initial goal is set the better. The goals, that week’s baselines, and the daily success with each is logged on charts by the patient, who
“ticks off the box” as soon as they have done it.
They may start with only one or two goals but as the weeks pass they usually add further goals;
most patients choose to set between four and seven. At each subsequent session they report to the group their success with each goal and later and individually with a member of the rehabilita- tion team discuss the next week’s baseline, either continuing at the same level for the next week, or increasing the duration by a small percentage, usually not more than 10%.
Exercise Program (10 Minutes per Patient)
Patients take part in a home-based, self-paced, exercise program of 5–8 different exercise sets. An individual baseline for each set is agreed in an initial session with a physiotherapist. A time limit of 10 minutes is set because one of the main reasons given by patients for stopping their exer-
cising program after CR is “no time”: no one can claim not to have 10 minutes free once or twice during the day. The training effect comes from increasing the number of repetitions in that fixed time. Patients are asked to practice at least once per day. Initial levels are deliberately set low because of the behavioral laws that: (1) behaviors that are punished, (through pain, tiredness, sore- ness, etc.) die out; and (2) the easier it is, the more likely it is they will succeed, thus rewarding them and raising their self-efficacy for exercise at the same time. They rate each exercise on a 10 cm line on two qualities: (1) on a scale “very pleas- ant”/“very unpleasant” and (2) as “very high effort”/“very low effort.” The center of both lines is marked as “just right.” They record their program on charts and score each set on both 10 cm lines on each occasion. As they become fitter, the effort scores become easier, and after 3 successive days of scoring a set lower on effort than “just right” they can add one extra repetition to the number of repetitions for that exercise but only if the new level chosen would still be “about right” on the pleasant/unpleasant line: no pain, more gain!
Educational Sessions (45 Minutes per Week)
Discussion topics cover: cardiac misconceptions;
mistaken ways of reacting to the diagnosis and symptoms; the psycho-physiology of stress; the physical symptoms of anxiety, panic attack, hyper- ventilation, and phobias; how thoughts interact with the autonomic system to produce vasocon- striction and hyperventilation; how psychological variables such as anxiety, depression, and hypo- chondriasis may all increase disability.
Relaxation and Stress Management
Techniques that may be used include relaxation training, breathing re-training, biofeedback, yoga, meditation, rapid relaxation and the identification (using questionnaires) of our own behavior and attitudes that lead to anger and stress. Each week one of the patients is asked to recall a recent event that had stressed them or made them very angry and the group is shown stress management tech- niques to avoid this. Patients are taught a rapid relaxation and distraction technique that they can
41. Cognitive Behavioral Rehabilitation for Angina 341
perform, wherever they are, during an acute angina attack.
The Staff
Staff are aware of the rationale and methods of the CB techniques being used. They use “differential reinforcement,” paying warm attention to success but ignoring or being emotionally neutral to self- defeating statements. Staff continually stress that the benefits the patient is experiencing are entirely a result of the patient’s own efforts.
Patient-Held Materials
Each session is accompanied by written informa- tion reinforcing what has been taught. Over the weeks this builds up, in a clip file, into a substan- tial volume complete with the record sheets of the exercise and goal setting. Patients are encouraged to read this material regularly and if possible to use it to explain the program to their partner and family.
References
1. Von Korff M, Gruman J, Schaefer J, et al. Collabora- tive management of chronic illness. Ann Intern Med 1997;127:1097–1102.
2. Maeland JG, Havik OE. After the myocardial infarc- tion. A medical and psychological study with special emphasis on perceived illness. Scand J Rehabil Med Suppl 1989;22:1–87.
3. Furze G, Bull P, Lewin RJ, Thompson DR. Develop- ment of the York Angina Beliefs Questionnaire. J Health Psychol 2003;8:307–315.
4. Lewin B. The psychological and behavioural man- agement of angina. J Psychosom Res 1997;5:
452–462.
5. Lewin RJ. Improving quality of life in patients with angina. Heart 1999;82:654–655.
6. Todd IC, Ballantyne D. Antianginal efficacy of exer- cise training: a comparison with beta blockade. Br Heart J 1990;64:14–19.
7. Deanfield JE, Maseri A, Selwyn AP, et al. Myocardial ischaemia during daily life in patients with stable angina: its relation to symptoms and heart rate changes. Lancet 1983;2(8353):753–758.
8. Lewin B, Cay EL, Todd I, et al. The Angina Manage- ment Programme: a rehabilitation treatment. Br J Cardiol 1995;1:221–226.
9. Lewin RJ, Furze G, Robinson J, et al. A randomised controlled trial of a self-management plan for patients with newly diagnosed angina. Br J Gen Pract 2002;52:194–196, 199–201 (see also www.
anginaplan.org.uk).
10. Lewin B, Robertson IH, Cay EL, et al. Effects of self- help post myocardial infarction rehabilitation on psychological adjustment and use of health ser- vices. Lancet 1992;339:1036–1340.
