A 1-year follow-up study of chest-pain patients with and without panic disorder

Patients with depression symptoms are more likely to experience improvements of internet-based cognitive behavioral therapy: a secondary analysis of effect modifiers in patients with non-cardiac chest pain in a randomized controlled trial

BACKGROUND

Non-cardiac chest pain is common and associated with increased anxiety and reduced health-related quality of life. Randomized controlled trials on psychological interventions for patients with non-cardiac chest pain have reported mixed results. Patients with non-cardiac chest pain are a heterogeneous group. Identifying sub-groups that could potentially benefit more (or less) from an intervention would be valuable knowledge. We have conducted a randomized controlled trial where internet-based cognitive behavioural therapy (iCBT) had effect on reducing cardiac anxiety and increasing health-related quality of life at 12-month follow-up. The aim of the present study was to explore potential effect modifiers of iCBT in patients with non-cardiac chest pain on cardiac anxiety and/or health related quality of life at 12-month follow-up.

METHODS

We analysed data from our randomized, controlled trial where 161 patients with non-cardiac chest pain were included and randomized to either iCBT or a treatment as usual (control). Cardiac anxiety measured by the Cardiac Anxiety Questionnaire and health-related quality of life measured by the EuroQol Visual Analog Scale at 12 month follow-up were the primary outcomes. Four potential baseline characteristics where identified as potential effect modifiers by a theory-based approach: (1) depression measured by the Patient Health Questionnaire; (2) anxiety measured by the Body Sensations Questionnaire; (3) prior healthcare contacts measured by a self-developed question; and (4) chest pain frequency measured by a self-developed question. Each potential effect modifier was analysed in a linear regression model where cardiac anxiety and EQ-VAS scores at 12-month follow-up, separately, were used as dependent variables. The potential differential treatment effect for each effect modifier was assessed by the interaction term: effect modifier x treatment group.

RESULTS

Depression symptoms at baseline predicted a differential treatment effect at 12-month follow-up on health-related quality of life in favor of the iCBT group (regression coefficient of the interaction term: -1.85 (CI -3.28 to -0.41), p = 0.01), but not on cardiac anxiety at 12-month follow-up. Fear of bodily symptoms, chest pain frequency and prior health care contacts at baseline did not predict a treatment effect on either health-related quality of life or cardiac anxiety.

CONCLUSIONS

Depression symptoms at baseline predicted a positive treatment effect of iCBT on health-related quality of life in patients suffering from non-cardiac chest pain. This indicates that it is important to identify patients with non-cardiac chest pain and co-occurring depression symptoms given that they are particularly likely to benefit from iCBT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03096925 .

Effectiveness of Internet-Based Cognitive Behavioral Therapy With Telephone Support for Noncardiac Chest Pain: Randomized Controlled Trial

Background

Noncardiac chest pain has a high prevalence and is associated with reduced quality of life, anxiety, avoidance of physical activity, and high societal costs. There is a lack of an effective, low-cost, easy to distribute intervention to assist patients with noncardiac chest pain.

Objective

In this study, we aimed to investigate the effectiveness of internet-based cognitive behavioral therapy with telephone support for noncardiac chest pain.

Methods

We conducted a randomized controlled trial, with a 12-month follow-up period, to compare internet-based cognitive behavioral therapy to a control condition (treatment as usual). A total of 162 participants aged 18 to 70 years with a diagnosis of noncardiac chest pain were randomized to either internet-based cognitive behavioral therapy (n=81) or treatment as usual (n=81). The participants in the experimental condition received 6 weekly sessions of internet-based cognitive behavioral therapy. The sessions covered different topics related to coping with noncardiac chest pain (education about the heart, physical activity, interpretations/attention, physical reactions to stress, optional panic treatment, and maintaining change). Between sessions, the participants also engaged in individually tailored physical exercises with increasing intensity. In addition to internet-based cognitive behavioral therapy sessions, participants received a brief weekly call from a clinician to provide support, encourage adherence, and provide access to the next session. Participants in the treatment-as-usual group received standard care for their noncardiac chest pain without any restrictions. Primary outcomes were cardiac anxiety, measured with the Cardiac Anxiety Questionnaire, and fear of bodily sensations, measured with the Body Sensations Questionnaire. Secondary outcomes were depression, measured using the Patient Health Questionnaire; health-related quality of life, measured using the EuroQol visual analog scale; and level of physical activity, assessed with self-report question. Additionally, a subgroup analysis of participants with depressive symptoms at baseline (PHQ-9 score ≥5) was conducted. Assessments were conducted at baseline, posttreatment, and at 3- and 12-month follow-ups. Linear mixed models were used to evaluate treatment effects. Cohen d was used to calculate effect sizes.

