Procedia - Social and Behavioral Sciences 127 ( 2014 ) 144 – 148

Available online at www.sciencedirect.com

1877-0428 © 2014 Anca-Daniela Fărcaş and Laura-Elena Năstasă. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).Selection and peer-review under responsibility of Romanian Society of Applied Experimental Psychology.doi: 10.1016/j.sbspro.2014.03.229

ScienceDirect

PSIWORLD 2013

Factors influencing the perception of stress in patients with heart failure

Anca-Daniela F rca a*, Laura-Elena N stas b*

aFaculty of Medicine, University of Medicine and Pharmacy “Iuliu Hatieganu”, 8 Babes Street 400012, Cluj-Napoca, Romania bFaculty of Psychology and Educational Sciences, Transilvania University of Brasov , 29 Eroilor Blvd. 500036, Brasov, Romania

Abstract

According to the definition of stress, heart failure is a stress factor because of the strains placed upon a person. Our study aims to investigate the level of stress perceived by 150 patients. The Perceived Stress Questionnaire was used to assess the stress level and to evaluate the frequency of its types. Analysis of the results showed increased levels of stress in all patients and several personal and clinical parameters that influence the patients’ perception of stress. Addressing these (often neglected) aspects of care can be important to the rehabilitation process or the emotional and mental well-being of the patients.

© 2014 The Authors. Published by Elsevier Ltd. Selection and peer-review under responsibility of PSI WORLD 2013 and their Guest Editors: Dr Mihaela Chraif, Dr Cristian Vasile and Dr Mihai Anitei

Keywords : stress; particular aspect of stress; cronic heart disease; heart failure

1. Introduction

Living with a chronic heart disease such as heart failure produces a physical discomfort and also an important psychological stress (Moser, 2002) that patients have to cope with. Coping is influenced by many individual parameters and generates anxiety and/or depression that influence the rehabilitation process and affect the coping with the changes in lifestyle.

Acute and chronic stress weakens the body through physiological, behavioural, emotional and cognitive changes it produces and also can produce or worsen some cardiac, immune or gastroduodenal diseases.

* Corresponding author. Tel.: +4074.478.0873 and +4074.009.0936 E-mail address: ancafarcas@yahoo.com

© 2014 Anca-Daniela Fărcaş and Laura-Elena Năstasă. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/).Selection and peer-review under responsibility of Romanian Society of Applied Experimental Psychology.

145 Anca-Daniela Fărcaş and Laura-Elena Năstasă / Procedia - Social and Behavioral Sciences 127 ( 2014 ) 144 – 148

Psychological stress associated with a cardiac condition varies from 2.8 % in the general population (i.e. without a cardiac condition) to 10 % in people with chronic heart disease (Ferketich & Binkley, 2005) but still, only 30 to 35 per cent of these patients are referred to a psychiatrist or psychologist.

2. Objective

Compared with studies on distress in patients with myocardial infarction (Kristofferzon, Lofmark & Carlsson, 2003), research on stress perceived in patients with heart failure is still in early stage (Pelle et. Al. 2010) therefore the objective of our study was to assess the stress perceived by patients with heart failure and to evaluate the influence of individual parameters on its perception.

3. Material and methods

Our study was performed on 150 patients with chronic congestive heart failure admitted for an episode of worsening heart failure in the Department of Cardiology of SCJU Cluj-Napoca. Patients interviews provided clinical, demographic and socioeconomic status data for each patient. The Perceived Stress Questionnaire (PSQ) (Levenstein et al. 1993) was used to evaluate the level of stress perceived by the patients. Global score was obtained by adding the results obtained on each item. We grouped the 30 items of PSQ in subscales to assess the weight of the types of stress perceived by each patient -„worries”, „tension”, „joy” i „demands”. (Fliege et. al. 2005).

Quantization of the quality of life was done by adding the results obtained on the 21 items of the Minnesota questionnaire (Rector, Kubo, Cohn, 1987). The results ranged on a scale from 0 – “I was not influenced” to 5 – “ I was very much influenced”.

To compare the scores obtained by different sociodemographic caractersitici I used a simple ANOVA for independent samples. Analysis of the relationship between the variables measured by the numerical scale was done using Pearson correlation coefficient.

4. Results

The results we obtained show that the level of stress perceived was increased in all patients and significantly more in women than in men (Table 1).

Paradoxically, aging decreases the perceived stress – patients aged 70-79 have a significantly lower global score than patients aged 60-69 or 50-59 (Fig. 1). This decrease in the level of stress with aging could be explained by lower scores in the “demands”, “tension” or “worries” scales and higher scores in the “joy” scale – showing a beneficial effect of positive aspects.

Having a partner, living in the rural areas and higher education decreased the level of stress perceived by the patients while employment and low income increased the level of stress.

