Personality change after heart surgery
Friday, Mar 22, 2024.
Can personality change after heart surgery?
One way science-based couples therapists are different is that we stay current with research that impacts relationships. Some of this research may, at first, seem pretty far-afield from conventional couples therapy topics. Recently, I updated my post about personality changes after bariatric surgery.
But can someone’s personality change after heart surgery as well?
Alan and Candace
Alan, a retiring CEO, and Candace (not their real names) had been in couples therapy for about 5 months when Alan had a sudden massive heart attack. Soon after, he had open-heart surgery. That was 4 years ago. Alan is 67 today.
“I had a great surgeon”, Alan said, “and he assured me that the procedure went flawlessly. My physical recovery was pretty quick.” Candace leaned forward and looked me in the eye. “But I knew something was wrong with Alan.”
Alan also leaned forward. “Candy saw it before I did… well, to be fair, I saw it too, but I didn’t want to worry her. It was obvious that I had mood swings. I was depressed and irritable…”
Candace interrupted. “We were on an emotional rollercoaster for 7 months. But when you finally told me about your nightmares, we went back to your cardiologist, and I told him… something just wasn’t right with Alan.”
But even now, 4 years later, Alan and Candace have a new topic to bring into their couples therapy with me; managing the cognitive and personality changes after Alan’s triple-bypass.
Pumphead…or personality change?
For nearly 50 years, there has been anecdotal evidence that open-heart surgery impacts personality and cognitive function.
As recently as 2014, the medical establishment has conceded that after recovery from heart surgery, some patients experience a temporary cognitive impairment of memory, processing speed, and focus.
While Alan was recovering, he also reported trouble remembering, and concentrating. This cognitive fog is nicknamed “Pumphead,” and was long believed to be a temporary aftereffect from the trauma of open-heart surgery.
However, new research suggests that the “Pumphead Effect” may have long-lasting negative impacts.
Where Does the Pumphead Effect Come From?
Coronary surgery was transformed in 1953 when the heart-lung machine was first introduced.
Doctors could now operate on the heart for an hour or more, where previous methods only allowed 15 minutes.
Cardiac surgeons quickly became aware of the phenomenon of post-surgery cognitive decline, but they saw the surgery, and not the technology as the culprit.
Not on their radar…
And any notion of personality change after heart surgery wasn’t on their radar. However, more recent longitudinal research suggests that cognitive decline and personality changes after heart surgery persist over time.
While the science is complex, researchers are now persuaded that the primary cause of the “Pumphead Effect” is the capillary blockage (called emboli) produced during surgery from the manipulation of the aorta by the heart-lung machine.
Personality change from particles in the blood?
The heart-lung machine extends the surgical time by pumping blood to keep the patient alive. During open-heart surgery, the heart's pumping action is stopped.
We now have reason to believe that this mechanical pumping action introduces tiny pieces of plastic debris, fat particles, and toxic gases into the bloodstream. Unfortunately, once in the bloodstream, these particles migrate to the brain.
The problem is that these particles begin to clog small blood vessels, decreasing the amount of blood and oxygen from flowing to the brain. Unfortunately, all open-heart surgery patients experience some degree of this blockage during surgery, and for many, the damage is irreversible.
Is the Pumphead Effect permanent or temporary?
The more dramatic symptoms of the “Pumphead Effect,” are usually short-lived.
This has led doctors to advise their patients that the cognitive impact is merely temporary.
A recent study of bypass patients has indicated that these cognitive challenges may worsen over time, despite assurances that cardiac surgery has no detectable impact on how the brain functions.
Skepticism for a subjective experience…
The issue of personality change after open-heart surgery was met with more skepticism by the medical establishment, perhaps because changes in personality can be a subjective experience. But as in bariatric surgery, attention to a patient’s physical recovery often eclipses their need for emotional support.
To date, no study has adequately examined whether heart surgery can change personality, mainly because personality changes are too difficult to define and measure.
New research offers new insight into the “cardiac blues”
We now know that nearly 80% of these patients experienced some flashes of anger, tearful sadness, anxiety, depression, and sometimes frequent nightmares.
I learned a lot about Alan and Candace during their assessment when they returned to intensive couples therapy:
“I knew something was profoundly different about Alan,” Candy said. “Alan was a highly decorated member of the Special Forces. He served 3 tours in Vietnam, breezed through Harvard Business School, and ended his career as a respected business leader. I have never seen him anxious or depressed. It was alarming.”