Results

In the main intention-to-treat analysis at the 12-month follow-up time point, participants in the internet-based cognitive behavioral therapy group had significant improvements in cardiac anxiety (–3.4 points, 95% CI –5.7 to –1.1; P=.004, d=0.38) and a nonsignificant improvement in fear of bodily sensations (–2.7 points, 95% CI –5.6 to 0.3; P=.07) compared with the treatment-as-usual group. Health-related quality of life at the 12-month follow-up improved with statistical and clinical significance in the internet-based cognitive behavioral therapy group (8.8 points, 95% CI 2.8 to 14.8; P=.004, d=0.48) compared with the treatment-as-usual group. Physical activity had significantly (P<.001) increased during the 6-week intervention period for the internet-based cognitive behavioral therapy group. Depression significantly improved posttreatment (P=.003) and at the 3-month follow-up (P=.03), but not at the 12-month follow-up (P=.35). Participants with depressive symptoms at baseline seemed to have increased effect of the intervention on cardiac anxiety (d=0.55) and health-related quality of life (d=0.71) at the 12-month follow-up. In the internet-based cognitive behavioral therapy group, 84% of the participants (68/81) completed at least 5 of the 6 sessions.

Conclusions

This study provides evidence that internet-based cognitive behavioral therapy with minimal therapist contact and a focus on physical activity is effective in reducing cardiac anxiety and increasing health related quality of life in patients with noncardiac chest pain.

Trial Registration

ClinicalTrials.gov NCT03096925; http://clinicaltrials.gov/ct2/show/NCT03096925

Anxiety disorders in patients with noncardiac chest pain: association with health-related quality of life and chest pain severity

BACKGROUND

Patients with noncardiac chest pain (NCCP) report more severe symptoms and lowered health-related quality of life when they present with comorbid panic disorder (PD). Although generalized anxiety disorder (GAD) is the second most common psychiatric disorder in these patients, its impact on NCCP and health-related quality of life remains understudied. This study describes and prospectively compares patients with NCCP with or without PD or GAD in terms of (1) NCCP severity; and (2) the physical and mental components of health-related quality of life.

METHODS

A total of 915 patients with NCCP were consecutively recruited in two emergency departments. The presence of comorbid PD or GAD was assessed at baseline with the Anxiety Disorder Schedule for DSM-IV. NCCP severity at baseline and at the six-month follow-up was assessed with a structured telephone interview, and the patients completed the 12-item Short-Form Health Survey Version 2 (SF-12v2) to assess health-related quality of life at both time points.

RESULTS

Average NCCP severity decreased between baseline and the six-month follow-up (p < .001) and was higher in the patients with comorbid PD or GAD (p < .001) at both time points compared to those with NCCP only. However, average NCCP severity did not differ between patients with PD and those with GAD (p = 0.901). The physical component of quality of life improved over time (p = 0.016) and was significantly lower in the subset of patients with PD with or without comorbid GAD compared to the other groups (p < .001). A significant time x group interaction was found for the mental component of quality of life (p = 0.0499). GAD with or without comorbid PD was associated with a lower mental quality of life, and this effect increased at the six-month follow-up.

