General Hospital Psychiatry 53 (2018) 131–138
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General Hospital Psychiatry
journal homepage: www.elsevier.com/locate/genhospsych
Cardiac-disease-induced PTSD and Fear of illness progression: Capturing the
unique nature of disease-related PTSD
T
Keren Faita, Noa Vilchinskya, , Rachel Dekelb, Nitza Levic, Hanoch Hodd,e, Shlomi Matetzkyd,e
⁎
a
Department of Psychology, Bar-Ilan University, Ramat-Gan, Israel
The Louis & Gabi Weisfeld School of Social Work, Bar-Ilan University, Ramat-Gan, Israel
c
RN, Leviev Heart Institute, Chaim Sheba Medical Center, Tel-Hashomer, Israel
d
Leviev Heart Institute, Chaim Sheba Medical Center, Tel-Hashomer, Israel
e
The Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
b
A R T I C LE I N FO
A B S T R A C T
Keywords:
Cardiovascular disease
CDI-PTSD
EST model
Fear of illness progression
PTSD
According to Edmondson's Enduring Somatic Threat (EST) Model of PTSD Due to Acute Life-Threatening Medical
Events, the nature of PTSD in the context of illness may differ from the nature of “traditional” PTSD in that it
includes future-oriented alongside past-related intrusive thoughts. Yet almost no empirical studies to date have
assessed the putative future-oriented quality of cardiac–disease-induced PTSD (CDI-PTSD). In the current study,
we assessed the hypothesized associations between CDI-PTSD and fear of illness progression (FoP) – a novel
theoretical conceptualization of patients' future-related anxieties. We hypothesized that FoP would be positively
associated with CDI-PTSD, and especially with its specific items of intrusive thoughts. Patients (N = 112) were
interviewed three months post-hospitalization for an acute coronary event via use of the PSS-SR-5 (to assess
PTSD symptomatology), the FoP-Q-SF (to assess fear of illness progression), and the HADS (to assess anxiety and
depression levels). Results indicated a strong positive association between CDI-PTSD and FoP, even when
controlling for anxiety and depression. As hypothesized, the concepts of CDI-PTSD and fear of illness progression
were strongly associated both at the level of the clusters as well as at the level of the specific items. The current
study provides an initial empirical validation of the EST Model, especially regarding the future-oriented nature
of PTSD resulting from acute cardiovascular disease.
1. Introduction
Although advances in medical technology have increased survival
rates from cardiovascular diseases [CVD; [1,2]], they are still a leading
cause of death and disability throughout the world [3] and are considered to present a serious threat to people's lives. This significant
threat to those coping with CVD can cause them to experience meaningful emotional distress that can actually meet the criteria for a diagnosis of posttraumatic stress disorder [PTSD; [4]]. The perceived
nature of CVD – the event's abruptness, the imminent possibility of
death, the patient's feelings of utter helplessness and impotence in the
face of it [5] – may all conspire to result in PTSD. The consistent finding
that one's illness perceptions – and not only the objective severity of the
illness – strongly predicts one's emotional outcomes [6], serves to
strengthen this postulation.
Indeed, in the past three decades, a large body of evidence has accumulated, showing that CVD and especially its acute clinical
expression – that is, 1) acute coronary syndrome (ACS) which refers to
myocardial infarction (MI) and/or severe unstable angina (UA), or 2)
cardiac arrest (CA) – can induce posttraumatic stress symptoms (PTSS)
and even full-blown PTSD [4]. Studies conducted thus far on cardiacdisease-induced PTSD (CDI-PTSD) point to a prevalence ranging from
0% to 38%, with an average of 4–16%, depending on the utilized diagnostic tool [4]. A recent meta-analysis yielded an aggregated prevalence estimate of 12% for clinically significant symptoms of ACS-induced PTSD [7]. As with PTSD originating from other causes, CDI-PTSD
has been associated with high levels of negative outcomes among patients [8,9]. Among these outcomes are higher levels of anxiety, depression, and hostility; lower levels of quality and satisfaction of life
[8,10]; non-adherence to medical regimens [11,12]; and higher odds
for recurrence and mortality [13,14].
Based on their recent systematic review of the studies in the CDIPTSD field, Vilchinsky et al. [4] concluded that acute cardiac events
meet the DSM-5 definition of Criterion A, and can thus be seen as
Corresponding author.