Depression is a familiar problem in couples therapy
About 1 in 20 Americans suffer from clinical depression, but over 40% of couples in therapy have at least one clinically depressed spouse.
New research tells us that 20% of emergency cardiac patients like Alan experience clinical depression. This is significantly higher than the general population.
The early weeks of post-surgical recovery often reveal significant cognitive, behavioral, and emotional changes.
But over the ensuing months of recovery, Alan and Candy saw Alan’s personality change after his heart surgery as the most problematic and bewildering issue they’d ever faced in their 42 years of marriage.
Significant…and unexpected
This is where a good, science-based couples therapist comes in.
The problem is that these couples get excellent transparency on all of the medical aspects of recovery from sudden cardiac surgery. Still, they are often blind-sided by emotional and mental changes.
Sudden cardiac surgery can be a heavy burden for a committed couple. Unlike bariatric surgery, heart surgery is not always a planned-for, elective procedure. Many surgical centers offer faint direction about the marital implications of bariatric surgery. As a result, few couples engage in pre-surgical counseling.
But couples grappling with open-heart surgery are suddenly dealing with life-and-death issues. What are the Couples Therapy implications for cognitive impairment and personality change after open-heart surgery?
Emotional and mental feedback loops
There is a feedback loop between the recovering cardiovascular system and the onset of clinical depression. But many other emotional feedback loops can be acutely pressured by open-heart surgery.
A research project undertaken in 2015 was published in Australian Family Physician. It showed that while over 80% of the 160 patients interviewed at two area hospitals would like to have received information about the ‘cardiac blues’, only a few couples ever received it.
Alan’s story
“I had just nominated my successor to the board when I had the heart attack. My first thoughts upon waking up concerned a small political dust-up with a large investor. It was 20 minutes before I knew what happened and how my life had changed.”
Alan described getting the cardiac blues pretty hard. “I would have nightmares about the evacuation of Saigon. I was in a helicopter looking down on a shrinking sea of faces. One of them was mine. I felt that I was leaving my soul behind.” Alan stiffened and he straightened his back. “I felt I had to get back to work. I had to finish what I had started. Then …suddenly…I felt an enormous sense of dread that my only legacy was the sure financial footing and steady stewardship of a sneaker company.”
Can couples therapists help to normalize and reassure?
Barbara M Murphy, Ph.D. is the Director of Research at the Heart Research Centre in Melbourne, Australia. Dr. Murphy is the leading thought leader on personality changes after heart surgery.
She aims to bring awareness of personality changes after heart surgery into public discourse. Here’s what she had to say about men like Alan:
About four out of five patients experience the cardiac blues, and we want to normalize it and reassure patients that it is likely to resolve in the first few months.
The heart event isn’t just a physical event, it’s an emotional one, and these things are likely to happen. However, in some cases, the symptoms do not resolve and can develop into full-blown depression. Barbara M. Murphy Ph.D.
How a United States President navigated personality change after heart surgery
Whatever your politics, it’s easy to admit President Bill Clinton had significant social skills. However, Bill Clinton has appeared significantly out of character in the speeches and interviews that I’ve watched since his bypass surgery in September of 2004.
President Clinton managed an impeachment, numerous sex scandals, and the # MeToo Movement with his reputation largely intact.
However, the Bill Clinton I saw in 2008 was noticeably irritated by hecklers, and sometimes said unfortunate and regrettable things supporting his wife’s failed presidential bid.
What struck me was the relative silence within the medical community. President Clinton was exhibiting an acute personality change after his open-heart surgery…but hardly anyone qualified to comment was talking about it.
Cognitive decline is a hot potato
It’s ironic what a hot potato bypass surgery cognitive dysfunction can be.
One of the best-kept secrets in medicine is the brain damage caused by bypass surgery.
It’s not uncommon for surgeons to field questions about uncharacteristic outbursts of anger post-surgery.
Here’s a startling truth. Medical Journals have been reporting on personality changes after open-heart surgery since 1969.
If the medical profession is reluctant to discuss this issue in depth, perhaps couples therapists can start the conversation instead.
Reduced mental capacity?
In 2001, an article in the prestigious New England Journal of Medicine reported that 5 years after bypass surgery, 42% of patients showed a measurable decline in mental function of approximately 20 percent or more.
