An association between anxiety and neurocardiogenic syncope during head-up tilt table testing

A complex interplay between autonomic symptoms and symptoms of depression, anxiety, and stress

BACKGROUND

We evaluated the influence of symptoms of depression, anxiety, and stress on the results of COMPASS-31 in a large population of people referred to the head-up tilt test (HUTT) and healthy controls (HC).

METHODS

Nine hundred fifty-nine consecutive patients referred to HUTT and 518 HC were enrolled. All participants completed Composite Autonomic Symptom Score-31 (COMPASS-31). Stress symptoms were evaluated by Depression, Anxiety, and Stress-21 (DASS-21) questionnaire. We corrected the result of the COMPASS-31 with the independent predictors in order to improve the specificity of the test.

RESULTS

In both patients and HC, COMPASS-31 was higher in participants with depression, anxiety, and stress symptoms (all p < 0.001). In a multivariable linear regression analysis, HC was negative, while female sex and symptoms of depression, anxiety, and stress were independent positive predictors of COMPASS-31. In HC, COMPASS-31 had a median of 7.913, and this value differentiated between HC and patients with a high sensitivity of 87% and low specificity of 50%. In order to adjust the value of COMPASS-31 with the parameters that were significant in the multivariable linear regression model, we calculated the new corrected COMAPSS-31 (cCOMPASS-31), which had comparable sensitivity of 77%, but an increased specificity of 73%.

CONCLUSION

This study has shown that symptoms of depression, anxiety, and/or stress worsen the perceived severity of autonomic symptoms in people with symptoms of orthostatic intolerance and healthy population. cCOMPASS-31 is a valuable tool that can help clinicians in discerning the true autonomic background of patients' complaints.

The relationship between clinical characteristics and psychological status and quality of life in patients with vasovagal syncope

OBJECTIVE:

Syncope is characterized by sudden and short-term loss of postural tone and consciousness. Vasovagal syncope (VVS) episode is usually self-limiting, and it may affect patients’ quality of life. In this study, we aimed to investigate the relationship between quality of life, Beck-depression and Beck-anxiety scales and clinical characteristics of the VVS patients.

METHODS:

The present study included 88 patients with VVS. Tilt table test was performed to all the patients. Patients filled out the Quality of life, Beck-depression, and Beck-anxiety scale forms. Demographics, medical history, echocardiography, blood pressures, electrocardiography and physical examination findings were recorded.

RESULTS:

There was a significant and negative correlation between the total syncope episodes (TSE) and EQ-5D index and EQ-5D-VAS index, respectively (p<0.001, r: -0.649; p<0.001, r: -0.587). TSE was significantly and positively correlated with the Beck-anxiety scale and Beck-depression scale. EQ-5D index, EQ-5D-VAS index, Beck-depression scale, and Beck-anxiety scales were defined as an independent predictor of TSE in VVS patients.

CONCLUSION:

Psychological factors play an essential role in VVS patients. EQ-5D index, EQ-5D-VAS index, Beck-depression, and Beck-anxiety scales were an independent predictor of the TSE in patients with VVS.

Reduced quality of life and greater psychological distress in vasovagal syncope patients compared to healthy individuals

BACKGROUND

Vasovagal syncope (VVS) patients have a reduced health-related quality of life (HRQoL). There are limited data comparing HRQoL and psychological profile in VVS patients and healthy individuals. We tested the hypothesis that VVS patients have greater impairment in both HRQoL and psychological profile compared to healthy nonfainting individuals, and that both outcome measures are negatively correlated for VVS patients.

METHODS

The RAND 36-Item Health Survey (RAND36), global health visual analogue scale (VAS), Hospital Anxiety and Depression Scale, Anxiety Sensitivity Index, and Positive and Negative Affect Schedule - Expanded Form were completed by healthy individuals and at baseline by VVS patients enrolled in the Second Prevention of Syncope Trial, a randomized, placebo-controlled trial of fludrocortisone for VVS.

RESULTS

Data were available on 76 VVS patients (34 ± 14 years; 68% F) and 85 healthy participants (35 ± 11 years; 80% F). Compared to healthy participants, VVS patients reported poorer HRQoL on all scales of the RAND36 and the VAS. VVS patients had significantly greater anxiety, depression, and anxiety sensitivity (each P < 0.001). VVS patients had more negative affect (P < 0.001) and less positive affect (P = 0.003) compared to healthy participants. Anxiety, depression, and anxiety sensitivity were negatively correlated with HRQoL for VVS patients, but not for healthy participants.

