Christopher Bass

Chest pain with normal coronary arteries: a comparative study of psychiatric and social morbidity.

Ninety-nine patients with chest pain and a presumptive diagnosis of coronary heart disease were assessed blindly within 24 hours of angiography, using standardized psychiatric and social interviews and a personality inventory. Thirty-one patients had normal coronary arteries (NCA), 15 had slight disease and 53 had significant coronary obstruction. Twenty-eight (61%) of the 46 patients with insignificant disease and 12 (23%) of the 53 with significant obstruction had psychiatric morbidity. Associations between the overall severity of psychiatric morbidity and measures of social maladjustment were strongest in the patients with normal coronary arteries. The 26 men with insignificant coronary artery disease had higher scores of neuroticism and extraversion than the 41 with important coronary occlusions. No differences were observed when the same comparisons were made for the women. The findings indicate that approximately two thirds of patients with normal and near-normal coronary arteries have predominantly psychiatric rather than cardiac disorders: the symptoms in these patients are more likely to represent the somatic manifestations of anxiety and overbreathing than the consequences of underlying cardiac disease. Physicians should be aware of the ways in which neurotic illness may present with symptoms mimicking cardiac disease, especially when cardiovascular symptoms are accompanied by phobic symptoms and unexplained shortness of breath.

CONTROLLED STUDY OF RESPIRATORY RESPONSES DURING PROLONGED MEASUREMENT IN PATIENTS WITH CHRONIC HYPERVENTILATION

The respiratory responses of 17 patients with chronic hyperventilation but without demonstrable organic disease (group H) to various manoeuvres were compared with those of 21 healthy controls (group C). The responses were tested according to a 60 min protocol in which periods of rest were replaced by exercise, voluntary hyperventilation (VHV), reading, and CO2 inhalation. 5 patients with severe resting hypocapnia were investigated overnight during sleep. Chronic hyperventilation was of two types--persistent or provoked by exercise or VHV. It was due to modest increases in tidal volume and respiratory frequency but was generally not conspicuous. End-tidal PCO2 levels were gradually corrected to near normal during sleep but not by inhalation of CO2.

UNEXPLAINED BREATHLESSNESS AND PSYCHIATRIC MORBIDITY IN PATIENTS WITH NORMAL AND ABNORMAL CORONARY ARTERIES

Of 99 patients with chest pain undergoing coronary arteriography, 31 had normal coronary arteries, 15 slight disease, and 53 significant coronary obstruction. 28 (61%) of the 46 with haemodynamically insignificant disease and 12 (23%) of the 53 with significant obstruction had psychiatric morbidity, assessed by standard interview. 37 patients had several respiratory symptoms and signs not attributable to organic disease, designated unexplained breathing disorder (UBD). UBD was found in 65% of the patients without and 13% of those with significant coronary disease; it was associated with psychiatric morbidity in the former but not in the latter group. Spirographic measurements of tidal volume and frequency were not helpful in detecting UBD but an end-tidal pCO2 below 30 mm Hg was highly suggestive. In the absence of significant coronary disease the associations of chest pain with psychiatric morbidity and UBD are striking. However, coronary disease and UBD are not mutually exclusive, and diagnostic difficulties can occur when they coexist.

TYPE A BEHAVIOUR: NOT SPECIFICALLY PATHOGENIC?

99 patients who underwent coronary arteriography for the investigation of chest pain were interviewed by the use of the Bortner type A questionnaire. The 26 men with normal and minimally diseased arteries had significantly higher mean type A scores than the 41 men with important coronary occlusions. Socioeconomic class had a large influence on the type A score in men, but not in women. There was no significant association between type A score and the extent of coronary disease. These findings do not support a specific association between type A behaviour and coronary heart disease. They also question the value of the use of type A and coronary-prone behaviour as interchangeable terms.

Fear talk versus voluntary hyperventilation in agoraphobics and normals: a controlled study

Twenty-three drug-free patients with agoraphobia and panic disorder (DSM-III criteria) had, at rest, lower mean end-tidal PCO2 (32 v. 36 mmHg) and higher mean heart rate (92 v. 83 bpm) than did 18 controls. During 5 min of listening to fear talk, only eight (35%) patients and three (16%) controls panicked, but panic was associated with marked physiological changes in only two patients and one control. Patients said that breathlessness began slightly more often before than after panic. In 59% of patients the symptoms from voluntary hyperventilation (VHV) were very similar or identical to those of their usual panics. Compared with the remainder, these patients felt more unpleasant during hyperventilation (HV); in such patients HV may aggravate somatic symptoms. Agoraphobics with panic differed from controls in having higher baseline arousal, but were not more reactive than controls to HV or fear talk.