E-mail addresses: noa.vilchinsky@biu.ac.il (N. Vilchinsky), rachel.dekel@biu.ac.il (R. Dekel), niza.levi@sheba.health.gov.il (N. Levi), Hod.Hanoch@sheba.health.gov.il (H. Hod),
shlomi.matetzky@sheba.health.gov.il (S. Matetzky).
⁎
https://doi.org/10.1016/j.genhosppsych.2018.02.011
Received 15 September 2017; Received in revised form 1 February 2018; Accepted 26 February 2018
0163-8343/ © 2018 Elsevier Inc. All rights reserved.
General Hospital Psychiatry 53 (2018) 131–138
K. Fait et al.
“unreasonable” situation [20]. Understandably, due to FoP, patients
may eventually end up being overly attentive to potential signs of recurrence and bodily symptoms, engage in checking behavior, and – as
often as not – misinterpret symptoms [22]. These reactions are in line
with Edmondson's EST Model [15] in terms of the stressor's location
and how it impacts the way CDI-PTSD symptoms display themselves.
Studies conducted on patients coping with cancer showed a strong
association between fear of illness progression and PTSD or PTSS
[23,24], For example, in a study conducted among women who survived breast cancer [24], intrusive cognitions were detected in 37% of
the sample. Fear of illness progression was found to be highly correlated
with intrusive thoughts, avoidance, and hyperarousal.
Despite its apparent relevance, no study to date has assessed FoP in
the context of cardiac illness. This gap is critical since it prevents a
deeper understanding of the unique manifestation of CDI-PTSD symptoms. Moreover, CDI-PTSD has been, and currently is, diagnosed and
measured using instruments designed for the assessment and diagnosis
of “traditional” PTSD; its unique manifestations of future-oriented intrusions are therefore not accounted for [4,15]. Thus, we aimed to reveal the existence of future-oriented content, possibly embedded in
CDI-PTSD.
potential causes of PTSD. Yet Edmondson [15] has suggested that PTSD
resulting from illness must be regarded as an enduring somatic threat,
with a unique display of symptoms. In his Enduring Somatic Threat
Model (EST Model), Edmondson points out the significant differences
between “traditional” PTSD (which manifests itself, for example, among
veterans of war or assault victims) and PTSD resulting from a lifethreatening illness. In the former, symptoms are related to a discrete
and external source, whereas in the latter, symptoms are related to an
internal, ongoing threat [15]. Despite the vast literature accumulating
in the field of CDI-PTSD, and despite the fact that a cardiac event is
clearly somatic and enduring, no explicit effort to date has been undertaken to empirically test the EST postulations in this context. The
current study's main aim was therefore to propose an empirical assessment of the EST assumptions, focusing on the unique future-oriented nature of CDI-PTSD.
1.1. The EST Model assumptions
According to the EST Model [15], the manifestation of posttraumatic symptoms is qualitatively different between the “traditional”
PTSD and illness-related- one. For example, avoidance – a strategy used
to cope with intrusive memories and elevated arousal – is an almost
impossible strategy for the MI patient, who because of his/her condition
must continue to engage with the medical establishment (i.e., attend
doctor appointments, be admitted to hospitals, etc.). In addition, the
ongoing existence of physical symptoms such as a racing heart, shortness of breath, or dizziness does not allow the patient to forget the
traumatic cardiac event he/she underwent. Worse, the hyperarousal
symptoms characteristic of CDI-PTSD are at times exactly the same as
those symptoms that indicate a life-threatening cardiac event. The CDIPTSD patient, therefore, is essentially trapped in this continuous cycle
of anxiety and sympathetic/cardiovascular reactivity. Finally, given
that the illness is often the acute manifestation of a long-term physiological disruption, the source of the threat is internal; the threat and the
individual, therefore, cannot be separated [15,16]. This threat is not
exclusively related to past experience; rather, it is chronic, and in many
ways it is anchored in fears and worries about the future, vis-a-vis
treatment, illness progression, potential recurrence, and even death
[16,17].
These unique illness characteristics shape the nature of CDI-PTSD
symptoms. Whereas the classic PTSD intrusive symptoms focus on the
past event, in cardiac disease the intrusive symptoms may also relate to
the future [15,17]. Thoughts and images related to the threat of another
cardiac event, fear of future death, worries about forthcoming doctor
appointments, and other future-oriented concerns may constitute what
Holmes and colleagues (2007) termed “flash-forward” intrusions [18].
