Atypical chest pain and panic disorder

[The Coupling of Pain, Anxiety, and Stress]

The Coupling of Pain, Anxiety, and Stress Abstract. There is considerable neurobiological, clinical and epidemiological evidence that the systemic phenomena of anxiety and pain closely interact. Both perceptions trigger stress activation processes and are in turn modulated by long-term stress. This overview illustrates the coupling of pain, anxiety and stress with some clinical examples. The relations shown here should help us to gain a holistic view of the individual patient and his/her psychosocial reality, in which nociceptive, affective and vegetative symptoms are often interdependent and mutually reinforcing each other.

The association of depression and anxiety with pain: a study from NESDA

Chronic pain is commonly co-morbid with a depressive or anxiety disorder. Objective of this study is to examine the influence of depression, along with anxiety, on pain-related disability, pain intensity, and pain location in a large sample of adults with and without a depressive and/or anxiety disorder. The study population consisted of 2981 participants with a depressive, anxiety, co-morbid depressive and anxiety disorder, remitted disorder or no current disorder (controls). Severity of depressive and anxiety symptoms was also assessed. In separate multinomial regression analyses, the association of presence of depressive or anxiety disorders and symptom severity with the Chronic Pain Grade and location of pain was explored. Presence of a depressive (OR = 6.67; P<.001), anxiety (OR = 4.84; P<.001), or co-morbid depressive and anxiety disorder (OR = 30.26; P<.001) was associated with the Chronic Pain Grade. Moreover, symptom severity was associated with more disabling and severely limiting pain. Also, a remitted depressive or anxiety disorder showed more disabling and severely limiting pain (OR = 3.53; P<.001) as compared to controls. A current anxiety disorder (OR = 2.96; p<.001) and a co-morbid depressive and anxiety disorder (OR = 5.15; P<.001) were more strongly associated with cardio-respiratory pain, than gastro-intestinal or musculoskeletal pain. These findings remain after adjustment for chronic cardio respiratory illness. Patients with a current and remitted depressive and/or anxiety disorder and those with more severe symptoms have more disabling pain and pain of cardio-respiratory nature, than persons without a depressive or anxiety disorder. This warrants further research.

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.

Anxiety disorder in patients with non-specific chest pain in the emergency setting

OBJECTIVES

Many patients who have been discharged from the emergency department (ED) with a diagnosis of "non-specific chest pain" (NSCP) have anxiety disorder (AD), a commonly missed entity in acute care. The objective of this study was to delineate characteristic properties that could enhance recognition of AD in ED patients admitted with NSCP.

METHODS

All patients between 18 and 65 years of age diagnosed with NSCP were enrolled. The Hospital Anxiety and Depression Scale (HADS) anxiety subscale was used as a screening test for AD. The patients with high HADS scores (> or = 10) were evaluated by a psychiatrist for AD.

RESULTS

In total, 157 patients were enrolled in the study. HADS scores were found to be "high" (> or = 10) in 49 patients (31.2%). Patients with high HADS scores had a higher frequency of associated symptoms (p = 0.004). Dizziness or lightheadedness, chills or hot flushes, and fear of dying were found to have been reported more frequently by patients with high anxiety scores. Of the group with high score, 33 patients (67.3%) were interviewed by a psychiatrist, and 23 (69.7%) of these patients were diagnosed with AD. Associated symptoms were described by 21 patients with AD (91.3%). Of those with AD, 18 (78.3%) had been previously admitted to the ED with chest pain. Atypical chest pain was described by 21 patients (91.3%).

CONCLUSIONS

Physicians should always consider AD in patients presenting to the ED with chest pain after ruling out organic aetiology. Patients' definition of atypical pain, recurrent admissions to ED, and presence of associated symptoms such as dizziness, chills or hot flushes, and fear of dying could aid in considering AD.

Panic in the emergency room

OBJECTIVE

This paper examines the relation between coronary artery disease (CAD) and panic disorder (PD), discusses the implications of this relation to the general medical system, and suggests future assessment and intervention strategies for emergency departments.

METHOD

We reviewed the literature on CAD and PD using Medline and PsycINFO.

RESULTS

PD is more expensive to our nonpsychiatric, general medical system than any other psychiatric condition. The main reason for PD patients' continued use of general medicine for their psychological symptoms is that their PD remains undiagnosed. In the emergency room (ER), PD patients with chest pain have their PD go undiagnosed about 98% of the time. By having ERs implement specific assessment and intervention strategies for patients presenting with chest pain, the savings to the general medical system could be substantial.