CONCLUSIONS

Comorbid PD or GAD are prospectively associated with increased chest pain severity and lowered health-related quality of life in patients with NCCP. PD appears to be mainly associated with the physical component of quality of life, while GAD has a greater association with the mental component. Knowledge of these differences could help in the management of patients with NCCP and these comorbidities.

Are Patients at Risk for Developing Panic Disorder After an Emergency Department Visit With Noncardiac Chest Pain?

BACKGROUND

Panic disorder (PD) is common in emergency department (ED) patients with noncardiac chest pain (NCCP). The literature suggests that initially PD-free patients may be at increased risk of developing PD in the months or years following an ED visit.

OBJECTIVES

This study aims to determine the incidence of PD in the 2 years following an ED visit with NCCP and to identify predictors of incident PD.

METHODS

This study was conducted using a longitudinal, observational design. Five hundred and eighty-five patients with NCCP (without PD) were recruited in two EDs. They underwent an interview and completed a series of questionnaires assessing anxiety disorders, perceived social support, psychological distress, anxiety sensitivity, comorbidities, and stressful life events. PD was assessed 6 months, 1 year, and 2 years after the initial interview.

RESULTS

PD incidence was 11.1% (95% confidence interval: 8.7-13.9) in the two years following the baseline assessment. Anxiety sensitivity (odds ratio = 1.08; 95% confidence interval: 1.04-1.11; P < .001) and stress related to life events (odds ratio = 1.14; 95% confidence interval: 1.06-1.24; P = .001) significantly predicted incident PD.

CONCLUSIONS

Patients with NCCP are at high risk for developing PD in the 2 years following an ED visit with NCCP. Anxiety sensitivity and stress related to life events may be promising clinical targets for preventive interventions.

Heart-focused anxiety and health care seeking in patients with non-cardiac chest pain: A prospective study

OBJECTIVES

This study aimed to estimate the incidence of medical consultations six months after an emergency department (ED) consultation for non-cardiac chest pain (NCCP). It also investigated the role of heart-focused anxiety (HFA) and other factors in predicting an increased healthcare utilization in these patients.

METHOD

This was a prospective study of 428 patients who came to an ED with NCCP. Patients completed an interview and questionnaires assessing HFA, psychological distress, the characteristics of NCCP, and comorbidities. Their medical consultations were assessed by telephone interview six months later. The contribution of each factor was assessed using a binomial negative regression.

RESULTS

Eighty-three percent of patients reported at least one medical consultation (mean=3.1, standard deviation=3.9). HFA (incident rate ratio 1.01; 95% CI, 1.00-1.02), the presence of a medical condition (2.14; 1.51-3.03), NCCP frequency (1.49; 1.16-1.91) and NCCP-related interference (1.08; 1.04-1.13) were predictive of further medical consultations.

CONCLUSIONS

A significant proportion of patients with NCCP are at risk of multiple medical consultations following discharge from the ED. HFA appears as a determinant of medical consultations after controlling for multiple confounding factors.

The prevalence of non-cardiac chest pain (NCCP) using emergency department (ED) data: a Northern Ireland based study

Background

The aim of this study was to assess the frequency of chest pain presentations and the subsequent non-cardiac chest pain diagnoses in an emergency department (ED) over a 3 year period.

Methods

Administrative data on ED attendances to an urban general hospital in Northern Ireland between March 2013 and March 2016 were used. Data were coded and analysed to estimate frequencies of ‘chest pain’ presentation and the subsequent diagnoses for each year.

Results

Both chest pain presentations and chest pain presentations with a subsequent diagnosis of unknown cause increased each year. In total, 58.7% of all chest presentations across 3 years resulted in a non-cardiac diagnosis of either ‘anxiety’, ‘panic’ or ‘chest pain of unknown cause’.

Discussion

There is a significant amount of patients in the ED leaving with a non-cardiac diagnosis, following an initial presentation with chest pain.

Conclusion

Given the link between non-cardiac chest pain and frequent use of services, the degree of repeat attendance should be investigated.

