Chest pain: relationship of psychiatric illness to coronary arteriographic results

Neuroticism and extraversion as predictors of health outcomes in depressed primary care patients

Depressed primary care patients (N = 217) were assessed to determine if certain personality characteristics predict health domains independent of chronic disease, demographics, depression, and psychiatric diagnoses. Eleven health variables were used to create three outcome factor scores: disability (e.g., days missed work); somatization (e.g., medically unexplained symptoms); and subjective pain (severity, interference). Neuroticism explained significant variance in all health outcomes independent of the other predictors. Depression and neuroticism interacted in the disability and pain models. Depression was related to health in neurotic patients, while in the absence of neuroticism, little relation between depression and health was observed. Neuroticism may explain why persons with similar health problems have differing levels of disability, pain, and somatization.

Cardiac autonomic function and sensitivity to pain in postmenopausal women with angina and normal coronary arteries

An increased sensitivity to painful stimuli and an abnormal cardiac autonomic function have previously been reported in patients with angina and angiographically normal coronary arteries, a syndrome that mainly affects postmenopausal women. In this study we compared both general sensitivity to pain, by evaluating time to forearm ischemic pain (FIP) provoked by sphygmomanometer cuff inflation, and cardiac autonomic function, by measuring heart rate variability (HRV), and QT and QT(c) intervals on 24-hour Holter recordings, in 25 postmenopausal women with angina and normal coronary arteries and in 22 healthy postmenopausal women. Compared with controls, patients had a reproducible strikingly lower time to FIP (149 +/- 121 vs 295 +/- 158 seconds, p <0.001), whereas there were no differences between the 2 groups in HRV variables and mean 24-hour QT and QT(c) intervals. HRV indexes, and QT and QT(c) intervals also showed similar circadian patterns. Thus, our data show that postmenopausal women with angina and normal coronary arteries have an enhanced sensitivity to systemic painful stimuli, but no detectable impairment in cardiac autonomic function compared with a well-matched control group of postmenopausal healthy women.

Psychosocial factors related to noncardiac chest pain during treadmill exercise

The authors examined historical, concurrent, and potentially secondary psychosocial problems related to noncardiac chest pain during exercise. The patients reporting chest pain during treadmill testing but who lacked cardiac ischemia (determined via nuclear scanning) were compared with the patients having both ischemia and chest pain, and with patients having neither ischemia nor chest pain. The noncardiac chest pain patients had the highest levels of 1) parental divorce and personal psychiatric treatment; 2) current depression, somatic awareness, and anger control; and 3) negative attitudes toward the health care system. The findings suggest that psychosocial problems predate, coexist with, and may result from noncardiac chest pain.

Unexplained chest pain: when is it panic disorder?

Noncardiac chest pain is a common costly phenomenon in the cardiology setting. Recent research suggests that panic disorder, a highly distressful yet treatable anxiety disorder, occurs in a significant proportion of noncardiac chest pain patients. This article reviews research on the prevalence of panic disorder in patients seen in cardiology settings for unexplained chest pain. Financial, psychosocial, and historical aspects of noncardiac chest pain are described. Panic disorder and the potential consequences of its nonrecognition by physicians are examined. Current psychological and pharmacologic treatments are reviewed. Recommendations on the management of panic patients in the cardiology setting are provided.

Managing recurrent nonischemic chest pain in the emergency department

Many patients who seek emergency evaluation for recurrent chest pain have had negative cardiac evaluations, sometimes including normal coronary angiograms. Despite reassurance, many of these patients return to emergency departments with complaints of chest pain. Studies have shown that one third to one half of these patients suffer from panic disorder characterized by attacks of intense fear accompanied by chest pain or discomfort, nausea, and shortness of breath. If panic disorder is identified, it can be successfully treated. This article explores the causes of recurrent nonischemic chest pain and offers treatment recommendations.

[Psychopathological disorders and coronary diseases]

The role of psychological factors in the genesis of coronary diseases has been considered for a long time. Friedman took it upon himself to describe a personality profile (pattern A) constituting a risk factor for coronary heart disease of which, however, the practical interest seems limited. The association of psychopathological conditions and coronary heart disease has on the other hand not been extensively studied. Recent epidemiological data show that anxiety and depressive states represent a high comorbidity with coronary heart diseases. Panic attacks remain underestimated; they seem to participate in a complex physiopathological mechanism along with ischemic coronary heart diseases. Recent studies have shown that the existence of a depressive illness during coronary heart disease and particularly in the time period following a myocardial infarction, constitutes an independent risk factor, thus increasing the mortality rate. The evolution of coronary heart disease seems greatly influenced by the existence of anxious or depressive states, the diagnosis and the treatment of these states represent a major interest towards a better management of coronary patients.

Oesophageal motility disorders in patients with psychiatric disease

Clinical and experimental observations indicate that the motility of the oesophagus may be affected by emotional stimuli. The aim of this study was to evaluate the incidence of oesophageal contractility impairment in patients suffering from a psychiatric disorder. Fifty-one patients admitted to the psychiatric department were submitted to an oesophageal transit study by means of krypton-81m. All patients with an abnormal oesophageal transit underwent manometry and endoscopy. The level of depression and anxiety was evaluated by the treating psychiatrist, using the Hamilton Depression and Anxiety Rating Scales. The oesophageal transit was abnormal in 13 patients. Two of these 13 patients refused manometric investigation. In ten of the 11 remaining patients, the manometry revealed functional motor abnormalities. Endoscopy, performed in all these ten patients, was normal. In conclusion, a high percentage of oesophageal contractility disturbances was found in psychiatric patients complaining of anxiety and/or depression. These abnormalities were detected by scintigraphy as well as by manometry. Owing to the normal endoscopic findings, these contraction abnormalities are likely to reflect a functional motor impairment.

