Angina Pectoris and Angina Innocens Diagnosis and Management of Chest Pain KERR L. WHITE, M.D., JOSEPH L. GRANT, M.D., and WILLIAM N. CHAMBERS, M.D.

l H E RISING INCIDENCE of coronary artery disease and the increased general awareness of its symptoms are focusing attention on the heart and mobilizing anxiety in a growing number of patients. Fifty per cent of hospitalized medical patients are said to complain of pain in the chest15 and, although knowledge has been advanced by extensive clinic a l e,

11,14, is. 24,25,34

an^

experimental 7 - 13 - 16 '

30,35,88 studies, the physician is at times unable to understand the nature and mechanism of a given pain. His interest often centers chiefly on establishing the presence or absence of organic heart disease, while the patient usually seeks both relief of pain and alleviation of anxiety, regardless of the diagnosis. Patients with classical angina pectoris are readily recognized, and in others it is obvious that the pain is not of cardiac origin. The latter pain has been called "angina innocens,"5 or chest discomfort not due to heart disease but referred to the heart by the patient. This term is more accurate than "pseudoangina,"17 which implies that the pain is spurious, whereas to the patient it is real. "Cardiac neuFrom the Dartmouth Medical School, the Hitchcock Clinic, Hanover, New Hampshire, and the Veterans Administration Hospital, White River Junction, Vermont. The work described herein was made possible by the support of the Hitchcock Foundation. Present address (K. L. W.): School of Medicine, University of North Carolina, Chapel Hill, N. C. Presented at the Tenth Annual Meeting of the American Psychosomatic Society, Atlantic City, N. J., April 18-19, 1953Received for publication January 13, 1954.

rosis" is a general term not restricted to chest pain. "Neurocirculatory asthenia" and "effort syndrome"9-12'14>16'37 often imply unidentified organic pathology. Miles and Cobb; and Weiss31 emphasize that the disorder has yet to be explained adequately except in terms of symptoms and neurotic personality features.

Material and Methods This study combines both psychological and medical points of view in considering 55 patients with anginoid pain. There were three groups: I. Twenty patients had classical angina pectoris for at least 6 months followed by a well-documented acute myocardial infarction, including characteristic ECG changes. Master's two-step test was not done on these patients. The criteria for angina pectoris of Zoll, Wessler, and Blumgart were used: "paroxysmal substernal or precordial pain or discomfort of short duration, frequently radiating to the shoulders and inner aspects of the arms, precipitated by exertion, emotion or other states in which the work of the heart is increased, and relieved by rest or nitroglycerin." II. Twenty patients had angina innocens5 —chest discomfort referred by them to the heart, without evidence of organic heart disease. The pain did not meet the criteria for angina and the two-step tests were negative. These patients were convinced that they had heart disease and in many instances their fears had been confirmed erroneously by other phyPSYCHOSOMATIC MEDICINE

WHITE ET

Results Age at Onset of Pain Ninety per cent of patients with angina pectoris were over 45 years of age when their VOL. XVII, NO. 2,

129

AL.

III. A mixed group of 15 patients had pain suggesting one of the first two diagnoses but not completely fulfilling the rigid criteria for either. Eleven of these were disqualified from the angina innocens group because- of the remote possibility of organic heart disease. In the other 4, heart disease was present but there was doubt that it caused the pain. Except for 2 with proved myocardial infarcts, all patients in the mixed group underwent Master's test. Of these, 10 were negative and 3 were positive, but the finding of a positive Master's test was not in itself considered adequate evidence for their inclusion in the angina pectoris group. Because of the small number of patients studied and the consequent statistical importance of each case, the authors have placed in this group patients concerning whom there was the slightest doubt about the nature of the pain, even in the presence of known heart disease. Consecutive patients with chest pain were studied until a series of 20 with angina innocens and 20 with angina pectoris was completed. During the study of these two groups 15 additional patients were encountered who were assigned to the mixed group. T h e history of each was taken and a physical examination, routine laboratory studies, ECG's, and x-rays of the chest, gallbladder, and upper gastrointestinal tract were made. Further laboratory studies, x-rays, and consultations were obtained where indicated. Social and personal data were secured from the patients, their relatives, social workers, and hospital records. Psychological evaluation was carried out by dynamically oriented interviews in accordance with an established protocol. A minimum of two hours, and in most cases more than four, was spent with each patient in addition to the time required for the medical aspects of diagnosis and treatment. Many of the patients were seen by at least two of the investigators and some have been followed for many years.

