The impact of perceived stress and perceived control on anxiety and mood disorders in noncardiac chest pain

Chest pain without detectable heart disease, noncardiac chest pain (NCCP), is linked with anxiety and depression. Theory posits stress and perceived control may relate to NCCP. We hypothesized stress would have direct and mediated effects via perceived control on anxiety and mood disorders in NCCP. Patients (N = 113) completed questionnaires and a structured diagnostic interview. Stress and perceived control were associated with anxiety and mood disorder severity. Perceived control fully mediated the relation between stress and mood disorder severity but not anxiety disorder severity. Results are partially supportive of anxiety-based theories of NCCP.     

Cardiac Exposure History as a Determinant of Symptoms and Emergency Department Utilization in Noncardiac Chest Pain Patients

Although comparative studies differentiate noncardiac chest pain (NCCP), panic disorder, and coronary artery disease (CAD), little research has examined the defining features of NCCP, such as cardiac complaints, medical utilization, and learning history. We administered self-report measures to 80 Emergency Department (ED) patients with a primary complaint of chest pain who were subsequently found to not have CAD. Forty-eight percent of the ED utilization variance was accounted for by NCCP duration, age, cardiac distress symptoms, and prior exposure to both siblings' and friends' cardiac distress symptoms. In turn, 67% of the variance in cardiac distress symptoms was explained by education, age, NCCP duration, number of illnesses, noncardiac panic symptoms, prior exposure (friends), and prior observation of others' cardiac distress. No effects emerged for gender, ethnicity, avoidance, or depression. Results suggest that beyond the effects of age and distress intensity, prior exposure to other people's cardiac distress may influence NCCP.     

Morbidity of DSM-IV Axis I disorders in patients with noncardiac chest pain: Psychiatric morbidity linked with increased pain and health care utilization

The present study examined current and lifetime psychiatric morbidity, chest pain, and health care utilization in 229 patients with noncardiac chest pain (NCCP), angina-like pain in the absence of cardiac etiology. Diagnostic interview findings based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; American Psychiatric Association, 1994) revealed a psychiatrically heterogeneous sample of whom 44% had a current Axis I psychiatric disorder. A total of 41% were diagnosed with a current anxiety disorder, and 13% were diagnosed with a mood disorder. Overall, 75% of patients had an Axis I clinical or subclinical disorder. Lifetime diagnoses of anxiety (55%) and mood disorders (44%) were also prevalent, including major depressive disorder (41%), social phobia (25%), and panic disorder (22%). Patients with an Axis I disorder reported more frequent and more painful chest pain compared with those without an Axis I disorder. Presence of an Axis I disorder was associated with increased life interference and health care utilization. Findings reveal that varied DSM-IV Axis I psychiatric disorders are prevalent among patients with NCCP, and this psychiatric morbidity is associated with a less favorable NCCP presentation. Implications for early identification of psychiatric disorders are discussed.     

Introduction to the special issue on medically unexplained symptoms: background and future directions

This special issue is devoted to the topic of medically unexplained symptoms (MUS), a heterogeneous group of conditions characterized by persistent physical symptoms that cannot be explained by medical illness or injury. Although psychological factors have long been regarded as central to these problems, patients with MUS have typically been managed within medical settings and referrals to mental health services have been relatively rare. In recent years, however, interest in the psychological nature and treatment of MUS has expanded, culminating in the development of tailored psychological interventions for these conditions. This, coupled with the increasing willingness of practitioners to diagnose conditions such as chronic fatigue syndrome, fibromyalgia and irritable bowel syndrome, has led to an increase in the number of patients who are referred for psychological treatment. At present, however, many psychological therapists are unfamiliar with the literature on MUS. With this in mind, this special issue presents a series of papers that provide an overview of what is known about the nature, aetiology and treatment of medically unexplained illness. This introductory paper provides general information about the clinical presentation, diagnosis, classification, terminology and epidemiology of MUS in adults, and concludes with an examination of important areas for future development in the field. Subsequent papers address the psychological mechanisms [Deary, V., Chalder, T., & Sharpe, M. (2007-this issue). The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review. Clinical Psychology Review; Iverson, A., Chalder, T., & Wessely, S. (2007-this issue). Gulf war illness: Lessons from medically unexplained illness. Clinical Psychology Review; Rief, W., & Broadbent, E. (2007-this issue). Explaining medically unexplained symptoms: Models and mechanisms. Clinical Psychology Review; Roelofs, K., & Spinhoven, P. (2007-this issue). Trauma and medically unexplained symptoms: Towards an integration of cognitive and neuro-biological accounts. Clinical Psychology Review] and management [Deary, V., Chalder, T., & Sharpe, M. (2007-this issue). The cognitive behavioural model of medically unexplained symptoms: A theoretical and empirical review. Clinical Psychology Review] of these conditions. A separate overview of the literature on MUS in children and adolescents is provided by Eminson [Eminson, J. (2007-this issue). Medically unexplained symptoms in children and adolescents. Clinical Psychology Review].     