Although the EST Model is a very appealing theoretical conceptualization of CDI-PTSD, the need for empirical data to validate it
remains. To date, only very few studies have focused, for example, on
the future-oriented component within CDI-PTSD. Sheldrick, Tarrier,
Berry & Kincey (2006) assessed MI patients' perceptions of their illnesses [19]. The authors found a positive correlation between CDIPTSD levels and perceptions of the illness as chronic and ongoing rather
than acute and episodic. Yet, the full spectrum of an individual's worries
regarding the progression of his/her illness is not expressed solely via
“perceptions of the illness as chronic.” Therefore, we suggest that the
theoretical concept of future-oriented worries may be better captured
by the concept of “fear of illness progression” [20].
1.3. Current study hypotheses
The current study focused on the associations between CDI-PTSD
and FoP in a sample of 102 patients, assessed three months after their
acute cardiac events. We hypothesized that FoP would be positively
associated with CDI-PTSD and especially positively associated with the
intrusion cluster. Due to the already well-established comorbidity of
PTSD and CDI-PTSD with depression and anxiety [25,26], we assessed
the formerly mentioned associations while controlling for depression
and anxiety symptoms. Controlling for these symptoms enabled us to
detect whether a specific association existed between fear of progression and PTSD above and beyond the abovementioned association between CDI-PTSD and distress symptoms; it also enabled us to differentiate between the FoP and PTSD association and the possible
association between FoP and depression or anxiety, which has been
detected in former studies in the context of cancer [27–29].
In order to obtain a better resolution of the interface between fear of
progression and CDI-PTSD, at the level of the particular items, an
Exploratory Factor Analysis (EFA) was carried out. We hypothesized
that the FoP items would converge most strongly with those symptoms
of CDI-PTSD that reflected ruminative, intrusive cognitions.
2. Method
2.1. Participants and procedure
The current study was part of a large-scale dyadic longitudinal
prospective study conducted on CDI-PTSD among patients diagnosed
with an acute coronary event and their intimate partners. The data were
collected between the period of March 2015 until December 2016, and
the sample consisted of patients hospitalized in the Intensive Cardiac
Care Unit (ICCU) of the Sheba Medical Center, the largest medical
center in Israel. The target population was defined as patients diagnosed with an acute coronary event (ACS, UA, MI, CA) who were in a
significant intimate relationship. Exclusion criteria included a cardiac
diagnosis other than an acute coronary event (aside from a cardiac risk
factor such as diabetes, high blood pressure, and hypercholesterolemia); elective hospitalization; patients' cognitive, physical, or language difficulties which precluded participation in interviews; CABG
(coronary artery bypass graft) surgery during hospitalization; patients
over the age of 85; patients who had died during hospitalization;
tourists; and patients under guardianship. Eligible patients were approached by a member of the research team during their hospitalization
in the ICCU. Upon patients' agreement, the research team also
1.2. Fear of illness progression
Fear of illness progression (FoP) indicates people's essentially rational fear that their disease will advance and that their condition will
likely deteriorate over time [20,21]. The fear stems from people's experiences of a chronic, life-threatening, and/or incapacitating illness,
and it is therefore considered a reasonable response to an
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K. Fait et al.
which he/she experienced each symptom during the previous week on
a scale ranging from 0 (not at all) to 3 (most of the time). Internal consistency (Cronbach's α) of the HADS subscales was 0.83 for the depression scale and 0.89 for the anxiety scale at Time 2.
approached the patients' partners. Couples consisting of two partners
who a) were eligible to participate and b) agreed to participate, signed a
consent form and were asked to complete Time-1 questionnaires during
hospitalization (either by self-report or with the help of an interviewer).
Three months post-discharge a research assistant contacted all consenting participants (both patients and partners) by phone and arranged
a follow-up interview at their private residences in order to complete
Time-2 questionnaires. Participation in the study was on a voluntary
basis, and couples received no reward for their participation. This study
was approved by the Sheba Medical Center's institutional review board.
Of the 406 eligible patients, 64 (15.8%) were discharged before the
research team was able to approach them, and 34 (8.4%) had an intimate partner who could not be interviewed due to various cognitive,
physical, or language barriers. Of the 308 eligible couples, 141 couples
agreed to participate in the study and completed the study questionnaires during the patient's hospitalization (45.8% recruitment rate
during Time-1). Of those couples, 107 couples (24.1% attrition rate)
also completed Time-2 questionnaires (3 months post patient's discharge). The questionnaires of five couples were removed from further
analysis due to substantial missing data; all of the other couples'
questionnaires had complete data. Thus, the final study sample consisted of 102 couples, of which, for the purposes of the current study,
only the patients' data was analyzed. Fig. 1 presents the flowchart of the
recruitment process.
