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Psychological symptom profiles in patients with chest pain
Jourrrd of Pswhosomarrr Rrrwrch.
PSYCHOLOGICAL
SYMPTOM PROFILES WITH CHEST PAIN
Vol. 38, No. 4, pp. 365-311, 1994 Elsewer Scmcr Ltd Prmed in Great Britan 0022-3999194 16.00 + 00
IN PATIENTS
C. TENNANT, A. MIHAILIDOU, A. SCOTT, R. SMITH, J. KELLOW, M. JONES, S. HUNYOR. M. LORANG and R. HOSCHL (Received 22 February 1993; accepted in revised form 30 Sepprrmber 1993)
Abstract-Five-hundred and thirty-two patients with ischaemic-like chest pain referred for symptomlimited exercise thallium myocardial perfusion studies, were assessed on a range of psychosocial measures. Three groups of patients were identified on the basis of their perfusion studies: (1) normal thallium perfusion; (2) current myocardial ischaemia; and (3) past myocardial infarction (but no current ischaemia). There were no significant psychological differences between these groups on a wide range of measures which included depression, state and trait anxiety, Type A behaviour, personality, suppression of affect, locus of control, alexythymia, and hypochondriasis. Significant differences were identified, however, on measures of anger and coping style. Subjects with no current ischaemia (normal thallium perfusion and those with past myocardial infarction) had higher scores on ‘immature coping’ and ‘anger in’, than subjects with current myocardial ischaemia. These findings are discussed in the light of other published research.
INTRODUCTION IN PRIMARY medical practice, 80% of patients presenting with chest pain are found to have no organic cause [ 11, while in patients referred for angiography, between 10 and 30% have no significant coronary artery disease [2]. A significant clinical problem is that few, if any, clinical features differentiate non-cardiac chest pain from chest pain of cardiac origin [3]. A range of psychological factors assessed in earlier research attempted to distinguish organic from non-organic ischaemia like chest pain. Firstly patients with anxiety disorders, especially panic disorder, may present with chest pain and other cardiologic symptoms [l]. For instance, Ayuso Mateos et al. [4] noted that 47% of subjects presenting acutely to casualty departments complaining of chest pain, were diagnosed as having panic disorder. Similarly, 48 % of angiography patients were found not to have significant coronary artery disease, and 42% of these had either panic disorder or major depression. In those with identified coronary artery disease, 19% had panic disorder [5]. These latter findings assume more importance when one considers that in one sample of subjects with ‘normal’ coronary angiograms who also had documented panic disorder, 41% had the disorder without the usual associated intense fear and apprehension [6]. This observation may explain why this severe anxiety syndrome is often misdiagnosed. Psychopathology, however is not restricted to panic disorder. Richter and Bradley [7] reviewed several studies which showed that chest pain patients with normal coronary arteries generally had higher scores on measurements of general anxiety,
Departments of Academic Psychiatry, Cardiology, Nuclear Medicine, Surgery, Medicine and Health Information Systems, Royal North Shore Hospital, Sydney, Australia. Author for correspondence: Professor C. Tennant, Department of Academic Psychiatry, Royal North Shore Hospital, St Leonards, NSW 2065, Australia. 365
366
C.
TENNANT
('1trl.
depression, hypochondriasis and neuroticism when compared to patients with identifiable coronary artery disease. While most such studies have used patients hospitalized for diagnostic catheterization (which itself may contribute to psychological distress). Lantinga rf al. [S] have shown that patients with normal coronary arteries continue to score significantly higher on tneasures of depression, state and trait anxiety, somatic anxiety and panic symptoms 1 yr after angiography. Anger or hostility are related variables also shown to have some impact on CHD variables [9]. Anger/hostility have been shown to correlate with CHD risk factors including BP reactivity [ 101and adverse lipid profile [l 1, 121. Hostility has also been shown to predict subsequent acute CHD events both over the short term (3 yr) [13] and long term (20 yr) [14] although there are studies which have failed to produce such positive associations [ 151. The most compelling evidence derives from studies of heart function however. Hostility is associated both with perfusion defects on thallium scan and with ischaemic changes on holter monitor [ 161 while ‘anger recall’ predicts diminished left ventricular ejection fraction [ 171. The present study assesses a range of psychosocial variables in patients presenting with chest pain and referred to thallium myocardial perfusion scan. These psychosocial variables were compared in three groups of subjects: those with nortnal scans, those with current ischaemia, and those with no current ischaemia but with evidence of past myocardial infarction.