CONCLUSION

In this first direct comparison, VVS patients have a significantly reduced HRQoL and more anxiety and depression compared to healthy nonfainting individuals. For VVS patients, there is a relationship between psychological distress and HRQoL, suggesting a potential benefit from more comprehensive assessment and treatment.

Neurovisceral phenotypes in the expression of psychiatric symptoms

This review explores the proposal that vulnerability to psychological symptoms, particularly anxiety, originates in constitutional differences in the control of bodily state, exemplified by a set of conditions that include Joint Hypermobility, Postural Tachycardia Syndrome and Vasovagal Syncope. Research is revealing how brain-body mechanisms underlie individual differences in psychophysiological reactivity that can be important for predicting, stratifying and treating individuals with anxiety disorders and related conditions. One common constitutional difference is Joint Hypermobility, in which there is an increased range of joint movement as a result of a variant of collagen. Joint hypermobility is over-represented in people with anxiety, mood and neurodevelopmental disorders. It is also linked to stress-sensitive medical conditions such as irritable bowel syndrome, chronic fatigue syndrome and fibromyalgia. Structural differences in “emotional” brain regions are reported in hypermobile individuals, and many people with joint hypermobility manifest autonomic abnormalities, typically Postural Tachycardia Syndrome. Enhanced heart rate reactivity during postural change and as recently recognized factors causing vasodilatation (as noted post-prandially, post-exertion and with heat) is characteristic of Postural Tachycardia Syndrome, and there is a phenomenological overlap with anxiety disorders, which may be partially accounted for by exaggerated neural reactivity within ventromedial prefrontal cortex. People who experience Vasovagal Syncope, a heritable tendency to fainting induced by emotional challenges (and needle/blood phobia), are also more vulnerable to anxiety disorders. Neuroimaging implicates brainstem differences in vulnerability to faints, yet the structural integrity of the caudate nucleus appears important for the control of fainting frequency in relation to parasympathetic tone and anxiety. Together there is clinical and neuroanatomical evidence to show that common constitutional differences affecting autonomic responsivity are linked to psychiatric symptoms, notably anxiety.

Prevalence and clinical factors of anxiety and depression in neurally mediated and unexplained syncope

PURPOSE

Several studies have demonstrated that psychiatric disorders such as anxiety, depression and panic attack are associated with syncope, especially vasovagal and unexplained syncope (US). The aim of this study was to compare the prevalence of anxiety and depression between patients with neurally mediated syncope (NMS) and US and to investigate the clinical factors associated with anxiety and depression.

MATERIALS AND METHODS

Between January 2009 and March 2010, 383 patients with syncopal episodes completed a Hospital Anxiety and Depression Scale questionnaire to assess symptoms of anxiety and depression. Inclusion criteria were NMS and US. Exclusion criteria were cardiac syncope, orthostatic hypotension and other disorders mimicking syncope. After exclusion, 199 patients were included.

RESULTS

There were 176 (88.4%) NMS patients and 23 (11.6%) US patients. The prevalence of abnormal anxiety and depression were not significantly different between the NMS and US groups (10.2% vs. 8.7%, p=0.99; 8.5% vs. 17.4%, p=0.24). Clinical factors associated with anxiety were female gender (p=0.01) and six or more recurrent syncopal episodes (p=0.01) by univariate analysis. The only factor associated with abnormal anxiety score (OR=20.26, 95% CI: 1.4-291.6, p=0.01) was more than six recurrent syncopal episodes, while a positive head-up tilt table testing response was inversely associated with abnormal depression score (OR=0.28, CI: 0.08-0.97, p=0.04) in the multiple logistic regression analysis.

CONCLUSION

Anxiety was associated with frequent syncopal episodes. Thus, anxiety might be considered in the management of syncope patients.

Psychological correlates of vasovagal versus medically unexplained syncope

OBJECTIVE

Psychiatric morbidity is quite common in vasovagal syncope (VVS), but findings are sometimes contradictory. Among patients with suspected VVS, up to 40% has a negative response to Head-Up Tilt test (HUT), the cause of syncope remaining unexplained (US). The authors evaluated and compared the psychological and psychosomatic profile in patients with positive (VVS) and negative HUT (US).