Panic disorder in emergency department chest pain patients: prevalence, comorbidity, suicidal ideation, and physician recognition

PURPOSE

To establish the prevalence of panic disorder in emergency department (ED) chest pain patients; compare psychological distress and recent suicidal ideation in panic and non-panic disorder patients; assess psychiatric and cardiac comorbidity; and examine physician recognition of this disorder.

DESIGN

Cross-sectional survey (for psychiatric data). Prospective evaluation of patient discharge diagnoses and physician recognition of panic disorder.

SETTING

The ambulatory ED of a major teaching hospital specializing in cardiac care located in Montreal, Canada.

SUBJECTS

Four hundred and forty-one consenting, consecutive patients consulting the ED with a chief complaint of chest pain.

PRIMARY OUTCOME MEASURE

Psychiatric diagnoses (AXIS I). Psychological and pain test scores, discharge diagnoses, and cardiac history.

RESULTS

Approximately 25% (108/441) of chest pain patients met DSM-III-R criteria for panic disorder. Panic disorder patients displayed significantly higher panic-agoraphobia, anxiety, depression, and pain scores than non-panic disorder patients (P < 0.01). Twenty-five percent of panic disorder patients had thoughts of killing themselves in the week preceding their ED visit compared with 5% of the patients without this disorder (P = 0.0001) even when controlling for co-existing major depression. Fifty-seven percent (62/108) panic disorder patients also met criteria for one or more current AXIS I disorder. Although 44% (47/108) of the panic disorder patients had a prior documented history of coronary artery disease (CAD), 80% had atypical or nonanginal chest pain and 75% were discharged with a "noncardiac pain" diagnosis. Ninety-eight percent of the panic patients were not recognized by attending ED cardiologists.

CONCLUSIONS

Panic disorder is a significantly distressful condition highly prevalent in ED chest pain patients that is rarely recognized by physicians. Nonrecognition may lead to mismanagement of a significant group of distressed patients with or without coronary artery disease.

Emotional distress among males with "syndrome X"

The present study examined traditional risk factors and various indices of emotional distress in males with positive angiograms (N = 122), "syndrome X" males with negative or nominal results on angiogram (N = 53), and age- and socioeconomic status-matched males with no manifest history of otherosclerotic disease (N = 56). Syndrome X patients reported more depression on the Ketterer Stress Symptom Frequency Checklist (KSSFC) than positive angiographic patients. And compared with healthy controls, they were more likely to be perceived by a spouse/friend as depressed and anxious on the KSSFC, scored higher on the Framingham Type A Scale, and reported more unprovoked nocturnal awakening. Syndrome X patients generally appear to be similar to patients with positive angiograms with regard to traditional risk factor history but are more distressed than healthy controls. This becomes most evident when denial is circumvented by discussion with significant others or inquiries are "framed" appropriately.

Heart-focused and general illness fears in relation to parental medical history and separation experiences

Disease fears, such as excessive heart-focused anxiety (HFA), are quite common, and yet their origin is only poorly understood. Explanatory models of HFA have emphasized observational learning, parental cardiac disease, and the effects of separation experiences as key ethological factors. The purpose of this study was: (a) to provide descriptive information on the prevalence of HFA in an unselect sample of younger adults; and (b) to investigate the relation of HFA and general illness fears to parental medical history and different types of separation experiences. 421 undergraduate students completed the Cardiac Anxiety Questionnaire (CAQ), Illness Attitude Scales, Parental Medical History Questionnaire, and Separation Anxiety and Experience Questionnaire. Approximately 2-3% of our sample reported excessive HFA, and both illness attitudes and parental cardiac disease predicted 23% of total CAQ variance. Subjects with high CAQ scores reported more parental cardiac and other medical problems than low HFA subjects. Although high and low HFA subjects did not differ in terms of number of personal intimate relationships that ended in separation, subjects with separated parents reported more HFA than persons with nonseparated parents. We discuss the relevance of these findings for our understanding of HFA.

Empirical psychological modeling of chest pain: a comparative study

In this study the psychological profiles of 67 patients with noncardiac chest pain (NCA) and 47 patients with coronary artery disease (CAD) were analyzed to construct an empirical-psychological model that would be able to discriminate these two groups. All patients were suffering from chest pain at the time of referral by their general practitioner. The noncardiac patients were significantly younger, more often female, single, and nonsmokers. The two groups differed significantly on anxiety, somatization, obsessive compulsive behavior, psychoneuroticism, and hyperventilation. Logistic regression analysis on the variables jointly, showed that age, gender, anxiety, and hyperventilation contributed significantly to the model for discriminating between the two groups. Crossvalidation showed that the constructed model was stable.

Consultation-liaison psychiatry and the practice of medicine. The Thomas P. Hackett Award lecture given at the 42nd annual meeting of the Academy of Psychosomatic Medicine, 1995

The contributions of consultation-liaison psychiatrists have significantly influenced the practice of medicine. The author reviews the pertinent literature that substantiates this observation as well as suggests areas that hold promise for such contributions in the future.