METHODS Consecutive patients (N = 590) with chest pain referred for symptom-limited exercise thallium myocardial perfusion studies, were asked to complete a comprehensive psychological questionnaire before undertaking the thallium test. Demographic. social and medical factors were included in the questionnaire. Patients also completed an extensive symptom questionnaire, the results of which have been previously reported [18]. This included the duration, frequency, nature and site of their pain. On the basis of the thallium scan, patients were categorized as having either: (i) normal thallium: N = 387 (59% male, mean age 56 f I I yr), i.e. those having normal excrcisc thallium studies; (ii) current ischaemia: N = 93 (Xl% male, mean age 59 f IO yr), i.e. those having abnormal studies. with evidence of reversible myocardial ischaemia; or (iii) past infarction: N = 52 (89% male, mean age 59 i 10 yr), i.e. those who had evidence of fixed perfusion defects consistent with previous myocardial infarction but no current reversible ischaemia. All patients gave informed consent for the study and the protocol was approved by the Institution’s Medical Research Ethics Committee. We used an extensive range of psychosocial measures which included the following: the Bortner scale [19] for assessing Type A behaviour, emotional dependency [20], the brief Eysenck personality questionnaire assessing neuroticism, introversion/extroversion [21], state and trait anxiety [22], anger [23]. CESD depression [24], suppression of affect [25], early parenting [26], hypochondriasis [27]. social intimacy [28]. locus of control [29] and alexythymia [30]. A coping measure [31] as modified by Andrew et nl. [32] was also included. This instrument assesses the diverse ways subjects cope with stress and categorizes these styles as mature or immature. All measures have established reliability and validity and were chosen on the basis of existing evidence that they may be important in either coronary artery disease. or non-organic chest pain, or that they might be expected to contribute to these disorders.
Study groups were compared with respect to psychosocial and other measures in two analyses: (i) by the Kruskal-Wallis test; and (ii) after controlling for a number of potentially confounding factors by covariance analysis. The latter analysis was carried out by fitting a logistic regression model with group membership as the outcome and age and a given psychological scale as the predictors; all scores were log 10
Psychological transformed As multiple values.
symptom
profiles in patients with chest pain
367
prior to the analysis and p-values icss than 0.05 have been reported ab statistically significant. hypothesis tests have been pcrformcd. some caution needs to he applied In interpreting ,I-
RESULTS
Forty-nine patients were unable to complete the questionnaire due to language difficulties; of the remaining 541 patients, 532 patients completed the psychosocial questionnaire, a response rate of 98.3%. There were 354 males and 178 females, of whom 78% were married. 16% were divorced and 6% were single. Thirty-five per cent had 3 or 4 yr secondary schooling, 16% had 5 or 6 yr secondary schooling, 26% had non-university tertiary education and 23% had university qualifications. Forty-seven per cent were in full-time employment. 8% part-time employment. 12% domestic duties and 32% not employed or retired. Fifty-seven per cent were current smokers. Patients with normal thallium studies were slightly, but significantly, younger 0, < 0.05) than the current ischaemia group; patients with ischaemia and infarction were similar in age. The three groups were comparable in marital status, education level. and rates of alcohol consumption and smoking. Significantly more normal subjects (46%) and ischaemic subjects (54%) were engaged in full-time employment compared to those with past myocardial infarction (37%) @ < 0.01). There were no differences in the past medical history among the three groups. When compared to those with a normal thallium mean, subjects with past infarction @ < 0.02) and those with current ischaemia (JJ < 0.07) were more likely to have right sided chest pain. These two clinical groups did not differ in frequency of right sided pain however. The three groups were not significantly different on the duration of chest pain. Pq~chological
evaluation
Statistically significant differences were found between the three groups in terms of Spielberger’s Anger-In (AI) 0, = O.Ol), and in terms of Immature Response on the Coping Questionnaire (IR) [31, 321 (p < 0.01) (Table I). Patients both with normal thallium scans and those with past infarction had significantly higher scores on AI than those with current ischaemia. Patients with normal thallium scans, and past infarction also had significantly higher IR scores than those with current ischaemia. In both instances, the normal thallium and past infarction group did not differ
TABLE I.-PSYCHOLOGICAL FACTOR DIFFERENCES IN THREE PATIENT GROUPS PRESETTING WITH SHEET PAIN (MEAN + st)
Group
Anger-In
Normal thallium (N = 387) Past infarction (N = 52) Current ischaemia (N = 145) p-value (KruskalLWallis) Anger-In. Immature *p < 0.01 compared
15.0 i 0.3* 16.0 * 0.6* 14.0 * 0.3 0.01
Response--see text for details. to patients with current ischaemia
Immature
Response
32.0 i 0.3* 33.0 i I .4* 30.0 f 0.9 0.009
368
C. TENNANT
rt al.
