The impact of depression and cardiophobia on quality of life in patients with essential hypertension.

Patients with chronic conditions like hypertension may experience many negative emotions which endorse the development of anxiety and depression symptomatology, thus they increase their risk for poor quality of life. Several studies have shown an association between symptoms of psychological distress and hypertension. In this study we aimed to quantify the link between depression, cardiophobia and quality of life in hypertensive patients. A cross-sectional design was employed. A sample of 197 hypertensive patients (89 men-108 women, mean age 53 years, SD=12 ranged 25-78) from a university outpatient hypertension clinic in Greece participated. Ninety-four (47.7%) of the participants suffered from essential grade I hypertension; 68 (34.5%) were grade II; 16 (8.1%) were categorized as grade III, while only 11 (5.6%) patients were recorded as normotensives with high normal values. The questionnaires included: (a) question for the recording of social-demographic characteristics and clinical features, (b) The Short Form (SF-36) Health Survey, (c) The Beck Depression Inventory -I, and (d) The Cardiac Anxiety Questionnaire. There were no significant differences between the two genders with exception of marital status (p=0.010), dyslipidemia (p=0.050), grade of hypertension (p=0.014), cardiac left ventricular hypertrophy (p=0.004), renal failure (p=0.043) and stroke (p=0.024). Lower levels of quality of life and higher levels of depression and cardiophobia were observed compared to the general population. There were no significant differences on psychological measures between the two sexes (p>0.05). Cardiophobia was positively related to depressive symptomatology (r=0.533, p=0.000) while negatively to both physical and mental health summary measures of SF-36 health survey (r=-0.467, p=0.000 r=-0.537, p=0.000 respectively). Multiple linear regression models found that for psychical health depression and cardiac anxiety, avoidance activities had an influence on levels of quality of life in hypertensive patients, after controlling for age and other socio-demographic variables and clinical characteristics (Beta=-0.133, p=0.007, Beta=-0.364 p=0.000 and Beta=-0.167 p=0.006, respectively). For mental component summary depression and cardiophobia, heart focused attention had also impact on mental health in hypertensives (Beta=-0.438, p=0.016, Beta=-0.564, p=0.000 and Beta=-0.223, p=0.037, respectively) after adjustments. Heart focused anxiety symptoms-as avoidance activities and/or attention and monitoring cardiac activity, are related to hypertensive patients' present deteriorated depressive symptoms and levels of quality of life. Both depressive symptomatology and heart focused anxiety may be a mechanism partly responsible for hypertensive patients' present impaired levels of quality of life.

I Keep a Close Watch on This Heart of Mine: Increased Interoception in Insomnia.

STUDY OBJECTIVES: Whereas both insomnia and altered interoception are core symptoms in affective disorders, their neural mechanisms remain insufficiently understood and have not previously been linked. Insomnia Disorder (ID) is characterized by sensory hypersensitivity during wakefulness and sleep. Previous studies on sensory processing in ID addressed external stimuli only, but not interoception. Interoceptive sensitivity can be studied quantitatively by measuring the cerebral cortical response to one's heartbeat (heartbeat-evoked potential, HEP). We here investigated whether insomnia is associated with increased interoceptive sensitivity as indexed by the HEP amplitude. METHODS: Sixty-four participants aged 21-70 years were recruited through www.sleepregistry.nl including 32 people suffering from ID and 32 age- and sex-matched controls without sleep complaints. HEPs were obtained from resting-state high-density electroencephalography (HD-EEG) recorded during evening wakeful rest in eyes-open (EO) and eyes-closed (EC) conditions of 5-minute duration each. Significance of group differences in HEP amplitude and their topographical distribution over the scalp were assessed by means of cluster-based permutation tests. RESULTS: In particular during EC, and to a lesser extent during EO, people with ID had a larger amplitude late HEP component than controls at frontal electrodes 376-500 ms after the R-wave peak. Source localization suggested increased neural activity time-locked to heartbeats in people with ID mainly in anterior cingulate/medial frontal cortices. CONCLUSIONS: People with insomnia show insufficient adaptation of their brain responses to the ever-present heartbeats. Abnormalities in the neural circuits involved in interoceptive awareness including the salience network may be of key importance to the pathophysiology of insomnia.