Role of anticipatory anxiety and anxiety sensitivity in children's and adolescents' laboratory pain responses

OBJECTIVE: To examine relationships among trait anxiety sensitivity, state task-specific anticipatory anxiety, and laboratory pain responses in healthy children and adolescents. METHODS: Participants (N=118, 49.2% female, ages 8-18 years) completed a measure of anxiety sensitivity and rated anticipatory anxiety prior to undergoing thermal, pressure, and cold pain tasks. Linear and logistic regressions were used to test the hypothesis that anxiety sensitivity and anticipatory anxiety would predict incremental variance in pain response after controlling for sex, age, and anxious symptoms. RESULTS: Anticipatory anxiety accounted for 35-38% of unique variance in pain report across tasks, and 10% of unique variance in thermal tolerance. Anxiety sensitivity was unrelated to pain responses. CONCLUSIONS: Task-specific anxiety is an important predictor of pain report and, in certain cases, pain tolerance. Interventions designed to reduce task-specific anticipatory anxiety may help reduce pain responses in children and adolescents.     

Myocardial infarction patients during the prodromal and acute phase: a comparison with patients with a diagnosis of 'noncardiac chest pain'

Symptoms as reported by myocardial infarction (MI) patients are not easily distinguishable from the symptoms reported by patients with a diagnosis of 'noncardiac chest pain' (NCCP) (hyperventilation and/or functional complaints). MI patients and patients with a diagnosis of NCCP were questioned by means of a structured interview in order to determine what symptoms they had perceived during the prodromal and the acute phase. In the acute phase, more MI patients reported pain in the center of the chest than did NCCP patients. In both the acute and the prodromal phase NCCP patients reported the following atypical symptoms more often than the MI patients: palpitations, tingling of fingers, and 'numb feelings' in arms and legs. The duration of the prodromal pain attacks of the NCCP patients varied from a few minutes to several hours (median: more than half an hour), the MI patients reported a shorter duration of prodromal pain attacks (median: 10 min).     

Parent reports of coping and stress responses in children with recurrent abdominal pain

OBJECTIVE: To examine relationships among coping, stress responses, pain, somatic symptoms, and anxious/depressed symptoms in a sample of children and adolescents with recurrent abdominal pain (RAP). METHOD: We assessed parents' reports of coping and involuntary responses to stress in relation to pain, somatic symptoms, and symptoms of anxiety and depression in a sample of 174 children and adolescents with RAP. RESULTS: Based on parent reports, children's primary control engagement coping (e.g., problem solving, emotional modulation) and secondary control engagement coping (e.g., acceptance, distraction, positive thinking) in response to pain were associated with fewer somatic complaints and symptoms of anxiety and depression; secondary control engagement coping was also associated with less pain. Involuntary engagement (e.g., physiological reactivity, rumination) and disengagement (e.g., escape, inaction) responses to pain were associated with more somatic symptoms and higher levels of anxiety and depression. CONCLUSIONS: We highlight implications of these findings for understanding processes of coping and stress reactivity in children with RAP.     

Cognitive features associated with depressive symptoms in adolescence: directionality and specificity.

In this study we examined cognitive features that have been posited to contribute to depressive vulnerability in adolescents. Using a longitudinal sample of 331 young adolescents followed from 6th to 7th grade, cross-lagged structural equation analyses were conducted. Controlling for baseline levels of depressive, conduct, and anxiety symptoms, low self-worth was associated with a vulnerability to both depressive symptoms and conduct problems, whereas rejection sensitivity was uniquely predictive of increases in anxiety. In support of cognitive "scar" models, baseline depressive and conduct problems were both predictive of a more negative attributional style. Depressive symptoms also predicted more rejection sensitivity, whereas conduct problems predicted lower self-esteem.     

