Abstract
Introduction
Arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is an inherited cardiomyopathy characterized by progressive fibrofatty replacement of the right ventricular myocardium, predisposing patients to ventricular arrhythmias, heart failure, and sudden cardiac death. Implantable cardioverter-defibrillators (ICDs) are implanted for prevention of sustained ventricular arrhythmias and sudden cardiac death, often around age 40. Early implantation exposes patients to decades of ICD therapy and psychological burden, yet evidence guiding management of shock anxiety in ARVD/C remains limited.
Case Info
We present a patient with ARVD/C who developed severe shock anxiety and phobic avoidance following an ICD electrical storm after 10 years of complication-free device function. Three months after hospitalization for five high-rate ventricular arrhythmias requiring ICD therapy, she was referred to psychiatry for inability to leave home because of fear of future ICD shocks. She had no prior psychiatric or substance/alcohol use history. Her symptoms progressed to panic attacks, hypervigilance, and avoidance of cardiologist-recommended physical activity.
Disc Clinical
Evaluation for reversible precipitants of electrical storm and ICD malfunction was unrevealing except for metoprolol nonadherence. Electrophysiology reprogrammed the ICD to reduce future shock episodes. Despite cardiac management, the patient developed disabling shock anxiety with panic, hypervigilance, and phobic avoidance. Given her marked functional impairment and limited evidence for pharmacologic treatment of shock anxiety, CBT was selected based on evidence supporting its use in ICD recipients. Treatment incorporated ICD-specific psychoeducation, cognitive restructuring, relaxation techniques, development of a shock-management plan, and systematic desensitization to feared activities. Her FSAS score decreased from 33 to 14, with return to occupational, social, and recreational activities.
Conclusion
Shock anxiety affects 20%–84% of ICD recipients, and experiencing more than five lifetime ICD shocks increases anxiety risk. This case highlights the importance of recognizing the psychiatric sequelae of ICD therapy in ARVD/C and supports CBT as a promising nonpharmacologic intervention. Early collaboration between cardiology and psychiatry may improve outcomes, although larger prospective studies are warranted.