A closer look at the relationships between panic attacks, emergency department visits and non-cardiac chest pain

This study examined the prevalence of emergency department visits prompted by panic attacks in patients with non-cardiac chest pain. A validated structured telephone interview was used to assess panic attacks and their association with the emergency department consultation in 1327 emergency department patients with non-cardiac chest pain. Patients reported at least one panic attack in the past 6 months in 34.5 per cent (95% confidence interval: 32.0%–37.1%) of cases, and 77.1 per cent (95% confidence interval: 73.0%–80.7%) of patients who reported panic attacks had visited the emergency department with non-cardiac chest pain following a panic attack. These results indicate that panic attacks may explain a significant proportion of emergency department visits for non-cardiac chest pain.

Quality of Life in Patients with Coronary Artery Disease and Panic Disorder: A Comparative Study

OBJECTIVES

The quality of life (QOL) of patients with coronary artery disease (CAD) is known to be impaired. Non-cardiac chest pain referrals are often under-diagnosed and untreated, and there are hardly any studies comparing the QOL of CAD and panic disorder related (non-cardiac) chest pain referrals (PDRC).

METHODS

We assessed the psychiatric morbidity and QOL of patients newly diagnosed with CAD (n = 40) at baseline and six weeks post-treatment and compared their QOL with patients with PDRC (n = 40) and age- and gender-matched healthy controls (n = 57). Psychiatric morbidity in the CAD group was assessed using the General Health Questionnaire (GHQ12) item, Hamilton Anxiety Scores (HAM-A), and Hamilton Depression Scores (HAMD). QOL measures were determined by the World Health Organization QOL questionnaire (brief) and Seattle Angina Questionnaire. The CAD group was treated with anti-ischemic drugs (nitrates, betablockers), antiplatelet drugs (acetylsalicylsalicylic acid), anticoagulants (low molecular weight heparin, clopidogrel), and managed for risk factors. The PDRC group was treated with selective serotonin reuptake inhibitors and anxiolytics.

RESULTS

Patients with panic disorder had a worse QOL than those with CAD and healthy controls in the physical domain and psychological domain (PDRC vs. CAD vs. healthy controls, p < 0.001). In the CAD group, smoking was associated with change in angina stability (p = 0.049) whereas other tobacco products were associated with change in angina frequency (p = 0.044). Psychiatric morbidity was present in 40.0% of patients with CAD. In the PDRC group, a significant correlation of HAM-A scores was noted in the physical (p = 0.000), psychological (p = 0.001), social (p = 0.006), and environment (p = 0.001) domains of QOL. Patients with panic disorder had a significant improvement in anxiety scores after treatment compared to baseline (HAM-A scores difference 21.0 [16.5-25.6]; p < 0.001).

CONCLUSIONS

Patients in the PDRC group had a worse QOL than those in the CAD and healthy control groups. This highlights the need for careful diagnosis and prompt treatment of panic disorder in these patients to improve their QOL. Additionally, smoking, the use of other tobacco products, and hypercholesterolemia were associated with angina symptoms in patients with CAD.

Feasibility and outcome of the implementation of a screening program for panic disorder in noncardiac chest pain patients in cardiac emergency department routine care

OBJECTIVE

This study assesses the feasibility and outcome of the implementation of a screening program for classifying panic disorder (PD) in patients presenting with noncardiac chest pain (NCCP(1)), when integrated in routine cardiac emergency department (CED(2)) care.

METHODS

Barrier analyses were made during the pilot phase and implementation period. NCCP patients aged 18-70 years presenting at the CED (n=252) were eligible for screening with the Hospital Anxiety and Depression Scale (HADS). Those scoring above cutoff on the HADS were referred to the psychiatric department and received the Composite International Diagnostic Interview.

RESULTS

Screening was initiated in 60 patients (23.8%), of whom nine refused participation. Staff adherence remained low despite implementing several improvements in the screening procedure. In total, 39 patients completed the program; 8 were diagnosed with a psychiatric disorder, including 2 patients with PD.