CONCLUSIONS

By improving recognition of PD in the ER, there is the potential to generate large savings in general medical care. With the availability of empirically supported or effective psychological and pharmacologic treatments for PD, appropriately diagnosing and subsequently treating patients with PD may prevent them from experiencing many years of disability and higher rates of fatal coronary events.

Predicting panic disorder among patients with chest pain: an analysis of the literature

As many as 25% of patients with chest pain who come to hospital emergency departments have panic disorder. Rates of panic disorder are even higher among those who present for outpatient evaluation of their chest pain. Unfortunately, panic disorder remains largely undiagnosed and untreated in these settings. The authors reviewed studies published between 1970 and 2001 that addressed the prevalence of panic disorder among persons who seek treatment for chest pain in an emergency department or outpatient cardiology clinic. A meta-analysis of the findings revealed five variables that appear to correlate with higher rates of panic disorder among persons who present with chest pain: 1). absence of coronary artery disease, 2). atypical quality of chest pain, 3). female sex, 4). younger age, and 5). a high level of self-reported anxiety. Further studies of these and other variables associated with panic disorder should aid in the detection of this disabling but treatable cause of chest pain.

Psychosocial factors in patients with noncardiac chest pain

OBJECTIVE

This study sought to explore some psychosocial factors that distinguished individuals with noncardiac chest pain (NCCP) from those without NCCP, and whether these psychosocial factors were associated with anxiety and depression that are co-morbid factors of NCCP.

METHODS

A matched case-control design was adopted to compare differences in psychosocial factors among a target group of patients with NCCP (N = 70), a pain control group of patients with rheumatism (N = 70), and a community control group of healthy individuals (N = 70).

RESULTS

Compared with subjects from the two control groups, NCCP patients tended to monitor more, use more problem-focused coping, display a coping pattern with a poorer strategy-situation fit, and receive less emotional support in times of stress. Moreover, monitoring perceptual style and problem-focused coping were associated with higher levels of anxiety and depression. Coping pattern with a strategy-situation fit and emotional support were related to lower levels of anxiety and depression.

CONCLUSIONS

The present new findings suggest that monitoring perceptual style and inflexible coping style are risk factors that enhance one's vulnerability to NCCP. Emotional support may be a resource factor that reduces one's susceptibility to NCCP.

Personality profiles in patients referred for chest pain. Investigation with emphasis on panic disorder patients

Patients (N = 199) referred to cardiac outpatient investigation because of chest pain were assessed with the Personality Diagnostic Questionnaire (PDQ-4). Thirty-nine percent scored positive for any personality disorder. Borderline and avoidant personality disorders were found significantly more often in patients with panic disorder (PD) (n = 72) than in patients without PD (12.5% vs. 2.5%, 23.7% vs. 7.7%, respectively). In PD patients, the presence of any personality disorder was significantly associated with higher scores of self-reported anxiety-agoraphobia symptoms, neuroticism, and the presence of suicidal thoughts. These results suggest that personality pathology is important in a subgroup of patients presenting with chest pain and that these patients may require more extensive treatment.

Medical assessment of patients presenting with psychiatric symptoms in the emergency setting

Psychiatrists in the emergency department (ED) are often asked to evaluate patients with disturbances of affect, behavior, and cognition. The first and most crucial step in the evaluation process is to eliminate possible medical causes for a patient presenting psychiatric symptoms. Failure to detect and diagnose underlying medical disorders may result in significant and unnecessary morbidity and mortality.

Panic disorder in chest pain patients referred for cardiological outpatient investigation

OBJECTIVES

The aims of the study were to: (i) determine the prevalence of panic disorder (PD) in patients referred to cardiological outpatient clinics for evaluation of chest pain; (ii) compare psychiatric comorbidity, psychological distress, pain characteristics and suicidal ideation in PD and non-PD patients: (iii) compare the prevalence of coronary risk factors and medical comorbidity in PD and non-PD patients; and (iv) describe current PD treatment and need for PD treatment as expressed by PD patients.

DESIGN

A cross-sectional study based on psychiatric and cardiological investigation.

SETTING

Four cardiological outpatient clinics in Oslo, Norway.

SUBJECTS

One-hundred and ninety-nine consecutive patients without known heart disease referred to out-patient clinics for investigation of chest pain.

MAIN OUTCOME MEASURES

Psychiatric state diagnosis (axis I); scores on self-assessment rating scales of psychological factors and pain modalities; cardiological diagnosis.