The cardiac anxiety questionnaire: cross-validation among cardiac inpatients.

OBJECTIVE: General anxiety symptoms are common in patients with cardiac disease and considered to have an adverse effect on cardiac prognosis. The role of specific cardiac anxiety, however, is still unknown. The aim of this study is to examine the factor structure, reliability, and validity of the Dutch version of the Cardiac Anxiety Questionnaire (CAQ), which was specifically designed to assess heart focused anxiety. METHODS: Two hundred thirty-seven patients admitted for an acute coronary syndrome (ACS) and a control group of 49 patients admitted for an exacerbation of rheumatoid arthritis (RA) completed the CAQ, the Agoraphobic Cognitions Questionnaire, Mobility Inventory, Beck Depression Inventory, Beck Anxiety Inventory, and the State-Trait Anxiety Inventory. RESULTS: Although the original three-factor solution (fear, avoidance, and attention) was acceptable (model fit parameters: CFI = 0.89 and TLI = 0.87), our data were best explained by a four-factor model including safety seeking behaviors. Internal consistency and test-retest reliability were good. The CAQ had moderate correlations with the other anxiety and depression questionnaires. Recently admitted ACS patients had significantly higher scores than RA patients, even after controlling for general anxiety and depressive symptoms (p < 0.001). CONCLUSION: The CAQ is a reliable and valid instrument to assess cardiac anxiety in patients hospitalized with ACS. These results enable longitudinal studies to examine the relationship of heart-focused anxiety with cardiac prognosis and to evaluate interventions specifically targeted at anxiety in cardiac patients.

Comparing two brief psychological interventions to usual care in panic disorder patients presenting to the emergency department with chest pain.

BACKGROUND: Panic disorder (PD) is a common, often unrecognized condition among patients presenting with chest pain to the emergency departments (ED). Nevertheless, psychological treatment is rarely initiated. We are unaware of studies that evaluated the efficacy of brief cognitive-behavioural therapy (CBT) for this population. AIM: Evaluate the efficacy of two brief CBT interventions in PD patients presenting to the ED with chest pain. METHOD: Fifty-eight PD patients were assigned to either a 1-session CBT-based panic management intervention (PMI) (n = 24), a 7-session CBT intervention (n = 19), or a usual-care control condition (n = 15). A structured diagnostic interview and self-reported questionnaires were administered at pre-test, post-test, 3- and 6-month follow-ups. RESULTS: Statistical analysis showed significant reduction in PD severity following both interventions compared to usual care control condition, but with neither showing superiority compared to the other. CONCLUSIONS: CBT-based interventions as brief as a single session initiated within 2 weeks after an ED visit for chest pain appear to be effective for PD. Given the high prevalence of PD in emergency care settings, greater efforts should be made to implement these interventions in the ED and/or primary care setting.

[Neurocirculatory asthenia: psychoautonomic features and treatment possibilities].

The authors present the results of clinical, physiological and psychological examination of 31 patients with neurocirculatory asthenia with arterial hypertension syndrome. There was an increase in the levels of state and trait anxiety correlated with a number of physiological traits that confirmed a leading role of psycho-emotional sphere in the formation of hypertensive reactions. An evaluation of the efficacy of the drug Adaptol used in daily dosage 1500 mg during 8 weeks in the treatment of these patients revealed its high efficacy (the improvement was seen in 74% of cases) confirmed by the data of clinical and psychological studies.

Psychometric properties and factor structure of the Greek version of the Cardiac Anxiety Questionnaire (CAQ).

The present study assesses the psychometric properties and factor structure of the Greek version of the Cardiac Anxiety Questionnaire (CAQ). The questionnaire was administered to 598 healthy individuals from 15 different regions of Greece with a measure of socioeconomic characteristics and the Symptom Checklist-90-Revised (SCL-90-R). The sample was split into two random halves, and exploratory factor analysis indicated a three-factor solution. This solution was tested using a confirmatory factor analysis on the second half of the sample. In terms of latent dimensions, the Greek version retains the three-factor structure as proposed by the initial authors. However, adequate fit was achieved only after omitting eight items. The shorter (10-item) version was submitted to further analysis. The shorter version provided satisfactory internal reliability and evidence indicating the validity of the scale with respect to SCL-90-R subscales. The stability of the questionnaire was verified by a high test-retest reliability over a 3-mo. period (r = .86). Sex and age differences were assessed. The 10-item version appears to be a practical, brief tool for clinical use.