2.2.4. Demographic measures
In order to assess sample characteristics and related variables, the
following demographic information was collected: age, gender, years of
education, duration of current intimate relationship (in years), number
of children, and income level (below the average income in Israel, equal
to the average income, or above the average income).
2.2.5. Illness severity
Illness severity was assessed by a senior cardiologist based on two
criteria: an echocardiogram (examines the structure and functioning of
the heart), and an angiogram (examines obstructed artery status). The
echocardiogram and angiogram were both measured on a scale ranging
from 1 (mild) to 4 (most severe).
2.3. Method of analysis
The data were analyzed using the IBM SPSS Statistics for Windows,
version 21 [37]. Pearson correlations were applied in order to assess the
inter-correlations between FoP, CDI-PTSD, depression and anxiety,
while controlling for confounding variables. Next, in order to pinpoint
which FoP item converged most strongly with each of the PSS-SR-5
scales, we applied four Exploratory Factor Analyses (EFAs), each time
looking at the FoP items together with the items of one of the four PTSD
clusters. For each analysis, a two-factor solution and 25 iterations were
requested. We deliberately requested a two-factor solution in order to
view whether the two instruments' items converged each time into two
distinct factors (i.e., FoP and one of the PTSD cluster items each time).
Each two numbered columns in Table 2 represent the factors' loadings
of an independent analysis (all-together, four analyses comprised of two
factors each). The loadings of each analysis are not customarily presented by the order of the loading size, but by the pre-determined order
of the items in each instrument. This order of events allowed us to
examine which FoP item converged most highly with each CDI- PTSD
cluster, separately. We made use of EFA, since this procedure is performed in order to detect the maximum common variance from all
variables. Due to the hypothesized inter-correlations between factors
[38], we applied a Promax rotation with Kaiser Normalization.
2.2. Measures
2.2.1. CDI-PTSD
CDI-PTSD during Time 2 was measured using the Hebrew version of
the PTSD Scale - self-report for DSM 5 [PSS-SR-5; [30]]. The PSS-SR-5
is based on the Post-Traumatic Stress Diagnostic Scale [PDS; [31]] with
added items in order to reflect the changes made to the PTSD diagnostic
criteria in the DSM-5. The PSS-SR-5 consists of 20 items all tapping
criteria B, C, D, and E of the DSM-5: that is, re-experiencing, avoidance,
negative alterations in cognitions and mood, and arousal symptoms.
The symptoms are measured on a scale ranging from 0 (not at all) to 4
(six or more times a week). The PSS-SR-5 also includes additional items
tapping feelings of distress and interference in daily functioning (Criterion G) and duration and onset of symptoms (Criterion F). In order to
generate a continuous measure for CDI-PTSD, symptom item scores
were summed, so that a higher score indicated a more severe level of
symptoms. Cronbach's α for the Hebrew version of the PSS-SR-5 in the
current study was 0.89.
3. Results
2.2.2. Fear of illness progression
Patients' fear concerning illness progression at Time 2 was measured
using the short form of the Fear of Progression Questionnaire [FOPQ-SF; [32]]. The FoP-Q-SF is a 12-item measure (e.g., “I am afraid that I
will not be able to work anymore due to my illness”; “I am afraid of
disease progression”) based on the Fear of Progression Questionnaire
[FoP-Q; [20]]. The FoP-Q-SF items are scored on a five-point Likertscale ranging from 1 (never) to 5 (very often), and higher values indicate
higher levels of fear. For the purposes of the current study, the FoP-Q-SF
was translated into Hebrew using Triandis and Brislin's (1984) backtranslation technique [33]. Cronbach's α for the Hebrew version was
0.86.
3.1. Sample characteristics
The majority of patients were male (N = 94, 92.2%) with a mean
age of 60.41 years (SD = 10.70), and a mean of 13.88 years of education (SD = 3.68). As this study was part of a larger study focusing on
CDI-PTSD in patients and their intimate partners, all participants were
married or cohabiting with an intimate partner. The average duration
of relationships was 31.28 years (SD = 14.78), and couples had an
average of 3.26 children (SD = 1.41). The majority of participants
(57.7%) reported that their income was below the average income in
Israel that year. In addition, illness severity for most patients was found
to be mild to moderate according to both angiogram (M = 2.25,
SD = 1.28) and echocardiogram (M = 2.10, SD = 1.10) scores.