significantly. The overall correlation between AI and IR was observed within the three groups-normal thallium: r = 0.40, p < 0.0 I ; past infarction: r = 0.27. p < 0.0 I; and current ischaemia: r = 0.46. p < 0.01. Patients with normal thallium scans and with infarction also demonstrated a tendency towards higher scores on the Anger Ex scale than patients with current ischaemia, indicating a greater tendency to express/ experience anger. On all other psychological measures there were no significant group differences. Covariance analysis indicated the possibility that the difference in IR, but not AI, between normal thallium and current ischaemia patients may be related to the slight difference in age (3 yr) between these two groups; after controlling for age. the difference between groups just ceased to be statistically significant 07 = 0.06). Such an age difference, however, is unlikely to be of any clinical importance. Moreover, given that approximately twenty covariance analyses were performed, it is difficult to be certain whether these results indicate true confounding or are a product of multiple analyses.
DISCUSSION
The major objective of this study was to attempt to determine if patients with organically determined ischaemia-like chest pain were any different psychologically from subjects with ischaemia-like pain where no organic heart disease could be elicited on thallium scan, thus we did not use a matched normal control sample. Most previous studies in this area show more marked psychopathology in patients with chest pain who do not have identified coronary artery disease, than in those with pain due to identifiable coronary disease [8, 333371. It is in the domain of anxiety, neuroticism and depression that the psychological differences have been reported most commonly. Our study, in contrast, shows relatively little difference in psychological profiles between patients with ischaemic pain and those without identifiable ischaemia. Measures of anxiety, depression and neuroticism did not distinguish our three patient groups, which encompassed those with chest pain and current myocardial ischaemia, pain and previous infarction, and pain without current ischaemia or previous infarction. There are several important differences between this and most earlier studies. Firstly. other reports have studied patients referred for coronary angiography, whereas our study has evaluated patients with chest pain who were referred for thallium myocardial perfusion studies. It may well be that patients having the less invasive thallium scan represent a somewhat different population than those having angiography, being more representative of the general body of patients presenting to physicians with chest pain. Secondly, differences in psychological measures used may also contribute to some difference in the findings. Finally, there may be demographic differences in various patient groups. We took into account age as a potentially confounding factor since it is related to a number of the psychological measures; we regarded differences in employment status, however, as likely to be an outcome of the disease rather than an antecedent factor. Although our study did not include ‘normal’ control data as it was not possible to derive demographically-matched normative data, the range of scores for our patients was not dissimilar to published normative
Psychological symptom profiles in patients with chest pain
369
data on these measures. In particular, for the two measures where group differences emerged, the range of scores for our total sample was again similar to published controls: for Anger-In our range was 8-23 (published normals 9-21) [38], while for Immature coping our patients ranged from 20 to 46 (published normals 3947) [32]. We did not feel it appropriate to compare our sample means with normative samples because of significant differences in the composition of our group (predominantly older and male) compared to normative samples. Our significant positive finding related to Spielberger’s Anger-In, and to Immature Response on the Coping Questionnaire. The correlations between these variables (Y = 0.42) supports the contention that these may be related variables; for instance, Anger-In may be reflective of an immature coping styles. These previously unreported higher scores on both measures in the normal thallium and past infarction groups are indicative of more psychopathology in these patients, when compared to those with identified ischaemic pain. Chest pain in both these groups was associated with immature coping and containment of angry feelings. Thus these apparently nonischaemic chest pain syndromes may therefore be influenced to some extent by how the individual copes with anger. It is of interest that we have also observed a similar phenomenon in relation to patients with functional dyspepsia and a tendency for delayed gastric emptying [39]. Indeed it is possible that such variables may be more likely to be associated with non organic pain syndromes generally. Further research is needed to explore this possibility. It is of particular interest that no affective variables (anxiety, depression, etc.) or other personality related variables (neuroticism, etc.) distinguished the three subject groups. This may indicate that these variables play little role in non-oschaemic pain. which is in contrast with findings from other studies. Our study does not address the possibility that patients with current ischaemia may have affective states reflecting an organic cause for their pain, while in the two groups without current ischaemia. affective states may influence the occurrence of their chest pain; the three groups may then not be significantly different in their scores on these affective measures. Our findings in relation to ‘anger-in’ and ‘immature coping’, however suggest that these two variables at least, influence only those categories of chest pain not associated with current ischaemia.
