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Query: UMLS:C0008031 (chest pain)
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Patients with panic disorder often complain of angina-like chest pain during panic attacks, but this is not usually considered life-threatening. We describe three patients with panic disorder and documented cardiac ischaemia during episodes of chest pain. In two, it progressed to myocardial infarction. As none had atherosclerosis evident at coronary angiography, the mechanism was presumed to be coronary artery spasm. These cases illustrate that pain typical of angina during panic attacks may have an organic cause.
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PMID:Panic disorder: coronary spasm as a basis for cardiac risk? 959 45

Disorders of the cardiovascular system are common. Heart pain is one of the most frequent complaints leading patients to seek medical help. Although psychologically conspicuous behaviour in patients with functional cardiac complaints are well known, they are--if at all--diagnosed quite late. Descriptive diagnostics of functional cardiac complaints according to the International Classification of Diseases (ICD-10, Chapter 5) are discussed (Figure 1). Possible physical causes of the disease must first be excluded. In a second step it must be clarified whether the complaints even those non-verbally conveyed are due to psychic illness in a narrower sense. Anxiety and depressive disorders must be taken into consideration here. If the patient demonstrates an avoidance behavior in the case of anxiety, than an agoraphobia can be assumed; in episodic paroxysmal fear on can assume panic attacks in which vegetative anxiety equivalents such as shortness of breath, numbness, palpitation of the heart, tachycardia and chest pain are prominent often accompanied by trembling, perspiration, nausea and dizziness. The different depressive disorders are characterized by a dejected mood, loss of interest, loss of enthusiasm and drive reduction; the disorders are divided up according intensity and course. Within the scope of depressive physical symptoms, frequently unpleasant sensations and pain in the chest area are described along with concern, despair, and an increase in self-observation. If no psychic disturbance in a narrower sense can be diagnosed, then the diagnosis of a somatoform disorder allows for this behavior. It is characteristic for this category of illness that the repeated presentation of physical symptoms in connection with the persistent demand for medical treatment may be observed although no physical causes can be demonstrated. The patients insist that their complaints are of a physical origin despite the doctor's assertion that this is not the case. If the symptoms are related to vegetative innervated organs then one speaks of somatoform autonomous functional disorders (F45.3, Table 1). Cardiovascular disorders fall within this scope. Further diagnoses within the spectrum of somatoform disorders are hypochondric and somatization disorders which demonstrate a variety of symptoms and inconsistent and frequently changing complaints. If a descriptive diagnosis can correspondingly be made then further analysis of the disorder must be carried out in order to reach an indication for psychotherapeutic treatment. From a psychodynamic point of view, the personality- and conflict-related background of the disturbance is relevant. Quite often unconscious ambivalent separation conflicted--be they real are fantasized situations of being left or being left alone--may be observed to trigger cardiovascular symptoms. In the cognitive-behavioral therapeutic tradition an exact analysis of the patients symptomatology is carried out in which prior and actual cause factors of the symptoms are looked for. Irrespective of the different approaches, information on the context of the complaints both on a biological, intrapsychic and interpersonal level is necessary for psychosomatic diagnostics. The better the causal conditions are known on the basis of which functional cardiovascular complaints have arisen, the easier it is to recognize those factors that will influence a change and allow a therapeutic approach. This is best done in cooperation with practitioners and internists who still have a key position in the diagnosis and treatment of patients with functional cardiac disorders. The ways and means in which they conduct the anamnesis is decisive in leading their patients to regard psychosomatic diagnostics as being either stuck in the so-called "psycho corner" or as a helpful relationship which they can accept.
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PMID:[Diagnosis of functional heart complaints from the psychosomatic viewpoint]. 1037 96

