Heller et al. indicated that for some patients, the shock is not preceded by symptoms of any kind and is without warning; others develop symptoms of tachyarrhythmia and often await the shock with trepidation. The situation creates an experience of ambivalence: without the device, the patient may die, but with the device, there is constant anticipation that the device will fire. The fear and anticipation of shock can lead to psychological and emotional problems that are unique to this population. Many in the psychological community4-6 and those in the cardiology community7-10 have supported the notion that psychological support is needed to assist these patients with the adjustments needed to maintain an active lifestyle. Giving these patients psychological support, through education and supportive follow-up, may help those with an ICD reduce the incidence of fear, isolation and other negative responses. The effectiveness of the implantable cardioverter defibrillator (ICD) in preventing sudden cardiac death is based on its proven capacity to convert 98% of ventricular tachycardias to normal sinus rhythm.11 Since the introduction of the ICD in 1980, there has been a striking reduction in mortality in patients with documented sustained ventricular tachycardia, as well as those with inducible ventricular arrhythmias.12 New technological advances offer sophisticated arrhythmia detection and programmable treatments.13 Recently, cardiac resynchronization therapy (CRT) was introduced and added to the programming capabilities of the ICD. CRT involves placing a lead in the coronary sinus as well as the right atrium and ventricle to optimize the order of contraction and enhance physiologic functioning of the cardiac circuit. The result is reduced mitral regurgitation, increased diastolic filling time, and improved contractility of the cardiac muscle.11 Given the results of past clinical trials such as AVID, MUSTT, and MADIT I, as well as more recent trials such as MADIT II, COMPANION and SCD-HeFT, it is expected that many more implants will take place for high-risk sudden cardiac death (SCD) and heart failure patients.2,11 The majority of patients who are implanted with the device experience a desirable quality-of-life and a high acceptance rate. Thirty to fifty percent of patients reported some degree of negative effect, such as fear, anxiety, and depression.14 Additionally, lifestyle changes that affect driving, sexual activity, social interactions, physical appearance and physical activity further complicate the life of the recipient. Younger implanted patients, some as young as 4 years of age, those 14,15 The major psychosocial concerns, no matter what the age of the patient, include device dependency, fear of shock, poor body image, device malfunction, significant lifestyle changes, unpredictability of therapy, and isolation.12,14,16 These concerns may translate into anxiety disorder, depression, shock expectancy, post traumatic stress disorder, panic attacks, and phobias.2,9,12,14,16 It appears that anxiety and depression increase with the frequency of shock episodes.16 Anxiety about the ICD firing is closely associated with the occurrence of depression, while avoidance of activities is associated with anxiety. Worry about the ICD and a belief that ICD firing can be predicted is associated with anxiety sensitivity.17 The patient develops a belief that shock can be predicted. Monitoring of signs of impending shock begin to increase. This leads to hypervigilance regarding body sensations that are often provoked by anxiety. This can lead to increased awareness of body sensations, which in turn may lead to the individual associating unrelated chance sensations with shock.17,22 When a patient begins to feel anxious or depressed, they begin to feel less secure and less satisfied with the ICD therapy and report a decrease in quality of life.16 The resulting anxiety promotes increased avoidance behavior, fear of increasing autonomic arousal, sleep disturbances, sexual dysfunction, increased irritability, and difficulty concentrating.17 Kuijper et al.18 note that based on the literature the presence of anxiety symptoms is related to rhythm disturbances, and an ICD discharge may trigger depressive symptoms, panic disorder and avoidance behavior. Researchers4,12,13,15,18 agree that psychological and emotional support for the ICD patient is an important aspect of care that has not been given as much attention as is needed to support this growing population. Sears and colleagues4,14,15 have intimated that when psychological and emotional issues are identified in an ICD patient, they must be treated appropriately. ICD implanted patients are recognizing the electrophysiology team as those to whom they may readily turn with their questions and concerns, which is of proven importance to this population.16 The ICD follow-up staff is able to commit time and energy to the specific needs of the ICD patient and facilitate both their physical and psychological adjustment.16 A device-based clinic in which trained staff are present and responsible for a select arrhythmia population is an ideal setting for intervention and therapy to take place. Providing the ICD patient time to verbalize fear or concerns related