REFERENCES I KATON WJ. Chest pain, cardiac disease, and panic disorder. ./ Clin P.sj,chol 1990; 5l(Suppl): 27-30. 2. SCHOFIELDPM, BROOKS NH. COGLAN S, BENNETTDH. WHORWELL PJ, BRAY CL, WARD C, JONES PE. Left ventricular function and oesophageal function in patients with angina pectoris and normal coronary angiograms. Br Heurr .I 1987;58: 2 18-224. 3. BFUNDERMANR, SRAMEKM, K~STER RW, GARSSEN V. VAN DISH. Criteria for differential diagnosis in cardial symptoms; left- or right-sided chest pain? N& T&i.xhr Genreskd 1990; 134: 2249-2252. 4. Ayuso MATEOS JL, BAYON PEREZ C, SANTA DOMINGO CARRASCO J, OLIVARFS D. Atypical chest pain and panic disorder. Psychother P.~~chosot~~ 1989; 52: 92-95. 5. CARNEY RM, FREEDLAND KE, LUDBROOK PA, SAUNDERS RD, JAFFE AS. Major depresslon, panic disorder, and mitral valve prolapse in patients who complain of chest pain. Anr J M& 1990: 89: 7% 760. 6. BEITMAN BD, KUSHNER M, LAMBERT~JW. MUKERJI V. Panic disorder without fear in patients with angiographically normal coronary arteries. .I Nrrv Mm/ Dis 1990; 178: 307-3 12. 7. RICHTER JE. BRADLEYLA. Chest pain with normal coronary arteries. Dig Di,r Sci 1990; 35: 1441-1444.
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8. LANTINGA LJ, SPRAFKIN RP, MCCROSKERY JH, BAKER MT, WARNER RA, HII.L NE. Psychosocial follow-up of patients with chest pain and normal coronary arteries: one year post-angiography. Arrr J C’ardiol 1988; 62: 209-213. predictors of heart disease: a quantitative review. 9. BOOTH-KEWLEY S, FRIEDMAN HS. Psychological Psycho1 Bull 1987; 101: 343-362. IO. CHRISTIANSEN AJ, SMITH TW. Cynical hostility and cardiovascular reactivity during self-disclosure. Psychosom Med 1993; 55(2): 193-202. 11. DUJOVNE VF. HOUSTON BK. Hostility-related variables and plasma lipid levels. J Behao Med 1991; 16: 555-565. 12. SIEGLER IC, PETERSON BL, BAREFOOT JC, WILLIAMS RB. Hostility during late adolesence predicts coronary risk factors at mid-life. Am J Epidemiol 1992; 136: 146-I 54. 13. KOSKENVUOM, KAPRIO J, ROSF.RJ, KESANIEMIA, SARNA S, HEIKKILA K. LANCINVAINIOH. Hostility as a risk factor for mortality and ischemic heart disease in men. Psychosom Med 1988; 50: 330-340. 14. MARUTA T, HAMBURGEN ME, JENNINGS CA, OFFORD KP, CULLIGAN RC, FRYE RL, MALINCHO~’ M. Keeping hostility in perspective: coronary heart disease and the Hostility Scale on the Minnesota Multiphasic Personality Inventory. Mayo C/in Proc 1993; 68: lO9%114. 15. HEARN MD, MURRAY DM, LUEPKER RV. Hostility. coronary heart disease, and total mortality: a 33year follow-up study of university students. J Behav Mcd 1989; 12: 102-121. 16. HELMENSKF, KRANTZ DS, HOWELL RH, KLEIN J, BAIREYCN, ROZANSKI A. Hostility and myocardial ischemia in coronary artery disease patients: evaluation by gender and ischemic index. Psychosom Med 1993; 55: 29-36. 17. IRONSON G, TAYLOR CB, BOLTWOOD M, BARTZOKIST, DENNIS C, CHESNEY M, SPIZER S, SIZALL GM. Effects of anger on left ventricular ejection fraction in coronary artery disease. Am J Cardiol 1992; 70: 281-285. 18. SCOTT A, MIHAILIDOU A, SMITH R. KELL~W J, JONES M, L~RANC C, HUNY~R S. LORANG M, HOSCHL R, TENNANT. C. Functional gastrointestinal disorders in unselected patients with non-cardiac chest pain. Sand J Gastroenterol 1993; 28: 585-590. 