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Tunnell NC, Corner SE, Roque AD, Kroll JL, Ritz T, Meuret AE. Biobehavioral approach to distinguishing panic symptoms from medical illness. Front Psychiatry 2024; 15:1296569. [PMID: 38779550 PMCID: PMC11109415 DOI: 10.3389/fpsyt.2024.1296569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 03/19/2024] [Indexed: 05/25/2024] Open
Abstract
Panic disorder is a common psychiatric diagnosis characterized by acute, distressing somatic symptoms that mimic medically-relevant symptoms. As a result, individuals with panic disorder overutilize personal and healthcare resources in an attempt to diagnose and treat physical symptoms that are often medically benign. A biobehavioral perspective on these symptoms is needed that integrates psychological and medical knowledge to avoid costly treatments and prolonged suffering. This narrative review examines six common somatic symptoms of panic attacks (non-cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress, and paresthesia), identified in the literature as the most severe, prevalent, or critical for differential diagnosis in somatic illness, including long COVID. We review somatic illnesses that are commonly comorbid or produce panic-like symptoms, their relevant risk factors, characteristics that assist in distinguishing them from panic, and treatment approaches that are typical for these conditions. Additionally, this review discusses key factors, including cultural considerations, to assist healthcare professionals in differentiating benign from medically relevant symptoms in panic sufferers.
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Affiliation(s)
- Natalie C. Tunnell
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Department of Psychiatry & Behavioral Sciences, The University of Kansas Medical Center, Kansas City, KS, United States
| | - Sarah E. Corner
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
| | - Andres D. Roque
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Primary Care Department, Miami VA Healthcare System, Miami, FL, United States
| | - Juliet L. Kroll
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Thomas Ritz
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
| | - Alicia E. Meuret
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
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Meuret AE, Tunnell N, Roque A. Anxiety Disorders and Medical Comorbidity: Treatment Implications. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1191:237-261. [PMID: 32002933 DOI: 10.1007/978-981-32-9705-0_15] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Anxiety disorders are debilitating psychological disorders characterized by a wide range of cognitive and somatic symptoms. Anxiety sufferers have a higher lifetime prevalence of various medical problems. Chronic medical conditions furthermore increase the likelihood of psychiatric disorders and overall dysfunction. Lifetime rates of cardiovascular, respiratory, gastrointestinal, and other medical problems are disproportionately high in anxiety and panic/fear sufferers. The heightened comorbidity is not surprising as many symptoms of anxiety and panic/fear mimic symptoms of medical conditions. Panic disorder specifically is strongly linked to medical conditions due to its salient somatic symptoms, such as dyspnea, dizziness, numbness, chest pain, and heart palpitations, all of which can signal danger and deterioration for chronic disease sufferers. This chapter identifies shared correlates of medical illness and anxiety disorders and evidence for misinterpretation of symptoms as medically relevant and offers an analysis of implications for treatment of both types of conditions. We will concentrate on medical conditions with high associations for anxiety and panic by aspects of symptomatology, specifically neurological disorders (fibromyalgia, epilepsy, cerebral palsy), diabetes, gastrointestinal illness (irritable bowel syndrome, gastroesophageal reflux disease), and cardiovascular and respiratory illnesses (asthma).
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Affiliation(s)
- Alicia E Meuret
- Department of Psychology, Southern Methodist University, Dallas, TX, USA.
| | - Natalie Tunnell
- Department of Psychology, Southern Methodist University, Dallas, TX, USA
| | - Andres Roque
- Department of Psychology, Southern Methodist University, Dallas, TX, USA
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Walach H, Loughlin M. Patients and agents - or why we need a different narrative: a philosophical analysis. Philos Ethics Humanit Med 2018; 13:13. [PMID: 30316296 PMCID: PMC6186295 DOI: 10.1186/s13010-018-0068-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 09/24/2018] [Indexed: 05/06/2023] Open
Abstract
BACKGROUND The success of medicine in the treatment of patients brings with it new challenges. More people live on to suffer from functional, chronic or multifactorial diseases, and this has led to calls for more complex analyses of the causal determinants of health and illness. METHODS Philosophical analysis of background assumptions of the current paradigmatic model. RESULTS While these factors do not require a radical paradigm shift, they do give us cause to develop a new narrative, to add to existing narratives that frame our thinking about medical care. In this paper we argue that the increased focus on lifestyle and shared decision making requires a new narrative of agency, to supplement the narrative of "the patient". This narrative is conceptually linked to the developing philosophy of person-centred care. CONCLUSIONS If patients are seen also as "agents" this will result in a substantial shift in practical decisions: The development and adoption of this narrative will help practitioners work with patients to their mutual benefit, harnessing the patients' motivation, shifting the focus from treatment to prevention and preventing unnecessary and harmful treatments that can come out of our preoccupation with the patient narrative. It will also help to shift research efforts, conceptual and empirical, from "treating" and "battling" diseases and their purported "mechanisms" to understanding complex contributing factors and their interplay.