CONCLUSION

Feasibility of implementation of this screening program for PD in NCCP patients in routine CED care was limited because offering screening frequently conflicted with provision of acute care and because patients showed relatively high refusal rates. Contrasting our assumption, various other psychiatric disorders besides PD were classified.

A study of myocardial perfusion in patients with panic disorder and low risk coronary artery disease after 35% CO2 challenge

BACKGROUND

We have previously reported that 35% CO2 challenge induced myocardial ischemia in 81% of coronary artery disease (CAD) patients with comorbid panic disorder (PD) and previous positive nuclear exercise stress tests. However, it is yet unclear whether this is the case among CAD patients with PD and normal nuclear exercise stress test results. We hypothesized that a potent mental stressor such as a panic challenge among CAD patients with PD would also induce ischemia in patients with normal exercise stress tests.

METHODS

Forty-one coronary artery disease patients with normal nuclear exercise stress tests (21 patients with PD and 20 without PD) were submitted to a well-established panic challenge test (with 1 vital capacity inhalation of a gas mixture containing 35% CO2 and 65% O2) and injected with Tc-99m-tetrofosmin (Myoview), upon inhalation. Single photon emission computed tomography imaging was used to assess per-panic challenge reversible myocardial ischemia and HR, BP, and a 12 lead ECG was continuously measured during the procedure.

RESULTS

Fifty-eight percent of panic disorder patients (12/21) had a panic attack during the panic challenge vs 15% (3/20) of controls (p=0.005). Only 10% of patients in each group displayed myocardial ischemia per panic challenge.

CONCLUSIONS

These findings suggest that panic attacks among panic disorder patients with lower-risk coronary artery disease may not confer a risk for myocardial ischemia.

A prospective cohort study to refine and validate the Panic Screening Score for identifying panic attacks associated with unexplained chest pain in the emergency department

INTRODUCTION

Panic-like anxiety (panic attacks with or without panic disorder), a highly treatable condition, is the most prevalent condition associated with unexplained chest pain in the emergency department. Panic-like anxiety may be responsible for a significant portion of the negative consequences of unexplained chest pain, such as functional limitations and chronicity. However, more than 92% of panic-like anxiety cases remain undiagnosed at the time of discharge from the emergency department. The 4-item Panic Screening Score (PSS) questionnaire was derived in order to increase the identification of panic-like anxiety in emergency department patients with unexplained chest pain.

METHODS AND ANALYSIS

The goals of this prospective cohort study were to (1) refine the PSS; (2) validate the revised version of the PSS; (3) measure the reliability of the revised version of the PSS and (4) assess the acceptability of the instrument among emergency physicians. Eligible and consenting patients will be administered the PSS in a large emergency department. Patients will be contacted by phone for administration of the criterion standard for panic attacks as well as by a standardised interview to collect information for other predictors of panic attacks. Multivariate analysis will be used to refine the PSS. The new version will be prospectively validated in an independent sample and inter-rater agreement will be assessed in 10% of cases. The screening instrument acceptability will be assessed with the Ottawa Acceptability of Decision Rules Instrument.

ETHICS AND DISSEMINATION

This study protocol has been reviewed and approved by the Alphonse-Desjardins research ethics committee. The results of the study will be presented in scientific conferences and published in peer-reviewed scientific journals. Further dissemination via workshops and a dedicated website is planned.

Incremental cost-effectiveness of pharmacotherapy and two brief cognitive-behavioral therapies compared with usual care for panic disorder and noncardiac chest pain

The aim of this study was to assess the incremental cost-effectiveness ratios (ICERs) of two brief cognitive-behavioral therapy (CBT)-based interventions and a pharmacological treatment, compared with usual care, initiated in the emergency department (ED) for individuals with panic disorder (PD) with a chief complaint of noncardiac chest pain. A total of 69 patients were followed up to 6 months. The primary outcome variables were direct and indirect costs of treatment and PD severity. Panic management (PM) had an ICER of $124.05, per the Anxiety Disorders Interview Schedule for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, severity score change (95% confidence interval [CI], $54.63-$314.57), compared with pharmacotherapy (paroxetine), with an ICER of $213.90 (95% CI, $133.51-$394.94), and brief CBT, with an ICER of $309.31 (95% CI, $151.27-$548.28). The pharmacological and CBT interventions were associated with a greater clinical improvement compared with usual care at posttest. PM presented a superior ICER, suggesting that it may be a promising treatment option to implement in EDs.