to the device, as well as allowing discussion of the meaning of his or her illness, is an important aspect of a psychological plan for these patients.16 Eads et al.12 suggest using seven unique principles to facilitate psychosocial adjustment during routine follow-up visits. These seven principles are: #1: Define the problem. Allow the patient to pinpoint specific concerns. Some specific concerns that would not ordinarily be identified are memory difficulties, difficulty sleeping, overprotective family, and sexual difficulties, as well as depression, fear of shock, and fear of device malfunction. Questioning patients about personal concerns during routine follow-up visits gives an opportunity to attain needed information, express feelings, and simply chat about the ICD. Patients need a chance to tell their story.12 Questions such as What are your concerns about having an ICD? and Are you worried about your ICD? may stimulate discussion between the pacemaker/ICD clinic staff and the patient. #2: Provide information. Eads and colleagues suggest this may be one of the most effective methods of increasing a sense of control. Patients who felt better prepared for living with the device after implantation had better medical and psychosocial outcomes.3 On the other hand, erroneous beliefs about the ICD may result in counterproductive behaviors, such as attempts to predict shock or activities that are believed to induce shock. For some patients, this may translate into a debilitating pattern consisting of progressive limitations in activities and escalation of fearful thoughts.12 Ongoing patient contact, along with medical knowledge and expertise, puts clinic staff in an exceptional position to provide information to enhance ICD patient perceptions of control over reactions to their medical diagnosis.12 Typically, targets of education for the ICD patient comprise of explanations about the medical condition, ICD function and action, and discussions about lifestyle change that come about as a result of the implant.12 We as electrophysiology professionals need to educate the patient that there is nothing the patient can do to control arrhythmias that cause ICD shock. Therefore, strategies focusing on steering the ICD patients efforts in the direction of developing confidence in their ability to manage their reactions to the device discharges, not in an ability to ward off shocks, will promote better outcomes. Fear of triggering the device during sexual activity is a fear in approximately 50% of patients. Addressing this subject directly is important. Sex is a natural part of life, and this type of physical exertion is particularly anxiety-provoking for patients. It is typically related to the erroneous assumption that sexual activity represents an extreme level of exertion. Interventions may normalize feelings about sexual activity; provide education regarding safe levels of sexual activity. Discussing the role of regular exercise may lead to increased confidence about engaging in sex. Give information concerning other sources of sexual dysfunction, i.e., medications and vascular disease. Starting the discussion with the question Do you have any questions for me about the ICD? may be a good way to engage use of this principle. #3: Create team support. Social support is a significant enhancement to adjusting to cardiac illness. Ensuring trusting and supportive relationships with family and friends on which the device patient can depend is important for adjusting to the implant.16 It is important to note that healthcare providers are psychosocial providers and significant sources of support to this patient group. Patients especially value the relationship that is developed with the people who fully understand their needs. Even so, the patient may still need an invitation to talk about and express their needs; therefore, open communication is very important.12 Open this discussion with We would like you to think of yourself as part of your treatment team. #4: Normalize fears. Approximately 13-38% of ICD patients experience diagnosable levels of anxiety, and nearly one-third report fear of shock.4 ICD shock can be extremely uncomfortable, and those patients that receive more than one shock consecutively may be at risk for a high incidence of psychosocial complications.4,14,16 Engaging the ICD patient in discussion that normalizes emotions enables the follow-up staff to help the patient talk about their fears and other reactions relating to the ICD. The follow-up staff can then assure the patient that fear is an expected part of having an ICD implant and is neither a sign of poor outcomes nor an abnormal occurrence. Eads and colleagues note when fear is labeled as a safe and inevitable part of treatment, patients become less sensitive to the presence of fear. Accepting fear may enhance the patient s confidence to resume a normal life despite the threat of shock. The statement Feeling stressed about the ICD is a normal reaction may spark this discussion. #5: Encourage emotional release. Patients who avoid talking about the negative aspects of their ICD are at increased risk of ongoing emotional distress. Merely affording a patient the opportunity to discuss worrisome issues with an open and empathic