19. BORTNER RW. A short rating scale as a potential measure of pattern A behaviour. J Chron Dis 1967: 22: 87-9 1. Yale University, 1975. 20. BLATT SJ, D’AFFLITTI JP, QUINLAN DM. Depressive experiences questionnaire. 21. DUNCAN-JONES P. Short, stable measures of extroversion and neuroticism for Australian general populations (unpublished paper), 19 NHMRC Social Psychiatry Research Unit, AN University. 22. SPIELBERC;ERCD, GORSUCH RL, LUSHENE RE. STAI Mum&for the State-trait Anxiety Inverztory. Palo Alto, CA: Consulting Psychologists Press, 1970. 23. SPIELBERGERCD, JOHNSONEH, RUSSELL SF, CRANE RJ, JACOBS GA, WORDEN TJ. The experience and expression of anger: Construction and validation of an anger expression scale. In Anger and No.sti/ity in Cardiovascular and Brhavioural Disorder.7 (Edited by CHESNEY MA, ROSENMAN RH) New York: Hemisphere/McGraw, 1984. 24. RADLOFF L. The CES-D scale: a self-report depression scale for research in the general population. Appl Psycho1 Meas 1977; 3: 385-401. measure ofemotional control. J P.~~&~som Rex 25. WATSON M, GREER S. Development of a questionnaire 1983; 27: 299-305. 26. PARKER G, TUPLINC; H. BROWN LB. A parental bonding instrument. Br J Med P.~who/ 1979; 52: I -~I(). Br J Psxchiatrv 1967; 113: 89-93. 27. PILOWSKY I. Dimensions of hypochondriasis. 28. WILHELM K, PARKER G. The development of a measure of intimate bonds. Ps~c~/ro/ Med 1988; 18: ?25234. Br J Med 29. CRAICI AR, FRANKLIN JA, ANDREWS G. A scale to measure locus of control of behaviour. Psycho1 1984; 57: 173~m180. 30. APFEL. RJ, SIFNEOSPE. Alexythymia: concept and measurement. Psychother Psvchosom 1979; 32: I80 190. 31. BOND M. GARDNERST, CHRISTIANJ, SIC;ALJJ. Empirical study of self-related defense styles. ,4rch GWI Psychiatry 1983; 40: 333-338. J Nrrv Ment Dis (in press). 32. ANI)REWS G, SINC;HM, BOND M. The Defense Style Questionnaire. 33. MCCROSKERY JH, SCHELL RE, SPRA~KIN RP, LANTINC;A LJ. WARNER RA, HILL N. Differentiating angina1 patients with coronary artery disease from those with normal coronary arteries using psychological measures. Am J Curdiol I99 1; 67: 645-646. 34. DEMARIA AM, LEE G, AMSTERDAMEA, Low R, MASON DT. The angina1 syndrome with normal coronary arteries: aetiological and prognostic considerations. JAMA 1980; 244: 826828. study of middle-aged 35. ELIAS MF, ROBBINSMA. BLOW FC, RICE AP, ED~~WOM~JL. A behavioural chest pain patients: physical symptom reporting, anxiety, and depression. E.Y~ Aging Re.r 1982; 8: 45 51.
Psychological 36. BASS C. WADE C. Chest
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with chest pain
371
pain with normal coronary artcries: a comparative study of psychiatric and social morbidity. /?SK+IO/ Mrcl 1984; 14: 51 -61. 37. COSTA PT JR. ZUNDERMAN AR, ENGEL BT, BAILI: WF, BRIMLOW DL, BRINKERJ. The relation of chest pain symptoms to angiographic findings of coronary artery stenosis and neuroticism. P.~~~/~oson~MN! 1985; 47: 285-293. 38. KNIGHT RG. C’EfIsHoLMBJ. PAULIN JM, WAAL-MANNNG HJ. The Spiclberger Anger Expression Scale: Some psychometric data. Br J Clirz P.Y.IY&I/1988: 27: 279 -28 I. 39. Bww-rT EJ. KELLOW JE. COWAN H, JONES MP. LANGELUDDECKE P, HOSNL R. TENNANT CC. Suppression of anger and gastric emptying in patients with functional dyspepsia. S~rnclJ Gtrstrorr~rrrol 1992; 27: 869~-874.