Psychosocial correlates of chest pain among African-American women

While 10-30% of individuals with chest pain who undergo cardiac arteriography are found to have no demonstrable pathology, women are far more likely than men to have normal coronary arteries in the presence of angina. Black women, in particular, frequently seek medical attention for persistent episodes of chest pain. This cross-sectional study was designed to examine the potential role of psychological and social factors in relation to chest pain among black women. Among our population-based sample of 188 women, 48% reported experiencing chest pain. Seventeen of these cases met the Rose criteria for classification as cardiac pain while 74 of them reported pain not consistent with cardiac origin. A statistically significant difference was observed in the stress scores among the women; the highest stress scores occurred among those with Rose angina and the lowest scores were obtained from those women reporting no chest pain experiences (p < 0.001). There was no association detected between the presence and type of chest pain and psychosocial measures of depression and coping abilities. These results confirm the high rates of chest pain experienced among black women, and provide insight into the role of psychological factors that should be considered in the identification of treatment options.

A long-term follow-up study of patients with ischaemic heart disease versus patients with nonspecific chest pain

Ninety consecutive patients who were admitted to hospital with acute chest pain were followed-up five years later. At the time of the original admission, all of the patients received a detailed physical and psychiatric evaluation. Seventy-one patients were diagnosed as having ischaemic heart disease, and 19 were diagnosed as having nonspecific chest pain. Patients with nonspecific pain were younger, consumed greater amounts of alcohol, smoked more than their organic counterparts, and were more likely to suffer from psychiatric disorder. The five-year assessment was carried out using a self-report questionnaire. Of the original 71 patients with ischaemic heart disease, 14 had died; 43 questionnaires were returned, 80.2% of the original sample. Sixteen (84.9%) of the patients with nonspecific pain were followed up; none had died. Both groups were predominantly male. The patients with nonspecific pain still smoked more than the patients with ischaemic heart disease, and they had significantly more symptoms of anxiety. The overall prevalence of psychiatric morbidity remained high, however, in both groups. Patients who had psychiatric illness at the time of the original assessment were more anxious at follow-up and more likely to complain of chest pain than those who had been well. Patients with nonspecific chest pain continued to seek treatment on a regular basis from their general practitioners either for chest pain or for other symptoms, but few were in frequent contact with hospital services. The possible preventive effects of psychiatric intervention at an earlier stage in both groups of patients needs to be investigated.

Psychological morbidity in patients with chest pain and normal or near-normal coronary arteries: a long-term follow-up study

Forty-six patients with chest pain but normal or near-normal coronary arteries were assessed using standardized interviews and rating scales at the time of angiography, after 1 year, and again 11.4 years later. Psychological morbidity was substantial and enduring: 61% of patients were designated as psychiatric cases at angiography and 49% at 11.4 years. Both at the time of angiography, and 1 year later, levels of morbidity were significantly greater than in a control group of 53 patients with coronary artery disease. Anxiety disorders were common at all three interviews, with panic disorder (15% of patients) the most common current diagnosis at final follow-up. Current somatoform disorders were diagnosed in 9 patients (22%), and 11 (27%) reported previous episodes of major depression. Psychological morbidity was associated with continuing chest pain, which was reported in 74% of patients, and with ongoing functional incapacity. These findings suggest that, in a sub-group of these patients, psychological factors contribute in part to the development of chest pain and other physical symptoms, and are also important in maintaining the disorder over long periods. Further research is now required to identify more fully the nature of these psychological factors, and how they interact with cardiac and non-cardiac physical pathology. There is also an urgent need to examine the clinical and economic benefits of specific psychological interventions.

Severity of somatization and its relationship to psychiatric disorders and personality

Medical patients' (75 with chronic fatigue complaints, 61 with dizziness, and 88 with disabling tinnitus; N = 224) current and past psychiatric diagnoses and personality characteristics were assessed to determine if they could independently explain the number of medically unexplained physical symptoms that the patients had experienced. Cloninger's Tridimensional Personality Questionnaire (TPQ) and the Diagnostic Interview Schedule based on DSM-III-R were used to assess the personality and psychiatric diagnoses, respectively. The results revealed that the number of lifetime medically unexplained symptoms were significantly, independently, and positively related to increasing numbers of current and past anxiety and depressive disorders and to the harm avoidance dimension of the TPQ. In a second analysis, the "worry/pessimism" and "impulsiveness" subscales were positively related to the number of medically unexplained symptoms. The results suggest that somatization is associated with current and past history of psychiatric illnesses and harm avoidance in this sample of medical patients.

Chest pain self-management training for patients with coronary artery disease

This study was designed to evaluate the efficacy of a brief, structured pain management program to improve control over chest pain episodes in patients diagnosed with coronary artery disease. Twenty-six male veterans who attended the three-session program were compared with twenty-six matched controls. Results indicated significant short-term reductions in self-report of number of chest pain episodes in treated subjects. Self-report of pretreatment daily physical activity level moderated treatment outcome, as individuals reporting lower levels of physical activity derived greater benefit than their high-activity counterparts. These results suggest the potential utility of incorporating chest pain control strategies into comprehensive cardiac rehabilitation programs.

Psychiatric disorders in medical outpatients complaining of palpitations

OBJECTIVE

To determine the prevalence of psychiatric disorders in ambulatory patients undergoing Holter monitoring to evaluate palpitations.