No significant differences in age or gender were found between
patients who agreed to participate in the study and patients who refused to participate (or whose partners refused to participate). In addition, no significant differences were found between patients who
completed Time-2 questionnaires and patients who either could not be
reached or who refused to continue their participation in the study
(patients were compared regarding age, gender, education, relationship
duration, income level, illness severity, and depression and anxiety
2.2.3. Anxiety and depression
Anxiety and depression levels at Time 2 were assessed using the
Hebrew version of the Hospital Anxiety and Depression Scale
[HADS; [34]]. The HADS was developed and has been used extensively
in populations coping with physical illness, and specifically cardiac
illness [35,36], given that it avoids reliance on those somatic aspects of
depression or anxiety that may also be related to being physically ill
[34]. The HADS includes two subscales, depression and anxiety, each
consisting of 7 items. Each participant was asked to rate the degree to
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K. Fait et al.
Patients hospitalized in the ICCU
(n = 1636)
Excluded (n = 1230, 75.2%)
Non-acute coronary event (n = 617, 50.2%)
Elective hospitalization (n = 183, 14.9%)
Patients not in an intimate relationship (n = 165, 13.4%)
Patients who could not be interviewed due to language, physical, or
cognitive difficulties (n = 151, 12.3%)
Patients transferred to CABG surgery during hospitalization (n = 52,
4.2%)
Patients over the age of 85 (n = 50, 4.1%)
Patients who died during hospitalization (n = 7, 0.6%)
Eligible patients (n = 406,
24.8%)
Discharged from the ICCU before being
approached by the research team (n = 64,
15.8%)
Partner not eligible for the study (n =34, 8.4%)
Eligible couples (n = 308,
75.9%)
Either patient or partner refused to participate
in the study – Time 1 (n = 167, 54.2%)
Included couples Time 1
(n = 141, 45.8%)
Time 2 attrition (n = 34, 24.1%)
Refused to participate at Time 2 (n = 28,
19.86%)
Not reachable by phone/mail/email (n = 6,
4.25%)
Couples completed Time2 questionnaires
(n = 107, 75.9%)
Couples not included in data analysis due to
substantial missing data (n = 5, 4.7%)
Analyzed couples Time 2
(n = 102, 95.3%)
Fig. 1. Flowchart of the study recruitment process.
Note: ICCU = intensive cardiac care unit; CABG = coronary artery bypass graft.
SR-5 was highly correlated with both the depression and the anxiety
scales. Unsurprisingly, FoP was also found to be positively correlated
with depression, and even more so with anxiety. As hypothesized, CDIPTSD and FoP were strongly and positively correlated even after controlling for anxiety and depression. It is important to note that the
correlations between FoP and CDI-PTSD, albeit substantial, were not at
the level that might suggest multicollinearity (we tested for multicollinearity in the regression analysis, described in Section 3.4 to
come).
levels taken during hospitalization).
3.2. Correlations analyses
In order to detect putative confounding variables, Pearson correlations were calculated among all psychological, medical, and demographic variables. No significant correlations were found among the
psychological measures (i.e., CDI-PTSD and FoP) and the demographic
or medical measures, except for a significant positive correlation detected between years of education and FoP (r = 0.23, p < 0.05). Thus,
years of education was controlled for in all further analyses.
Table 1 presents the inter-correlations among the PSS-SR-5 total
score – and separate symptom cluster scores – with FoP, anxiety, and
depression. As can be seen, CDI-PTSD measured with the use of the PSS-
3.3. Applying exploratory factor analysis
Results are presented in Table 2. First and foremost, Table 2 shows
that the items of the PSS-SR-5 converged well with the four known
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K. Fait et al.
Table 1
Pearson Correlations among PSS-SR-5 total score, PSS-SR-5 symptom cluster scores, FoP total score, and anxiety and depression levels (N = 102).
