INT’L. J. PSYCHIATRY IN MEDICINE, Vol. 22(3)291-298,1992

CHEST PAIN IN GENERALIZED ANXIETY DISORDER

CAMERON S. CARTER RICHARD J. MADDOCK University of California at Davis, Sacramento

ABSTRACT

Objectives: The objectives of the current study were to evaluate the prevalence of chest pain and related medical utilization in patients with generalized anxiety disorder and to investigate the possible relationship between the occurrence of chest pain in these patients and the episodes of excessive worry which characterize this disorder. Method: The presence of a history of chest pain in patients with generalized anxiety disorder was investigated in an outpatient psychiatric sample using a structured interview which also assessed related medical utilization and the relationship of chest pain to panic attacks and episodes of excessive worry. Results: Of fifty sequentially evaluated patients meeting DSM-I11 R criteria for G.A.D., twenty-four (48%) reported a history of chest pain. Seven of these patients also had a history of panic attacks, however, four of the seven reported that their pain occurred independently of their panic attacks. Sixteen patients with G.A.D. reported that their chest pain episodes were associated with episodes of excess worry. Eleven had sought medical evaluation for their pain. Patients with chest pain and normal coronary arteries are frequently found to have panic disorder. The pattern of utilization of medical care was comparable in this sample of patients with G.A.D. and a group of patients with panic disorder recruited in a similar manner. Conclusions: These results suggest that in addition to panic disorder, G.A.D. may also be a common diagnosis in chest pain patients with no demonstrable coronary disease. Future studies of coronary artery disease negative patients with chest pain should include assessments for the presence of G.A.D. Our results also suggest that chest pain may be a common symptom in G.A.D. The possibility that chest pain should be included in the diagnostic criteria for this disorder should be the subject of further investigation. (/nt’/.J. Psychiatv in Medicine 22:291-298, 1992)

Key Words: chest pain, generalized anxiety disorder, panic disorder, normal coronary arteries, cognitive worry 291

0 1992,Baywood Publishing CO., Inc.

doi: 10.2190/RGC5-PJK2-7TG5-KL1B http://baywood.com

292 / CARTER AND MADDOCK

INTRODUCTION

Unexplained chest pain in patients with normal coronary arteries and an absence of other physical findings is a common problem in medical practice. Despite reassurance to the contrary these patients frequently continue to attribute their symptoms to cardiac disease and demonstrate considerableongoing morbidity and disability, despite having a benign cardiac course [l-41. This patient group has been described under a number of terms during the last century and in each of these syndromes the prominence of anxiety, depression, and other “neurotic” symptoms has been stressed [5]. During the past decade patients with chest pain and normal coronary arteries (NCA) have been the subject of a number of systematic studies by psychiatric investigators. In both outpatient and acute care settings between 30 percent and 50 percent of chest pain patients who are found to have no evidence of coronary artery disease meet diagnostic criteria for panic disorder [6-81. Preliminary studies also suggest that these patients tend to respond to lactate and 35 percent carbon dioxide challenges and to pharmacologic and cognitive behavioral treatments in a manner similar to panic disorder patients presenting to psychiatric settings [9-111. Despite the consistent success in identifying panic disorder as a cause of symptoms in a substantial minority of NCA patients there remain many patients who do not have this disorder, yet continue to experience their elusive chest pain symptoms. Attempts to identify occult visceral causes for these patient’s symptoms, such as microvascular angina and esophageal motility disorders, have met with limited success, and with the exception of those suffering from gastroesophageal reflux, the majority of these patients appear unlikely to have their primary pathology in those organ systems [12]. Many investigatorscontinue to suggest that even in this residual group of patients, who do not appear to have panic disorder, psychopathology, or “neuroticism” is the basis of their symptoms. Recent studies in chest pain patients have suggested that patients with panic do not account for all of the neuroticism or trait anxiety in the subgroups with normal coronary arteries [8, 131. In the studies performed to date, the focus has been on panic disorder, phobic disorders, substance abuse and major depression. Although Cormier and colleagues reported an association between major depression and chest pain in NCA patients [6], other studies have not confirmed this association independent of comorbid panic disorder [8]. Phobic disorders seem primarily associated with chest pain through their association with panic disorder, while substance abuse disorder seems to be equally common in patients with and without coronary artery disease [6-81. In these and other studies, other anxiety disorders have not been studied. In a recent study in a psychiatric population it was found that patients with generalized anxiety disorder (G.A.D.) reported a similar pattern of cardiac consultation utilization to patients with primary panic disorder, with complaints of chest pain being common in the former, as well as in the latter group [14]. It was

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not clear, however, to what extent the complaints of the G.A.D. patients were related to the presence of a history of panic disorder or to the occurrence of occasional panic attacks not meeting the frequency criteria for panic disorder. In a study of a group of patients with atypical chest pain referred by their physicians for psychological treatment Pearce and colleagues reported approximately equal numbers of patients having panic disorder and G.A.D. [15].These authors did not report on the extent of comorbidity between these two disorders or the possible role of occasional panic attacks producing chest pain in patients with G.A.D. However, together these two studies raise the possibility of an association between G.A.D. and chest pain. In order to test the hypothesis that G.A.D. is associated with a history of chest pain and related medical utilization we systematically evaluated the psychiatric histories and the chest pain histories of a group of patients with G.A.D. If a history of chest pain and cardiac consultation were to be obtained in a significant proportion of G.A.D. patients, it would suggest that future studies of NCA patients should include G.A.D. among the diagnoses evaluated. Such a finding would raise the possibility that an even greater proportion of these patients are suffering from an anxiety disorder than the 30 percent to 50 percent previously described.