Another study published in 2008 in the Annals of Thoracic Surgery used MRI testing just after bypass surgery. Their shocking finding was that 51% had a measurable degree of brain damage.
What kind of cognitive decline? What type of personality change?
Another study followed cardiac patients 3 years after encountering a heart-lung machine.
The cognitive decline in 31% of the patients was described as “significant.” Specifically, dates, names, and numbers elude them. These patients are also experiencing mood swings and serious depression. In 30% of cases, they have even contemplated suicide.
Open heart surgery is also an expensive event. It’s performed about a half-million times yearly at a cost of around 100K or more. We can do better to help couples manage their emotional aftermath.
The 3 skills needed to manage personality change after heart surgery
For years, the medical establishment claimed that evidence did not support the notion that permanent changes in cognitive ability or mood occur after cardiac surgery.
Dr. Murphy argues that just because no research has directly looked at personality changes after open-heart surgery, we can’t rule out the idea that such deficits are taking place on a smaller scale.
Science-based couples therapy can help these couples with 3 specific interventions:
Regulation and Co-Regulation
Regulation and co-regulation are skills we teach in science-based couples therapy. It describes being open to continuous influence by your partner in the service of collaborative emotional regulation.
For everybody, a stable, trusting relationship is linked to relatively high survival rates from cardiovascular disease, cancer, surgery, and other illnesses. Love increases the odds of living a long life and having good health.
High-trust partners benefit each other by ‘co-regulating’ their physiologies. Put simply, they calm each other when they cannot calm themselves.
Repair Early and Repair Often
I told Alan “The partner in your wife’s head is being updated. Candy’s asking you for an emotional availability upgrade, and I know you can do it. Discuss the likelihood that you will be irritable and challenging to live with at times. Couples therapy can help you both to repair more quickly, and learn how to take time outs when needed. Another thing. Consider externalizing the Cardiac Blues and the personality changes that you might be inflicting on Candy.”
Candace liked that idea. She told Alan that the “Cardiac Blues” were the herald of the “Cardiac Bear.”
And that became a special “couple code” between them. Alan and Candace continued their intensive couples therapy online.
They discussed the arc of his recovery and their real-life situations with me in couples therapy. We even used pulse oximeters to keep their nervous systems in check during these sessions.
Dreams within conflict for personality change after heart surgery
Research on long-term committed relationships tells us that some disputes are solvable and some are perpetual. That was true for all couples.
Dealing with personality change after open-heart surgery was a new, but Perpetual Problem for Alan and Candace.
Perpetual differences are fundamental personality differences, even sudden ones, that may resist change over time.
The Dreams Within Conflict Intervention taught Alan and Candace a new way of discussing their differences.
Happy couples learn how to have a dialogue about their perpetual differences. But unhappy couples, more often, become emotionally gridlocked.
Finding understanding and compassion
In “The Dream Within Conflict” exercise, Alan and Candace learned how to have Generative Conversations. They handled their new perpetual problems in a more positive way, which deepened their mutual understanding and compassion. This was a lot easier on their nervous systems.
“When you first explained Dreams Within Conflict to me, you almost lost me, Daniel. It seemed a bit woo-woo for my taste. But I like how you explained it. I didn’t have to fix anything.
It was like coming out of the bush. Once I started paying attention to what I was feeling or thinking, I didn’t worry so much about it.
Something in me shifted. I mean, I’ve been married to Candy for over 40 years. If I can’t tell her how scared and helpless I felt…who could I tell?” Alan.
Final thoughts
Illness is a significant stressor in long-term marriage, but the quality of the intimate bond can be a powerful support in recovery. Science-based couples therapy for couples struggling in the aftermath of open-heart surgery can make the difference between a speedy recovery or an equally precipitous decline.
Couples need good psychoeducation about what to expect in the weeks and months after a sudden open-heart surgery.
While personality change after open-heart surgery and cognitive challenges may be of concern, Gottman Couples Therapy can help each partner to be their best selves under difficult and challenging circumstances.
Be Well, Stay Kind, and Godspeed.
RESEARCH:
Berkman LF, Blumenthal J, Burg M, et al. Effects of treating depression and low perceived social support on clinical events after myocardial infarction: The Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD) Randomized Trial. JAMA, 2003;289:3106–16.
van Melle JP, de Jonge P, Spijkerman TA, et al. Prognostic association of depression following myocardial infarction with mortality and cardiovascular events: A meta-analysis. Psychosom Med 2004;66:814–22.
