What Happens When You Become Afraid of Health Care

After surviving a heart attack, what’s the first thing many patients do? If you said "adopt new healthy behaviors" you’re not quite right.

Science shows many people develop fear after experiencing sudden, serious health scares. Their fear becomes an obstacle to changing habits that may have led to the health scare. And without change, old habits may bring on another heart attack, stroke, or other serious illness.  

At Columbia’s Roybal Center for Fearless Behavior Change in the Division of Cardiology, director Ian Kronish, MD, is finding the best way to help survivors get past their fear and adopt new health-promoting habits. 

We recently spoke with him about his research and how to help a survivor.

Why do people often become afraid to adopt healthier habits after an acute medical event?  

When people experience a scary event like a heart attack or stroke, fear responses, also known as the fight-or-flight system, get activated. This system is helpful for dealing with acute stress but can become maladaptive if it stays on too long. That reaction is the essence of post-traumatic stress disorder (PTSD).  

If someone developed PTSD after being near the World Trade Center on Sept. 11, they might avoid walking around downtown New York City to avoid reminders of that day. Seeing an airplane flying overhead might trigger a fear response. They might even find themselves checking the sky more frequently for possible airplanes. 

What happens if health care treatments become reminders of a traumatic experience?

Some patients skip medications or avoid follow-up visits so they're not confronted with memories of the experience or their fears. Some also become overly watchful for bodily symptoms that could be harbingers of future events and then misinterpret benign symptoms like the occasional palpitation or tingling as something concerning. They react with exaggerated distress. If left unchecked, it can lead a patient to be paralyzed with fear. 

The severity of the medical event, interestingly, does not necessarily correspond with the likelihood of developing PTSD or a fearful response. It comes down to the patient’s experience; how scared they were when the event happened.  

How many people develop fear-based responses?  

When patients first go to the hospital with acute chest pain, about half feel they are going to die, they feel afraid, or they feel a loss of control.  

One month later, symptoms of PTSD impact: 

• 1 in 8 patients after an acute coronary syndrome 
• 1 in 4 patients after a stroke 
• 1 in 3 patients after a cardiac arrest 

That’s a tremendous percentage of people.  

Further, we found that people who came to the hospital’s emergency department with acute chest pain were equally likely to have elevated PTSD symptoms one month later, whether or not they had a heart attack or a non-life-threatening condition.  

All of us are vulnerable. 

How are you helping people reduce fear and adopt healthy habits? 

We are testing a number of approaches. In one, we gradually expose people to internal bodily sensations through light physical activity with a counselor present. The patient can learn not to be fearful of internal bodily symptoms and become better at determining which are concerning and which are not.   

We are also trying to figure out when and how best to engage people after these medical events. Many patients do not think of themselves as having a psychological problem and many wish to avoid reminders of their traumatic event.

We are excited about several pilot studies using smartphone apps and the internet to deliver psychological interventions, such as cognitive behavioral therapy and mindfulness training. This is convenient and also helpful with recruiting patients for whom the hospital may be an aversive place to come. 

Fear-based responses to life-threatening medical events are not limited to patients. Family members and caregivers can also develop traumatic reactions. Some cardiac arrest patients do not remember the initial event. It is their loved ones who were witnesses who can be most emotionally affected. They can transmit their fears onto patients as patients are recovering. If we can help reduce the fear in family members, we can help patients too. 

What doesn’t work when trying to help survivors adopt healthier habits? 

Research suggests that using fear as a motivator can backfire and lead patients to become more avoidant.

Family members with the best of intentions can also become overprotective: They may encourage a heart attack survivor to not exert themselves when the survivor really needs to become more physically active. 

Can these techniques be applied to other patients trying to adopt new routines?  

Yes, we are very excited about this. Fear can get in the way of developing healthy behaviors in many situations. It does not just occur in the setting of life-threatening medical events. 

One study we’re supporting tests "pain reprocessing therapy" to help reduce fear of physical activity in patients with low back pain. By interrupting fear pathways, disconnecting movement from fear, back discomfort no longer triggers anxiety. Not only do patients become more active, but in many cases, the pain also goes away. We hope this brain rewiring helps patients become more physically active and achieve a higher quality of life.