Treatment of panic in chest pain patients from emergency departments: efficacy of different interventions focusing on panic management

OBJECTIVE

The aim was to assess the efficacy of two brief cognitive-behavioral therapy (CBT)-based interventions (7×1-h sessions and 1×2-h session) and a pharmacological treatment (paroxetine), compared to supportive usual care, initiated in the emergency department (ED) for individuals suffering from panic disorder (PD) with a chief complain of noncardiac chest pain (NCCP). We hypothesized that the interventions would be more efficacious than supportive usual care on all outcomes.

METHOD

A 12-month follow-up study of patients who received a diagnosis of NCCP in the ED and who met diagnostic criteria for PD (n=71) was performed. Assessments included several psychological questionnaires and a structured interview. A series of repeated-measures analyses of variances, using a split-plot design, were conducted, as well as planned comparisons to examine the differences.

RESULTS

The seven-session CBT (n=19), one-session panic management (n=24) and pharmacotherapy (n=13) led to greater improvements in PD severity (primary outcome) compared to supportive usual care (n=15) at posttest, and no significant difference was noted between the three active interventions. On the other measures, patients improved in all conditions, and the therapeutic gains were maintained up to 1 year following the visit to the ED.

CONCLUSIONS

These results suggests that early intervention, in particular seven sessions of CBT, one session of PM or pharmacotherapy (generic paroxetine), should be considered for the treatment of PD patients consulting the ED with a discharge diagnosis of NCCP.

Quality of life in panic disorder: looking beyond symptom remission

PURPOSE

Panic Disorder (PD) is a classic example of a disease where symptom remission may be achieved, yet patient quality of life (QOL) remains low, providing further support for the need to measure QOL as an additional outcome in patient care. The objectives of this review are to examine the substantial QOL impairments in PD and to determine whether modern treatments for PD, which have been proven to achieve symptom remission, have been shown to restore QOL.

METHODS

We identified studies on QOL in PD from 1980 to 2010 by searching MEDLINE, PsycINFO, and PubMed databases.

RESULTS

The literature reveals substantial QOL impairments in PD, often resulting in poor sense of health, frequent utilization of medical services, occupational deficiency, financial dependency, and marital strife. Modern therapies have been demonstrated to achieve symptom remission and improve QOL in PD; however, post-treatment QOL is still significantly lower than community averages.

CONCLUSIONS

QOL needs to be added as an essential outcome measure in patient care. Further research should be conducted to better understand the nature of comorbidities in PD as well as to determine whether additional interventions that have been studied in other psychiatric disorders, such as exercise, meditation, yoga, humor, massage, and nutritional supplements, can be utilized to improve QOL in PD to normal community levels.

Comparing Two Brief Psychological Interventions to Usual Care in Panic Disorder Patients Presenting to the Emergency Department with Chest Pain

Background: Panic disorder (PD) is a common, often unrecognized condition among patients presenting with chest pain to the emergency departments (ED). Nevertheless, psychological treatment is rarely initiated. We are unaware of studies that evaluated the efficacy of brief cognitive-behavioural therapy (CBT) for this population. Aim: Evaluate the efficacy of two brief CBT interventions in PD patients presenting to the ED with chest pain. Method: Fifty-eight PD patients were assigned to either a 1-session CBT-based panic management intervention (PMI) (n = 24), a 7-session CBT intervention (n = 19), or a usual-care control condition (n = 15). A structured diagnostic interview and self-reported questionnaires were administered at pre-test, post-test, 3- and 6-month follow-ups. Results: Statistical analysis showed significant reduction in PD severity following both interventions compared to usual care control condition, but with neither showing superiority compared to the other. Conclusions: CBT-based interventions as brief as a single session initiated within 2 weeks after an ED visit for chest pain appear to be effective for PD. Given the high prevalence of PD in emergency care settings, greater efforts should be made to implement these interventions in the ED and/or primary care setting.

