Psychological treatments for noncardiac chest pain: Recommendations for a new approach

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Abstract

Objective

Our objective is to describe the current state of treatment for NCCP, identify barriers to treatment and limitations of current approaches, and to recommend treatment strategies, which may address these challenges.

Methods

We describe the underlying rationale for treating NCCP and review the current literature concerning NCCP treatments and other brief approaches to outpatient treatment for psychosomatic illness.

Results

Most treatments for NCCP have been based on the Attribution Model. Although effective, these treatments are appropriate and acceptable to only a small minority of NCCP patients. The Biopsychosocial Model has been used to treat psychosomatic conditions in outpatient groups and may overcome or avoid many of the limitations inherent in current treatment strategies for NCCP.

Conclusions

We recommend an intervention for NCCP that is brief, would be delivered in the emergency department setting (to take advantage of the Teachable Moment), and which is based on the Biopsychosocial Model.

Section snippets

Noncardiac chest pain: common and expensive

Chest pain is one of the most frequent presenting complaints in medical settings [1], [2], [3], [4]. Each year in the United States over 5 million people present to emergency departments with chest pain [5]. Moreover, about 13 billion dollars are spent annually to care for patients who are admitted for chest pain symptoms but who subsequently rule out for myocardial infarction [6]. In cardiology and primary care settings, more than 50% of patients with chest pain do not have identifiable

“There's nothing wrong” does not reassure patients

Emergency Department procedures for the management of acute chest pain are principally aimed at identifying patients with potentially life-threatening illness, such as acute myocardial infarction. However, most patients have no clear diagnosis at the time of their initial assessment [24]. Patients with NCCP often receive insufficient or inconsistent information related to the chest pain episodes they are experiencing. Typically, patients with NCCP are offered no additional treatment beyond

Characteristics of patients with NCCP

Numerous studies have examined the prevalence of psychiatric disorders among NCCP patients (Table 1), and have found a high prevalence of panic disorder (24–70%), generalized anxiety disorder (33–50%) and major depressive disorder (11–22%). Many patients with NCCP who do not meet criteria for psychiatric disorders [28], still experience significant psychological distress and dysfunction [3]. For example, panic spectrum problems comprise a significant portion of the distress among patients with

An etiological model of noncardiac chest pain: attribution model

Cognitive–behavioral treatments for NCCP to date have been based on the Attribution Model of chest pain. The central component of this model is attribution (or “cognitive appraisal”) of minor physiological symptoms as evidence of serious illness [3]. Specifically, since NCCP episodes share some features of panic disorder, in that patients develop hypersensitivity to physical sensations that they perceive as threatening, relatively benign physical sensations are interpreted catastrophically as

Cognitive behavioral treatment for NCCP based on attributional model

Treatments based on this Attribution approach are essentially modeled after treatments for panic disorder. Patients are first required to have cardiac workups that definitively classify their chest pain as noncardiac. The length of these treatments varied from 7 to 16 sessions (8–38 h), and they were held in outpatient medical or cardiac clinics [31], [32], [33], [34], [35], [36]. The goal of treatment is to correct the misattributions regarding physical symptoms (e.g., chest pain) as being

Practical problems with attribution model

Although the Attribution Model treatment studies suggest that this treatment is effective for NCCP, there are numerous problems associated with this approach (see Table 2). One of the primary problems is difficulty in accessing treatment, resulting in low participation rates. For attributional approaches to make sense, patients and counselors must know definitively that stress tests are negative and that the chest pain is noncardiac. Many patients in the cardiac OU rule out for acute cardiac

The biopsychosocial model

The Biopsychosocial Model is based on the following principles: (1) Most illness, whether physical or psychiatric, is influenced and determined by biological, psychological and social phenomena; (2) Biological, psychological and social variables influence the predisposition, onset, course and outcome of most illnesses; (3) Better patient outcomes are achieved when therapeutic interventions are based on evaluation of the relationship between biological, psychological and social variables. Even

Advantages of the biopsychosocial model for chest pain patients

In contrast to Attribution Model interventions, which require patients to adopt a view of their condition as psychological in nature, the Biopsychosocial Model does not force an “either/or” view of the patient's condition (medical vs. psychological). This model allows for the co-occurrence of biological, psychological and social factors, which influence the course, and outcome of distressing symptoms. Chest pain may be an ideal candidate for this intervention approach, as it is a classic

Recommendations and future directions

A new approach to the treatment of NCCP patients is greatly needed. Interventions which educate patients about the causes and nature of chest pain, the appropriate use of medical services, and methods of coping with and reducing the incidence of chest pain symptoms such as stress management training are needed. The ultimate goal of intervention should be to reduce unnecessary utilization of the ED and other medical resources, to reduce the incidence and severity of chest pain symptoms, and

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      Despite this prognosis, the syndrome of NCCP is associated with impaired psychosocial functioning, reduced quality of life (Mayou, 1998), and discomfort and disability comparable to patients with CAD (Eifert, Hodson, Tracey, Seville, & Gunsawardane, 1996). Many patients experience worry, anxious preoccupation with heart functioning, and recurrent chest pain (Esler & Bock, 2004; White & Raffa, 2004) that results in increased health care costs due to repeat hospitalizations, emergency department visits, and cardiac catheterizations (Johnson et al., 2004; Ockene, Shay, Alpert, Weiner, & Dalen, 1980). Early conceptualizations of cardiophobia characterized this syndrome by fears of heart attack and death, suggesting that NCCP patients may focus attention on their heart when experiencing stress and arousal (Eifert, 1992).

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