Posted by Scott L. Schofield on March 11, 2000, at 14:05:13
In reply to body over mind, posted by judy on March 3, 2000, at 9:46:12
> Hi,
> Just went through an angiogram (abnormal thallium stress test and chest pains) despite being female and under 40. The angiogram came back normal except for an anomaly in my right coronary artery. Despite "clean pipes", I am experiencing recurrent bouts of angina which the doc just says to pop klonopin- he feels it's panic attacks. I know elevated cortisol can cause all kinds of anxiety symptoms- going along the theme of the previous posts. Yet, nitroglycerin alleviates my symptoms, benzos do not. Any thoughts? Thanks.
Hi Judy,After reading your post, the first word to pop into my head was "somatization". This diagnosis is a bit of a pain in the butt, so I'll leave it for later. The second word to pop into my head was "vasospasm". My guess is that the angina you experience may actually be an expression of spasms occurring in coronary arteries that result from changes in autonomic nervous system dynamics. In either case, it can be argued that antidepressants would be a more effective treatment than the typical anxiolytics (anti-anxiety drugs), such as Klonopin and Xanax.
The autonomic nervous system is part of the central nervous system. It is comprised of two components: the sympathetic and parasympathetic nervous systems. In affective-spectrum disorders (depression, bipolar disorder, anxiety disorders, etc.), there is often a tendency towards dysautonomia. Specifically, there may be an excess in the activity of the sympathetic nervous system, which is responsible for producing the"fight or flight" response. This response can include an increase in heart rate and blood pressure. There may also be a decrease in the activity of the parasympathetic nervous system, which is responsible for offsetting (antagonizing) the "fight or flight" response, and maintaining autonomic balance.
Two mechanisms come into play here. Cardiac function is in part controlled by the direct stimulation of the heart by nerves coming from sympathetic pathways. It is also influenced by the release of epinephrine (adrenaline) and norepinephrine from the adrenal glands that is directed by this increase in sympathetic tone. It may be that you are predisposed to having spasms of the coronary arteries that are elicited by the disturbances of autonomic function associated with affective and anxiety disorders. If this is the case, it makes sense that nitroglycerine would alleviate it. . Be aware that panic-disorder is also a presentation among the anxiety disorders. This may have been your doctor's rationale for wanting to treat you with Klonopin. I think Inderal (propanolol) or some other beta-blocker may be helpful. Using treatments that target the underlying affective illness, including antidepressants, may cause your angina to resolve as your affective condition improves. That would be pretty cool.
I still don't have much of a grasp of the essential nature of "somatoform" and "somatization" disorders, but they involve the presence of physical symptoms for which no physiological cause can be determined. This does not including the feigning or faking of maladies. I found a couple of abstracts referring specifically to angina. These disorders fall within the realm of psychosomatic medicine. By definition, the physical complaints of somatization disorder must begin before age 30 and be chronic in nature. The DSM IV provides strict diagnostic guidelines for somatization disorder. Some feel that they are too rigid and let many cases slip by. It seems that this diagnosis appears more frequently in females than in males. I find the construct and proposed etiologies of these disorders to be vague and potentially misleading. Most of the literature considers somatization to be the result of the repression of one's psychological anomalies and their conversion into physical complaints. No particular mechanism is suggested, making it seem as if the whole thing is simply a mysterious psychological phenomenon. Other contributors in the field treat the physical complaints as real physiological consequences of the interaction between the psychological and the biological. I tend to subscribe to this construct. Within this context, I would view vasospasm-induced angina as being a psychosomatic manifestation of the underlying psychiatric illness.
Perhaps a better title for your post would have been "Body over mind over body".
- Scott
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Psychosom Res 1996 Jun;40(6):625-35Empirical psychological modeling of chest pain: a comparative study.
Serlie AW, Duivenvoorden HJ, Passchier J, ten Cate FJ, Deckers JW, Erdman RA
Erasmus University Rotterdam, Department of Medical Psychology and Psychotherapy, The Netherlands.In this study the psychological profiles of 67 patients with noncardiac chest pain (NCA) and 47 patients with coronary artery disease (CAD) were analyzed to construct an empirical-psychological model that would be able to discriminate these two groups. All patients were suffering from chest pain at the time of referral by their general practitioner. The noncardiac patients were significantly younger, more often female, single, and nonsmokers. The two groups differed significantly on anxiety, somatization, obsessive compulsive behavior, psychoneuroticism, and hyperventilation. Logistic regression analysis on the variables jointly, showed that age, gender, anxiety, and hyperventilation contributed significantly to the model for discriminating between the two groups. Crossvalidation showed that the constructed model was stable.
-------------------------------------------------------Harefuah 1993 Feb 15;124(4):193-6, 247-8
[Chest pain and anxiety-panic disorders in a primary care clinic].
[Article in Hebrew]
Schlosberg A, Shpiz M
Mental Health Center, Beer Ya'acov.Chest pain is one of the most common complaints in primary care clinics. About 10-30% of patients with chest pain diagnosed as suffering from angina pectoris have normal coronary angiograms. Some of them suffer from psychiatric disorders. We present a 47-year-old man with several risk factors for ischemic heart disease: smoker in the past, obesity, hyperlipidemia and family history of coronary disease. He had complaints typical of anginal syndrome and normal coronary arteriograms. After 1.5 years of unsuccessful medical treatment, he was referred to the psychiatrist in the primary care clinic who diagnosed anxiety and panic disorders with somatization. All cardiac drugs were stopped and psychopharmacological treatment and psychotherapy were started immediately. Within a month he was almost free of symptoms and was treated successfully for a year. Treatment was then stopped and he has remained symptom-free for the past 4 years. We conclude that in such atypical somatic cases, only the collaboration of general practitioner and psychiatrist will lead to quick diagnosis and successful treatment.
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South Med J 1988 Nov;81(11):1412-6Angina as a symptom of psychiatric illness.
Kane FJ Jr, Harper RG, Wittels E
Department of Psychiatry, Methodist Hospital, Houston, TX 77030.We retrospectively studied all patients who had normal coronary angiograms at The Methodist Hospital during the year 1984 (8% of all angiograms). Patients were surveyed eight to 18 months after angiography. Of the 216 patients (83% of total sample), 130 were female and 86 male. Sixty-three percent of the women and 50% of the men satisfied the criteria for generalized anxiety disorder, and 20% satisfied the criteria for panic attacks. On the Brief Symptom Inventory (BSI) Somatization Scale, 64% had scores above the average reported for psychiatric outpatients. Eighty-one percent received only reassurance about the absence of heart disease, and 25% received continuing nitrate therapy in the absence of heart disease. A majority of these patients remain untreated functional "cardiac neurotics" with untreated anxiety symptoms. We make suggestions regarding a clinical profile to identify these patients and appropriate measures to avoid prolonged disability
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Somatization Disorder
SYMPTOMS
A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.
Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance:four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination)
two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods)
one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy)
one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting)
Either (1) or (2):
after appropriate investigation, each of the symptoms in Criterion_B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication)
when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings
The symptoms are not intentionally feigned or produced (as in Factitious Disorder or Malingering).
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poster:Scott L. Schofield
thread:25726
URL: http://www.dr-bob.org/babble/20000302/msgs/26696.html