Nonfearful Panic Disorder in Chest Pain Patients

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.

Description of Unexplained Chest Pain and Its Influence on Daily Life In Men and Women

Background: Patients with unexplained chest pain have seldom organic pathology. Although both physical and psychological factors have been studied and suggested as causes of chest pain.

Aim: The aim was to describe the experience of unexplained chest pain and its influence on daily life situation in men and women.

Methods: Nine women and eleven men with unexplained chest pain, aged 31–62 years were interviewed. A qualitative descriptive design was used. The interviews were analyzed by content analysis focusing on experience by gender.

Results: The results embraced two domains descriptions and consequences of chest pain and daily life situation. Words like pressure, cramp, strong, or burning were used in the descriptions of the chest pain experienced with more similarities than variations between men and women. Physical, psychological and social consequences due to chest pain influenced daily life. The men specifically reported having a ‘fast tempo’ in their lives, with stress at work being seen as a feature experienced by both men and women.

Conclusions: This study shows that men and women had more similarities than variations in descriptions of chest pain. Their unexplained chest pain influenced their functions in daily life that led to, especially for the men, few contacts outside the family and therefore a weak social network.

Subtypes of panic attacks: a critical review of the empirical literature

BACKGROUND

Panic disorder is a heterogeneous disorder, comprising a variety of somatic, physiological, and cognitive symptoms during repeated panic attacks. As a result, considerable data have examined whether panic attacks may be classified into distinct diagnostic or functional subtypes. The aim of this study is to evaluate the existing literature regarding the validity of panic attack subtypes.

METHODS

This review focuses on data published since 2000, with the publication of DSM-IV-TR, augmented by replicated data published since 1980, with the publication of DSM-III and subsequently DSM-IV. Published reports evaluating empirical evidence for the validity of panic attack subtypes are reviewed.

RESULTS

Five sets of panic symptoms (respiratory, nocturnal, nonfearful, cognitive, and vestibular) have been shown to cluster together at varying degrees of consistency. However, none of these potential subtypes have been associated with sufficient and reliable external validation criteria indicative of functional differences. This apparent lack of findings may be related to methodological inconsistencies or limitations across the reviewed studies.

CONCLUSIONS

Although at present the data do not warrant the utility of subtyping, further research aimed at patent gaps in the literature, including clearer operationalization of symptom subtypes, greater use of biological challenge paradigms and physiological and other more objective measures of fear and anxiety, and exploration of subtyping based on biological factors such as genetics, may support the future designation of panic attack subtypes and their ultimate clinical utility.

Efficacy of functional relaxation and patient education in the treatment of somatoform heart disorders: a randomized, controlled clinical investigation

BACKGROUND

Recurrent heart problems and, especially, chest pain in the absence of somatic heart disease is a common finding, although challenging to treat.

OBJECTIVE

The authors assessed a body-oriented approach to the somatic fixation frequently seen in these patients.

METHOD

They conducted a controlled study to assess the effect of functional relaxation in 22 patients with non-specific chest pain. The primary outcome measures were self-reported changes on the subscales Somatization and Anxiety of the Symptom Checklist of Derogatis, as well as the subscale Cardiovascular Complaints of the Giessen Inventory of Complaints.

RESULTS

Significant improvements of the primary outcome measures were observed in patients treated with functional relaxation, whereas no significant improvements could be seen in the control group.

CONCLUSION

Functional relaxation appears to be a safe and effective, non-pharmacological approach in the treatment of non-specific chest pain.

Non-fearful vs. fearful panic attacks: a general population study from the National Comorbidity Survey

BACKGROUND

Non-fearful panic attacks constitute a subgroup of panic attacks without the experience of subjective fear. However, previous studies were mostly carried out under medical settings and with small samples. The present study aims to clarify and expand the previous findings including the prevalence and characteristics of non-fearful panic attacks by using the National Comorbidity Survey (NCS) database.