DESIGN

Patients referred for 24-hour ambulatory electrocardiographic (ECG) monitoring were studied with a structured diagnostic interview and self-report questionnaires prior to monitoring.

SETTING

Holter laboratory of a large academic medical center.

PATIENTS AND OTHER PARTICIPANTS

One hundred forty-five consecutive patients complaining of palpitations and 70 asymptomatic non-patient volunteers.

OUTCOME MEASURES

DSM-III-R psychiatric diagnoses.

RESULTS

Forty-five percent (44.8%) of the participants had at least one lifetime anxiety or depressive disorder and 24.8% had at least one current (one month) disorder. The lifetime prevalence of panic disorder was 27.6%, and that of major depression was 20.8%. Current prevalence rates showed a similar pattern; the current prevalence of panic disorder was 18.6%. Panic disorder and somatization disorder symptoms were significantly more prevalent in the palpitation group than in the general medical clinic at the same hospital. Patients with a psychiatric diagnosis were more likely to report cardiac symptoms during monitoring than were those without psychiatric disorder, and more commonly described their symptoms as "pounding" and reported faintness, lightheadedness, and vertigo. Although cardiac histories and ECG results were no more serious, the patients with psychiatric diagnoses rated their overall health status as significantly worse.

CONCLUSIONS

Almost half of palpitation patients referred for Holter monitoring have a psychiatric disorder. More than a fourth have lifetime panic disorder and a fifth have had panic attacks in the month before monitoring.

Imipramine in patients with chest pain despite normal coronary angiograms

BACKGROUND

Ten to 30 percent of patients undergoing cardiac catheterization because of chest pain are found to have normal coronary angiograms. Because these patients may have a visceral pain syndrome unrelated to myocardial ischemia, we investigated whether drugs that are useful in chronic pain syndromes might also be beneficial in such patients.

METHODS

Sixty consecutive patients underwent cardiac, esophageal, psychiatric, and pain-sensitivity testing and then participated in a randomized, double-blind, placebo-controlled three-week trial of clonidine at a dose of 0.1 mg twice daily (20 patients), imipramine at a dose of 50 mg nightly with a morning placebo (20 patients), or placebo twice daily (20 patients); this treatment phase was compared with an identical period of twice-daily placebo for all patients (placebo phase).

RESULTS

Thirteen (22 percent) of the 60 patients had ischemic-appearing electrocardiographic responses to exercise, 22 of the 54 tested (41 percent) had abnormal esophageal motility, 38 of 60 (63 percent) had one or more psychiatric disorders, and 52 of 60 (87 percent) had their characteristic chest pain provoked by right ventricular electrical stimulation or intracoronary infusion of adenosine. During the treatment phase, the imipramine group had a mean (+/- SD) reduction of 52 +/- 25 percent in episodes of chest pain, the clonidine group had a reduction of 39 +/- 51 percent, and the placebo group a reduction of 1 +/- 86 percent, all as compared with the placebo phase of the trial. Only the improvement with imipramine was statistically significant (P = 0.03). Repeat assessment of sensitivity to cardiac pain while the patients were receiving treatment showed significant improvement only in the imipramine group (P = 0.01). The response to imipramine did not depend on the results of cardiac, esophageal, or psychiatric testing at base line, or on the change in the psychiatric profile during the course of the study, which generally improved in all three study groups.

CONCLUSIONS

Imipramine improved the symptoms of patients with chest pain and normal coronary angiograms, possibly through a visceral analgesic effect.

Neurocirculatory asthenia: a reassessment using modern psychosomatic criteria

The purpose of this study was to assess the prevalence of mental illness and to evaluate the quality of life of patients with neurocirculatory asthenia. A consecutive series of 80 patients who satisfied the diagnostic criteria developed by Kannel et al. for neurocirculatory asthenia was included in this study. Patients underwent a psychiatric diagnostic research interview and extensive psychometric evaluation, with both observer and self-rated scales for depression, anxiety, phobic symptoms, quality of life and abnormal illness behavior. In 47 patients (59%), a psychiatric diagnosis (mainly an anxiety disorder) antedated the onset of neurocirculatory asthenia, which was thus defined as secondary, also because cardiorespiratory symptoms were part of the mental symptoms. In the remaining 33 patients (41%) neurocirculatory asthenia was the primary disorder. Patients with secondary neurocirculatory asthenia reported significantly higher levels of anxiety, depression, social phobia, abnormal illness behavior and an impaired quality of life compared with patients with primary neurocirculatory asthenia. This latter did not significantly differ in these variables (except for depression) from healthy control subjects matched for sociodemographic variables. At a 1-year follow-up, patients with primary neurocirculatory asthenia had a much better prognosis than those with secondary neurocirculatory asthenia. The results indicate the feasibility of the primary/secondary distinction based on the time of onset of mental and cardiorespiratory symptoms in neurocirculatory asthenia. Since only about one quarter of the patients were found to suffer from decreased energy and fatigue according to specified criteria, the terms neurocirculatory asthenia and effort syndrome should probably be discarded.

