Jennifer Gracie* &
¶, Christine Baker*, Mark H. Freeston
¶, Julia L. Newton§
*Department of Psychology, Royal Victoria
Infirmary, Newcastle, NE1 4LP, UK.
¶ Department of Psychology, University
of Newcastle, Newcastle, UK.
§Falls and Syncope Service, Royal Victoria
Infirmary, Newcastle, NE1 4LP, UK
Address for correspondence: Dr Julia Newton, Senior Lecturer,
Care of the Elderly Offices, Royal Victoria Infirmary, Newcastle, NE1 4LP.
E-mail:
Julie.Newton@nuth.northy.nhs.uk
Introduction
Syncope is
a sudden transient loss of consciousness with loss of postural tone, followed
by spontaneous recovery
1.
Around 30 percent of the general population have one syncopal event in their
lifetime, with 3% having recurrent episodes
2.
Vasovagal syncope (VVS) is an exaggerated tendency towards the common faint
that accounts for up to 29% of syncope
3
and affects all age groups. VVS is characterised by profound hypotension
with or without bradycardia. Those with VVS are at risk of injury
during episodes and the long term implications of recurrent episodes of
hypotension are unclear
1.
The underlying pathophysiology of VVS is uncertain and current treatments
involve salt and fluid replacement and maintenance of blood pressure using
mineralocorticoids or alpha agonists
1.
These treatments are largely symptomatic and may be associated with side
effects that make their use in younger age groups inappropriate
4.
VVS can generally
be differentiated from other causes of syncope through clinical evaluation.
A definitive diagnosis of VVS is made by Head-up Tilt Table (HUT) test with
the diagnosis of VVS being confirmed when a patient develops hypotension
and/or bradycardia in association with syncopal or presyncopal symptoms
5.
One of the
main methodological threats to current research into VVS is the appropriate
measurement of VVS. A HUT is the most sensitive tool to diagnose VVS
5.
The majority of studies however have recruited participants diagnosed by
medical evaluation and symptom pattern recognition only
6,7,8,9,10. Although this method of diagnosis
has some degree of reliability and validity, it is not as reliable as a diagnosis
made by HUT.
There can be
a wide range of reported illness and disability associated with the same
level of disease
11. The experience
of VVS is at best inconvenient, and may be perceived as threatening and disabling.
In this review
we will consider the evidence that psychological factors play a role in
the development and maintenance of the symptoms of syncope, and more specifically
vasovagal syncope, and whether psychological interventions might impact
upon the manifestation and consequences of these symptoms.
Research into
the psychological factors in syncope has mainly involved groups of participants
who have syncope of mixed origin. There are very few studies that
have focussed exclusively on VVS as a separate condition. Further, it is
also important to appreciate that there are no measures specific to VVS and
that in many studies the diagnosis of VVS is by clinical evaluation rather
than by a positive diagnostic test, raising the question that all that is
syncope may not be vasovagal in origin.
Psychological factors associated with syncope
1. Impact of syncope on reported quality of life
Patients with
frequent syncope have been shown to have a markedly reduced quality of life,
similar to that of patients with severe rheumatoid arthritis or chronic
low back pain
8,12.
This provides some indication of the significantly disabling nature of this
condition
Quality of
life appears to decrease with increasing frequency of syncope, and there
is evidence of impairment in all reported dimensions - particularly in
terms of mobility, usual activities, and self care
13. This impact upon quality of life
is reversible and improves within six months when the frequency of syncope
is reduced, as exemplified when syncopal events are reduced on permanent
pacemaker implantation
14.
Linzer’s group
have developed a disease specific measure of impairment due to recurrent
syncope (mixed aetiology)
12.
This tool measures psychosocial impairment due to syncope and has reported
difficulties with activities of daily living (71%), driving (60%), physical
activities (56%), and even walking (42%). Problems in relationships
with friends, family and spouses have also been noted. Twenty one
per cent of patients have a high degree of fear and worry about their condition
which is not associated with injury due to syncope.
2. Psychological reactions to syncope
Patients with
syncope have a high prevalence of psychological distress, especially anxiety
and depression
6,8,15,16. Individuals may
fear their syncope and the negative consequences of fainting and can be severely
disabled by their condition
17.
Insights into
thoughts immediately before syncope come from a study involving US Air force
active flying personnel who had experienced syncope
9. Thoughts included predictions about
potential bodily or psychological harm, particularly people’s reactions
to their action, fear of others laughing at them, or being embarrassed due
to being socially inappropriate. Virtually all subjects reported that they
felt helpless in avoiding the threatening situation.
Vigilance of
somatic symptoms linked with fainting, such as feeling hot and giddy, may
also sustain apprehension and fear about fainting. The autonomic
symptoms of syncope and anxiety are similar, so fear arousal may amplify
the physiological signs associated with syncope and lead to an increase
in the fear associated with syncope
18.
Some studies suggest that co morbid diseases, number of syncopal events,
duration of syncope and injury due to syncope have no relationship to impairment
due to syncope
12.
Psychological factors may mediate impairment associated with syncope, and
this would mirror findings in other fields of chronic disease, for example
chronic pain
19 and angina
20. Studies suggest
6 that psychiatric illness is more likely in
females, younger age groups (as would be expected in the general population),
and in those with a higher number of previous syncopal events.