FoP
PSS-SR-5
Intrusions
Avoidance
Hyper-Arousal
Negative alterations in
cognition and mood
Anxiety
Depression
FoP
PSS-SR-5
Intrusions
Avoidance
Hyper-Arousal
Negative alterations in
cognition and mood
Anxiety
Depression
1.00
0.74⁎⁎
(0.57⁎⁎)a
1.00
0.68⁎⁎
(0.53⁎⁎)a
0.85⁎⁎
(0.79⁎⁎)a
1.00
0.68⁎⁎ (0.50⁎⁎)a
0.64⁎⁎
(0.41⁎⁎)a
0.90⁎⁎
(0.80⁎⁎)a
0.64⁎⁎
0.61⁎⁎
1.00
0.62⁎⁎ (0.43⁎⁎)a
0.60⁎⁎ (0.18)b
0.37⁎⁎ (0.00)b
0.92⁎⁎ (0.89⁎⁎)a
0.69⁎⁎
(0.45⁎⁎)c
0.55⁎⁎
0.60⁎⁎
0.68⁎⁎
0.57⁎⁎
0.51⁎⁎ (0.37⁎⁎)c
1.00
0.63⁎⁎
1.00
0.75⁎⁎ (0.62⁎⁎)a
0.65⁎⁎
1.00
0.69⁎⁎
0.57⁎⁎
0.79⁎⁎
1.00
0.34⁎⁎
0.29⁎⁎
0.53⁎⁎
0.51⁎⁎
Note: the correlations were controlled for years of education. FoP = Fear of progression scale; PSS-SR-5 = PTSD scale.
⁎⁎
p < 0.01 level (2-tailed).
a
Controlling for anxiety and depression levels.
b
Controlling for CDI-PTSD levels.
c
Controlling for FoP levels.
Table 2
Content and structural coefficients of the fear of progression (FoP) and PTSD scale-self report for DSM 5 (PSS-SR-5) (N = 102).
Scales
Items
1
2
1
2
1
2
1
2
FoP
I become anxious if I think my disease may progress
I am nervous prior to cardiologist appointments or periodic
examinations
I am afraid of pain
I have concerns about reaching my professional goals because of my
illness
When I am anxious, I have physical symptoms such as a rapid
heartbeat, stomach-ache, or agitation
The possibility of my children contracting my disease disturbs me
It disturbs me that I may have to rely on strangers for activities of
daily living
I am worried that at some point in time I will no longer be able to
pursue my hobbies because of my illness
I am afraid of severe medical treatments during the course of my
illness
I worry that my treatment could damage my body
I worry about what will become of my family if something should
happen to me
The thought that I will not be able to work because of my illness
worries me.
Unwanted upsetting memories about the cardiac event
Bad dreams or nightmares related to the cardiac event
Reliving the event or feeling as if it were actually happening again
Feeling very emotionally upset when reminded of the event
Having physical reactions when reminded of the cardiac event (for
example, sweating, racing heart)
Trying to avoid thoughts or feelings related to the cardiac event
Trying to avoid activities or places related to the cardiac event
Inability to recall important aspects of the cardiac event
Seeing yourself, others, or the world in a more negative way (for
example, “I can't trust people,” “I'm a weak person”)
Blaming yourself or others for what happened
Having intense negative feelings like fear, horror, anger, guilt, or
shame
Losing interest or not participating in activities you used to take part
in
Feeling distant or cut off from others
Having difficulty experiencing positive feelings
Treating others with aggression
Acting in a dangerous way
Being overly alert or on guard
Being jumpy or more easily startled (for example when someone
walks up behind you)
Having trouble concentrating
Having trouble falling or staying asleep
0.388
0.014
0.401
0.665
0.382
0.775
0.430
−0.152
0.312
−0.109
0.520
0.627
0.285
−0.061
0.522
0.559
0.278
0.427
0.227
0.217
0.523
−0.231
0.004
0.886
−0.173
0.823
0.603
0.018
−0.063
0.747
0.520
−0.017
0.127
0.537
0.455
0.178
0.182
0.463
0.165
0.467
0.265
0.604
0.199
−0.029
0.480
0.259
−0.037
0.292
−0.093
0.173
0.453
0.343
−0.200
0.081
0.585
0.458
0.893
−0.109
−0.040
0.849
0.510
0.325
0.537
0.275
0.804
0.056
0.361
0.549
0.360
0.540
0.277
0.601
0.655
0.353
−0.124
0.231
0.343
0.753
0.241
−0.129
−0.008
−0.354
0.568
0.886
0.076
−0.188
0.483
0.763
0.659
0.031
0.000
0.711
0.431
0.297
0.579
0.131
−0.187
0.042
−0.108
0.291
0.171
0.837
0.586
0.837
0.438
0.492
0.579
0.413
0.095
0.163
0.314
0.672
0.006
−0.038
0.438
0.161
−0.147
0.504
0.714
−0.158
0.816
0.787
−0.157
−0.085
0.922
0.587
0.428
0.718
−0.248
−0.086
0.057
−0.096
0.140
0.238
0.368
0.243
Intrusion
Avoidance
Negative cognitions and
affect
Arousal
Note. Numbers in bold represent loadings of the items grouped under each CDI-PTSD cluster.