1955

symptoms began, while 85 per cent of those with angina innocens were under 45. Presenting Complaint Figure 1 indicates the striking tendency of patients with angina pectoris to avoid using the word "heart" when first describing their complaints. Only one used this word at the first interview. In contrast to this is its frequent use by the other patients, 14 (70 per cent) in the angina innocens group and 9 (60 per cent) in the mixed group Qp = 0.01*). Attitude Toward Symptoms Seventeen (85 per cent) of the patients with angina pectoris denied the significance of their symptoms by word or behavior; for example, by refusing emergency hospitalization or persisting in excessive activity against advice. Five of these continued heavy work despite their angina. In contrast, none with angina innocens denied their symptoms and 18 (90 per cent) dramatized them Qp = 0.01). (See Fig. 1.) A 69-year-old painter had severe exertional chest pain for a year and was told by his doctor that he had a bad heart and should not work so hard. He nevertheless continued hard work, and when he collapsed from coronary thrombosis refused to have a physician or go to a hospital. A 42-year-old garageman, who had angina; pectoris for 5 years and had constantly beeni warned by his physician against doing physical! labor of any kind, shovelled snow regularlythrough the winter until after an unusually heavy snowstorm he had an extensive myocardial infarction. On the other hand, a 40-year-old laborer who developed chest pain 4 months after his brother's death from a coronary thrombosis immediately took his doctor's advice to give up work even though the doctor told him he was not sure it was his heart. The patient gave a description of gas "like a ball in the left chest," and on study proved to have a hiatus hernia, but reassurance about his heart was difficult for him to accept. He said, * When appropriate, the data have been treated statistically and the level of confidence indicated. "f = 0.1" indicates that the results would occur by chance alone less than once in ten times; "p = 0.01," less than once in 100 times, and so on.2

130

CHEST PAIN

"I'd go to work if I could, but I know I have heart trouble. I can't help it if I do. I have that awful crushing feeling across my chest." The final diagnosis was angina innocens. Another patient with angina innocens was a jeweler, age 39, who complained of "pain going

%

Pain The pain was substernal in all patients with angina pectoris, and 6 (30 per cent) of the angina innocens group also had substernal pain. In contrast, 14 (70 per cent) of those

ATTITUDE TOWARD SYMPTOMS

1001 80-

60-

40-

20-

ANGINA PECTORIS = 20 DENIAL

MIXED GROUP N = I5 NEITHER

ANGINA INNOCENS

DRAMATIZATION

WORD "HEART* USED IN COMPLAINTS Fig. 1. There was an inverse relationship in the frequency of denial and dramatization in patients with angina pectoris and those with angina innocens. At the initial interview patients with angina pectoris rarely referred to their "hearts," in contrast to those with angina innocens. toward the heart; I feel as though my heart were coming out." He had suffered from "spastic colitis" until his father died of coronary thrombosis, after which his chest pain began. He was treated for psychoneurosis by his own doctor, but suffered a relapse when the doctor himself had a coronary attack. "That really threw me," the patient said, "there is no use being the richest man in the cemetery." There was no evidence of any organic disease on thorough study, but the patient accepted reassurance poorly.

with angina innocens complained primarily of pain in the left chest; their descriptions were frequently bizarre and variable. Radiation to the left shoulder and arm was frequent in all groups. T h e pain of angina pectoris lasted less than 20 minutes, while in the angina innocens and mixed groups it varied from a few seconds to many days. Twelve patients with angina innocens referred to the pain as "choking," "pressing," or "squeezing," terms usually rePSYCHOSOMATIC MEDICINE

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served in the physician's mind for angina pectoris. Pain was brought on by exertion and emotion in all groups and relieved by nitroglycerin in i patient with angina innocens, as well as in all those with angina pectoris. Rest brought relief more promptly and certainly in angina pectoris. Organic Conditions and Their Relation to Anginoid Pain By definition all patients with angina pectoris had coronary artery disease. Three patients in this group had conditions producing chest pain in addition to their angina TABLE 1.