[Psychiatric syndromes associated with atypical chest pain]

BACKGROUND/AIM

Chest pain often indicates coronary disease, but in 25% of patients there is no evidence of ischemic heart disease using standard diagnostic tests. Beside that, cardiologic examinations are repeated several times for months. If other medical causes could not be found, there is a possibility that chest pain is a symptom of psychiatric disorder. The aim of this study was to determine the presence of psychiatric syndromes, increased somatization, anxiety, stress life events exposure and characteristic of chest pain expression in persons with atypical chest pain and coronary patients, as well as to define predictive parameters for atypical chest pain.

METHOD

We compared 30 patients with atypical chest pain (E group) to 30 coronary patients (K group), after cardiological and psychiatric evaluation. We have applied: Mini International Neuropsychiatric Interiview (MINI), The Symptom Checklist 90-R (SCL-90 R), Beck Anxiety Invetory (BAI), Holms-Rahe Scale of stress life events (H-R), Questionnaire for pain expression Pain-O-Meter (POM). Significant differences between groups and predictive value of the parameters for atypical chest pain were determined.

RESULTS

The E group participants compared to the group K were younger (33.4 +/- 5.4: 48.3 +/- 6,4 years, p < 0.001), had a moderate anxiety level (20.4 +/- 11.9: 9.6 +/- 3.8, p < 0.001), panic and somatiform disorders were present in the half of the E group, as well as eleveted somatization score (SOM > or = 63-50%: 10%, p < 0.01) and a higher H-R score level (102.0 +/- 52.2: 46.5 +/- 55.0, p < 0.001). Pain was mild, accompanied with panic. The half of the E group subjects had somatoform and panic disorders.

CONCLUSION

Somatoform and panic disorders are associated with atypical chest pain. Pain expression is mild, accompained with panic. Predictive factors for atypical chest pain are: age under 40, anxiety level >20, somatization > or =63, presence of panic and somatoform disorders, H-R score >102, and a lack of positive diagnostic test of coronary disease. Defining of these parameters could be useful for early psychiatric evaluation of persons with atypical chest pain.

Patients with noncardiac chest pain and benign palpitations referred for cardiac outpatient investigation: a 6-month follow-up

OBJECTIVES

The aims were to (a) study the characteristics and outcome in patients with noncardiac chest pain or benign palpitations referred for cardiac evaluation, (b) compare psychological characteristics in the two groups, (c) identify predictors of outcome (d) and explore characteristics of patients who wanted psychological treatment.

METHODS

The patients (N=154) were first evaluated by a psychiatrist and than by a cardiologist at the initial attendance and by self report after 6 months.

RESULTS

Thirty nine percent had at least one DSM-IV psychiatric disorder at attendance. At the 6-month follow-up, 43% still had clinically significant complaints and/or impaired function. Patients with palpitations were more likely to be female, younger and less likely to attribute cardiac symptoms to heart disease, but had otherwise similar psychological features to noncardiac chest pain patients. Depression score at attendance predicted significant complaints at follow-up. Interest in psychological treatment was associated with more fear of bodily sensations, more impaired function, and greater tendency to attribute symptoms to heart disease.

CONCLUSION

Psychiatric disorders were common. The 6-month outcome was poor and was associated with the depression score at attendance. Patients with fear of bodily symptoms and impaired function were most interested in psychological treatment.

Nine-year follow-up of panic disorder in chest pain patients: clinical course and predictors of outcome

OBJECTIVE

The aim was to investigate the association between panic disorder (PD) and long-term outcomes in terms of psychiatric morbidity, psychological distress and health-related quality of life (HRQOL), and to identify predictors of poor outcome for PD in chest pain patients.