False heart rate feedback and the perception of heart symptoms in patients with congenital heart disease and anxiety.

BACKGROUND: Little is known about the mechanisms explaining an increased perception of heart symptoms in congenital heart disease (ConHD). In the present study, it was suggested that a combination of high trait anxiety and disease history increases the perception of heart symptoms. PURPOSE: It was tested whether false heart cues will result in an increased perception of heart symptoms in patients with ConHD and anxiety. METHOD: Thirty-six patients with ConHD and 44 healthy controls performed two exercise tasks. During one of the exercise tasks, participants were exposed to a false heart cue consisting of false heart rate feedback (regular or irregular). Perceived heart symptoms were assessed and heart rate, arterial partial pressure of CO(2), and respirator rate were monitored continuously. RESULTS: In line with the predictions, false heart rate feedback resulted in an increased perception of heart symptoms in high trait anxious patients with ConHD that could not be explained by acute heart dysfunction. However, unexpectedly, this effect was not observed immediately after the false heart rate feedback task but after a second exercise task without false feedback. CONCLUSION: The results suggest that not the sole presence of ConHD but ConHD in combination with high trait anxiety results in a vulnerability to overperceive heart symptoms.

Cardiac anxiety in people with and without coronary atherosclerosis.

Many studies have shown that cardiac anxiety when occurring in the absence of coronary artery disease is common and quite costly. The Cardiac Anxiety Questionnaire (CAQ) is an 18-item self-report measure that assesses anxiety related to cardiac symptoms. To better understand the construct of cardiac anxiety, a factor analysis was conducted on CAQ data from 658 individuals who were self or physician-referred for electron beam tomographic screening to determine whether clinically significant coronary atherosclerosis was present. A four-factor solution was judged to provide the best fit with the results reflecting the following factor composition: heart-focused attention, avoidance of activities that bring on symptoms, worry or fear regarding symptoms, and reassurance-seeking. Factorial invariance across groups was also assessed to determine whether the factor structure of the CAQ was similar in individuals with and without clear evidence of coronary atherosclerosis. The factor structure of the CAQ did not differ between the two groups. However, the group without coronary atherosclerosis had significantly higher mean scores on their attention and worry/fear factors suggesting that people without a diagnosed cardiac condition pay more attention to and worry more about their cardiac-related symptoms than those people who have coronary atherosclerosis.

[Neurocirculatory dystonia (does this disease exist?)]. / Neirotsirkuliatornaia distoniia.

Difficulties of diagnostics of neurocirculatory dystonia are discussed. Definition based on Myasnikov's ideas about hyperreactivity, that is inadequate cardiovascular responses to psychoemotional stress, is proposed. Peculiarities of classification and therapy of neurocirculatory dystonia are presented.

Cardiac anxiety in patients self-referred for electron beam tomography.

Studies have repeatedly shown that as many as 43% of patients undergoing coronary angiograms have no evidence of coronary heart disease (CHD). Fear of cardiac-related sensations has been posited as one explanation for complaints of chest pain in patients without CHD. The purpose of this study is to examine variables associated with cardiac anxiety in a sample of individuals self-referred for noninvasive coronary calcium screening. Nearly one quarter of the subjects screened experienced chest pain in the absence of coronary artery calcium (CAC). Individuals without evidence of CAC were more likely to report higher levels of heart-focused attention, even when subjects with any risk factors for CHD were excluded from the analyses. Men were more likely to have evidence of coronary calcium, although a greater proportion of women reported chest pain. Women generally endorsed higher levels of cardioprotective behavior, heart-focused attention, and fear of heart-related sensations. Findings are discussed in relation to treatment of cardiac anxiety and the prevention of unnecessary medical procedures.

[General significance and quality standards in psychosomatic care]. / Allgemeine Bedeutung und Qualitätsstandards in der psychosomatischen Versorgung.

The relevance of psychosomatic and psychotherapeutic in--and--out patient service is evident. Two important examples of psychosomatic care are described: somatoform and cardiovascular disorders. Quality assurance is necessary. There are data concerning the efficacy and the cost-benefit relation.