Mental disorders in patients with noncardiac chest pain

About 70% of noncardiac chest pain (NCCP) patients have mental disorders as reported from Western countries. The phenomenon of somatization is considered to be aetiologically important in the genesis of NCCP. Though somatization is generally considered as more prevalent among non-Western cultures, systematic studies of mental disorder among NCCP patients are rare from developing countries. Based on treadmill test, 54 male inpatients in a cardiology general ward in India were divided into a group having ischaemic heart disease (IHD) and another group of NCCP. A psychiatric interview was conducted blindly on these subjects with the help of a structured interview schedule, and DSM-III-R diagnosis was made. Sixty-eight percent in the NCCP group and 27% in the IHD group had a mental disorder. The total number of subjects with a mental disorder, including panic disorder and major depression, were significantly more in the NCCP group. Mental disorders appears to be equally common among NCCP patients in developing countries also and detailed psychiatric assessment is warranted in patients with chest pain of non-IHD origin.

Cost of anxiety disorders: impact of comorbidity

The aim of this study was to assess the relative impact of co-mobidity and of symptom severity on the costs of caring for patients with generalized anxiety disorders (GAD). One thousand and forty-two patients with GAD according to DSM III-R were observed by psychiatrists using a cross-sectional methodology. Demographic, clinical, therapeutic as well as health care utilization data were collected at a single point in time. Patients were stratified according to prevalence of co-morbidity. An economic analysis was performed based on a societal perspective. Hospitalizations and losses of productivity were the two major components of costs both in patients with and without co-morbidity. On the other hand costs of pharmaceuticals remain a marginal component of costs associated with GAD in the two groups. Controlling for confounding variables, the prevalence of health care utilisation was found to be significantly higher in patients with co-morbidity for hospitalization, laboratory tests, medications and absenteeism from work. Most of cost components were found to be significantly higher in patients with co-morbidity. The relative risk of health care utilization was higher in patients with co-morbidity, past history of anxiety, high level of anxiety as well as in older patients. Overall our findings suggest that both co-morbidity and symptom severity play a role in cost generation in GAD patients.

Psychiatrically referred adolescents with panic attacks: presenting symptoms, stressors, and comorbidity

OBJECTIVE

This study examined presenting symptoms, precipitants and comorbidity in a sample of 28 adolescents (21 females, 7 males) who met criteria for clinically significant panic attacks.

METHOD

A semistructured psychiatric interview was used to gather information about symptoms and precipitants, from which probable diagnoses were derived for each case. Thirteen subjects also completed a computerized version of the Diagnostic Interview for Children and Adolescents.

RESULTS

The majority of cases (64%) were referred for anxiety related problems, although 36% presented with other symptoms that obscured the presence of panic attacks. Refusal to eat associated with nausea was noted in one third of the females. Psychosocial stressors regularly precipitated the onset of panic attacks. Phobic avoidance was present in more than three quarters of the sample and affective disorder preceded or occurred independently of panic attacks in half. Six cases met criteria for attention-deficit hyperactivity disorder and six for oppositional disorder.

CONCLUSIONS

Clinicians need to inquire about the presence of panic attacks, especially in adolescents who present with concerns about eating. Management of adolescents with panic attacks should address coexisting symptomatology, including behavioral and attentional difficulties.

Estimated prevalences of panic disorder and depression among consecutive patients seen in an emergency department with acute chest pain

OBJECTIVE

1) To determine whether the frequencies of panic disorder (PD) and depression (DEP) in an emergency department (ED) population were comparable to those in other primary care groups; 2) to evaluate whether patients without the clinical diagnosis of acute cardiac ischemia (ACI) had higher frequencies of these disorders; and 3) to identify characteristic clinical findings in patients with PD or DEP.

SETTING

An urban teaching hospital ED.

PATIENTS

Three hundred thirty-four patients with acute chest pain were evaluated prospectively over an eight-week period. The cohort participating (69%-229/334) completed psychiatric screening measures, including the Panic Disorder Self-Rating Scale, the Beck Depression Inventory, and the Zung Self-Rating Anxiety Scale.

MEASUREMENTS AND MAIN RESULTS

A symptom profile consistent with PD was identified in 17.5% of the patients (40/229), DEP in 23.1% (53/229), and either disorder in 35% (80/229). The prevalences of PD were similar in those with and without ACI (19.4% vs 16.6%, respectively, p > 0.05). The likelihoods of one or more ED visits for chest pain in the previous year were significantly greater in those with PD (57.5% vs 36%, p < 0.05) and DEP (54% vs 35%, p < 0.05) than in those without these psychiatric disorders.

CONCLUSION

This study suggests that approximately one in three patients presenting to the ED with acute pain has symptoms consistent with a psychiatric disorder. These disorders occur frequently in both those with and those without acute cardiac ischemia, and clinical variables may help identify these frequent ED utilizers.

Panic disorder in cardiology patients: a review of the Missouri Panic/Cardiology Project

This paper reviews current evidence from several cardiology populations that suggests that panic disorder is prevalent and underdiagnosed. Cardiology patients with atypical angina, and no heart disease have a high likelihood of having panic disorder, as suggested by studies of two separate cardiology populations. That they resemble psychiatric populations with panic is suggested by their positive response to alprazolam. A panic disorder subtype, called non-fear panic disorder also appeared in about one-third of these cardiology panic patients. These patients have most of the panic symptoms but do not report fear during their episodes.