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Affiliation(s)
- Harald Walach
- Department of Pediatric Gastroenterology, Medical University Poznan, Poznań, Poland
- Department of Psychology, University Witten-Herdecke, Witten, Germany
- Change Health Science Institute, Schönwalder Str. 17, 13347 Berlin, Germany
| | - Michael Loughlin
- University of West London, St Mary’s Rd, London, W5 5RF UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
- England Centre for Practice Development, Canterbury, UK
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Schroeder S, Gerlach AL, Martin A. Implicit affective evaluation of somatosensory sensations in patients with noncardiac chest pain. J Behav Ther Exp Psychiatry 2014; 45:381-8. [PMID: 24799152 DOI: 10.1016/j.jbtep.2014.04.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 04/04/2014] [Accepted: 04/07/2014] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND OBJECTIVES Etiological models of noncardiac chest pain (NCCP) stress the importance of abnormal implicit affective evaluations of somatosensory sensations, but this has never been studied empirically. The aim was therefore to assess implicit affective evaluations of somatosensory stimuli in NCCP using an experimental design. METHODS A total of 34 patients with NCCP, 24 patients with cardiac chest pain, and 46 healthy controls, took part in the study. Participants completed a tactile modification of the Affect Misattribution Procedure (tAMP) and answered self-report measures on anxiety sensitivity, somatosensory amplification, and somatic symptom distress. RESULTS A 3 × 3-ANOVA revealed that most negative judgments were found in the aversive condition, but this effect was not specific to patients with NCCP. Anxiety sensitivity was positively associated with negative implicit evaluations of aversive tactile stimuli in the tAMP. LIMITATIONS The task seemed to be too difficult for older participants. Also, future studies should apply clinically more relevant, e.g., heart related, stimuli that are more ecologically valid than the electrical stimulation of the finger used as a proxy for aversive somatosensory sensations here. CONCLUSIONS Against theoretical assumptions, patients with NCCP do not seem to show a stronger implicit negative interpretation bias concerning somatosensory sensations in comparison to patients either with cardiac chest pain, or without chest pain. Nevertheless, anxiety sensitivity seems to contribute significantly to implicit affective interpretations of somatic sensations. Further studies are required investigating the relevance of implicit interpretative processes for the course of NCCP and distressing somatic symptoms in general.
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Affiliation(s)
- Stefanie Schroeder
- Department of Psychosomatic Medicine and Psychotherapy, University of Erlangen-Nürnberg, University Hospital of Erlangen, Schwabachanlage 6, D-91054 Erlangen, Germany.
| | - Alexander L Gerlach
- Department of Clinical Psychology and Psychotherapy, University of Cologne, Pohligstraße 1, D-50969 Köln, Germany.
| | - Alexandra Martin
- Department of Clinical Psychology and Psychotherapy, University of Wuppertal, Max-Horkheimer-Straße 20, D-42097 Wuppertal, Germany.
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McGillion M, Arthur HM, Natarajan M, Cook A, Gunn E, Watt-Watson J, Thorpe K, Cosman T. Nonischemic Chest Pain Following Successful Percutaneous Coronary Intervention at a Regional Referral Centre in Southern Ontario. Can J Cardiol 2012; 28:S60-9. [DOI: 10.1016/j.cjca.2011.10.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2011] [Revised: 10/18/2011] [Accepted: 10/25/2011] [Indexed: 12/14/2022] Open
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Abstract
PURPOSE OF REVIEW Chest pain is one of the most common symptoms for seeking acute medical care. Evidence of myocardial ischemia, however, can only be established in a minority of patients. The establishment or ruling out of myocardial ischemia is difficult and the cost is high. An effective rationale for ischemia detection, without unnecessary hospital admission, is needed. The development of chest pain units potentially offers a rapid, effective way of identifying patients at high risk for acute coronary syndromes, as well as those with a low probability of ischemia. Other cardiac or noncardiac causes of chest pain should also be considered. RECENT FINDINGS Recent developments in chest pain, including the ruling in or out of ischemic pain by triage and different ischemia detection methods, are discussed. Other causes of chest pain such as esophageal, drug related, psychiatric and post-coronary bypass surgery pain are also discussed. Recent findings on syndrome X are reviewed and patients with myocardial infarction presenting without chest pain are discussed. SUMMARY The possibility of safely and quickly ruling out myocardial ischemia by point-of-care biochemical analyses is reviewed, which might influence our clinical handling of chest pain patients. The importance of biopsychosocial factors, pain perception, esophageal dysfunction, drugs and the coronary artery bypass procedure in itself, is discussed and vital clinical information is provided for the handling of our chest pain patients.