Behavioral medicine approaches to somatoform disorders

This article reviews the research evidence for the efficacy of cognitive-behavioral therapy (CBT) for somatoform disorders. Randomized controlled studies support the efficacy of individual CBT for the treatment of hypochondriasis, body dysmorphic disorder (BDD), and undifferentiated somatoform disorders including medically unexplained symptoms, chronic fatigue syndrome, and noncardiac chest pain, and group CBT for the treatment of BDD and somatization disorder. On the basis of this review of the existing research and a theoretical model of the processes involved in somatoform disorders, the authors offer suggestions for future research and effective treatment.     

Comparison of adolescents with and without diabetes on indices of psychosocial functioning for three years

OBJECTIVE: To determine whether diabetes is associated with psychosocial difficulties over the transition to adolescence. METHODS: We compared adolescents with diabetes (n = 132) with a healthy comparison group (n = 131) on indices of psychosocial functioning for 3 years. We interviewed both groups annually and had one parent complete a questionnaire. RESULTS: There were no group differences in depressive symptoms, anxiety, anger, or behavioral problems. However, adolescents with diabetes showed greater declines in social acceptance compared with healthy adolescents, and a greater rise in disturbed eating behavior. Over time, depressive symptoms and anxiety increased and self-worth decreased for females but not males; however, these differences were not qualified by group CONCLUSIONS: Diabetes is not associated with indicators of psychological distress from early to middle adolescence, but may be associated with the emergence of social difficulties and eating disturbances. Gender differences in psychological distress emerged, replicating past research.     

Perceived family characteristic differences between depressed and anxious children and adolescents.

BACKGROUND: The present study compared anxious vs. depressed children's and adolescents' perceptions about their family environment. METHODS: One hundred inpatient youngsters were interviewed for the study. Of these participants, 21 who met criteria for a depressive disorder without an anxiety disorder and 18 who met criteria for an anxiety disorder without a depressive disorder were compared on several self-report family measures. These measures included the Family Adaptability and Cohesion Evaluation Scales-II (FACES-II), Family Strengths, and Social Support Questionnaire-Revised (SSQS-R). RESULTS: Youngsters with depressive disorders reported having less pride in their families and perceived their families as being less adaptable to problems than did anxious children. Also, depressed children expressed lower levels of satisfaction with their social network than did anxious children. LIMITATIONS: The fact that our study only included reports from inpatient youngsters, families of anxious and depressed children may differ in the way family members relate to one another and in the way they deal with everyday problems. CONCLUSIONS: Based on the evidence obtained in this study, anxiety and depression may be two distinct internalizing disorders with specific family characteristics.     

Differential Fear of Cardiopulmonary Sensations in Emergency Room Noncardiac Chest Pain Patients

Fear of bodily sensations has received extensive attention in relation to panic disorder, and more recently, other types of anxiety pathology and chronic pain problems. Extending this work, the present study examined fear of bodily sensations and its underlying dimensions in emergency room patients with Noncardiac Chest Pain (NCCP; n = 63). We posited a differential specificity hypothesis, expecting that specific cardiopulmonary fears would be more strongly associated with NCCP symptoms relative to other bodily fears. As hypothesized, participants reported cardiopulmonary sensations as significantly more fear-provoking than numbness, dissociation, and gastrointestinal sensations. Additionally, regression analysis indicated that after accounting for theoretically relevant demographic variables and health status, cardiopulmonary fear was the best predictor of a composite index of cardiac complaints intensity, even after removing variance related to the absolute number of cardiac complaints. We discuss these findings in relation to the specific role for the fear of cardiopulmonary sensations in chest pain complaints, with implications for better understanding the underlying psychological processes involved in NCCP.     

Parental reinforcement of recurrent pain: the moderating impact of child depression and anxiety on functional disability

OBJECTIVE: To examine whether children's distress moderates the relationship between parental responses to children's pain behaviors and functional disability. METHODS: Participants were 215 children (ages 8 to 16 years) diagnosed with either headaches, juvenile idiopathic arthritis, or sickle cell disease. Children and parents completed questionnaires assessing sociodemographics, pain, depression, anxiety, parental solicitous responses to pain behaviors, and functional disability. RESULTS: Hierarchical linear regressions computed for parental responses to children's pain significantly predicted child functional disability, controlling for children's pain intensity. Significant interactions between parental solicitous behaviors and child depressive symptoms (beta =.74, p <.01) and between solicitous behaviors and child anxiety symptoms (beta =.91, p <.01) indicated that for children with more psychological distress, parental solicitous behaviors were associated with greater child functional disability. CONCLUSIONS: Child psychological distress may exacerbate the impact of parental solicitous responses to pain on functioning, suggesting the potential role of family intervention to enhance optimal functioning in children with recurrent pain.     