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K. Fait et al.
FoP and CDI-PTSD are two independent yet connected constructs. Thus,
we could suggest that the more traumatized patients are by the cardiac
event, the more worried they are about the future consequences of their
illness. However, due to the cross-sectional design of the current study,
the opposite conclusion could be equally deduced, suggesting that the
more troubled patients are with worries about the future ramifications
of their illness, the more traumatized they become. Either way, the
strong association between negative illness cognitions about the future
and CDI-PTSD resulting from a cardiac event was verified at the level of
the full scales.
When we look at the specific items, findings show that intrusions
characterizing the CDI-PTSD experience are strongly related to the
context of needing to visit the cardiologist, a visit which consists of the
possibility of being told the illness has progressed. This fear, as well as
the fear of the pain that the illness might bring about, also seems to be
associated with post-traumatic related avoidance tendencies: the efforts
to avoid painful thoughts as well as concrete reminders of the illness. In
addition, avoidance tendencies seem to be associated with worries
about the future suffering of the patient's family, due to the patient's
illness. Thus, cardiac patients – seeing the cardiac event as not only a
past trauma but also as a future threat – tend to avoid reminders of the
illness. Finally, cardiac patients' posttraumatic cognitions seem to be
marked by worries regarding their future un-productivity as a result of
their illness; these cognitions are also associated with patients' nervousness and aggression. Thus, based on the shared variance found
between CDI-PTSD and FoP both at the level of the scales as well as at
the level of the separate items, we may cautiously infer that, as the EST
Model [6] suggests, the content of patients' post-traumatic intrusions is
very much connected to thoughts about the progression of the illness in
the future, and not only to recollections of the event that happened in
the past.
Lastly, our post hoc analyses revealed an interesting dynamic
among FoP, CDI-PTSD, and mental distress (depression and anxiety
symptoms). The finding that the associations between FoP and mental
distress disappear once the levels of CDI-PTSD are controlled for
strengthens the postulation that the negative mental consequences of
FoP are salient only insofar as FoP is a part of the CDI-PTSD experience.
In other words, FoP is not necessarily debilitating, but it can become
such as part of a more profound posttraumatic experience. The partial
correlation (Table 1) showing that the associations between CDI-PTSD
and mental distress decrease significantly in the present of FoP
(meaning that part of the variance between CDI-PTSD and distress is
shared by FoP) corroborates this conclusion.
PTSD clusters. There were only three items that did not produce loadings > 0.4 (one for the negative cognition cluster and two for the
arousal cluster).
Table 2 makes evident that the FoP items most related to the cluster
of intrusions were related to the specific anxiety that emerges when one
needs to visit the cardiologist or undergo a regular medical checkup The
FoP item tapping the physical symptoms of anxiety is also most related
to the cluster of intrusions. The anxiety one undergoes before meeting
the cardiologist, as well as the fear of pain and worries about the future
suffering of one's family, due to the patient's illness, were found to be
related to the avoidance cluster. Finally, future-oriented worries regarding one's ability to pursue one's career and hobbies were mostly
related to the PTSD clusters of negative cognitions and hyper-arousal.
3.4. Post hoc analyses
The findings portrayed in Table 1 show very clearly that after
controlling for CDI-PTSD levels, the significant substantive correlations
between FoP and anxiety, and especially between FoP and depression,
become insignificant. The pattern of correlations seems to point to the
possibility of a complex interface among CDI-PTSD FoP and both anxiety and depression. Exploring this complexity may shed additional
light on the relationship between FoP and CD-PTSD. We therefore applied two post hoc linear regression analyses in order to investigate this
interface.
First, it is important to note that no multicollinearity between PTSD
and FoP was detected [Average VIF = 1.87 (should be < 10);
TF = 0.45 (should be > 0.1); [39]]. As can be seen in Table 3, in predicting both anxiety and depression levels, after introducing CDI-PTSD
to the model, the significant contribution of FoP found in the first step
becomes insignificant. Thus, it seems that a complete mediation effect
exists between FoP and both anxiety and depression levels, with CDIPTSD being the mediator.