METHODS

Subjects were fifty consecutively evaluated patients meeting DSM-I11 R criteria for generaIized anxiety disorder who were presenting for treatment at the Anxiety Research Center in the Department of Psychiatry at the University of California at Davis Medical Center. Because patients were being evaluated for a treatment study of “pure” GAD they had been pre-screened by telephone and patients with obvious comorbid depression, panic disorder or substance abuse were excluded from further evaluation. Psychiatric diagnoses were made using the Structured Clinical Interview for DSM-111 R [16] administered by a clinical psychologist trained in the use of this instrument with patients with anxiety disorders. Using a second structured interview (available on request) administered immediately after the SCID subjects were evaluated for a previous history of chest pain along with a previously established history of coronary heart disease. We did not attempt to characterize chest pain episodes in terms of pain quality, duration or frequency. Rather, in this preliminary study we relied on medical utilization as our marker for the clinical significance of the patients’ chest pain history. Patients were questioned as to whether they had sought medical consultation for chest pain and if so, for the details and results of any tests which they underwent during the evaluation. Patients were evaluated for a history of panic attacks during the SCID and if present the relationship of their chest pain symptoms to these attacks was established during the second interview. Finally, the relationship of previous episodes of chest pain to periods of excessive worry was established. An association with

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cognitive worry was defined as excessive worry about at least two life circumstances in addition to their chest pain. Statistical comparisons of demographic and comorbidity findings were undertaken using the chi-square for categorical measures and Student’s t-test for the continuous variable of age, All comparisons were two-tailed. RESULTS

Twenty-four (48%) of the fifty patients with G.A.D. reported a history of chest pain. Seven of these patients also reported a history of panic attacks, however, four of these seven patients reported that their chest pain occurred independently of panic. Eleven (45.8%) of the twenty-four patients with chest pain histories reported that they had sought medical evaluations for chest pain. Only one of these patients had pain associated with panic attacks. The panic patient had an office visit and an E.K.G. Nine of the ten patients with no history of panic had made office visits with complaints of chest pain, five had visited emergency rooms and one had been hospitalized and monitored to rule out myocardial infarction. Eight of these patients had received E.K.G.’s, six had undergone treadmill exams and two had undergone cardiac catheterization. None of these evaluations revealed demonstrable cardiac pathology and none of these patients were treated for coronary artery disease. One patient received a diagnosis of hiatal hernia based on upper (3.1. studies. She was treated briefly with antacids with no relief of her symptoms. Sixteen (75.2%) of the twenty-one patients who had chest pain independent of panic attacks reported that their chest pain was associated with episodes of excessive worry. Table 1 presents demographic and comorbidity findings in patients with and without chest pain histories. There were significantly more males in the chest pain group (chi-square (ldf) = p c .01) and a trend towards a higher prevalence of dysthymia in this group. No other differences approached significance. DISCUSSION

The findings of the present study suggest that patients with generalized anxiety disorder frequently have the complaint of chest pain. Almost one half of this group had a history of this complaint and in only three cases was the chest pain secondary to panic attacks. Eleven of these patients (22%) had sought medical consultation for their symptoms. This included one of the three patients whose symptoms were secondary to panic. In all cases, despite evaluations which at times included exercise testing, and cardiac catheterization, cardiac causes were excluded. During a previous study at our center (unpublished data) twenty-eight patients meeting DSM-111 R criteria for panic disorder on SCID completed a questionnaire which elicited a history of cardiac consultation along with the relevant details of

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Table 1. Demographic and Comorbidity Findings of G.A.D. Patients With and Without a History of Chest Pain

Age, means 2 S D Gender, maleflemale History of panic disorder Current major depression Lifetime major depression Dysthymia Social phobia Lifetime substance abuse