Chest pain is a common presentation to both primary and secondary care physicians but is often non-cardiac in origin. Patients presenting with chest pain may be experiencing a panic attack. Panic disorder is a disabling psychiatric condition with serious consequences, such as impaired social functioning and increased risk of suicide. Comorbidity of panic disorder with other psychiatric conditions is common and often leads to increased severity of anxiety symptoms and a poorer prognosis. The cost of misdiagnosing non-cardiac chest pain is high. It is important for physicians to be able to recognise panic attacks and to distinguish them from cardiac disease, thus avoiding unnecessary use of healthcare resources. This review discusses the prevalence and diagnosis of panic attack and panic disorder in patients presenting with chest pain to primary care physicians and cardiologists. Treatment options for panic disorder are considered, particularly the selective serotonin reuptake inhibitors, which are emerging as the first-line choice for the treatment of panic disorder.
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PMID:Chest pain: panic attack or heart attack? 1119 40

Is it possible to have panic attacks without fear? Beitman et al. reported that 32%-41% of panic disorder (PD) patients seeking treatment for chest pain have non-fearful panic disorder (NFPD). To replicate and extend this work on NFPD, the authors compared NFPD patients (N = 48), PD patients (N = 60), and No-PD patients (N = 333) at the time of an emergency department visit and follow-up approximately 2 years later. The authors compared comorbid Axis I diagnoses, panic attack symptoms, and scores on self-report measures. A significantly greater proportion of PD patients had comorbid generalized anxiety disorder and agoraphobia than NFPD patients. NFPD patients had self-report scores that were between no-PD and PD patients or similar to no-PD patients, with the exception of the Beck Depression Inventory. At follow-up, NFPD patients, like PD patients, were still symptomatic and had either not improved or had worsened according to scores on all self-report measures. NFPD should be recognized as a variant of PD, both because of its high prevalence in medical settings and its poor prognosis.
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PMID:Non-fearful panic disorder: a variant of panic in medical patients? 1090 53

A young person presenting with shortness of breath is common to the accident and emergency department. Usually this hyperventilation is anxiety related or a panic attack, but sometimes it can be caused by a serious underlying condition like pulmonary embolus. Acute shortness of breath in any patient should never be dismissed lightly. It is important to realise that pulmonary embolus can present without chest pain and with shortness of breath as the major symptom. Such patients can be distinguished by close attention to history and examination, risk factors for thromboembolic disease and the use of basic investigations (electrocardiogram, chest radiography and arterial blood gas analysis). A serious cause for shortness of breath must be excluded before labelling it as "hysteria" or "panic".
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PMID:Hyperventilation: cause or effect? 1100 17

Panic disorder (PD) is one of the most common psychiatric illnesses in Thailand but the picture of PD in Thailand is not clear. Therefore, the objective of this research was to review, summarize, and analyse data from research reports concerning the clinical aspects of PD in Thailand. Relevant papers were searched comprehensively. Four groups of data including prevalence and incidence rates, sex differences, clinical symptoms during panic attacks, and scores of the Hamilton anxiety scale (HAM-A) were extracted where available. Data thus obtained were then grouped and compared. It was found that 2.1 per cent to 12.4 per cent of patients who visited the psychiatric outpatient clinic for the first time were diagnosed as having PD. Males were affected at a similar rate to females with a ranging ratio of female:male from 1.3:1 to 0.67:1. The most common symptoms during panic attacks were palpitations, chest pain or discomfort, and dizziness or vertigo, similar to South American studies. Regarding scores of original HAM-A, mean somatic anxiety scores of PD patients who attended the cardiology clinic were significantly higher than generalized anxiety disorder patients (15.0 vs 9.8, p < 0.05). PD patients who attended the psychiatric clinic had higher mean scores of HAM-A when compared to PD patients who visited the cardiology clinic, but it was not statistically significant (27.7 vs 26.6, p > 0.05). However, the fear item of PD patients at the psychiatric clinic had significantly higher scores (2.1) than the other one (0.7). The difference between these findings and those of Western studies may be caused by cultural factors. Thai men tend to react more promptly to panic attacks and seek medical attention while women mostly attributed their symptoms to "Air Disease". However, incidence rates from other rural areas are lacking. Before conclusions can be drawn, research on epidemiologic data in the community should be further investigated.
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PMID:Panic disorder in Thailand: a report on the secondary data analysis. 1114 81