Adjustment to chronic arthritis of childhood: the roles of illness-related stress and attitude toward illness

OBJECTIVE: To examine the relationship of psychosocial stress and attitude toward illness to psychological adjustment among youth with chronic arthritis. METHODS: Seventy-five youths with chronic arthritis aged 8-18 years were administered a semi-structured interview assessing illness-related and nonillness-related stressors in important life domains. Children also completed measures of attitude toward illness, depressive symptoms, and anxiety. Parents completed a measure of child psychosocial adjustment. RESULTS: Higher levels of illness-related and nonillness-related stress were associated with higher levels of anxiety and depressive symptoms and parent-reported adjustment problems, while a more positive attitude toward illness was associated with lower levels of anxiety and depressive symptoms. Attitude toward illness moderated the relationship between stress and depressive symptoms. CONCLUSIONS: Results suggest the importance of assessing life stress and attitude toward illness among youth with arthritis and developing interventions to help children cope with arthritis-related stressors and promote a more positive attitude toward illness.     

Heart-focused anxiety,illness beliefs,and behavioral impairment: Comparing healthy heart-anxious patients with cardiac and surgical inpatients

Psychological features and complaints of persons presenting to medical settings with heart-focused anxiety and noncardiac chest pain are poorly understood. Comparing 20 healthy heart-anxious patients to cardiac and surgical inpatients and nonpatient controls, we found that healthy heart-anxious patients (a) were as afraid of chest pain and heart palpitations as inpatients with heart disease, (b) were as incapacitated by symptoms and using medical services as much as both inpatient groups; and (c) reported higher levels of cardiac disease conviction, heart awareness, and behaviors designed to protect their heart than surgical patients and nonpatients. Compared to all other groups, healthy heart-anxious patients reported more panic and other anxiety disorders, hypochondriacal beliefs, physical symptoms, obsessive-compulsive concerns, and negative affect. Following a hyperventilation test, heart-anxious patients also indicated more distressing symptoms and thoughts, and felt less safe and in control than surgical patients and nonpatients. Results support efforts for a timely recognition, diagnosis, and behavioral treatment of persons with heart-focused anxiety.     

Anxiety Sensitivity in Adolescents at Risk for Psychopathology

Examined the associations of adolescents' self-reported anxiety sensitivity with semistructured, interview-based anxiety and depressive symptoms and anxiety disorders. The sample included 121 adolescents and their parents who participated in a larger epidemiological, high-risk family study of substance abuse and anxiety disorders (Merikangas, Dierker, & Szatmari, 1998). A series of hierarchical multiple regressions revealed the incremental validity of anxiety sensitivity, beyond the contribution of self-rated anxiety, to anxiety symptoms and comorbid anxiety disorders. Furthermore, familial risk for anxiety moderated the association between anxiety sensitivity and number of anxiety symptoms as well as number of comorbid anxiety disorders. Analyses of high- and low-risk groups demonstrated that the association between anxiety sensitivity and anxiety symptoms and disorders was evident in high-risk adolescents only. Although self-reported anxiety was associated with depressive symptoms, anxiety sensitivity was not. Results from this investigation further support the utility of assessing anxiety sensitivity in an adolescent population and suggest it as a trait marker of anxiety among at-risk individuals.     

Correlation of psychological and physical symptoms with chronically elevated cytokine levels associated with a common immune dysregulation.

BACKGROUND: Chronically elevated levels of proinflammatory cytokines are associated with inflammatory diseases and psychological symptoms of depression and tiredness. OBJECTIVE: To test the prediction that, in a healthy population without medically diagnosed diseases, psychological symptoms (depression and tiredness) associated with proinflammatory cytokines correlate with physical symptoms associated with inflammatory disease. METHODS: A total of 1,143 women between 45 and 65 years old completed a health complaint checklist containing 11 target symptoms (5 related to allergy, 4 to gastrointestinal symptoms, and 2 to pain), 7 control symptoms or health complaints, and 2 psychological symptoms (depression and tiredness). They also completed a menopausal quality-of-life questionnaire; to compensate for response bias, we removed variance attributable to quality of life. RESULTS: The partial correlations show that tiredness (but not depression) correlated with 9 of the 11 target symptoms (P < .001) but with 0 of the 7 control symptoms or complaints. Symptoms of both the specific and the systemic components of inflammatory disease are correlated in a healthy population. CONCLUSION: Immune dysregulation may explain the existence and covariation of psychological and physical symptoms in the healthy population, including people with medically unexplained symptoms.     

