Women with congestive heart failure who repress their emotions, especially anger, are more likely than emotionally expressive women to experience symptoms of depression associated with knowledge about their disease, according to new research.
Coping styles of women in the study influenced how depressed or anxious they felt. The less they talked about or expressed their emotions, the more likely they were to have symptoms of depression and anxiety.
When Ohio State University researchers examined the influence of knowledge about their illness on the patients' mental well-being, they found that some women with heart failure felt worse emotionally when they had more information about the disease. For those women -- who tend to deny their emotions -- less information is better. For them, certain types of knowledge can actually lower their emotional quality of life, according to the research.
The findings of this pilot study suggest that clinicians should consider patients' individual coping styles when educating them about their illness, the researchers say. For example, women who cope by denying their emotions might become particularly distressed by information that provokes fear -- such as learning about the increased risk of hospitalization as a consequence of not taking medication or exercising enough.
"We're not saying knowledge is not a good thing," said Charles Emery, professor of psychology at Ohio State and co-author of the study. "For patients who are greater in denial, knowledge seemed to be a negative factor. Whereas for people who either had difficulty expressing emotion or putting a label on their emotion, knowledge is still beneficial."
Emery co-authored the study with Jamie Jackson, a former Ohio State graduate student who is now a postdoctoral fellow at Northwestern University. The study is published in a recent issue of the journal Heart & Lung.
The study involved 35 women diagnosed with at least stage C congestive heart failure as categorized by the American College of Cardiology, meaning they had structural heart damage, experienced symptoms that might include shortness of breath and swelling in the legs and abdomen, and were managing the disease with medication. Heart failure is a condition in which the heart muscle is weakened, resulting in reduced blood flow throughout the body.
The researchers asked the participants to complete a number of questionnaires to measure their coping styles, illness knowledge, emotional quality of life and physical quality of life.
Women's coping styles were categorized in three ways: anger-in, or a tendency to withhold angry emotions; alexithymia, or difficulty identifying and describing feelings; and emotional expressivity, which could be either low or high.
Overall, the women reported elevated symptoms of depression and anxiety compared to national data on these symptoms in healthy adults.
Depressive symptoms -- which can include loneliness, sadness, fear, sleep problems and an unshakable sense of the "blues" -- as well as anxiety symptoms were associated with repression of anger, difficulty describing feelings and low emotional expressivity. Those with a higher level of emotional expression were less likely to report depressive symptoms.
"The basic idea is very simple: that in general, it is better to express your emotions than to hold them in," said Emery, also an investigator in Ohio State's Institute for Behavioral Medicine Research. "The correlations in this paper are exactly what one would expect."
And when the researchers then factored in how much the women knew about their illness, a clear link emerged between higher knowledge and more depressive symptoms in women who repressed their anger.
"These are women who would not want to deal with their negative emotions. I think the reason we're seeing this pattern is that if you're scared about your health condition, and you're confronted with more and more information, that makes it more real to you," Jackson said. "If you're somebody who doesn't want to acknowledge the emotion around the situation, it may result in reacting with greater negative emotion.
"In this particular study, depressive symptoms are where we see the effect."
On the other hand, women who had trouble describing their emotions felt more anxious if they had less knowledge about their illness than did women with similar coping traits who had greater knowledge.
The study showed no indication that coping style and illness knowledge influenced the patients' physical quality of life.
Emery noted that the education patients receive about an illness is critical to keeping them informed about the best ways to maintain their health. So ensuring that patients receive the information in a way that preserves their emotional health is likely to encourage greater compliance with doctors' orders, he said.
"The longer-term purpose of this line of research is to better predict which patient is going to benefit from which kind of intervention," he said. "Even with a high-denial patient, we would still embrace using knowledge. But we might identify non-aversive ways of presenting them with the knowledge."
The researchers suggest in the paper that clinicians may want to consider using mindfulness strategies for patients who tend to repress anger or have trouble describing their feelings. This technique helps people monitor their emotional response and observe their thoughts without judgment, said Jackson, who has been trained to provide mindfulness-based interventions in a clinical setting.
"Mindfulness encourages people to be comfortable with living in the moment with whatever emotional experience they're having," she said. "If we can help patients do that, they might be more receptive to information about their condition, and might have a better quality of life in general."
- Jamie L. Jackson, Charles F. Emery. Illness knowledge moderates the influence of coping style on quality of life among women with congestive heart failure. Heart & Lung: The Journal of Acute and Critical Care, 2011; 40 (2): 122 DOI: 10.1016/j.hrtlng.2009.12.005
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