A randomized controlled trial of a brief educational and psychological intervention for patients presenting to a cardiac clinic with palpitation.

BACKGROUND: We sought to determine whether a brief psycho-educational intervention reduced disability in patients with benign palpitation. METHOD: In a pragmatic randomized controlled trial within a cardiology clinic at a district general hospital, 80 consecutive patients diagnosed as having benign palpitation--either palpitation due to awareness of extrasystoles or sinus rhythm--with associated distress or disability were randomized to an intervention group (usual care plus nurse-delivered intervention based on cognitive-behavioural principles) or to a control group (usual care). Principal outcome was difference in proportion of participants with good or excellent researcher-rated activity levels at 3 months. Subsidiary outcomes were self-rated symptoms, distress and disability, researcher-rated unmet treatment needs. RESULTS: The principal outcome showed a statistically and clinically significant benefit for the intervention group, with a number needed to treat of 3 (95% CIs 2 to 7). All but one subsidiary outcomes also showed a difference in favour of the intervention group, and several differences reached statistical significance. Significantly more of the control group had unmet treatment needs at 3 months. CONCLUSIONS: A brief, nurse-delivered, psycho-educational intervention, was an effective treatment for benign palpitation. Further evaluation, including assessment of cost-effectiveness, is needed. The findings have application to the care of patients presenting with other types of 'unexplained' medical symptoms.

[Patient education, medication and physical therapy. Balm for "cardiac neurosis"]. / Aufklärende Gespräche, Medikation und Physiotherapie. Balsam für die "Herzneurose".

In the management of psychogenic chest pain, the family doctor has a key role to play. His main task is to exclude physical or organic causes and identify the underlying psychogenesis--admittedly without wishing to establish a definitive (ICD-10) diagnosis. For this purpose, empathic reassurance of the patient is of major importance. Wherever possible, hospitalization of the patient for a diagnostic clarification should be avoided. Therapeutic options comprise suitable physiotherapy, psychohygienic measures, and appropriate pharmacotherapy. Major goals of such an approach are the establishment of a trusting relationship, and improving the patient's sleep patterns, physical fitness and emotional status. In the event of long-term persistence of the condition or a severe course, referral to a specialist is indicated.

Psychiatric morbidity and the presence and absence of angiographic coronary disease in patients with chest pain.

OBJECTIVE: To assess psychiatric morbidity in coronary angiogram patients. METHOD: A psychiatric assessment of 200 consecutive chest-pain patients was performed the day before coronary angiography in a double-blind study design. The sample included 132 men (mean age 57.2 years, SD 9.5) and 68 women (mean age 59.8 years, SD 8.9). A Structured Clinical Interview for DSM-III-R was used to obtain psychiatric diagnosis. The 21-item Beck Depression Inventory, the 20-item Toronto Alexithymia Scale and a four-item Life Satisfaction Scale were used to assess mental symptoms. A coronary angiography with obstruction of a coronary artery by more than 50% was considered to indicate angiographic coronary disease. RESULTS: Mental disorders were found in 28% (95% CI 14-41) of the patients with normal angiographic findings (n=47) and in 24% (95% CI 17 - 30) of the patients with angiographic coronary disease (n=153). Furthermore, no difference was found between these two groups in other rating scales assessing mental symptoms even when adjusted for the New York Heart Association class, duration of chest-pain symptoms or exercise capacity. CONCLUSION: Psychiatric morbidity may not be associated with angiographic findings in patients with chest pain.

[Cardiac neuroses]. / Herzneurose.

Cardiac neurosis is defined as heart complaints for which no organic cause can be found. Other common terms are "cardiac anxiety neurosis", "cardiac anxiety disorder", "cardiac phobia", "functional heart complaints" and "somatoform autonomous functional disorders of the cardiovascular system" (ICD-10). Although cardiac neurosis is rarely diagnosed, it is estimated that approximately 30 bis 40% of patients with cardiovascular disorders are actually suffering from functional complaints. Predisposing to the development of cardiac neurosis are insufficient internalization processes during childhood, leading to an insoluble autonomy dependency conflict. Cardiac neurosis is treated with drugs and psychotherapy.