Type A behaviour in patients with chest pain: Test-retest reliability and psychometric correlates of Bortner scale

Ninety-nine patients with chest pain and a presumptive diagnosis of coronary heart disease were assessed within 24 hr of angiography using a standardised psychiatric interview, personality inventory and Bortner Type A questionnaire. Ninety-six of the 99 patients completed the Bortner scale 4 months later, when test-retest reliabilities were 0.84 for both the 65 men and 31 women. There were significant correlations between Bortner score and measures of both psychiatric morbidity and neuroticism in men; and those items on the Bortner scale denoting speed and impatience were most highly correlated with neuroticism. None of these associations were noted in women. Men with normal or near-normal coronary arteries had higher measures of extraversion, neuroticism and Type A score than those with important occlusions, suggesting an association between insignificant coronary artery disease, complaint behaviour and raised Type A score. The findings question the unitary nature of Type A behaviour, and suggest an important association between the behaviour pattern and the personality dimension of neuroticism in men.

HYPERVENTILATION PROVOCATION IN PATIENTS WITH CHEST PAIN AND A NEGATIVE TREADMILL EXERCISE TEST

Seventeen (39%) of 44 patients with chest pain but without significant ST depression on treadmill exercise had their usual chest pain reproduced during or after 3 min of voluntary hyperventilation (VHV) at rest. These patients with hyperventilation positive tests had not only significantly more hyperventilation-related symptoms and respiratory complaints but also shorter breath-holding times, lower mean resting end-tidal pCO2 and higher mean respiratory rates than those with negative tests and normal controls. Of the psychological variables, only phobic avoidance scores for agoraphobia were higher in patients with positive tests. These findings suggest that in two fifths of patients with exercise tests negative for ischaemia, chest pain is associated with HV, but abnormalities of breath control and relative hypocapnia are present even in the absence of chest pain. It is possible that a chronic abnormality of respiratory control may interact with attitudinal factors in the experience of non-cardiac chest pain.

The test-retest reliability of the hyperventilation provocation test

The hyperventilation provocation test (HPT) has been widely used for reproducing symptoms of panics. It is assumed that subjects experience similar symptoms on consecutive occasions of hyperventilation. Fourteen subjects with a history of panics and fourteen without such a history underwent the HPT on two occasions one week apart. In the group of 28 subjects as a whole, there were moderate similarities between the HPTs in both the choice and severity of symptoms reported, even when pre-existing symptoms were controlled statistically. Nevertheless, in the subject-by-subject analysis, many subjects showed no resemblance between the two HPTs in the choice of symptoms. This suggests that many subjects would not show any resemblance between the symptoms experienced in an HPT and those of their latest panic even if hyperventilation occurred in that panic.

Physical and psychological correlates of severe heart disease in men

Seventy eight men were assessed one month before coronary artery bypass graft surgery using standardized measures of psychiatric morbidity and personality as well as a measure of emotional expression (the CECS). All patients had at least one coronary vessel occluded by 75% or more of its diameter, and functional capacity was assessed by calculating the exercise treadmill time (in seconds) for each patient. Most of the variance in exercise treadmill time was accounted for by the following variables: young age, short duration of symptoms, and less severe angina. Only one of five men was designated a psychiatric case. The only psychological measure significantly associated with atherosclerosis was expression of fear (on the CECS). A measure of Type A behaviour (Bortner score) was related to exercise treadmill time, but not to any of the angiographic or clinical indices of coronary heart disease (CHD). Like other measures of Type A behaviour, the Bortner scale is psychometrically impure and has doubtful validity. More valid behavioural variables (such as those measured by the CECS) require further investigation. Future studies on the relation between psychological factors and the extent of CHD should take account of not only sex differences but also patients without significant CHD: high rates of psychiatric morbidity in such patients confound the relation between psychological trait measures and atherosclerosis.

Type a behaviour: Recent developments

This paper discusses: (1) the difficulties associated with description and assessment of Type A behaviour (TAB); (2) the association between measures of TAB and psychopathology; (3) new approaches to the measurement of TAB; and (4) the results of recent studies that have attempted to modify the behaviour pattern, using (a) psychological treatment, (b) exercise, and (c) drug treatment. The psychological dimensions underlying Type A behavioral characteristics have not been identified, and attention is drawn to the very small overlap between the main instruments used to measure the behaviour pattern. An examination of the association between the different measures of TAB and psychopathology suggests that both the Framingham Type A scale and the Bortner scale show high correlations with neurotic manifestations of personality. A case is made for exploring the relationship between the behavior pattern and other psychosocial variables that have been shown in both retrospective and prospective studies to be associated with CHD risk. The paper describes a new method of conceptualising and describing TAB, derived from cognitive social learning theory. This model asserts that assessment of the individuals personal beliefs and fears is essential if the observable behaviours associated with pattern A are to be modified. In the Recurrent Coronary Prevention Project, attempts to modify TAB using techniques derived from cognitive behaviour therapy have produced encouraging results. Future large scale studies of CHD prevention should take account of psychosocial and personality variables as well as more traditional risk factors.