Mitral valve prolapse (MVP), is the most frequent valvulopathy, although it is difficult to evaluate its incidence since this pathology is often asymptomatic. However, in some patients a rich variety of symptoms such as chest pain, dyspnea, palpitations, syncope, dizziness, panic attacks and autonomic dysfunctions have been found. The pathogenesis of these symptoms, incompletely understood, appears to be multifactorial, related to altered autonomic function, adrenergic responsiveness and to combinations of these factors. In patients with MVP a variety of neuroendocrine anomalies has been found: high epinephrine and norepinephrine plasma levels, altered rennin-angiotensin-aldosteron (RAA) response to volume depletion and orthostatic stimulation, and high plasma levels of atrial natriuretic factor (ANF) especially in hypovolaemic individuals. The role of ANF could be important in the genesis of MVP syndrome, it could contribute to determine: the imbalance between the sympathetic and parasympathetic system, the altered RAA response to orthostatic stimulus, the volemic and venous flow reductions (with a direct action, other than diuretic and natriuretic action). Factors that can determine ANF secretion abnormality in MVP could be: 1) Mitral regurgitation; 2) increased heart rate and the high incidence, in MVP syndrome, of arrhythmias; 3) central nervous system neuroendocrine imbalance; 4) increased catecholamines secretion.
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PMID:Atrial natriuretic factor and mitral valve prolapse syndrome. 1153 51

The prevalence of non-fearful panic disorder (panic attacks without the experience of fear) was estimated in 199 patients consecutively referred to outpatient cardiac investigation for chest pain. Fifty-nine patients met the criteria for panic disorder, and 17 patients fulfilled the criteria for non-fearful panic disorder. The patients with non-fearful panic disorder had lower scores on self-reported panic symptoms and lower frequencies of agoraphobia and comorbid axis I disorders than the patients with panic disorder and had a higher prevalence of somatic disorders than the patients without panic disorder. The patients with non-fearful panic disorder did not differ significantly from the patients with panic disorder in health-related quality of life.
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PMID:Nonfearful panic disorder in chest pain patients. 1470 62

Approximately one quarter of patients who present to physicians for treatment of chest pain have panic disorder. Panic disorder frequently goes unrecognized and untreated among patients with chest pain, leading to frequent return visits and substantial morbidity. Panic attacks may lead to chest pain through a variety of mechanisms, both cardiac and noncardiac in nature, and multiple processes may cause chest pain in the same patient. Panic disorder is associated with elevated rates of cardiovascular diseases, including hypertension, cardiomyopathy, and, possibly, sudden cardiac death. Furthermore, patients with panic disorder and chest pain have high rates of functional disability and medical service utilization. Fortunately, panic disorder is treatable; selective serotonin reuptake inhibitors, benzodiazepines, and cognitive-behavioral psychotherapy all effectively reduce symptoms. Preliminary studies have also found that treatment of patients who have panic disorder and chest pain with benzodiazepines results in reduction of chest pain as well as relief of anxiety.
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PMID:Panic Disorder and Chest Pain: Mechanisms, Morbidity, and Management. 1501 45

Panic attacks are a frequently cited cause of noncardiac chest pain. A strict separation of the internist's job (i. e., ruling out an "organic" cause of the patient's complaints) from the psychiatrist's job (e. g., diagnosing and treating panic disorder if present) may not always be the most efficient way of diagnostic work-up. We present the case of a 56-year-old female referred to our institution for elective coronary arteriography. Significant cardiovascular risk factors and symptoms compatible with unstable angina illustrate the common problem of a high probability of cardiac pathology in a patient with possible psychiatric symptoms. A modified SCID-interview complementing the coronary angiography results finally led to the definite diagnosis in this patient after symptoms had been present for over 20 years.
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PMID:[Panic disorder and angina pectoris]. 1525 95


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