Chest Pain n = 24

No Chest Pain n=26

41.7 2 9.9 1519 3 2 9

42.5 2 7.3 6/20 1 1 13 1

5 3

2

2

3

P .74 NS p c .01* p > .25 NS p > .50 NS p > .37 NS p > .07 NS p > .55 NS p > .70

"Significant at p < .05 NS = not significant

tests performed as in the interview with G.A.D. patients outlined above. This measure did not provide us with an estimate of the number of patients with panic disorder who had histories of chest pain but only of those who had sought medical evaluation. This comparison data is included to provide a perspective for the findings among the G.A.D. group, since the relevance of the presence of panic disorder to the problem of chest pain in NCA patients has been well established. Five (18%) of the group of twenty-eight patients with panic disorder reported having a medical consultation because of chest pain. Of these patients, two had undergone treadmill evaluations, both of which were normal. The different measures used here (structured interview versus questionnaire) make direct statistical comparisons between the G.A.D. and panic disorder groups inappropriate, however, the pattern of reported use of medical consultation for chest pain by patients with panic disorder (18%)and G.A.D. (22%) appear to be similar. This is consistent with the finding of Logue et al. [14]. Bass and Wade, in their seminal study of psychopathology in NCA patients, reported that anxiety neurosis (ICD 9) accounted for the bulk of psychiatric cases in their sample [17]. This diagnostic category is similar to that bearing the same name in DSM I1 and includes both panic disorder and G.A.D. as they are currently defined in DSM I11 revised. Cormier and colleagues found panic in 47 percent of their NCA patients without evaluating G.A.D. [ 6 ] .Similarly Beitman et al. [7] reported that 34 percent of the NCA patients in their sample of ninety-four patients referred for catheterization met modified (stringent) criteria for panic disorder. Carter et al. found that 55 percent of NCA patients on a coronary care unit met criteria for panic [8]. Since elusive cardiovascular and gastrointestinal abnormalities, such as microvascular angina or esophageal motility disorders account for only a small proportion of the symptomatic NCA patients [13,18] other causes

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for their symptoms must be sought. In the context of the strong association between panic disorder and chest pain in NCA patients our finding suggests that future psychiatric studies of this group should include an evaluation for G.A.D. Bass has suggested that chest pain in non-panicking NCA patients represents a form of somatization [19]. Mancuso and colleagues found a substantial overlap between somatization disorder and G.A.D.and that when hierarchical rules are invoked that exclude somatization disorder when the symptoms of the latter are present only during periods of illness meeting criteria for G.A.D.,G.A.D.supersedes the diagnosis in a large majority of cases [20]. In our comparison of G.A.D.patients with and without chest pain, the most striking difference between these groups is the preponderance of males reporting a history of chest pain. We are only able to speculate, at this point, as to the basis of this. It has been suggested that chest pain in anxious individuals is a consequence of autonomic arousal accompanying anxiety and perpetuated by cognitive worry [15]. If this is the case then middle-aged males, recognizing their greater cardiac risk, may be more likely to attribute a possible cardiac cause to their symptoms than their female counterparts. Therefore, males may have greater awareness of pain, worry more, increase arousal, and perpetuate the symptom. An alternative to this cognitive explanation is that our patients were actually experiencing angina, since the gender distribution of chest pain in our sample follows that of coronary artery disease. Although none of our patients who had been evaluated for chest pain were found to have evidence of coronary artery disease, only two patients had undergone coronary angiography. The possibility that the chest pain seen in G.A.D.patients such as those in the current study is due to coronary artery disease could be effectively ruled out in a prospective study where each participant receives a sensitive measure of coronary perfusion, such as angiography or radionucleotide scintigraphy, in addition to a careful psychiatric evaluation. Other important factors which should be evaluated in such a study include chest pain quality (atypical versus anginal) and the contribution of medical comorbidity to the Occurrence and presentationof chest pain in patients with G.A.D. With the exception of a trend towards a greater prevalence of dysthymia, there were no differences between patients with and without chest pain histories on psychiatric comorbidities. This lack of differences must be considered preliminary, however, as our comparisons are limited by a lack of statistical power. The prevalence of comorbidity is lower than that usually reported in samples of G.A.D., a bias due to our prescreening process [21]. This relationship needs to be evaluated further in an unbiased sample. Finally, we consider the relationship between chest pain and generalized anxiety disorder. Sixteen of the twenty-one patients in the current study with chest pain independentof panic attacks reported that their symptoms occurred during periods of excess worry. This preliminary finding suggests that chest pain may be a symptom of this disorder, along with the other cardiovascular and respiratory symptoms listed in the D symptoms for this disorder in the DSM 111-R (palpitations

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or tachycardia, flushing and shortness of breath or smothering) [22]. Because of the relevance of this to the diagnosis and treatment of patients with chest pain and normal coronary arteries, this possibility should be the subject of further studies. In summary, the findings of the current study suggest that chest pain is a common symptom in patients with generalized anxiety disorder and that these patients frequently seek medical evaluation for this symptom. They suggest the value of including an evaluation for G.A.D. in prospective studies of chest pain patients in medical settings. Since a high proportion of patients reported that their chest pain was associated with episodes of excessive worry, future studies should address the possibility that chest pain be included among the cluster of somatic symptoms in the diagnostic criteria for this disorder. ACKNOWLEDGMENTS

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Direct reprint requests to: Cameron S. Carter, M.B.B.S. Department of Psychiatry University of California at Davis Medical Center 4430 V Street Sacramento, CA 95816