Social and Personal Data A history of broken homes due to divorce, domestic strife, or the death of a parent before the patient was 12 years old was found most frequently in the mixed group and often in the angina innocens group. On the other hand no statistically significant differences were

ORGANIC CONDITIONS PRODUCING C H E S T P A I N

Angina •pectoris

Patients Number in each group With myocardial infarctions With conditions other than angina pectoris producing chest pain Gastrointestinal Hiatus hernia (and 1 umbilical hernia) Duodenal ulcer Gallbladder disease Splenic flexure syndrome Musculoskeletal (includes intercostal neuralgia, radiculitis, and scalenus anticus syndrome) Aggravating conditions Hypoglycemia Secondary anemia TOTALS

pectoris. Treatment of these conditions improved the patients but did not take away all their pain. In 1, chest pain was alleviated by treatment of a hiatus hernia, and in another by removal of a diseased gallbladder. Angina pectoris in the third was improved after correction of severe secondary anemia due to lymphoma (Table 1). Organic diseases were present in some patients without causing pain. Duodenal ulcer, gallbladder disease, and hiatus hernia (conditions to which anginoid pain is sometimes ascribable) existed unsuspected in 6 (30 per cent) of the 20 patients with angina pectoris. In 11 (55 per cent) of the 20 patients with angina innocens, 13 definite organic conditions contributed to the pain, but similar orVOL. XVII, NO. 2,

ganic lesions failed to produce pain in 2 (10 per cent) of these patients. In another 9 (45 per cent) of the patients with angina innocens, no organic disease was found. The mixed group showed a variety of relationships between the pain and various organic diseases.

1955

20

20 (100%)

Mixed group

15

5 (33%)

1 0 1 0

4 0 0 0

Angina innocens 20 0

5 1 2 1

0

4

3

0 1

1 0

0 0

3 (15%)

9 (60%)

12 (60%)

found between the three groups in levels of education, reasons for leaving school, socioeconomic status, work patterns, position in family, or incidence of familial psychopathy. Angina Pectoris and Cardiac Symptoms by Identification A family history of coronary artery disease occurred in 14 (70 per cent) patients with angina pectoris and in 7 (35 per cent) of the angina innocens group. In addition to the familial occurrence of heart disease, the development of cardiac symptoms resembling those of friends, relatives, or associates by means of identification was observed in the angina pectoris group and was common in the mixed and angina innocens groups. In the last group,

132 there was a familial history of heart disease in 7 (35 V^ c e n 0 patients while cardiac symptoms by identification were present in 19 (95 per cent). T h e relationships of the patients to the people with whom they identified were more diffuse in the mixed and angina innocens groups. "Diffuseness" was recorded when patients identified with those beyond their immediate families, such as business associates and public figures. Identification in angina pectoris was illustrated by the case of a 60-year-old carpenter with a family history negative for heart disease, who had served in the British Navy in World War I on the same ship with the late King George VI of England. In 1947 this patient developed intermittent claudication of the legs. From 1948 on he followed newspaper accounts of the king's illness with keen interest, and later stated, "He had the same trouble in his legs that I did, and finally died of a heart attack." The patient felt his fortunes linked somehow to those of his royal shipmate, identifying with him in a manner often adopted by those who have personally known world-famous figures. His attacks of coronary thrombosis coincided with the king's illness and he frequently referred to the similarity between his disorders and those of the king. ,

CHEST PAIN manner rather than in their statements. Patients with angina innocens, on the other hand, had openly expressed anxiety, the focus of which often shifted from their hearts to other organs after the original pain had been treated. This displacement of symptoms occurred in 15 (70 per cent) patients with angina innocens and in 10 (67 per cent) of the mixed group, compared to only 5 ( 2 5 per cent) with angina pectoris (j; = 0.01). Displacement from the heart occurred most often to the gastrointestinal tract (24 patients) and the genitourinary tract (6 patients); cancerophobia became apparent in 7 patients. A 51-year-old janitor, who developed fainting spells and left chest pain localized in the nipple, radiating "all over," and bearing no relation to exercise, had been told by a doctor that he had heart disease and had given up his job. Further investigation established that no heart disease was present. The patient then developed fear of lung cancer. A 50-year-old loom fixer was receiving 100 per cent compensation for "coronary artery disease," of which repeated thorough investigation revealed no evidence. He shifted the site of pain to his esophagus after diagnosis was changed. He complained thereafter of difficulty in swallowing. Barium swallow, esophagoscopy, and laryngoscopy were all normal.

