Dear Editor
Mitral valve prolapse (MVP) is a common heart valve condition that affects the mitral heart valve, which separates the left atrium from the left ventricle. MVP has various physical symptoms and mainly affects the cardiovascular system. It can also affect cognitive beliefs and emotional well-being [1]. Anxiety is associated with the physical symptoms of MVP such as palpitations and chest discomfort. Individuals can become anxious since they may consider these symptoms as indicators of a serious heart problem. This anxiety can be worsened by metacognitive beliefs, such as the belief that they cannot control the heart symptoms or the symptoms are dangerous. This worry in people includes repetitive and intrusive thoughts about potential negative outcomes related to their conditions. Individuals may engage in catastrophic thinking, imagining the worst possible scenarios. It can be difficult for them to control this worry, even when they recognize that their thoughts are irrational. Moreover, the unpredictability of MVP symptoms can contribute to anxiety. Patients may constantly be worry about the occurrence of symptoms, leading to a chronic sense of unease [2].
Health anxiety is a mental health condition characterized by excessive and irrational worry and fear of having a serious illness or medical condition, despite having no or only mild, non-specific symptoms. Individuals with health anxiety are often worry about their physical health, including the heart health in case of MVP. They may constantly have a fear of a severe heart disease, even when medical tests and evaluations indicate no problems. Health anxiety can lead to frequent doctor visits and seeking reassurance from doctors about their health. They may consult with many healthcare providers to confirm that they are not seriously ill. Individuals with health anxiety tend to be excessively aware of bodily sensations and may misinterpret normal sensations as signs of a serious illness. They may engage in extensive search for information related to medical conditions and symptoms, often on the internet, which can increase their fears as they encounter various alarming medical information. In some cases, individuals with health anxiety may avoid situations or activities that are perceived as health risks. They may avoid exercise or participation in social activities due to a fear that these activities could trigger heart symptoms [3].
Catastrophic thinking is a cognitive distortion or thinking pattern characterized by the tendency to focus on the worst possible outcomes or scenarios of a situation. Catastrophizers tend to magnify the awfulness of their symptoms. A minor discomfort or palpitation, which can be common in individuals with MVP, is interpreted as a severe issue, leading to heightened anxiety and distress. People engaged in catastrophic thinking often have a dreadful “what if” situations in their minds. They dwell on feelings that a situation could go wrong or become worst, leading to heightened worry and anxiety. Catastrophic thinkers may feel a lack of control over their condition or symptoms. They believe that the worst possible outcome will happen, no matter what they do, contributing to feelings of helplessness and despair. To cope with their catastrophic thoughts, some individuals may use avoidance strategy, e.g. avoiding physical activities or situations they believe that they can exacerbate their symptoms. This avoidance can reduce their quality of life and reinforce their negative thinking patterns. Catastrophic thinking can lead to significant emotional distress. The constant anticipation of negative outcomes and fear of the worst-case scenario can contribute to heightened anxiety and even symptoms of depression [2, 4].
Therefore, individuals with MVP may avoid physical activities or exercise because they worry that the activities could worsen their heart symptoms. This avoidance is a safety behavior for preventing discomfort or perceived danger, even though exercise is generally beneficial for heart health. Safety behaviors in these people include constant monitoring of heart rate or using heart rate monitors to keep tracking their cardiac activity. Although monitoring can be useful for controlling health, its obsessive use can cause anxiety. Other safety-seeking behavior in these people is the excessive reliance on medical tests such as frequent ECGs or echocardiograms, to check changes in heart function. This frequent testing may provide temporary reassurance but can lead to increased anxiety in the long term [5].
Individuals with MVP can experience perceived lack of control, where they believe they have little or no impact over their conditions or symptoms. Therefore, they may experience heightened anxiety. The unpredictability of symptoms and the fear of not being able to manage or prevent them can lead to constant worry and fear. Perceived lack of control can reduce an individual’s self confidence to manage their conditions and make informed decisions about their health. This loss of confidence can further exacerbate feelings of helplessness. People who believe they have no control over their conditions may resort to avoidance behaviors which can lead to social isolation. Some individuals may become dependent on healthcare providers for reassurance and guidance. Although it is essential to seek medical advice and support, the excessive reliance on healthcare providers can lead to a lack of self-efficacy and independence in managing health condition. Individuals with perceived lack of control may struggle to find meaning and purpose in their lives when they feel powerless to manage their conditions effectively, which can influence their decision-making processes. They may make decisions based on fear and uncertainty rather than making informed decisions that are consistent with their goals [5, 6].

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of the Mazandaran University of Medical Sciences (Code: IR.MAZUMS.REC.1398.1344).

Funding
This research was supported by the research project (No. 7056), Funded by the Student Research Committee of Mazandaran University of Medical Sciences.

Conflict of interest
The author declared no conflict of interest.


References

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