RESULTS

Thirty-eight per cent of the patients met criteria for current panic disorder (PD). Panic disorder was associated with psychological distress, comorbid psychiatric disorders, medical disorders and significantly higher prevalence of coronary risk factors (P<0.05). Furthermore. the results suggest that these patients were not identified and appropriately treated for panic disorder prior to cardiological investigation. The results indicate that the patients are positive to screening for psychiatric disorder and communicate a need for treatment early in the investigation process.

CONCLUSION

PD commonly occurs in this chest pain population. Thus, there is a need to educate physicians caring for these patients about PD identification and treatment.

Panic disorder associated with gastrointestinal disease: review and hypotheses

An association between panic disorder and functional gastrointestinal disease has emerged since the introduction of reliable diagnostic criteria, first for psychiatric disorders and more recently for functional gastrointestinal disorders. At the same time, a more rigorous review of methodology of older reports linking structural gastrointestinal diseases such as peptic ulcer and inflammatory bowel disease to psychiatric illness has cast doubt on the validity of their association. In this review original articles reporting an association between panic disorder and globus, functional chest pain of presumed esophageal origin, functional dyspepsia, and irritable bowel syndrome are critically reviewed and it is concluded that panic disorder is overrepresented in noncardiac chest pain and irritable bowel syndrome. Original reports of the prevalence of panic disorder in structural gastrointestinal disease are reviewed and it is concluded that they do not support an association with panic. Hypotheses explaining the statistical link of panic disorder and functional gastrointestinal disease are discussed.

Psychological symptom profiles in patients with chest pain

Five-hundred and thirty-two patients with ischaemic-like chest pain referred for symptom-limited exercise thallium myocardial perfusion studies, were assessed on a range of psychosocial measures. Three groups of patients were identified on the basis of their perfusion studies: (1) normal thallium perfusion; (2) current myocardial ischaemia; and (3) past myocardial infarction (but no current ischaemia). There were no significant psychological differences between these groups on a wide range of measures which included depression, state and trait anxiety, Type A behaviour, personality, suppression of affect, locus of control, alexythymia, and hypochondriasis. Significant differences were identified, however, on measures of anger and coping style. Subjects with no current ischaemia (normal thallium perfusion and those with past myocardial infarction) had higher scores on 'immature coping' and 'anger in', than subjects with current myocardial ischaemia. These findings are discussed in the light of other published research.

The relationship between mental health and drug use

The aim was to examine the relationship between mental health and use of different kinds of drugs. The study was a cross-sectional survey of a total population aged 45-69 years, conducted in 2 municipalities in southwestern Finland. Altogether 1821 people (80% of those invited), 815 men and 1006 women, took part in the screening. The subjects were examined by a questionnaire mailed beforehand and checked in a personal interview. The questionnaire contained questions about the currently used drugs and Goldberg's questionnaire on mental health. Half of the people examined used prescribed drugs currently, more women used drugs than men, and the use of drugs increased with age. Mental symptoms measured with the Goldberg Index appeared in one fifth of the subjects, showing a slight increase with age. Men with mental symptoms showed a fourfold psychotropic drug use compared with the men without mental symptoms. The women with mental symptoms showed a threefold use of psychotropic drugs compared with the women without mental symptoms. Similar differences were found also in other drug groups, for example cardiac glycosides, other cardiovascular drugs, analgesics and drugs for respiratory and digestive organs. Persons with mental disorders showed a high tendency to drug use, also when those drugs had no direct attachment to the mental problem. Men seemed more liable to somatization of mental problems than women.

Functional gastrointestinal disorders in unselected patients with non-cardiac chest pain

Patients with non-cardiac chest pain (NCCP) (n = 387) and cardiac chest pain (CCP) (n = 93) were compared with community controls (n = 81), using a symptom questionnaire that assessed the presence of irritable bowel syndrome (IBS), functional dyspepsia, and oesophageal dysfunction and chest pain characteristics. A significantly (p < 0.05) increased prevalence of symptoms compatible with IBS occurred in NCCP patients when compared with those with CCP and with controls. Dysphagia was more frequent in both those with non-cardiac and cardiac chest pain than in controls; this was not apparent, however, when patients with concomitant IBS were excluded. The presence of oesophageal or gastrointestinal symptoms did not enable discrimination with regard to the chest pain characteristics. We conclude that unselected referred patients with documented NCCP are more likely to have IBS and that the presence of oesophageal symptoms such as dysphagia may merely reflect the spectrum of the 'irritable gut'.