Anxiety and the heart--a historical review

The panic attack-posttraumatic stress disorder model: applicability to orthostatic panic among Cambodian refugees

This article examines the ability of the panic attack-posttraumatic stress disorder (PTSD) model to predict how panic attacks are generated and how panic attacks worsen PTSD. The article does so by determining the validity of the panic attack-PTSD model in respect to one type of panic attack among traumatized Cambodian refugees: orthostatic panic (OP) attacks (i.e. panic attacks generated by moving from lying or sitting to standing). Among Cambodian refugees attending a psychiatric clinic, the authors conducted two studies to explore the validity of the panic attack-PTSD model as applied to OP patients (i.e. patients with at least one episode of OP in the previous month). In Study 1, the panic attack-PTSD model accurately indicated how OP is seemingly generated: among OP patients (N = 58), orthostasis-associated flashbacks and catastrophic cognitions predicted OP severity beyond a measure of anxious-depressive distress (Symptom Checklist-90-R subscales), and OP severity significantly mediated the effect of anxious-depressive distress on Clinician-Administered PTSD Scale severity. In Study 2, as predicted by the panic attack-PTSD model, OP had a mediational role in respect to the effect of treatment on PTSD severity: among Cambodian refugees with PTSD and comorbid OP who participated in a cognitive behavioural therapy study (N = 56), improvement in PTSD severity was partially mediated by improvement in OP severity.

Orthostatic panic attacks among Vietnamese refugees

Viewed historically and cross-culturally, orthostatic-induced dizziness, i.e., dizziness caused by standing up from a sitting or a lying position, forms a key aspect of many syndromes: irritable heart (American Civil War), effort syndrome (World War I and World War II), chronic fatigue syndrome (contemporary USA), Gulf War syndrome (contemporary USA), and orthostatic dysregulation (contemporary Japan). Among Vietnamese refugees attending a psychiatric clinic, this study documents a high rate of orthostatic panic (OP), as well as certain processes seemingly generating these panic attacks, viz., flashbacks and culturally specific catastrophic cognitions. Case examples are used to demonstrate OP's phenomenology and relevance to clinical care. To illustrate the mechanisms producing OP, we adduce the multiplex model of panic generation. Culturally appropriate care of Vietnamese refugees should include assessment and treatment of OP.

Orthostatic Panic as a Key Vietnamese Reaction to Traumatic Events: The Case of September 11, 2001

This article discusses a culturally specific response to traumatic events: orthostatic panic attacks among Vietnamese refugees. We compared the rate and severity of orthostatic panic as well as the rates and severity of associated flashbacks a month before and a month after September 11, 2001. After that date, the rate and severity of orthostatic panic greatly increased, as did the rate and severity of associated flashbacks. The central role of orthostatic panic as a response to traumatic events is illustrated through a patient's vignette. An explanation of why September 11 so profoundly influenced this population is adduced, including an explanation of why it resulted in considerable worsening of orthostatic panic.

Somatic hypotheses of war syndromes

Since the end of the American Civil War, unexplained symptoms in military personnel arising after a war or peace mission have frequently been described. The pattern of symptoms is highly similar for all of the various war syndromes although the conditions of each war or peace mission are widely different. Many somatic hypotheses have been formulated to explain these syndromes; a considerable proportion of them are already outdated. In the last few years much attention has been given to Gulf War Syndrome and to unexplained symptoms of military personnel who were sent to Cambodia, Rwanda, Burundi, Zaire, or the former Yugoslavia. In this review the symptoms of war syndromes will be considered in more detail and the suggested somatic explanations will be discussed. During the last decade the following somatic causes have been suggested as possible explanations for these symptoms: (persistent) infection, abnormal immune response, administration of multiple vaccinations within a short period of time, use of malaria chemoprophylaxis, neurological abnormalities, exposure to toxicological substances and environmental factors. The various investigations performed to study these hypotheses are discussed. The fact that bias regularly occurs in the course of these investigations is pointed out. For the future, a reliable investigation of a war syndrome should be a prospective multidisciplinary study and should distinguish between causative and sustaining factors.

The psychiatric sequelae of civilian trauma

Much of the literature on the psychiatric consequences of stress has focused on wartime combat trauma. However, traumatic events also frequently occur in civilian life. Controlled studies on the psychiatric effects of noncombat trauma were reviewed and a meta-analysis of these data was conducted. Generalized anxiety disorder (GAD), posttraumatic stress disorder (PTSD), substance abuse, phobia, and major depressive disorder (MDD) were significantly elevated compared with a pooled control group, whereas panic disorder and dysthymic disorder were not significantly increased. These data suggest that the psychiatric effects of civilian trauma include both anxiety and depressive disorders. The results are strikingly similar to those reported in combat veterans, suggesting that severe trauma, even in very different populations, may be associated with similar psychopathology.