PSYCHOLOGICAL
SYMPTOM PROFILES WITH CHEST PAIN
Vol. 38, No. 4, pp. 365-311, 1994 Elsewer Scmcr Ltd Prmed in Great Britan 0022-3999194 16.00 + 00
IN PATIENTS
C. TENNANT, A. MIHAILIDOU, A. SCOTT, R. SMITH, J. KELLOW, M. JONES, S. HUNYOR. M. LORANG and R. HOSCHL (Received 22 February 1993; accepted in revised form 30 Sepprrmber 1993)
Abstract-Five-hundred and thirty-two patients with ischaemic-like chest pain referred for symptomlimited exercise thallium myocardial perfusion studies, were assessed on a range of psychosocial measures. Three groups of patients were identified on the basis of their perfusion studies: (1) normal thallium perfusion; (2) current myocardial ischaemia; and (3) past myocardial infarction (but no current ischaemia). There were no significant psychological differences between these groups on a wide range of measures which included depression, state and trait anxiety, Type A behaviour, personality, suppression of affect, locus of control, alexythymia, and hypochondriasis. Significant differences were identified, however, on measures of anger and coping style. Subjects with no current ischaemia (normal thallium perfusion and those with past myocardial infarction) had higher scores on ‘immature coping’ and ‘anger in’, than subjects with current myocardial ischaemia. These findings are discussed in the light of other published research.
INTRODUCTION IN PRIMARY medical practice, 80% of patients presenting with chest pain are found to have no organic cause [ 11, while in patients referred for angiography, between 10 and 30% have no significant coronary artery disease [2]. A significant clinical problem is that few, if any, clinical features differentiate non-cardiac chest pain from chest pain of cardiac origin [3]. A range of psychological factors assessed in earlier research attempted to distinguish organic from non-organic ischaemia like chest pain. Firstly patients with anxiety disorders, especially panic disorder, may present with chest pain and other cardiologic symptoms [l]. For instance, Ayuso Mateos et al. [4] noted that 47% of subjects presenting acutely to casualty departments complaining of chest pain, were diagnosed as having panic disorder. Similarly, 48 % of angiography patients were found not to have significant coronary artery disease, and 42% of these had either panic disorder or major depression. In those with identified coronary artery disease, 19% had panic disorder [5]. These latter findings assume more importance when one considers that in one sample of subjects with ‘normal’ coronary angiograms who also had documented panic disorder, 41% had the disorder without the usual associated intense fear and apprehension [6]. This observation may explain why this severe anxiety syndrome is often misdiagnosed. Psychopathology, however is not restricted to panic disorder. Richter and Bradley [7] reviewed several studies which showed that chest pain patients with normal coronary arteries generally had higher scores on measurements of general anxiety,
Departments of Academic Psychiatry, Cardiology, Nuclear Medicine, Surgery, Medicine and Health Information Systems, Royal North Shore Hospital, Sydney, Australia. Author for correspondence: Professor C. Tennant, Department of Academic Psychiatry, Royal North Shore Hospital, St Leonards, NSW 2065, Australia. 365
366
C.
TENNANT
('1trl.
depression, hypochondriasis and neuroticism when compared to patients with identifiable coronary artery disease. While most such studies have used patients hospitalized for diagnostic catheterization (which itself may contribute to psychological distress). Lantinga rf al. [S] have shown that patients with normal coronary arteries continue to score significantly higher on tneasures of depression, state and trait anxiety, somatic anxiety and panic symptoms 1 yr after angiography. Anger or hostility are related variables also shown to have some impact on CHD variables [9]. Anger/hostility have been shown to correlate with CHD risk factors including BP reactivity [ 101and adverse lipid profile [l 1, 121. Hostility has also been shown to predict subsequent acute CHD events both over the short term (3 yr) [13] and long term (20 yr) [14] although there are studies which have failed to produce such positive associations [ 151. The most compelling evidence derives from studies of heart function however. Hostility is associated both with perfusion defects on thallium scan and with ischaemic changes on holter monitor [ 161 while ‘anger recall’ predicts diminished left ventricular ejection fraction [ 171. The present study assesses a range of psychosocial variables in patients presenting with chest pain and referred to thallium myocardial perfusion scan. These psychosocial variables were compared in three groups of subjects: those with nortnal scans, those with current ischaemia, and those with no current ischaemia but with evidence of past myocardial infarction.