Another apparently paradoxical result is that patients with more severe conditions (in NYHA class IV) have reported lower stress levels than patients in NYHA class III. This result might be explained by a negative correlation between the duration of heart disease and the perceived stress (Table 2).

146 Anca-Daniela Fărcaş and Laura-Elena Năstasă / Procedia - Social and Behavioral Sciences 127 ( 2014 ) 144 – 148

Table 1. PSQ scores in patients with heart failure

Parameter Value Global PSQ score p-value Gender Female 70,2 ± 23,1

Male 62,7 ± 21,2 < 0,001 Age 50-59 80,6 ± 11,4

60-69 67,3 ± 9,8 < 0,001 70-79 52,8 ±10,3 < 0,001

Background Urban 82,5 ± 11,7 Rural 54,8 ± 10,2 <0,001

Marital status Married 64,9 ± 21,2 „Single/not married” (divorced, widows and not married) 72,7 ± 26,9 < 0,001

Employment status Active 73,4 ± 14,9 Inactive (retired) 59,6 ± 18,2 < 0,001

Education Elementary and secondary 66,8 ± 12,2 Highschool 55,4 ± 11,6 < 0,001 Higher education 48,5 ± 11,5 < 0,01

NYHA class NYHA IV 65,7 ± 10,2 NYHA III 76,8 ± 14,4 < 0,001

Etiology of heart failure Ischemic coronary disease 75,8 ± 12,6 Hypertension 61,6 ± 11,8 <0,001

Psychological factors Anxiety trait 58,8 ± 17,2 Depression 72,3 ± 21,1 < 0,001

Fig. 1. Level of stress perceived by the patients

Table 2. Factors influencing the level of stress in patients with heart failure

Correlation coefficient p-valueEducation level - 0,21 0,05Income level - 0,18 0,02Duration of heart failure - 0,27 0,001Ejection fraction 0,11 0,10Anxiety trait 0,34 0,001Depression 0,41 0,001Quality of life global score - 0,57 0,001

147 Anca-Daniela Fărcaş and Laura-Elena Năstasă / Procedia - Social and Behavioral Sciences 127 ( 2014 ) 144 – 148

The cardiac condition causing heart failure has also a major importance in perception of stress. Ischemic heart disease produces a significantly higher stress than hypertension, probably because of the relevance of informational resources regarding the importance and consequences of ischemic heart disease.

Patients with depression perceive a higher level of stress compared to patients with anxiety. The higher the perceived stress level the more affected was the quality of life.

5. Discussion

As expected, the presence of a chronic heart condition with a major evolutive potential produces a significant stress in these patients. Perceived stress is modulated by the type of cardiac condition leading to heart failure, thus ischemic heart disease (angina pectoris, myocardial infarction) produce a higher level of stress than living with hypertension because of the availability and extent of information on the importance and consequences of the disease. On the other hand, hypertension is not always perceived by the population as a severe condition with major consequences because there still exist beliefs such as „normal blood pressure increases with age”, „a higher blood pressure improves the blood flow”, „my blood pressure is always high when I’m in the doctor’s office therefore it’s just a stress reaction” etc.

Increased levels of stress perceived by women with cardiac disease were also found in other studies, regardless of the investigational questionnaire (PQS or SRI) or the type of cardiac condition (acute or chronic) (Kristofferzon, Lofmark & Carlsson, 2003).

The apparently paradoxical finding of a decreased level of stress with aging is supported by previous published research (Felton & Revenson, 1983). The positive influence of the presence of a partner and rural background is based on the social support they bring, on the higher scores on the „joy” scale and also on the lower scores on the „demands” scale.

The education level and the income level represent major cognitive and behavioural resources in the coping with disease and with stress. A low income level also induces a significant stress in healthy people (Baum, Garofalo & Yali, 1999).

Anxiety and depression influence the way patients evaluate stressor factors from the environment (Friedmann et al. 2006). Various studies have confirmed the correlations between the levels of anxiety and depression and the levels of stress perceived by the patients.

A study found significantly higher global PSQ scores in patients with depression compared with anxiety disorders (Koh, Park, Kim & Cho, 2001).

Data analysis has provided answers to some pertinent questions and also has opened new research directions, based on the limits of the study – which of these factors has a higher impact, which is the dynamic of these relationships in time in longitudinal studies etc.

6. Conclusions

Living with chronic heart disease requires an important cognitive and behavioural effort. A higher education level, higher income and presence of a partner represent important resources for coping, whereas living in a rural area and the lack of employment decrease the strain. Knowledge of resources and demands is relevant to the rehabilitation process or the emotional and mental balance/well-being of the patient and also has practical consequences in guiding the therapy.

148 Anca-Daniela Fărcaş and Laura-Elena Năstasă / Procedia - Social and Behavioral Sciences 127 ( 2014 ) 144 – 148

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