Is alexithymia a risk factor for unexplained physical symptoms in general medical outpatients?

OBJECTIVE: Alexithymia is presumed to play an important predisposing role in the pathogenesis of medically unexplained physical symptoms. However, no research on alexithymia has been done among general medical outpatients who present with medically unexplained physical symptoms as their main problem and in which anxiety and depression have been considered as possible confounding factors. This study investigated whether patients with medically unexplained physical symptoms are more alexithymic than those with explained symptoms and whether, in patients with unexplained symptoms, alexithymia is associated with subjective health experience and use of medical services. METHODS: We conducted a cross-sectional study among patients attending an internal medicine outpatient clinic. All patients were given a standardized interview and completed a number of questionnaires. RESULTS: After complete physical examinations, 169 of 321 patients had unexplained physical symptoms according to two independent raters. Patients with medically unexplained symptoms more often had a mental disorder, but overall they were not more alexithymic. In patients with unexplained physical symptoms, alexithymia was not associated with subjective health experience or use of medical services. However, patients with both unexplained symptoms and a mental disorder who also denied any possible connection between emotional problems and their physical symptoms did have more alexithymic traits. CONCLUSIONS: In the majority of patients with medically unexplained physical symptoms, alexithymia does not play a role of clinical significance. Patients with unexplained physical symptoms are heterogeneous with respect to psychiatric syndrome pathology and probably also with respect to personality pathology.     

The role of depression in pain, psychophysiological syndromes and medically unexplained symptoms associated with chronic fatigue syndrome

BACKGROUND: The association between depression and pain, function, medically unexplained symptoms and psychophysiological syndromes such as irritable bowel syndrome has not been explored before in chronic fatigue syndrome. METHODS: Cross-sectional controlled study of the current prevalence of psychophysiological syndromes, pain, function and lifetime prevalence of medically unexplained symptoms in 77 out-patients with chronic fatigue syndrome (CFS) without DSM-III-R depression, 42 CFS out-patients with DSM-III-R depression and 26 out-patient with primary DSM-III-R depression. RESULTS: Both CFS groups differed significantly from the primary depression group but not each other in the prevalence of tension headaches (P < 0.001), reporting of widespread bodily pain (P < 0.001) and the number of lifetime medically unexplained symptoms (P < 0.001). The three groups did not significantly differ in the prevalence of irritable bowel syndrome or fibromyalgia. CFS patients with depression were more impaired in social function than other CFS patients. CONCLUSION: Depression is not associated with the reporting of pain, psychophysiological syndromes and medically unexplained symptoms in CFS patients. Depression is associated with decreased social function in CFS patients. LIMITATIONS: Study depended on recall of symptoms, not confirmed by medical records and current investigations. Patients with depression were taking antidepressants. CLINICAL RELEVANCE: Treating depression in chronic fatigue syndrome is unlikely to diminish reporting of pain and medically unexplained symptoms but may improve social function.     

对难以解释的胸痛病人的心理评估与心理干预

目的 :分别对心内科冠心病心绞痛患者和难以解释的胸痛患者进行心理评估、心理干预 ,观察不同组患者的患病行为、对支持性心理治疗的反应。方法 :在心内科连续收集因胸闷、胸痛疑为冠心病而住院行心导管检查的患者 ,心导管检查阳性者为冠心病心绞痛组 ,阴性者为难以解释组。在心内科诊断明确前进行精神检查并对有精神障碍者做出诊断 (ICD -10标准 )。使用《患病行为问卷》评定患者的患病行为。以汉密尔顿焦虑量表和抑郁量表在入院和心导管手术前分别评定患者情绪状态 ,用以评估支持性心理治疗的效果。住院期间对难以解释胸痛的患者进行针对疾病观念的短期认知干预 ,并在一年后随访 ,与上一年住院而未加干预的难以解释胸痛的患者进行了疾病观念和就医行为方面的比较。结果 :在心内科共收集 46例 ,难以解释组 2 8例 ,其中存在明显心理健康问题的有 60 % (17/2 8) ,而冠心病组 (18例 )中这一比例只有11% (2 /18)。在患病行为上 ,难以解释组不良情绪较心绞痛组明显 ,同时 ,他们也更多地意识到自己的问题与心理有关。在疾病观念上 ,难以解释组中的心理障碍患者比没有心理障碍者病感强 ,疑病倾向重。而 1年后随访发现 ,短期认知干预对改善疾病观念和就医行为效果不显著。结论 :心内科患者中有相当部分其主诉难