METHOD

A consecutive series of 67 patients with suspected VVS underwent HUT: 45 patients had a positive HUT, 22 negative. They were evaluated by means of observer- and self-rated measures.

RESULTS

Of the total sample, 95.5% had at least one Diagnostic and Statistical Manual of Mental Disorders diagnosis or one psychosomatic syndrome, such as specific and social phobias, illness denial and demoralization. Comparing VVS and US patients, no statistical differences on diagnoses' frequencies were found. However, the US group had significantly poorer health habits, lower levels of well-being and higher psychological distress. They also reported to be more anxious, depressed and hostile. VVS patients were significantly more blood and social phobic than US patients.

CONCLUSION

Despite similar and remarkable observer-rated psychopathology, US patients reported higher self-perceived psychological distress than VVS patients. Psychological evaluation of patients undergoing HUT should incorporate both clinical and subclinical methods to better address syncope management.

Depressive symptoms and neurocardiogenic syncope in children: a 2-year prospective study

OBJECTIVE

To evaluate prospectively the relationship between neurocardiogenic syncope (NCS) and depressive symptoms in pediatric patients.

METHODS

Forty-five patients (aged 12.3 ± 2.9 years) with NCS (diagnosed as ≥ 1 syncopal episodes with typical symptoms, reproduced by tilt-table testing, in the absence of structural or primary electrical heart disease) were compared with 45 age- and gender-matched control subjects. Assessment was performed at baseline and 2 years thereafter. Depressive symptoms and self-perception profile of participants were evaluated, along with their parents' psychological distress, defensive profile and hostility. Family cohesion and adaptability, as well as the opinion of parents and teachers on children's strengths and difficulties, were also examined.

RESULTS

At baseline, patients showed more (P = .008) depressive symptoms than controls, correlating with the number of syncopal episodes, impaired relationship with parents and poor family cohesion. A conservative management strategy of NCS was adopted and psychological counseling was offered, focusing on patients with clinically significant depressive symptoms and their families. During follow-up, depressive symptoms decreased in patients (P < .001), but remained stable in controls. Child-parent relationship, family cohesion and family adaptability improved at follow-up in patients. No recurrent syncope was noted during follow-up and this along with improvement in child-parent relationship were associated with depressive symptoms improvement.

CONCLUSIONS

Depressive symptomatology is common in pediatric patients with NCS. Our findings call for additional investigation in larger controlled clinical interventional studies that will enhance understanding of the possible pathophysiological association between depressive symptomatology and NCS in pediatric populations.

Association between psychological complaints and recurrence of vasovagal syncope

PURPOSE

Vasovagal syncope (VVS), the most common cause of transient loss of consciousness (T-LOC), is often accompanied by higher levels of psychological distress. We investigated to what extent psychological complaints interact with the effects of non-pharmacological treatment in patients with frequently recurring VVS.

METHODS

Patients with ≥3 episodes of VVS in the 2 years prior to the start of the study openly received non-pharmacological treatment. Before treatment initiation, we determined the level of general psychological complaints by the Symptom Checklist 90-R (SCL-90-R) questionnaire. We regularly evaluated syncopal recurrence during follow-up. We compared the SCL-90-R scores of VVS patients in our study with the corresponding scores of healthy Dutch subjects (reference population). We examined whether patients with more recurrences during follow-up had higher SCL-90-R scores at baseline and whether this association changed when adjusting for other factors associated with recurrence using logistic regression.

RESULTS

Total SCL-90-R scores were higher in our cohort of patients with frequent episodes of VVS than in the reference population (142 vs. 118; p < 0.001). During the first 6 months of treatment, 42% of patients experienced syncopal recurrence(s). The SCL-90-R scores of these patients were significantly higher compared with patients without syncopal recurrence in this period (160 vs. 130; p = 0.01). After adjusting for other predictors of recurrence, especially the number of episodes before inclusion, the association between SCL-90-R scores and recurrence remained intact.

CONCLUSIONS

Levels of general psychological complaints are higher in patients with syncopal recurrence during non-pharmacological treatment of VVS, even after adjusting for previous syncopal episodes.