A patient in the angina innocens group who furnishes an example of identification is the jeweler mentioned above, whose chest pain be- Life Situations at Onset of Pain came much worse after his doctor's heart attack. Most patients gave a history of chronic Another is a 45-year-old minister whose angina emotional tension, often associated with deinnocens began after several prominent members terioration in their life situations. Usually of his congregation developed heart disease. there was a superimposed threat to their interpersonal relations or sense of security prior to Personality Data the onset of symptoms. Phobias, hysteria, and hypochondria were most common in the angina innocens and A 63-year-old woman without previous angina mixed groups. Depressive reactions were more experienced an attack of coronary thrombosis when her husband, who had previously been frequent in angina pectoris, both as a response to the disease and as part of the premorbid well, suddenly had a convulsion and died. Another woman of 62 had mounting debts, personality. Obsessive-compulsive traits were common in all three groups, as were strong disagreeable tenants, and strong feelings of idendependent needs and a tendency to fall short tification with her mother, who had died of heart disease. She felt increasingly insecure, and when of personal goals. her husband left home one day to look for work in another town she became desperate and develAnxiety oped chest pain which proved to be due to a In the angina pectoris group anxiety usu- myocardial infarction. ally was evident in the patients' facies and A 49-year-old power company worker was seen PSYCHOSOMATIC MEDICINE

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because of angina innocens. While at work on a dam he was accidentally trapped, and narrowly escaped drowning. Thereafter he had nightmares about the episode and eventually had to change to a less well paid but safer job. The reduction in income led to friction with his wife. The patient began to drink heavily and had repeated fainting spells. At the same time he began to have sharp shooting pains in the left chest.

i.o in angina pectoris and 1.5 in angina innocens. There were 4.2 hospitalizations per patient in the mixed group, 2.4 in the angina pectoris, and 2.4 in the angina innocens groups (Fig. 2). In the angina innocens and mixed groups changes of physician by the patient were most frequent. There were 23 deliberate changes of

INDICES OF MORBIDITY

432-

ANGINA PECTORIS N=20

MIXED GROUP N = 15

ANGINA INNOCENS N = 2O

AVERAGE NO. OF HOSPITALIZATIONS PER PATIENT

•

AVERAGE NO. OF PHYSICIANS CONSULTED PER PATIENT

Fig. 2. There was a high incidence of morbidity in the mixed group compared to the other two, and a marked need for patients in the angina innocens and mixed groups to change physicians frequently. Though he was reassured by his own doctor that he did not have heart disease, he felt sure that he had, and when first seen by us had been depressed and bedridden for 5 months.

Indices of Morbidity The average number of all diseases (other than coronary artery disease) per patient was highest in the mixed group, 2.7, compared to VOL. XVII, NO. 2, 1955

doctors by the 35 patients in these two groups compared to none in the angina pectoris group. These patients tended to consult one doctor after another, searching for confirmation of their neuroticworries about their hearts or for effective relief of their anxiety. The average number of physicians consulted per patient (including those consulted because of changes caused by the doctors or by circum-

134 stances as well as by the patients themselves) was 4.4 in the angina innocens group, 4.3 in the mixed group, and 1.5 in the angina pectoris group (see Fig. 2). Response to Treatment Somatic treatment included sedation, nitroglycerin, antispasmodics, antacids, procaine blocks, surgical repair of hiatus hernia and gallbladder removal, and in 1 patient a pericardial poudrage. Psychological treatment was largely supportive and suppressive but also employed simple ventilating and uncovering techniques. All patients had much interest shown in them as persons, and several had more prolonged psychotherapy. Of the 12 patients who have died since the study began, 10 were in the angina pectoris group and 2 in the mixed group. Three quarters of those in both the angina innocens and mixed groups were improved by combined medical and psychological treatment; none was cured. Seven (35 per cent) of the patients with angina pectoris showed improvement. They reported that discussion of their problems and feelings brought relief of their anxiety and a reduction in the frequency and intensity of pain. It was found useless and occasionally illadvised to insist on the absence of heart disease in patients who were intensely dependent upon the gain which they derived from their "illness." A 50-year-old housewife had asthma, osteoarthritis of the spine with chest pain, and a deep-seated conviction that she had heart disease. Her father died of a coronary thrombosis when she was 12 years old. In 1944, while visiting an orthopedist, the patient overheard him say about another patient, "She has only three months to live and doesn't know it." She wrongly assumed he referred to her and that he meant she had heart disease, although he actually had made no mention of the word heart and was referring to another patient. It became impossible to convince her she had no heart disorder. She developed an extreme degree of cardiac fixation and became outraged and panicky if her physicians refused to acknowledge the existence of her heart disease. She left the doctors who insisted her heart was sound and finally remained under the

CHEST PAIN care of those who allowed her to maintain her fantasy. A 55-year-old railroad engineer, who had a severe obsessive-compulsive personality, phobias, and morphine addiction, had an unusually high degree of secondary gain from the anginoid pain associated with a hiatus hernia. He had been given pensions from the railroad, Veterans Administration, and a private insurance company. There was no clinical or laboratory evidence of heart disease but his whole life and activity were based on the regular receipt of this income which was granted because of "arteriosclerotic coronary artery disease." Following careful medical evaluation the "innocent" nature of his symptoms was discussed with him. He appeared relieved at the improvement in his prognosis but 10 days later on leave from the hospital committed suicide.