Generalized anxiety disorder patients seek evaluation for cardiological symptoms at the same frequency as patients with panic disorder

Although panic disorder (PD) and generalized anxiety disorder (GAD) have similar somatic symptoms, panic attacks with chest pain and/or palpitations may seem more likely to be mistaken for heart attacks because of their acute onset. One would therefore expect that PD patients are more likely than GAD patients to seek cardiological consultations. In a survey of 146 PD and 154 GAD patients entering a multi-site drug trial, we found virtually identical rates of such consults. Approximately 50% of each patient group sought medical evaluation for cardiac symptoms. Furthermore, 40% of each group had standard treadmill evaluations and 33% reported having an echocardiogram. This study suggests that future epidemiological studies in cardiology populations should include probes for generalized anxiety disorder.

The effects of physical illness on psychiatric disorder

Somatic symptoms of both organic and non-organic causes are associated with an increase in psychiatric morbidity irrespective of setting; patients with chronic medical conditions are approximately twice as likely to report psychiatric disorder as controls. This increase cannot be entirely explained in terms of help-seeking behaviour, recognition rates by treating doctors or treatment outcome. The detection and treatment of coincident psychiatric disorder in this group of patients needs further clarification.

A population survey of ischaemic heart disease and minor psychiatric disorder in men

Associations between ischaemic heart disease and psychiatric morbidity in hospital recruited samples may be confounded by differential referral of patients with co-morbidity. Associations of angina, past history of myocardial infarction, blood pressure, and electrocardiographic evidence of ischaemia with psychiatric disorder can best be examined in community samples as reported here in 2204 middle-aged men from the Caerphilly Collaborative Study. There was a strong association between past history of myocardial infarction, non-specific chest pain, Angina Grade II and psychiatric disorder measured by the 30-item General Health Questionnaire. Electrocardiographic evidence of ischaemia alone was not significantly associated with psychiatric disorder. It is suggested that non-specific chest pain is a symptom of psychiatric disorder; conversely in severe angina psychiatric disorder is secondary to the pain, restricted activity and threat to life which angina implies.

Costovertebral joint dysfunction: another misdiagnosed cause of atypical chest pain

The diagnostic work-up of atypical chest pain frequently leads to invasive procedures. However, this painful symptomatology can sometimes be of benign origin and respond to simple therapeutic manoeuvres. A number of musculoskeletal conditions such as costovertebral joint dysfunctions should be carefully considered. We report five cases in which patient discomfort and high costs could have been avoided if awareness of these conditions had led to a correct diagnosis upon initial physical examination.

Psychopharmacologic approaches to therapy for chest pain of presumed esophageal origin

Psychoactive medications have been used to manage chest pain of presumed esophageal origin, especially in syndromes associated with esophageal motor dysfunction. The rationale for their use is based on (a) the high prevalence of psychiatric disorders reported in patient groups with esophageal symptoms and minor motor dysfunction, (b) recognized psychophysiologic effects on esophageal motor activity, (c) the potential benefits that nerve-modulating drugs may have on the pathogenesis of the syndromes (independent of psychiatric factors), and (d) observations from treatment trials for chronic pain--including irritable bowel syndrome, a disorder that shares some clinical features with functional esophageal chest pain. Although psychiatric factors may have interactive effects on the presentation and course of reflux disease, the use of psychoactive drugs in reflux disease has not been tested. The effects of psychoactive drugs have been systematically explored and documented in only one study. At present, the mechanisms of esophageal symptom reduction resulting from psychopharmacologic treatments are not clear, but reduced sensitivity to visceral stimuli remains one possibility.

Microvascular angina and the sensitive heart: historical perspective

As our understanding of the etiology of chest pain of undetermined origin has evolved, the focus for studying this problem has switched from individual subspecialties to a multidisciplinary approach. In the subspecialties of gastroenterology and cardiology, the focus has shifted from organ-specific diagnoses to concepts of altered pain thresholds. Cardiologists began to look for functional causes of ischemia following the recognition that many patients with chest pain had normal coronary arteries. Abnormal responses of the coronary microcirculation to stress were identified in this population, and the concept of "microvascular angina" originated. Further evaluation, however, demonstrated that many of these patients did not have evidence of ischemia. In addition, a significant overlap with esophageal motility disorders was shown, and multiple sensitivities to otherwise nonirritating stimuli, whether in the heart or the esophagus, could be elicited in these patients. This finding led to the concept of abnormal visceral nociception, that is, the "sensitive heart" and the "tender esophagus," both the focus of ongoing clinical research.

Panic disorder in patients with angiographically normal coronary arteries

Several lines of investigation strongly support the notion that panic disorder afflicts at least one third of patients with angiographically normal coronary arteries and unexplained chest pain. Panic disorder is a common problem, affecting 1-2% of the U.S. population. Current research suggests an etiology that is both psychophysiologic and cognitive. The locus ceruleus and cortico-releasing factor are implicated in the biological circuit associated with panic attacks, while psychological research indicates that catastrophic thinking, phobic responses to somatic sensations, and repressed anger, grief, and traumatic events play a part in triggering attacks. Treatment consists of pharmacologic interventions, including antidepressants and benzodiazepines, as well as psychotherapeutic work focusing on catastrophic thinking and repressed anger, grief responses, and other traumatic experiences.