METHODS Consecutive patients (N = 590) with chest pain referred for symptom-limited exercise thallium myocardial perfusion studies, were asked to complete a comprehensive psychological questionnaire before undertaking the thallium test. Demographic. social and medical factors were included in the questionnaire. Patients also completed an extensive symptom questionnaire, the results of which have been previously reported [18]. This included the duration, frequency, nature and site of their pain. On the basis of the thallium scan, patients were categorized as having either: (i) normal thallium: N = 387 (59% male, mean age 56 f I I yr), i.e. those having normal excrcisc thallium studies; (ii) current ischaemia: N = 93 (Xl% male, mean age 59 f IO yr), i.e. those having abnormal studies. with evidence of reversible myocardial ischaemia; or (iii) past infarction: N = 52 (89% male, mean age 59 i 10 yr), i.e. those who had evidence of fixed perfusion defects consistent with previous myocardial infarction but no current reversible ischaemia. All patients gave informed consent for the study and the protocol was approved by the Institution’s Medical Research Ethics Committee. We used an extensive range of psychosocial measures which included the following: the Bortner scale [19] for assessing Type A behaviour, emotional dependency [20], the brief Eysenck personality questionnaire assessing neuroticism, introversion/extroversion [21], state and trait anxiety [22], anger [23]. CESD depression [24], suppression of affect [25], early parenting [26], hypochondriasis [27]. social intimacy [28]. locus of control [29] and alexythymia [30]. A coping measure [31] as modified by Andrew et nl. [32] was also included. This instrument assesses the diverse ways subjects cope with stress and categorizes these styles as mature or immature. All measures have established reliability and validity and were chosen on the basis of existing evidence that they may be important in either coronary artery disease. or non-organic chest pain, or that they might be expected to contribute to these disorders.
Study groups were compared with respect to psychosocial and other measures in two analyses: (i) by the Kruskal-Wallis test; and (ii) after controlling for a number of potentially confounding factors by covariance analysis. The latter analysis was carried out by fitting a logistic regression model with group membership as the outcome and age and a given psychological scale as the predictors; all scores were log 10
Psychological transformed As multiple values.
symptom
profiles in patients with chest pain
367
prior to the analysis and p-values icss than 0.05 have been reported ab statistically significant. hypothesis tests have been pcrformcd. some caution needs to he applied In interpreting ,I-
RESULTS
Forty-nine patients were unable to complete the questionnaire due to language difficulties; of the remaining 541 patients, 532 patients completed the psychosocial questionnaire, a response rate of 98.3%. There were 354 males and 178 females, of whom 78% were married. 16% were divorced and 6% were single. Thirty-five per cent had 3 or 4 yr secondary schooling, 16% had 5 or 6 yr secondary schooling, 26% had non-university tertiary education and 23% had university qualifications. Forty-seven per cent were in full-time employment. 8% part-time employment. 12% domestic duties and 32% not employed or retired. Fifty-seven per cent were current smokers. Patients with normal thallium studies were slightly, but significantly, younger 0, < 0.05) than the current ischaemia group; patients with ischaemia and infarction were similar in age. The three groups were comparable in marital status, education level. and rates of alcohol consumption and smoking. Significantly more normal subjects (46%) and ischaemic subjects (54%) were engaged in full-time employment compared to those with past myocardial infarction (37%) @ < 0.01). There were no differences in the past medical history among the three groups. When compared to those with a normal thallium mean, subjects with past infarction @ < 0.02) and those with current ischaemia (JJ < 0.07) were more likely to have right sided chest pain. These two clinical groups did not differ in frequency of right sided pain however. The three groups were not significantly different on the duration of chest pain. Pq~chological
evaluation
Statistically significant differences were found between the three groups in terms of Spielberger’s Anger-In (AI) 0, = O.Ol), and in terms of Immature Response on the Coping Questionnaire (IR) [31, 321 (p < 0.01) (Table I). Patients both with normal thallium scans and those with past infarction had significantly higher scores on AI than those with current ischaemia. Patients with normal thallium scans, and past infarction also had significantly higher IR scores than those with current ischaemia. In both instances, the normal thallium and past infarction group did not differ
TABLE I.-PSYCHOLOGICAL FACTOR DIFFERENCES IN THREE PATIENT GROUPS PRESETTING WITH SHEET PAIN (MEAN + st)
Group
Anger-In
Normal thallium (N = 387) Past infarction (N = 52) Current ischaemia (N = 145) p-value (KruskalLWallis) Anger-In. Immature *p < 0.01 compared
15.0 i 0.3* 16.0 * 0.6* 14.0 * 0.3 0.01
Response--see text for details. to patients with current ischaemia
Immature
Response
32.0 i 0.3* 33.0 i I .4* 30.0 f 0.9 0.009
368
C. TENNANT
rt al.