Discussion Evaluation of Symptoms Our findings of denial of symptoms by patients with true angina and exaggeration of symptoms by those with angina innocens confirm those of other authors. In 1931 Fahrenkamp noted that in cardiovascular disease, the subjective complaints of the patient and the objective findings of the physician varied almost inversely. Wenckebach considered the manifestations of denial and exaggeration of symptoms specific enough in cardiovascular disease to use them routinely in his evaluation of anginoid pain. Baker found by statistical study that patients without structural heart disease complained of a greater number of symptoms than those with organic changes. In our patients with angina pectoris, denial was more emphatic at the onset of symptoms than later in the course of the disease. Because of its threat to their personal security systems, these patients either consciously or unconsciously refused to accept the presence of heart disease. When they finally did go to a doctor they complained of gas, indigestion, or rheumatic pains, but rarely of their "hearts."36 Those with angina innocens, on the other hand, emphasized and dramatized their symptoms and displayed their emotions more readily. Dramatization was readily recognized, but denial often had to be sought for specifically. PSYCHOSOMATIC MEDICINE

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AL.

The nature of the pain, its radiation, duration, and the precipitating causes in the angina pectoris and angina innocens groups conformed in general to their usual descriptions but there was considerable overlapping of the syndromes. Associated Pathology Somatic Conditions The literature1' 20' 21' 24' 27-20':!3 stresses the great number of conditions which may simulate angina pectoris. Gallbladder disease, peptic ulcer, hiatus hernia, and other organic lesions have been found to give rise to pain in the chest. These were present most often in our angina innocens group. However, their presence does not always explain the symptoms any more than the presence of coronary artery disease in a patient necessarily explains all his chest pain. Schnur has criticized "the erroneous teaching that the diagnosis of neurosis is to be entertained only when organic disease has been excluded." Patients with angina pectoris may also have angina innocens, either concurrently or at another time. So anxietyevoking is the belief that heart disease is present that any chest pain experienced thereafter may be interpreted as arising from the heart.2 This reactivates the patient's primitive anxiety patterns which may find somatic expression as tachycardia and extrasystoles, and result in more cardiac awareness. Such a vicious cycle confirms the patient's conviction that the pain is due to heart disease. Under these circumstances it can be difficult for the physician to separate symptoms of angina innocens from those of angina pectoris. This is illustrated by the mixed group, in which the high incidence of multiple organic conditions resulted in more numerous complaints, required more hospitalization and made the diagnosis more difficult. This group had the highest incidence of divorce, domestic strife, and broken homes, and there was a high correlation between social, psychological, and somatic disturbances in these patients. Psychological Conditions The frequent occurrence of anxiety hysteria, VOL.

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135 associated phobias, and hypochondriacal reactions in angina innocens is in agreement with the findings of Wittkower.6 Patients with angina innocens tended to display overt and more easily displaced anxiety, which contrasted with the organ-fixated anxiety and realistic fear in angina pectoris. The importance of anxiety in patients with and without heart disease had been stressed by Conner, and Viko has shown that neurotic patients develop many more symptoms in rheumatic heart disease than do those without neuroses. In our patients with angina innocens the neurotic quality of the anxiety focused on their hearts was confirmed in many cases by the later development of symptoms related to other organs or body systems. Somatic treatment of anginoid pain and superficial reassurance regarding the heart usually were inadequate without effective handling of the underlying anxieties and life situations. The high incidence and diffuseness of identifications indicate their importance in both angina innocens and angina pectoris. In all groups the pain had many causes, of which the organic was only one. In some patients identification with sufferers from heart disease appeared as important in symptom formation as was organic disease. Anginoid pain in all three groups was precipitated by increasing emotional tension, deterioration of life situations, and threats to personal security. This is in agreement with the findings of many observers. Wittkower found that the "factor common to all precipitating causes of cardiac pain is a menace to vital feelings, life or existence."34 Similar stresses are observed in other cardiac conditions.8' 23t 35 Response to Therapy Most patients responded to somatic and psychological treatment. In patients with angina pectoris, supportive psychotherapy often resulted in a decrease in anxiety and in symptomatic improvement. In the angina innocens group improvement was often short-lived, and frequently gave way to the appearance of symptoms elsewhere in the body. In patients with deep-rooted neuroses a cardiac fixation for anxiety may be preferable to