The course of psychiatric disorder associated with non-specific chest pain

One hundred and eight consecutive patients admitted urgently for the first time with chest pain were interviewed to assess psychiatric symptoms prior to admission, at admission and three months later. Seventy-one patients had ischaemic heart disease, 19 had non-specific chest pain and 18 patients were excluded because of other organic causes for the pain. Compared to the ischaemic heart disease subjects, the non-specific chest pain patients tended to have more psychiatric disorder which increased over the three assessments; at follow up 33% of ischaemic heart disease patients and 59% of non-specific chest pain patients had psychiatric disorder. Chest pain was reported by 71% of the non-specific group at three months but this was not related to presence of psychiatric disorder. Unlike previous studies which 'have assessed out-patients with normal coronary angiograms', this study has shown that males predominate among patients admitted urgently with non-specific chest pain. In addition, these subjects use greater amounts of cigarettes and alcohol, and experience significantly more psychiatric disorder compared to patients admitted with ischaemic heart disease. The factors which lead to some of these patients developing chronic non-specific chest pain need to be investigated in further studies.

Chest pain in patients with normal coronary arteries. A new look at potential causes

Recurrent chest pain in patients with normal coronary arteries is a difficult clinical problem. Although long-term studies have shown that these patients have an excellent prognosis in terms of cardiac morbidity and mortality, many patients remain physically debilitated and continue to visit emergency departments. Recent information suggests that microvascular angina, esophageal disorders (including reflux disease and dysmotility), and panic disorder may be important causes of pain in such patients. It is particularly important to consider the diagnosis of gastroesophageal reflux disease, which is easier to diagnose and treat than most other causes of recurrent chest pain.

Further evaluation of the MMPI Pan scale in psychiatric and medical patients

The efficiency of a recently developed MMPI scale (Pan) to identify panic disorder was assessed in samples of both psychiatric and medical patients. Particular attention was paid to base rates and cutting scores. The Pan scale was found to have utility in rule-out clinical decision making. Suggestions for further validation studies are discussed.

Denial specific to Friedman's pathogenic emotions in Jenkins Activity Survey Type A and angiography-referred males

A pilot study of 27 firemen yielded a number of significant positive partial correlations between Type A Scale scores on the Jenkins Activity Survey and the spouse-or friend-reported frequency of items indicative of aggravation, irritation, anger, and impatience (AIAI), while controlling for subject self-reported frequency. A second study then assessed AIAI, depression, and anxiety with identical subjective (self-reported) and objective (spouse- or friend-reported) measures in 100 male angiography patients. Analysis of variance indicated that 1) angiographically normal or subclinical patients are psychologically distressed; 2) denial (as defined by diminished self-report vs. spouse- or friend-report) is specific to AIAI in this population; and 3) denial is observed with about equal intensity in both occluded and nonoccluded groups.

Panic disorder: relationship to high medical utilization

The purpose of this review is to describe the relationship between panic disorder, somatization, functional disability, and high medical utilization. Data from community, primary-care, and specialty studies were reviewed to determine the prevalence of anxiety and panic disorder in these populations. Data from the Epidemiologic Catchment Area Study were reviewed to emphasize the effect of panic disorder on health-care utilization and health perception in a community population. Data on the prevalence of panic disorder in primary care and mode of presentation of primary-care patients with panic disorder were also reviewed. Finally, the epidemiologic psychiatric findings from our recent study of distressed high utilizers of primary care were presented. Panic disorder was found to occur in 1-3% of people in the study community and 1.4-8% of primary-care patients. Of people with or without psychiatric disorder, people with panic disorder in the community had the highest risk of having multiple medically unexplained symptoms and of being high utilizers of medical ambulatory services. People with panic disorder in the community compared to both community psychiatric and nonpsychiatric controls tend to perceive themselves as having poor physical health and to be high users of emergency and hospital inpatient services, as well as ambulatory services. Most patients with panic disorder present to their primary-care physician with somatic complaints, especially cardiac (tachycardia, chest pain), gastrointestinal (epigastric pain or irritable bowel syndrome), or neurologic complaints (headaches, dizziness, or presyncope). Patients who were distressed high utilizers of primary care had an extremely high prevalence of current panic disorder (12%) and lifetime panic disorder (30%), which supported the association between panic disorder and high medical utilization found in the Epidemiologic Catchment Area (ECA) Study.

Palpitations, cardiac awareness, and panic disorder

This article reviews and appraises a variety of studies on panic disorder, visceral sensitivity, and cardiac disease. The literature reviewed includes descriptive surveys, small-scale experimental manipulations, and clinical interventions. Instruments have included structured diagnostic interviews, clinical observation, self-report inventories, direct measures of perceptual sensitivity, and cognitive tests. The subjects in these studies have ranged from community residents to carefully defined samples of designated patients with psychiatric or cardiac disease. We then outline a prospective investigation to examine the prominence of palpitations in panic anxiety and speculate on the importance of sensitivity to cardiac sensation in several other clinical conditions characterized by marked discrepancies between cardiac activity and cardiac symptoms.

Response to 35% CO2 in patients with chest pain and angiographically normal coronary arteries

OBJECTIVES

Several interview studies have suggested that panic disorder (PD) exists in patients with angiographically normal coronary arteries (NCA). Interview studies require corroboration by other studies in order to validate them. The purpose of this study is to test whether response to the inhalation of 35% CO2 reliably discriminates between PD and non-panic disorder patients in this population.

METHOD

Three groups were studied: six with NCA and PD, five with NCA and no PD, and ten in the control group. All subjects breathed room air, then 35% CO2 in a single-blind fashion. Each completed the Acute Panic Inventory (API) before and during the procedure.