Disorders of the autonomic nervous system in patients with Brugada syndrome: a pilot study

INTRODUCTION

The aim of this study was to examine autonomic disorders in patients with Brugada syndrome by performing a cardiac sympathetic innervation evaluation, a head-up tilt-test (HUT) and heart rate variability (HRV) analysis.

METHODS AND RESULTS

We enrolled 20 patients with Brugada syndrome (mean age 42.5 +/- 8.8 years), 9 with spontaneous and 11 with an induced type 1 electrocardiogram (ECG) in the setting of symptoms and 20 age-matched controls. All subjects underwent a HUT with parallel measurements of plasma catecholamines and cortisol, a (123)I-metaiodobenzylguanidine single photon emission tomography, and HRV evaluation. Ten control subjects participated in the innervation portion of the study. The tilt-test with clomipramine challenge was positive in 15 of 20 (75%) patients (7 spontaneous, 8 induced) and in 1 in controls (P < 0.01). A sympathoadrenal imbalance was shown in positive tests. The pattern of innervation in all groups was heterogenic and similar to controls with a trend towards lower measurements in patients with a spontaneous type 1 ECG and a positive HUT. HRV analysis did not reveal any significant differences during day and night. Four patients (20%) had sustained ventricular arrhythmias during a follow-up of 31.1 +/- 8.6 months, but no correlations with innervation or response to tilting were found.

CONCLUSION

A high susceptibility to vasovagal syncope was observed in patients with Brugada syndrome, which could be disease-related symptoms. Conversely, sympathetic innervation was observed to follow a physiological, heterogenic pattern; however, these factors did not have prognostic value for life-threatening arrhythmias.

Prospective evaluation of psychological distress and psychiatric morbidity in recurrent vasovagal and unexplained syncope

Syncope is experienced by a third of the population, and in the absence of cardiac pathology is most commonly of vasovagal (VVS) or unexplained origin (US). Psychiatric morbidity has been observed in up to 81% of patients with US but findings with VVS are contradictory. Little is known regarding the chronicity of their psychiatric morbidity.

OBJECTIVE

To determine the psychological profile of patients with recurrent syncope prior to and following diagnostic head-up tilt testing (HUT), and whether it predicts syncope recurrence.

METHOD

Seventy-three women and 43 men (mean age=48+/-16.6) were recruited from all consenting patients referred for HUT. Psychological status (Psychiatric Symptom Index, Anxiety Sensitivity Index (ASI), Fear of Blood Injury Subscale) and presence of mood/anxiety disorders (Primary Care Evaluation of Mental Disorders) were evaluated 1 month prior to and 6 months following HUT. Follow-up data were collected for 83 patients (mean age=48+/-17.34).

RESULTS

At baseline, clinically significant levels of distress were observed in 60% of patients. Those with US (negative HUT) had a fivefold greater risk of suffering from a depressive or anxiety disorder compared to VVS (positive HUT) after controlling for significant covariates. There was no significant change in distress level over follow-up, although psychiatric morbidity dropped from 33% to 22% (P=.049). Syncope recurrence was predicted by elevations in baseline psychological distress (OR=1.544, P=.013) independently of lifetime number of syncopes.

CONCLUSIONS

Patients exhibited high levels of psychological distress and psychiatric morbidity despite reassurance and education received after HUT. Improved screening for and treatment of psychological distress in these patients is critical.

Vulnerability to simple faints is predicted by regional differences in brain anatomy

Neurocardiogenic syncope (NCS, simple fainting) is a common and typically benign familial condition, which rarely may result in traumatic injury or hypoxic convulsions. NCS is associated with emotional triggers, anxiety states and stress. However, the etiology of NCS, as a psychophysiological process, is poorly understood. We therefore investigated the relationship between NCS and brain anatomy. We studied a non-clinical sample of eighteen individuals with histories characteristic of NCS, and nineteen matched controls who had never fainted. We recorded fainting frequency, resting heart rate variability measures and anxiety levels. Structural T1-weighted magnetic resonance images (MRI) were acquired at 1.5 T. Associations between brain morphometry (regional gray and white matter volumes) and NCS, resting physiology and anxiety were tested using voxel-based morphometry (VBM). Compared to controls, NCS participants had lower regional brain volume within medulla and midbrain (a priori regions of interest). Moreover, across NCS individuals, lower gray matter volume in contiguous regions of left caudate nucleus predicted enhanced parasympathetic cardiac tone, fainting frequency and anxiety levels. Our findings provide preliminary evidence for a hierarchical anatomical basis to NCS. First, differences in the volume of brainstem centers supporting cardiovascular homeostasis may relate to constitutional predisposition to NCS. Second, differences in the structural organization of the caudate nucleus in NCS individuals may relate to fainting frequency via interactions between emotional state and parasympathetic control of the heart. These observations highlight the application of VBM to the identification of neurovisceral mechanisms relevant to psychosomatic medicine and the neuroscience of emotion.