4. Discussion
The current study is the first in a series of studies trying to unfold
the unique content of the experience of CDI-PTSD. In the current study
we focused on the theoretical concept of fear of illness progression as a
means of detecting the future- oriented nature of CDI-PTSD, as predicted by the EST Model [15].
First, significant and high correlations were found between FoP and
CDI-PTSD, above and beyond the contribution of depression and anxiety. The lack of multicollinearity contributes to our conclusion that
Table 3
Summary of hierarchical regression analysis for variables predicting anxiety and depression levels (N = 102).
Variables
Explaining anxiety symptom levels
Step1
Education
FoP
Step2
Education
FoP
CDI-PTSD
Explaining depression symptom levels
Step1
Education
FoP
Step2
Education
FoP
CDI-PTSD
⁎⁎
B
SE (B)
β
t
0.07
0.27
0.10
0.04
0.06
0.59
0.68
7.07⁎⁎
0.09
0.08
0.24
0.09
0.05
0.05
0.08
0.18
0.54
1.07
1.65
4.96⁎⁎
0.02
0.13
0.09
0.03
0.02
0.37
0.22
3.82⁎⁎
0.04
−0.00
0.16
0.08
0.05
0.04
0.04
−0.00
0.49
0.47
−0.03
3.76⁎⁎
p < 0.001; Note: FoP = fear of progression scale.
136
R2
R2 change
F change
0.36
0.36
27.77⁎⁎
0.49
0.13
24.60⁎⁎
0.14
0.14
7.94⁎⁎
0.25
0.11
14.14⁎⁎
General Hospital Psychiatry 53 (2018) 131–138
K. Fait et al.
4.1. Limitations
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The current study's findings seem to provide additional empirical
validation of the postulations of the EST Model [15], at least with regard to the future-oriented nature of PTSD resulting from an acute and
life-threatening illness. Yet this conclusion should be arrived at cautiously due to the fact that the current study was cross-sectional and
had a relatively small sample. Future studies are advised to apply a
longitudinal prospective design where FoP and CDI-PTSD would be
measured along the illness timeline. Doing so might facilitate our understanding of the cause-and-effect relationship between these experiences. Measuring FoP as early as during hospitalization might have
allowed for an assessment of its predictive contribution to PTSD at the
three-month follow-up. Future studies, using FoP measured at the threemonth post-ACS follow-up, might well provide this insight to predict
future PTSD. Another major limitation of the current study was the fact
that our sample consisted of patients who were in committed relationships only. Given that social support is known to moderate PTSD
[4], our sample may therefore have been biased in terms of PTSD
prevalence. Future studies should assess the relationship between fear
of progression and PTSD in more comprehensive samples; as such, one
would be better able to generalize from the results.
4.2. Final conclusions and recommendations
The current findings shed further light on the diagnostic and conceptual question regarding the correct way to assess CDI-PTSD [4,15];
that is, are the standard instruments used to assess PTSD applicable to
the cardiac patient population? It may well be that new and more accurate instruments should be developed and applied – instruments
which would consist of items tapping the unique manifestations of CDIPTSD, such as future-oriented cognitions. To achieve this aim, future
studies should make use of diagnostic interviews, such as the ClinicianAdministered PTSD Scale-CAPS [40]. They should also utilize qualitative interviews in order to better understand the content of patients'
intrusions, negative cognitions and avoidance tendencies, all of which
constitute illness-related PTSD. More suitable illness-related PTSD
measures may be better able to detect those individuals whose unique
CDI-PTSD manifestations are not picked up by the standard PTSD instruments. In addition, a better understanding of the nature and manifestation of PTSD resulting from cardiac illness, or from any other illness, would help researchers and clinicians develop appropriate and
effective interventions and treatment protocols for those who are suffering both physically and emotionally from their illnesses. These interventions must address the factors that make CDI-PTSD unique: that
is, CDI-PTSD is essentially a response to a threat that is both internal
and ongoing.
Acknowledgments
This study is partially based on the first author's dissertation study
carried out at Bar-Ilan University, Ramat-Gan, Israel. The study was
supported by a grant from the Schnitzer Foundation for Research on the
Israeli Economy and Society, Bar-Ilan University.
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