RESULTS

The NCA-panic group scored significantly higher than the other two groups on the Acute Panic Inventory from baseline to post-inhalation.

CONCLUSION

Despite several methodological limitations including a relatively small number people in each cells, 35% CO2 was shown to trigger more intense responses in panic patients, thus helping to validate the interview findings.

Clinical, psychological and thallium stress studies in patients with chest pain and normal coronary arteries

The clinical and psychological profiles of 36 consecutive patients with chest pain and normal coronary arteries (study group) were compared to those of 34 patients with chest pain and significant coronary arterial disease (control group). All 70 patients were hospitalized for chest pain at least once prior to coronary angiography. The features of a typical episode of chest pain were similar in the normal coronary arteries and coronary arterial disease groups, but the female patients with normal coronary arteries had a shorter duration of a typical episode of chest pain, and the male patients with normal coronary arteries had a lower frequency of positive effort tests. Psychological testing showed the women with normal coronary arteries to have a tendency to increased somatization, anxiety, and a lower ability to identify origin of difficulties. The patients in the normal coronary and coronary arterial disease groups had psychological profiles typical of patients with chronic somatic disease. A psychiatric interview demonstrated an increased frequency of depressive trait (score 0-2) in the normal women (0.6 +/- 0.8 vs 0, P less than 0.05), and a tendency to increased somatization, anxiety, and sleeping disorders. Increased somatization was found in the normal coronary men (1.1 +/- 0.7 vs 0.5 +/- 0.7, P less than 0.05). Twenty-five patients of the normal coronary group underwent quantitative thallium stress studies, and 13 patients (52%) had evidence of stress-induced myocardial perfusion defect. There were no differences in the clinical and psychological profiles of the patients with normal and those with pathological thallium stress tests.(ABSTRACT TRUNCATED AT 250 WORDS)

The prevalence of anxiety disorders among patients with mitral valve prolapse syndrome and chest pain

Nineteen patients from a cardiology practice with complaints of chest pain and with mitral valve prolapse syndrome were compared with 26 patients with chest pain but no discernible cardiac disorder. Instruments included a truncated form of the Diagnostic Interview Schedule, the symptom checklist 90 revised (SCL-90-R), the McGill Pain Questionnaire, and life events, physical activity, and family history questionnaires. Neither panic disorder nor self-rated anxiety were more common in the mitral valve prolapse group. This study failed to confirm the reported high association between mitral valve prolapse syndrome and panic disorder.

Unexplained chest pain and breathlessness

Complaints of chest pain and breathlessness are common in both primary care and medical outpatient settings. A subgroup of these patients who find their way into tertiary care settings and subsequently are found to have no relevant organic pathology are at risk of continuing morbidity. One possible reason for this is that diagnostic strategies often focus on establishing an organic cause of pain and ignore psychosocial factors. In this article I have attempted to describe not only the prevalence but also the clinical characteristics of patients with medically unexplained cardiorespiratory symptoms. A method of establishing a positive diagnosis of noncardiac chest pain has also been outlined. This is based on an interactive and overlapping model that takes into account not only a number of psychological and social factors but also current physical and cardiac risk factors. It is important for nonpsychiatric physicians to diagnose noncardiac pain at an earlier stage in the evolution of the disorder. This would have major beneficial effects for patients, including (1) fewer unnecessary investigations; (2) less distress and functional disability; (3) reduced cost to the hospital; and (4) fewer iatrogenic complications.

Clinical symptoms in young adults with atypical chest pain attending the emergency department

Clinical symptoms were studied in 69 consecutive patients below the age of 40 years who were attending the emergency unit because of unexplained chest pain. In a structured interview a few weeks after the emergency visit, only one-third of the patients reported that they believed in the doctor's diagnosis; they believed in a psychological or cardiac origin of the pain more often than the doctors. The chest pain was most often described as oppressive and/or stabbing. In 95% of cases it was central or left-sided. Associated symptoms were commonly reported, breathlessness being most commonly reported by two-thirds of the patients, followed by dizziness, palpitation and numbness/tingling. Mental symptoms such as tiredness, anxiety and tension were frequently reported. On the basis of the background literature the aetiology is discussed. We conclude that immediate symptom analysis, including psychosomatic symptoms, particularly breathing problems, is of central importance.

Psychiatric disorders in patients with esophageal disease

Psychiatric disorders have potentially important roles in the manifestations of esophageal disease. A primary causative role for psychiatric factors in the common motility disorders associated with chest pain (esophageal spasm and the nonspecific motor disorders) remains unproven, but psychiatric disorders appear particularly prevalent in this group. In most other esophageal diseases, psychiatric factors interact through recognized psychophysiologic or behavioral mechanisms to affect the clinical presentation. Recognizing the possible levels of interaction has significant therapeutic implications.

Microvascular angina. Cardiovascular investigations regarding pathophysiology and management

A significant minority of patients with chest pain who undergo cardiac catheterization are found to have angiographically normal coronary arteries. Over the past 25 years, several studies have shown that a subset have demonstrable abnormalities in coronary flow and cardiac function; however, only a minority of these patients have convincing evidence for myocardial ischemia during stress, and alternative mechanisms have been explored to explain the frequent and debilitating symptoms of pain experienced by the majority of these patients undergoing study. Abnormal visceral nociception appears to be a fundamental abnormality in this population, whether or not demonstrable abnormalities in coronary flow or cardiac function can be demonstrated.