The role of psychological factors in response to treatment in neurocardiogenic (vasovagal) syncope

AIMS

Studies have established a link between vasovagal syncope (VVS) and anxiety, depression, and functional impairment. This study examines the prevalence of psychological problems in patients with VVS and whether non-responders are psychologically different from those whose symptoms respond to conservative treatment.

METHODS AND RESULTS

Subjects with tilt-confirmed VVS completed the hospital anxiety and depression scale (HADS) (measures current levels of anxiety and depression) and the syncope functional status questionnaire (SFSQ) (syncope-specific quality-of-life measure) and participated in a semi-structured interview to ascertain potential triggers, thought content, and coping strategies. In this study, 41 subjects participated. There was no difference in gender and age duration of symptoms between responders (n=21) and non-responders (n=20). Non-responders were significantly more anxious (P=0.003) and depressed (P=0.003) and had a higher level of state (P=0.008) and trait (P=0.004) anxiety than responders. Non-responders reported more fear/worry (P=0.02), a significantly higher degree of impairment owing to syncope (P=0.01), and a greater number of perceived triggers (P=0.039); on average, participants reported eight negative thoughts about the consequences of VVS, with particular emphasis on threats of physical harm or death. Non-responders had higher levels of avoidance/protection coping and rumination.

CONCLUSION

This study has confirmed that patients with VVS have a significant degree of psychological distress, which is worthy of consideration in its own right, out with management purely aimed at reducing syncopal or pre-syncopal symptoms. Further, this distress may actually influence the natural history of what is a chronic relapsing condition and may in fact be more relevant to the patient than the number of syncopal episodes that they are experiencing.

Prevalence and prognostic significance of psychiatric disorders in patients evaluated for recurrent unexplained syncope

We aimed to assess the psychiatric profile and prognostic value of psychiatric disorders (PDs) in patients presenting with unexplained syncope. Forty patients with recurrent unexplained syncope referred for head-up tilt testing were compared with age- and sex-matched patients free of known chronic PDs referred for arrhythmia. All patients underwent a semistandardized psychiatry questionnaire (Mini-International Neuropsychiatric Interview) to assess their profile. Additional stress coping was performed to study adaptational processes to stressful situations. After tilt testing and psychiatric evaluation, a drug-free follow-up was performed in patients with syncope. Of the 80 patients who referred to the psychiatric interview, 40 had evidence of at least 1 psychiatric disorder. They were 26 patients (65%) in the syncope group and 14 patients (35%) in the control group (p = 0.01). Detailed analysis revealed a more frequent subprofile of anxiety and panic disorders in patients with syncope than in controls (30% vs 12% and 20% vs 10%, respectively), whereas the subprofile of depression was similar in both groups. Moreover, those with syncope were more likely to have a high anxiety index (25 +/- 5 vs 22 +/- 4, p = 0.004), and were more prone to avoidance-oriented coping strategies when experiencing undesirable life events than controls. Considering syncope patients, no difference could be found between the 25 with a positive tilt test and the 15 with a negative tilt test with respect to the number of syncopal episodes and psychiatric profile. After a 3-year drug-free follow-up, 15 patients (37.5%) had at least 1 recurrent syncope. The recurrence rate was similar in patients with positive and negative head-up tilt test results (9 of 25 vs 6 of 15, respectively). In contrast, the syncopal recurrence rate was higher in patients who fulfilled criteria for affective disorders (13 of 26 vs 2 of 14, 95% confidence interval 1.09 to 2.55, relative risk 1.7, p = 0.04). Thus, patients with recurrent unexplained syncope are more anxious and are more prone to panic disorders and avoidance-oriented coping strategies than control patients with arrhythmia. The presence of a psychiatric disorder is associated with an increased risk of recurrence. The outcome of such patients may be improved with recognition and treatment of PDs.