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Affiliation(s)
- Mats Börjesson
- Multidisciplinary Pain Center, Department of Medicine, Sahlgrenska University Hospital/Ostra, Göteborg, Sweden.
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Amsterdam EA, Kirk JD, Diercks DB, Lewis WR, Turnipseed SD. Exercise testing in chest pain units: rationale, implementation, and results. Cardiol Clin 2006; 23:503-16, vii. [PMID: 16278120 DOI: 10.1016/j.ccl.2005.08.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Chest pain units are now established centers for assessment of low-risk patients presenting to the emergency department with symptoms suggestive of acute coronary syndrome. Accelerated diagnostic protocols, of which treadmill testing is a key component, have been developed within these units for efficient evaluation of these patients. Studies of the last decade have established the utility of early exercise testing,which has been safe, accurate, and cost-effective in this setting. Specific diagnostic protocols vary, but most require 6 to 12 hours of observation by serial electrocardiography and cardiac injury markers to exclude infarction and high-risk unstable angina before proceeding to exercise testing. However, in the chest pain unit at UC Davis Medical Center,the approach includes "immediate" treadmill testing without a traditional process to rule out myocardial infarction. Extensive experience has validated this approach in a large, heterogeneous population. The optimal strategy for evaluating low-risk patients presenting to the emergency department with chest pain will continue to evolve based on current research and the development of new methods.
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Affiliation(s)
- Ezra A Amsterdam
- Department of Internal Medicine, University of California School of Medicine (Davis) and Medical Center, Sacramento, CA 95817, USA.
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Abstract
OBJECTIVE To describe factors influencing chest pain expression in patients with cardiac or noncardiac disease. METHODS The authors conducted a case presentation and review of literature. RESULTS Causes of chest pain are diverse. Psychologic factors influence chest pain expression commonly in patients with or without cardiac disease. CONCLUSIONS Physicians and other therapists must be aware of psychologic influences on chest pain expression to provide optimal treatment to their patients.
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Affiliation(s)
- David S Sheps
- University of Florida and the Malcom Randall VA Medical Center, P.O. Box 100181, Gainesville, FL 100181-0181, USA.
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Amsterdam EA, Kirk JD, Diercks DB, Lewis WR, Turnipseed SD. Early exercise testing in the management of low risk patients in chest pain centers. Prog Cardiovasc Dis 2004; 46:438-52. [PMID: 15179631 DOI: 10.1016/j.pcad.2004.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Ezra A Amsterdam
- Department of Internal Medicine, University of California School of Medicine, Davis, USA.
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Biggs AM, Aziz Q, Tomenson B, Creed F. Do childhood adversity and recent social stress predict health care use in patients presenting with upper abdominal or chest pain? Psychosom Med 2003; 65:1020-8. [PMID: 14645781 DOI: 10.1097/01.psy.0000097333.02618.8d] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVE A comprehensive model of health care use by patients with functional gastrointestinal disorders has not been fully tested. This study aimed to establish whether reported childhood and/or recent adversity are independent predictors of health care use when all other relevant factors are also included in the model. MATERIALS AND METHODS Consecutive new patients with upper abdominal or chest pain presenting to a secondary/tertiary clinic were assessed using the Childhood Experience of Care and Abuse and Life Events and Difficulties Schedules. They completed the Hospital Anxiety and Depression and Health Anxiety Questionnaires. Outcome was total number of health care visits recorded in hospital and general practice (GP) records over 18 months. RESULTS One hundred fifty-one patients were included (65% response rate). Health care visits were most frequent in unmarried (p < 0.0005), females (p < 0.0005), and those lacking social support (p = 0.012). In multiple regression analysis to predict number of health care visits, reported sexual abuse (p = 0.042) and death of a sibling during childhood (p = 0.026) were also independent predictors, together with SF36 subscale scores for physical function, health perception, and mental health (35% of variance explained). Childhood adversity predicted health care use in patients with functional gastrointestinal disorders and recent social stress did so in patients with demonstrated pathological findings. CONCLUSION After adjustment for demographic, physical, and psychological factors, childhood adversity, especially in severe form, is an independent predictor of health care use in patients with upper functional gastrointestinal disorders. The same was not true for patients consulting for demonstrable pathological abnormalities, for whom ongoing social stress was an independent predictor.
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Affiliation(s)
- Anne-Marie Biggs
- School of Psychiatry and Behavioural Sciences, Rawnsley Building, Manchester Royal Infirmary, Manchester, UK.
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