Despite the
methodological problems that make it difficult to draw definite conclusions
for these populations with VVS, there is a suggestion that the ways that
people understand their condition and their experience and then make predictions
about the consequences of fainting is associated with different styles of
coping and adjustment, and subsequent quality of life. This raises some
interesting areas of potential psychological investigation.
Psychological factors associated with vasovagal syncope
Studies specifically
carried out in those with VVS are few, and in those with VVS diagnosed exclusively
by HUT are rarer still. It could be argued that it is not appropriate
to extrapolate data from heterogeneous groups of syncopal patients to those
with VVS. Our experience would support the fact that VVS can lead
to high levels of illness and impact profoundly upon the quality of life
of the sufferer. For example VVS is associated with school absences
in children and absence from work in adults
4.
Studies suggest
that the measurement of psychological constructs in VVS is narrow and tend
to focus on demonstrating there is psychological distress among VVS participants.
The measures used however are not specific to VVS. For example, McGrady
et al
17 used the Beck Depression
Inventory (BDI) and the State Trait Anxiety Inventory (STAI). These
give a level of depression and anxiety within the groups, but it does not
allow for the question of cause or effect to be resolved.
One retrospective
study
16 has gathered data from
medical notes around the emotional impact of VVS and the reported stressful
aspects of VVS. Over half (56%) reported a history of mood disturbance
and twenty-one percent were taking a psychotropic medication. A range of
psychological problems were reported including suicidal ideation, but in
particular depression, panic and chronic anxiety. This is in line with
levels of emotional distress reported in other groups with chronic disease.
This study also found that patients often experience disabling and uncomfortable
symptoms that persist for hours or days after an episode of syncope.
The symptoms they reported as distressing include fatigue, dizziness and
dyspnoea. Over forty percent were anxious, worried and frustrated by
their situation. The thoughts reported by this group concerned the condition
becoming worse, transportation problems due to driving restrictions, not being
able to fulfil occupational or family roles, concern about mood swings, interpersonal
relationships and the impact of the condition on spouses.
The more frequently
reported personality characteristics of these individuals were of discipline,
motivation, organisation, perfectionism, punctuality and sensitivity. In
this group, those who struggled most to cope with their condition were those
who tended to be somewhat self-stressing in their personal style.
The perceived
negative consequences of fainting and assumptions of having little or no
control together may result in fear and avoidance or restriction of activity
leads to an impact on the individual’s quality of life. In anxiety
disorder such as panic, avoidance and other self-protecting behaviours have
been shown to reinforce the belief that particular situations are dangerous
and prevent the development of more adaptive ways of coping with the condition
21.
The potential role of psychological intervention in the treatment
of VVS
Given the high
prevalence of psychological dysfunction in those with syncope and VVS and
the role of illness-related beliefs and predictions in this condition,
psychological interventions could potentially have a part to play in the
management of VVS. Indeed, case reports have described the successful use
of applied tension (the use of physical manoeuvres such as muscle tensing)
and cognitive behaviour therapy (CBT) in patients with VVS
22,23,24,25,26.
A recent case
series of patients with a definite diagnosis of VVS (i.e. positive head
up tilt and full reproduction of symptoms), in whom conventional treatments
had not improved symptoms showed that CBT (incorporating applied tension)
resulted in dramatic improvements in symptomatology, consultation behaviour
and outcome. In nine patients there were significant reductions in
syncopal episodes and consultation rates post CBT intervention with clear
subjective improvements in quality of life and ability to return to work
or school
4. The CBT treatment
components included identifying and restructuring unhelpful beliefs; addressing
maladaptive somatic attention; reducing avoidance of certain activities and
situations; the use of applied tension, and addressing idiosyncratic issues,
for example, difficulties sleeping and coping with reactions of others.
Whether similar
affects are seen in patients with milder symptoms of VVS is unclear.
Likewise, whether psychological symptoms are present early in the natural
history of the disease or whether psychological symptoms develop as the
symptoms become more entrenched requires clarifying.
There is evolving
evidence that the SSRI class of antidepressant is effective in the treatment
of VVS and the neurotransmitter serotonin has been implicated in the aetiology
of VVS. Serotonin inhibits central neurons that regulate sympathetic
activity and there is an association between VVS and depression, in which
serotonin is also involved
28.
Further work is needed in order to clarify whether the effectiveness of
SSRI in VVS is due to syncope recurrence or whether it has affects upon the
subjects’ mood and ability to cope with their symptoms
Conclusions
There are a
number of psychological issues that appear to be important in the development
and maintenance of disability and psychological distress associated with
VVS. Current research suggests there is a role for psychological intervention
in addressing the distress and disability caused by VVS. Further longitudinal
research may help to develop the understanding of the experience of adapting
to and coping with VVS, and provide a valuable insight into the long-term
psychological consequences of having VVS. Researchers must aim to study
pure groups of patients with VVS and develop and use measures that are specific
to VVS. This process has started with the development of a measure
of impairment due to syncope
8,12. More work is needed to identify
and match effective interventions to those who might most benefit.
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