METHODS

From the 8098 original respondents in the NCS, subjects who met the DSM-III-R diagnostic criteria for a lifetime panic attack were selected. Of these, individuals with non-fearful panic attacks were identified and comparisons with subjects with fearful panic attacks were conducted.

RESULTS

30% of panic attacks occur without fears of dying or going crazy. Although these non-fearful panic attacks do not differ from their fearful counterparts in terms of age, age of onset or frequency of attacks, they are less often associated with some symptoms including shortness of breath, trembling, smothering and depersonalization, lead less often to anticipatory anxiety, and lead to less treatment with medication. Although they lead equally to panic disorder diagnosis and cause as much functional impairment, the non-fearful ones are less often associated with diagnoses of agoraphobia, as well as many other Axis I disorders such as major depressive disorder, simple phobia and substance-related disorders.

LIMITATIONS

Recall bias and response bias may have distorted estimated relationships.

CONCLUSIONS

Although milder in terms of symptomatology and some comorbidity, clinicians need to pay appropriate attention to non-fearful subtypes of panic attacks which appear to be equally dysfunctional.

Nonfearful panic disorder in chest-pain patients: status after nine-year follow-up

BACKGROUND

Nonfearful panic disorder (NFPD) is a type of panic disorder (PD) that was first described in 1987 among cardiology patients who had panic attacks without the experience of fear. NFPD may be considered a subtype of PD with significant impact on the long-term outcome of chest pain patients.

OBJECTIVE

The authors sought to explore the long-term outcome of NFPD and PD.

METHOD

Authors studied 199 patients previously referred to cardiology outpatient investigation because of chest pain. Assessments comprising cardiological and psychiatric (SCID-I) examinations were conducted after 9 years.

RESULTS

At follow-up, no patients suffered from NFPD, but 18% had panic disorder with fear (PD). There were no significant differences between the baseline NFPD (N=11) and PD (N=44) patients regarding psychiatric comorbidity, chest pain, healthcare utilization, and health-related quality of life at follow-up.

CONCLUSION

NFPD can have a significant impact on the long-term outcome of chest pain patients even though they may not seek psychiatric treatment.

Carbon dioxide inhalation induces dose-dependent and age-related negative affectivity

Background

Carbon dioxide inhalation is known to induce an emotion similar to spontaneous panic in Panic Disorder patients. The affective response to carbon dioxide in healthy subjects was not clearly characterized yet.

Methodology/Principal Findings

Sixty-four healthy subjects underwent a double inhalation of four mixtures containing respectively 0, 9, 17.5 and 35% CO₂ in compressed air, following a double blind, cross-over, randomized design. Affective responses were assessed according to DSM IV criteria for panic, using an Electronic Visual Analogue Scale and the Panic Symptom List. It was demonstrated that carbon dioxide challenges induced a dose dependent negative affect (p<0.0001). This affect was semantically identical to the DSM IV definition of panic. Older individuals were subjectively less sensitive to Carbon Dioxide (p<0.05).

Conclusions/Significance

CO₂ induced affectivity may lay on a continuum with pathological panic attacks. Consistent with earlier suggestions that panic is a false biological alarm, the affective response to CO₂ may be part of a protective system triggered by suffocation and acute metabolic distress.

Cardiac pain or panic disorder? Managing uncertainty in the emergency department

Emergency department admissions for chest pain might be related to a psychological problem, such as panic. Panic disorder adversely affects the person's lifestyle, general health, and psychological well-being. Panic disorder is difficult to recognize, so nursing assessment and management of these clients is important. This paper presents research findings from a New Zealand study that explored emergency nurses' differentiation of non-cardiac chest pain from panic disorder and raised significant issues in the nursing assessment and management of such clients. The data were gathered from focus group interviews and were analyzed thematically. Three themes, prioritizing time, managing uncertainty and ambiguity, and the life-threatening lens, were identified. The findings confirm that a panic disorder is not always diagnosed when biomedical assessment is used in isolation from a psychosocial assessment. Emergency nurses are pivotal in reversing the cycle of repeat presenters with non-cardiac chest pain. Recommendations for assessing and managing this complex condition are presented.