Barth J, Schumacher M, Herrmann-Lingen C. Depression as a risk factor for mortality in patients with coronary heart disease: A meta-analysis. Psychosom Med 2004;66:802–13.
Colquhoun DM, Bunker SJ, Clark DM, et al. Screening, referral, and treatment for depression in patients with coronary heart disease: A consensus statement from the National Heart Foundation of Australia. Med J Aust 2013;198:483–84.
Goble AJ, Biddle N, Worcester MUC. Depression after an acute cardiac illness. Qual Life Cardiovasc Care 1989;5:60–65.
Hare DL, Toukhsati SR, Johansson P, Jaarsma T. Depression, and cardiovascular disease: A clinical review. Eur Heart J 2014;35:1365–72.
Hasnain M, Vieweg WVR, Lesnefsky EJ, Pandurangi AK. Depression screening in patients with coronary heart disease: A critical evaluation of the AHA guidelines. J Psychosom Res 2011;71:6–12.
Higgins RO, Murphy BM, Nicholas A, Worcester MU, Lindner H. Emotional and adjustment issues faced by cardiac patients seen in clinical practice: A qualitative survey of experienced clinicians. J Cardiopulm Rehabil Prev 2007;27:291–97.
Lichtman JH, Bigger JT, Blumenthal J, et al. Depression and coronary heart disease. recommendations for screening, referral, and treatment. A science advisory from the American Heart Association Prevention Committee of the Council on Cardiovascular Nursing, Council on Clinical Cardiology, Council on Epidemiology and Prevention, and Interdisciplinary Council on Quality of Care and Outcomes Research. Circulation 2008;118:1768–75.
Murphy, BM, Ph.D., Director of Research, Heart Research Centre, Melbourne, VIC; Department of Psychology, University of Melbourne, VIC; School of Medicine & Public Health, University of Newcastle, NSW. barbara.murphy@heartresearchcentre.org
Murphy BM, Ludeman D, Elliott P, et al. ‘Red flags’ for persistent or worsening anxiety and depression after an acute cardiac event: A 6-month longitudinal study in regional and rural Australia. Eur J Prev Cardiol 2014;21:1079–89.
Murphy BM, Rogerson M, Worcester MUC, et al. Predicting mortality 12 years after an acute cardiac event: Comparison between in-hospital and 2-month assessment of depressive symptoms in women. J Cardiopul Rehabil Prev 2013;33:160–67.
Murphy BM, Elliott PC, Higgins RO, et al. Anxiety and depression after coronary artery bypass graft surgery: Most get better, some get worse. Eur J Cardiovasc Prev Rehabil 2008;15:434–40. Schleifer SJ, Macari-Hinson MM, Coyle DA, et al. The nature and course of depression following myocardial infarction. Arch Intern Med 1989;149:1785–89.
Thombs BD, Bass EB, Ford DE, et al. Prevalence of depression in survivors of acute myocardial infarction: a review of the evidence. J Gen Intern Med 2006;21:30–38.
Thombs BD, de Jonge P, Coyne JC, et al. Depression screening and patient outcomes in cardiovascular care. JAMA 2008;300:2161–71.
Thombs BD, Jewett LR, Knafo R, Coyne JC, Ziegelstein RC. Learning from history: A commentary on the American Heart Association Science Advisory on depression screening. Am Heart J 2009;158:503–05.
Thombs BD, Ziegelstein RC. Screening in Cardiovascular Care. In: Mitchell AJ, Coyne JC, editors. Screening for depression in clinical practice: An evidence-based guide. New York: Oxford University Press, 2010. Tully PJ, Baker RA. Depression, anxiety, and cardiac morbidity outcomes after coronary artery bypass surgery: A contemporary and practical review. J Geriatr Cardiol 2012;9:197–208.
Tully PJ, Higgins R. Depression screening, assessment, and treatment for patients with coronary heart disease: A review for psychologists. Australian Psychologist 2014;49:337–44.
Worrall-Carter L, Ski CF, Thompson DR, et al. Recognition and referral of depression in patients with heart disease. Eur J Cardiovasc Nurs 2012;11:231–38.
Zigmond AS, Snaith RP. The Hospital Anxiety and Depression scale. Acta Psychiatr Scand 1983;67:361–70.