listener allows for emotional catharsis. Asking Can we discuss your feelings about your ICD? may lead to relief from the burden of harboring unexpressed concerns, and may precede resolution of uncertainties connected with the ICD. As important as this principle is, implementation is time-intensive. The clinic staff might consider allowing brief discussion periods with the patient on a routine basis, which may help in decreasing extreme emotional outburst that take more time with which to deal.12 #6: A statement such as It is possible to return to your normal activities after you recover will instill hope. Eads and colleagues suggest the implanted patient benefit from assurance in the short term that the physical discomfort and emotional distress they are experiencing will more than likely diminish with time. Overall, quality of life and psychosocial functioning in the areas of emotional behavior, alertness, and social interaction temporarily decline six-months post implant. Follow-up at 12 months finds that all areas of functioning returned to baseline.19 #7: Encourage patients to take action. The follow-up staff can effectively foster self-efficacy behaviors in patients by providing instruction about self-care and by encouraging the belief that patients possess the capacity to successfully care for themselves.12 Eads and colleagues assert that it is psychologically enhancing for patients to resume everyday activities after receiving the ICD. There are times patients may need encouragement to maintain a degree of physical exertion over time, including exercise or sexual activity.4 Eads et al. also suggest that having brief, routine communication between healthcare providers and ICD patients about psychosocial issues can facilitate patient adjustment. This may not be sufficient to meet the needs of all ICD patients; however, supportive communication bolsters problem-solving and coping strategies of most ICD patients. Providing patients with more severe psychological adjustment difficulties, supportive communication may lead to better identification of patients who would benefit from referrals to mental health professionals. There are other approaches for psychosocial intervention of the ICD patient. One such approach is the initiation of Cognitive Behavioral Therapy (CBT). This type of therapy addresses the link between thoughts, feelings, and behaviors regarding ICDs and illness. Staff educated in the use of CBT provides a means for the ICD patient to regain a sense of control over their lives. CBT is successfully used in the treatment of cancer and epilepsy, and provides the patient a new tool to fight the fear of shock.16 Sears et al.,4 Smith and colleagues,20 and White16 have reported positive outcomes because of CBT. Alternative therapies also have been successfully implemented to support the ICD patient. Relaxation techniques such as progressive muscular relaxation, breathing techniques, deep relaxation, and self hypnosis, taught early and re-enforced through out follow-up, have helped the patient cope with the new stress of an implant.4,21 Having a complete medical, emotional, and psychological history of the patient is essential for a focused treatment plan.13 Family dynamics should be assessed to identify family and social concerns that may influence recovery. Identify any non-cardiac medications that might influence electrical activity of the heart; SSRIs and herbal supplements are known pro-arrhythmics.16 The ICD follow-up staff should give information concerning the device implant as soon as the recipient is informed the device is necessary.13 The patient should be provided an opportunity to hold the device in order to see what it looks and feels like. Patients need to be taught what to expect immediately post-op, during recovery, long-term effects, and any limitations that will be present post-implant.13 Patient questions concerning sexual activity, anxiety and guilt, device failure and potential death must be dealt with openly and honestly.16 The family of the patient must be included in this education process. Families of the patient experience some of the same fear and anxiety felt by the device recipient. Reports of parents of children with implants becoming overprotective and spouses exhibiting hypervigilant behaviors are widely reported by Sears and colleagues,14,15 May et al.,19 and others. White16 suggests information and therapies should be age-specific, because adolescent patients have unique needs associated with peer acceptance and body image. Being able to speak to a same-gender, same-age recipient may help the adolescent adjust more easily. Using this same strategy for the adult population has also proven successful.13 Teaching coping skills related to ICD discharge, and increasing knowledge and understanding of the disease process that precipitates the need for the device, provides the patient with a degree of control. Interventions of this type also facilitate self-management.16 The role of the ICD follow-up staff as educators and advocates for this unique and challenging population is extremely important, and are the continuous link to the multidisciplinary team of professionals that guide the oftentimes forgotten humanistic care of the ICD patient.