Increasing identification and referral of panic disorder over the past decade

The study's objective was to contrast the prevalence, phenomenology, and medical care utilization for panic disorder from 1980 to 1990. All psychiatric consultations from a university consultation service from the years 1980, 1985, and 1990 were located (N = 2,400). Patients meeting DSM-III-R panic disorder criteria were selected for chart review. Variations in demographics, comorbidity, prior medical evaluations, and referral patterns were analyzed. The prevalence rate for consultations meeting panic disorder criteria has increased (2.5% in 1980, 4.2% in 1985, and 5.1% in 1990; chi 2 = 7.5, P = 0.024). Referring physicians more frequently noted panic attacks in 1990 (5% in 1980, 21% in 1985, and 59% in 1990; chi 2 = 21.2, P = 0.0001). A summary measure of medical care utilization revealed no significant interval change. Panic disorder is being recognized and referred more frequently by medical physicians since the publication of DSM-III and DSM-III-R. However, delay of diagnosis and high medical care utilization remain significant problems.

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.

Post-traumatic stress disorder: supportive evidence from an eighteenth century natural disaster

Post-traumatic stress disorder was first recognized as a diagnostic category embracing reactions in response to overwhelming environmental stress 'outside the range of usual human experience' in DSM-III (APA, 1980). Such abnormal stressors are by no means a product of the twentieth century but have featured, sporadically, in all societies from the earliest civilizations. Longitudinal investigations of traumatic stress have rarely gone further back than the nineteenth century, and have been concerned, almost exclusively, with adverse effects following railway accidents and military combat. The present study, utilizing a mid-eighteenth century medical source, presents an analysis of the impact of a natural disaster on members of a peasant family trapped in an avalanche in the Italian Alps in 1755.

Subtyping of panic disorder by symptom profile

During Phase II of the Cross-National Panic Study, descriptions of the patient's last severe panic attack were collected for 1168 patients. Statistical analysis indicated that patients could be divided into two groups, characterised by the presence or absence of prominent respiratory symptoms. The two groups did not differ on demographic variables or coexisting diagnoses, but they did differ on psychopathology on entry to the study and treatment outcome. The group with prominent respiratory symptoms suffered more spontaneous panic attacks and responded to imipramine, whereas the group without prominent respiratory symptoms suffered more situational panic attacks and responded more to alprazolam. It is important to distinguish spontaneous and situational panic attacks, to aid choice of treatment.

[Cardiovascular pathology and panic disorder]

The relationship between anxiety and cardiovascular function and symptoms has long been of interest, culminating in the recent emphasis on the modulation of cardiovascular response in patients with panic disorder. The relationship between panic disorder and mitral valve prolapse remains controversial. Panic disorder appears to be significantly associated with increased incidence of cardiovascular morbidity. The detection and treatment of panic disorder in patients with cardiovascular risk or diseases could have an important impact on prognosis and quality of life of the patients.

Cardiovascular complaints following the uprising of December 1989 in Romania

The cardiovascular system may react to stress either by coronary events, such as angina pectoris or myocardial infarction, or by non-coronary responses, such as rises in blood pressure or non-specific circulatory disorders and chest pain. There is contradictory information about the cardiovascular reactions to war stress. The aim of this study was to investigate the effects of stress produced by the uprising of December 1989 in Romania on the cardiovascular system. Cases referred from 21 to 31 December 1989 to the emergency department of the largest university clinic of the Cluj district, and those admitted there, were analysed and compared with cases referred in the same periods in 1988, 1990 and 1991 and from 1 to 10 January 1990. There was a significant increase in non-coronary cardiovascular complaints referred for consultation in the first 10 days from the beginning of the uprising in Cluj and a non-significant increase in the following 10 days, but no increase in consultations for complaints of coronary origin due to unstable angina and acute myocardial infarction or changes in hospital admissions. In conclusion, the stress produced by the uprising in Romania was correlated with a higher incidence of non-coronary cardiovascular complaints but no alteration in coronary events (unstable angina, acute myocardial infarction), or in hospital admissions for cardiovascular complaints.

Panic disorder in cardiac outpatients

The prevalence of and nature of panic disorder were investigated in an ambulatory cardiology practice. Questionnaires about panic symptoms were mailed to 414 patients, and possible or definite panic disorder was found in 104 of the 310 respondents. Interviews with 52 of the 104 patients substantiated diagnoses of panic disorder, for a prevalence of 9.2% of the total sample population of 414. Comparison of patients grouped by duration of panic disorder revealed that long-duration panic disorder had its onset before age 30 and followed a chronic course. Short-duration panic disorder developed at an older age following the appearance of cardiac disease.

Invited review: post-traumatic stress disorder; a new clinical entity?

