Metacognitive therapy in cardiac rehabilitation
A potentially effective evidence-based model suitable for the treatment of anxiety and depression in cardiac patients is Metacognitive Therapy (TMC). This model, belonging to third-generation cognitive-behavioral approaches, maintains that a maladaptive style of thinking and coping is responsible for maintaining dysfunctional emotional states over time (Wells., 2008).
Advertising message There are numerous scientific evidences that support the crucial role of psychological factors in the onset of cardiovascular diseases. In fact, it has been demonstrated that the classic risk factors, such as genetics (e.g. family history of cardiovascular diseases), involving unhealthy (e.g. smoking, inadequate nutrition, physical inactivity), socioeconomic conditions of disadvantage, explain less than 50% of the variance in the onset of cardiovascular disorders (Futterman and Lemberg, 1998). The remaining variance is explained by the link identified between cardiovascular health indices and cognitive-emotional factors (Chida and Steptoe, 2009). In particular, it was found that negative emotional states (depression, anger, hostility and anxiety) correlate with high heart rate values, systolic and diastolic pressure, therefore representing risk factors especially for coronary heart disease (Suls, 2018; Haas et al., 2005). Among the psychological variables it has been seen that rumination also plays a role in amplifying the cardiovascular stress response (Gerin et al., 2012). According to the hypothesis of perseverative cognitive processes, in fact, rumination, like other repetitive styles of thought, maintains the activation of the sympathetic nervous system over time (Brosschot, Gerin and Thayer, 2006). Some research suggests that this physiological response to stress, if prolonged, has a greater negative impact on the cardiovascular system than that associated with normal short-term sympathetic activation peaks (Glynn, Christenfeld and Gerin, 2002). Therefore rumination,
These data contributed to the inclusion of the psychologist in the multidisciplinary teams in the cardiac rehabilitation departments.
From a recent meta-analysis (Biondi-Zoccai and coll., 2016) it was found that Cognitive-Behavioral Therapy (TCC) was one of the most frequently used psychotherapeutic interventions with patients with cardiac pathologies. treatment of anxious and depressive symptoms. However, there was no maintenance in follow-up of the effects of TCC on this symptomatology (Writing Committe for ENRICHED Investigators, 2003). This could be attributed to the poor appropriateness of CCT, and in particular to the reference to reality data, in the clinical context with patients living a reality of disability, where the risk of sudden and premature death is objective (Taylor-Ford, 2014) . Another potentially effective evidence-based model suitable for the treatment of anxiety and depression in cardiac patients is Metacognitive Therapy (TMC). This model, belonging to third-generation cognitive-behavioral approaches, maintains that a maladaptive style of thinking and coping, characterized by the processes of (1) repetitiveness, (2) attentional focus aimed at potential threats (e.g. physical sensations), and (3) unsuitable attempts to control unwanted thoughts, be responsible for maintaining dysfunctional emotional states over time (Wells., 2008). Therefore, TMC intervenes by modifying the processes that maintain emotional distress (Wells, 2012). This approach has been found to be highly effective in the treatment of anxiety and depression and to have effects that are maintained even in follow-ups (Normann, Van Emmerik and Morina, 2014). A recent study by McPhillps and collaborators (2019) performed a qualitative analysis on emotional distress in cardiac patients, based on what was reported by the subjects in an ad hoc structured interview in which it was requested to describe in detail the experienced distress, in particular the content of disturbing thoughts, the nature of emotional distress, when they experienced these emotions and thoughts and how they reacted to them.
Advertising message From the results it emerged that the contents of the concerns were mainly catastrophic and concerned the ongoing risk for their lives, the lack of confidence in energy recovery, the constraints linked to the reduction of energy, the continuous treatment and medical care which are subjected to the current and future challenges, including those not related to physical health, that await them. In the face of these concerns, associated with depressive and anxious symptoms, patients reported repetitive styles of thinking, such as rumination and brooding, implemented with the belief of utility with respect to understanding why they experienced the cardiac event and how to prepare in the future to prevent any recurrence. After the qualitative analysis, the researchers compared the conceptualization of patient distress from a cognitive-behavioral and metacognitive perspective. In particular, the authors argue that it is difficult to decide how realistic or not a dysfunctional thought linked to the heart problem, taking into account the objective greater physical fragility that these patients present. Therefore, TCC, since focused on questioning the contents of dysfunctional thoughts on the basis of reality data, would prove to be little effective in the treatment of emotional distress in cardiac patients. In contrast, TMC, being focused on the modification of cognitive processes, is hypothesized to be more effective and adequate in this clinical population.
In conclusion, emotional states of distress, such as anxiety, depression, anger, and repetitive thinking styles are common in patients with heart disease. The guidelines recommend the importance of the inclusion of psychological psychotherapy activities in cardiovascular rehabilitation contexts, in order to improve the quality of life of patients by reducing the risk of recurrence. TMC shows itself as an appropriate approach to this context in that, by modifying repetitive cognitive processes, it has a positive physiological impact since it reduces the cognitive cause responsible for maintaining sympathetic activation over time, therefore it would reduce one of the major risk factors present in patients with heart disease.