METHOD

Nine-year follow-up study of chest pain patients (n=199) referred to cardiology outpatient investigation. Assessments included Structured Clinical Interview for DSM-IV, Symptom Checklist-90-R (SCL-90-R), Illness Attitude Scale, Agoraphobia Cognitions Questionnaire, the Mobility Inventory for Agoraphobia, Personality Diagnostic Questionnaire and the Medical Outcome Study Short Form-36. At baseline, 76 patients suffered from PD.

RESULTS

Of 184 eligible patients, 150 participated in the follow-up study. Panic disorder at baseline was associated with a higher prevalence of comorbid Axis I disorders, psychological distress and poorer HRQOL at follow-up compared with patients without PD. Of the participants with PD at baseline (n=55), 14 suffered from persistent PD at follow-up. Patients with persistent PD had particularly poor outcomes regarding comorbid Axis I disorders, suicidal ideation (21%) and HRQOL. A mean baseline SCL-90-R somatization score above 1.4 predicted a 5-fold increased risk of persistent PD.

CONCLUSION

Chest pain patients with PD have a negative long-term outcome and those who score high on somatization require special attention because of particularly poor outcomes.

Anxiety disorders and suicidal behaviour: an update

PURPOSE OF REVIEW

The primary aim of this review is to present the main findings from the literature published between January 2006 and May 2007 on anxiety and suicidal behaviour. The secondary aim is to present critical comments on methodological issues, highlighting areas for future research.

RECENT FINDINGS

Traditionally, anxiety disorders have not been viewed as independent risk factors for suicidal behaviour, and therefore assessment of anxiety disorders has not been particularly emphasized in clinical enquiries and suicide screening tools. This review identifies evidence suggesting that specific anxiety disorders (e.g. generalized anxiety disorder, panic disorder and obsessive-compulsive disorder) may be independently associated with suicidality, to which they particularly contribute when they are co-morbid with bipolar disorder, depression, schizophrenia, or post-traumatic stress disorder, in both child/adolescent and adult populations.

SUMMARY

Despite methodological issues preventing firm conclusions from being drawn in most cases, these findings should prompt clinicians to evaluate more specifically the impact of anxiety disorders on suicidal behaviour, particularly when they are co-morbid. Further research into treatment of anxiety disorders in relation to preventing suicide is required.

Chest pain and its importance in patients with panic disorder: an updated literature review

CONTEXT

Chest pain is a common symptom in primary care settings, associated with considerable morbidity and health care utilization. Failure to recognize panic disorder as the source of chest pain leads to increased health care costs and inappropriate management.

OBJECTIVE

To identify characteristics of the chest pain associated with the presence of panic disorder, review the consequences and possible mechanisms of chest pain in panic disorder, and discuss the recognition of panic disorder in patients presenting with chest pain.

DATA SOURCES

Potential studies were identified via a computerized search of MEDLINE and PsycINFO databases and review of bibliographies. MeSH headings used included panic disorder with chest pain, panic disorder with coronary disease or cardiovascular disorders or heart disorders, and panic disorder with cholesterol or essential hypertension or tobacco smoking.

STUDY SELECTION

The diagnosis of panic disorder in eligible studies was based on DSM criteria, and studies must have used objective criteria for coronary artery disease and risk factors. Only case control and cohort studies were included.

DATA SYNTHESIS

Although numerous chest pain characteristics (believed to be both associated and not associated with coronary artery disease) have been reportedly linked to panic disorder, only nonanginal chest pain is consistently associated with panic disorder (relative risk = 2.03, 95% CI = 1.41 to 2.92).

CONCLUSION

Chest pain during panic attacks is associated with increased health care utilization, poor quality of life, and phobic avoidance. Because the chest pain during panic attacks may be due to ischemia, the presence of panic attacks may go unrecognized. Ultimately, the diagnosis of panic disorder must be based on DSM criteria. However, once panic disorder is recognized, clinicians must remain open to the possibility of co-occurring coronary artery disease.