significantly. The overall correlation between AI and IR was observed within the three groups-normal thallium: r = 0.40, p < 0.0 I ; past infarction: r = 0.27. p < 0.0 I; and current ischaemia: r = 0.46. p < 0.01. Patients with normal thallium scans and with infarction also demonstrated a tendency towards higher scores on the Anger Ex scale than patients with current ischaemia, indicating a greater tendency to express/ experience anger. On all other psychological measures there were no significant group differences. Covariance analysis indicated the possibility that the difference in IR, but not AI, between normal thallium and current ischaemia patients may be related to the slight difference in age (3 yr) between these two groups; after controlling for age. the difference between groups just ceased to be statistically significant 07 = 0.06). Such an age difference, however, is unlikely to be of any clinical importance. Moreover, given that approximately twenty covariance analyses were performed, it is difficult to be certain whether these results indicate true confounding or are a product of multiple analyses.
DISCUSSION
The major objective of this study was to attempt to determine if patients with organically determined ischaemia-like chest pain were any different psychologically from subjects with ischaemia-like pain where no organic heart disease could be elicited on thallium scan, thus we did not use a matched normal control sample. Most previous studies in this area show more marked psychopathology in patients with chest pain who do not have identified coronary artery disease, than in those with pain due to identifiable coronary disease [8, 333371. It is in the domain of anxiety, neuroticism and depression that the psychological differences have been reported most commonly. Our study, in contrast, shows relatively little difference in psychological profiles between patients with ischaemic pain and those without identifiable ischaemia. Measures of anxiety, depression and neuroticism did not distinguish our three patient groups, which encompassed those with chest pain and current myocardial ischaemia, pain and previous infarction, and pain without current ischaemia or previous infarction. There are several important differences between this and most earlier studies. Firstly. other reports have studied patients referred for coronary angiography, whereas our study has evaluated patients with chest pain who were referred for thallium myocardial perfusion studies. It may well be that patients having the less invasive thallium scan represent a somewhat different population than those having angiography, being more representative of the general body of patients presenting to physicians with chest pain. Secondly, differences in psychological measures used may also contribute to some difference in the findings. Finally, there may be demographic differences in various patient groups. We took into account age as a potentially confounding factor since it is related to a number of the psychological measures; we regarded differences in employment status, however, as likely to be an outcome of the disease rather than an antecedent factor. Although our study did not include ‘normal’ control data as it was not possible to derive demographically-matched normative data, the range of scores for our patients was not dissimilar to published normative
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data on these measures. In particular, for the two measures where group differences emerged, the range of scores for our total sample was again similar to published controls: for Anger-In our range was 8-23 (published normals 9-21) [38], while for Immature coping our patients ranged from 20 to 46 (published normals 3947) [32]. We did not feel it appropriate to compare our sample means with normative samples because of significant differences in the composition of our group (predominantly older and male) compared to normative samples. Our significant positive finding related to Spielberger’s Anger-In, and to Immature Response on the Coping Questionnaire. The correlations between these variables (Y = 0.42) supports the contention that these may be related variables; for instance, Anger-In may be reflective of an immature coping styles. These previously unreported higher scores on both measures in the normal thallium and past infarction groups are indicative of more psychopathology in these patients, when compared to those with identified ischaemic pain. Chest pain in both these groups was associated with immature coping and containment of angry feelings. Thus these apparently nonischaemic chest pain syndromes may therefore be influenced to some extent by how the individual copes with anger. It is of interest that we have also observed a similar phenomenon in relation to patients with functional dyspepsia and a tendency for delayed gastric emptying [39]. Indeed it is possible that such variables may be more likely to be associated with non organic pain syndromes generally. Further research is needed to explore this possibility. It is of particular interest that no affective variables (anxiety, depression, etc.) or other personality related variables (neuroticism, etc.) distinguished the three subject groups. This may indicate that these variables play little role in non-oschaemic pain. which is in contrast with findings from other studies. Our study does not address the possibility that patients with current ischaemia may have affective states reflecting an organic cause for their pain, while in the two groups without current ischaemia. affective states may influence the occurrence of their chest pain; the three groups may then not be significantly different in their scores on these affective measures. Our findings in relation to ‘anger-in’ and ‘immature coping’, however suggest that these two variables at least, influence only those categories of chest pain not associated with current ischaemia.
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