Recently a spate of large scale disasters has caught public attention. Survivors of unexpected catastrophes find their lives radically changed. They may develop a characteristic pattern of symptoms in response to their exposure to overwhelming stress. Ten years ago, American psychiatrists introduced a new diagnostic category, post-traumatic stress disorder (PTSD), referring to the range of psychological symptoms survivors demonstrate after extreme trauma (Diagnostic and Statistical Manual of Mental Disorders, APA, Washington D.C.). Although the validity of this syndrome remains debatable, the term PTSD is increasingly in use, a practice likely to continue given its inclusion in the draft edition of ICD 10 (WHO, Geneva). This review looks at the evidence that PTSD describes a specific clinical entity. The historical background to the belief that individuals respond to stress is summarized. The criteria that must be fulfilled and methods of establishing a diagnosis are described. A discussion of aetiological factors and the natural history of the psychological response to stress follows, with reference to clinical management, including the provision of effective intervention for survivors to prevent a full blown stress reaction emerging.

Sinking heart: a Punjabi communication of distress

Within transcultural psychiatry there is a continuing debate between universalist and relativist positions. This debate focuses on the translation of Western psychiatric categories to non-Western languages and cultural contexts, and on the cross-cultural applicability of a Western model of human nature. This debate is of concern to medical practitioners and other primary carers who work with ethnic minority patients. The paper describes a syndrome of heart distress referred to as "sinking heart' by Punjabis living in Bedford, and it discusses how far this condition correlates with Western psychiatric categories. "Sinking heart' is an illness in which physical sensations in the heart or in the chest are experienced and these symptoms are thought to be caused by excessive heat, exhaustion, worry and/or social failure. The Punjabi model of "sinking heart' offers a culture-bound explanation of somatic symptoms. It is based on culturally specific ideas about the person, the self and the heart and on the assumption that physical, emotional and social symptoms of pathology accompany each other. This model is compared with Western notions of depression and with medical models of heart distress, type A behaviour pattern and stress. The paper concludes that the Punjabi model of sinking heart does not exactly correspond to any of these. The sinking heart model bears closest resemblance to a Western model of stress. The similarity between these two models is in the form rather than in the content.

Chest pain: relationship of psychiatric illness to coronary arteriographic results

Seventy-four patients with chest pain and no prior history of organic heart disease were interviewed with a structured psychiatric interview immediately after coronary arteriography. The majority of patients with both negative and positive coronary angiographies had undergone previous exercise tolerance tests, but the patients with angiographic coronary artery disease were significantly more likely to have had positive results on a treadmill test. Patients with chest pain and negative coronary arteriograms were significantly younger; more likely to be female; more apt to have a higher number of autonomic symptoms (tachycardia, dyspnea, dizziness, and paresthesias) associated with chest pain, and more likely to describe atypical chest pain. Patients with chest pain and normal coronary arteriographic results also had significantly higher psychologic scores on indices of anxiety and depression and were significantly more likely to meet criteria of the Diagnostic and Statistical Manual of Mental Disorders, third edition, for panic disorder (43 percent versus 6.5 percent), major depression (36 percent versus 4 percent), and two or more phobias (36 percent versus 15 percent) than were patients with chest pain and a coronary arteriography study demonstrating coronary artery stenosis.

Aetiology and mechanisms of anxiety disorders

Theories on the aetiology of pathological anxiety abound. A critical review is given of the most influential approaches (e.g. psychoanalytical, "somatogenic", behavioural, psychophysiological and "biological" theories), with emphasis on panic and agoraphobic disorders. Evidence is presented from epidemiological and genetic research and from observations on the course of illness. A surprisingly constant prevalence of anxiety syndromes, and a familial distribution suggesting a pivotal importance of genetic factors, speak in favour of a biological model. The course of illness, however, points to the importance of environmental influences as triggering factors, and to cognitive and behavioural mechanisms for the perpetuation of the symptoms. Treatment responses hitherto documented support the biological and behavioural concepts, but the cognitive and psychophysiological theories are also supported to some extent. An attempt is made to combine these findings with biochemical and pharmacological findings in an integrated model of panic and agoraphobia. This model takes the form of a vicious circle, and is compatible with biological and neuropharmacological as well as evolutionary and psychological concepts.

Chest pain with normal coronary arteries: a comparative study of psychiatric and social morbidity

Ninety-nine patients with chest pain and a presumptive diagnosis of coronary heart disease were assessed blindly within 24 hours of angiography, using standardized psychiatric and social interviews and a personality inventory. Thirty-one patients had normal coronary arteries (NCA), 15 had slight disease and 53 had significant coronary obstruction. Twenty-eight (61%) of the 46 patients with insignificant disease and 12 (23%) of the 53 with significant obstruction had psychiatric morbidity. Associations between the overall severity of psychiatric morbidity and measures of social maladjustment were strongest in the patients with normal coronary arteries. The 26 men with insignificant coronary artery disease had higher scores of neuroticism and extraversion than the 41 with important coronary occlusions. No differences were observed when the same comparisons were made for the women. The findings indicate that approximately two thirds of patients with normal and near-normal coronary arteries have predominantly psychiatric rather than cardiac disorders: the symptoms in these patients are more likely to represent the somatic manifestations of anxiety and overbreathing than the consequences of underlying cardiac disease. Physicians should be aware of the ways in which neurotic illness may present with symptoms mimicking cardiac disease, especially when cardiovascular symptoms are accompanied by phobic symptoms and unexplained shortness of breath.