Differences in cognitions during chest pain of patients with panic disorder and ischemic heart disease

A significant number of patients with chest pains who undergo coronary angiography (20-30%) have normal coronary arteries. Up to 50% of this group are eventually diagnosed as Panic Disorder and most continue to complain of their symptoms, in spite of the normal coronary angiogram. We hypothesized that the cognitions of panic disorder subjects on presentation with chest pain would differ from those of patients suffering from true angina pectoris.

We investigated the cognitions associated with chest pain of three patient groups: proven symptomatic coronary artery disease (CAD+), subjects with chest pain and a normal coronary angiogram (CAD-), and patients with panic disorder (PD). All patients were classified according to whether the symptomatology was, firstly, associated with frightening cognitions (during the episode), and, secondly, whether either these cognitions (cognitive predominance), or the physical symptom (physical predominance), dominated the clinical picture.

We observed that in the CAD+ group, 18% experienced frightening cognitions but in only 4% (2 of 66 patients) were the cognitions the dominant experience during the chest pain. In contrast, all the PD patients experienced frightening cognitions and in 83% of this group, the cognitions were the predominant experience. In the CAD- group, 48% were found to be PD compatible.

This study indicates that the cognitions of patients during episodes of chest pain, evaluated by three questions, help to differentiate between PD and true coronary symptoms. Consequently, the presence of frightening cognitions in the presence of chest pain, particularly at the onset of the clinical problem, makes necessary the need for psychiatric evaluation with the objective of excluding PD.