CHEST PAIN

136 the reactions which can occur when anxiety is displaced from the heart. Most patients could be partly rehabilitated without attempting to remove all their psychological and somatic symptoms. When the self-esteem and compensation factors often associated with chronic invalidism are lost, the effect may be extremely disturbing, and overenthusiastic assurance to the patient that his disease is "not serious" may be hazardous.

Conclusions

plaints to other body systems or organs. When simple uncovering techniques and supportive psychotherapy were used, three quarters of the patients in the angina innocens and mixed groups and one third of those with angina pectoris were improved symptomatically. 8. Consideration of the patient's psychological, social and physical attributes is essential in the evaluation, treatment, and prevention of anginoid pain. Summary

Fifty-five patients with anginoid pain were 1. Denial of symptoms was marked in patients with angina pectoris, in contrast to studied medically and psychologically. Twenty dramatization of symptoms in those with had angina pectoris, twenty had angina innocens, and the remaining 15 did not fulfill the angina innocens. 2. Hysterical and hypochondriacal symp- criteria for either. The somatic and psychotoms, usually with phobias, characterized the logical features characteristic of each group angina innocens group. Depressive reactions are described. The heterogeneous factors predominated in angina pectoris. Anxiety and which may combine to produce anginoid pain compulsive and dependent features were com- are discussed, and the importance of a comprehensive approach to the patient is emphamon in all patients. 3. Chronic emotional tension, superimposed sized. deterioration of life situations, and threats to personal security were associated with the References onset of symptoms in all groups. 1. ALLISON, D. R. Pain in the chest wall simu4. Pain and other symptoms were more lating heart disease. Brit. M. / . 1:332, 1950. diffuse in location and character in the angina 2. ABLOW, J. A. Anxiety patterns in angina innocens and mixed groups. Extracardiac pectoris. Psychosom. Med. 14:461, 1952. causes for anginoid pain were found in all 3. BAKER, D. M. Left inftamammary pain. three groups but were most common in the Lancet 1:1280, 1930. angina innocens and mixed groups. Extra- 4. BAKER, D. M. Cardiac Symptoms in the Neuroses. London, Lewis, 1942. cardiac conditions to which anginoid pain is 5- BOURNE, G. The symptomatology of cardiac often ascribable occurred asymptomatically in pain. Brit. M. J. 1:1109, '935some patients. The presence of organic disease, 6. BOURNE, G., SCOTT, R. B., and WITTKOWER, including coronary arteriosclerosis, did not E. The psychological factor in cardiac pain. necessarily mean that it caused the pain. Lancet 2:609, '9377. BRAUN, L. Herz und Angst: Ewe Arztlich5. The incidence of familial coronary artery •psychologische Studie. Vienna, Austria, disease was highest in angina pectoris. Cardiac Deuticke, 1932. symptoms by identification were observed in 8. CHAMBERS, W. N., and REISER, M. F. Emoall three groups. Identifications were more diftional stress in the precipitation of congestive fuse in the angina innocens and mixed groups. heart failure. Psychosom. Med. 15:38, 1953. 6. Patients with angina innocens had deep- 9. COHEN, M. E., and W H I T E , P. D. Life situations, emotions and neurp-circulatory asthenia: seated anxiety focused on their hearts which Anxiety neurosis, neurasthenia, effort syndrome. drove them from doctor to doctor in search of Psychosom. Med. 13:335, 1951relief for both their pain and anxiety. 10. CONNER, L. A. The psychic factor in cardiac 7. Following somatic treatment and reasdisorders. ].A.M.A. 94:447, 1950. surance regarding their hearts, patients with 11. DUNBAR, FLANDERS. Character and symptom angina innocens often displaced their comformation. Psychoanalyt. Quart. 8:18, 1939. PSYCHOSOMATIC MEDICINE

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Effect of

exercise on soldiers with neurocirculatory asthenia. Psychosom. Med. 8:188, 1946. KILGORE, E. G. Angina pectoris and pseudoangina. J.A.M.A. 87:455, 1926. MASTER, A. M., NUZIE, S., BROWN, R. C ,

and PARKER, R. C. The electrocardiogram and the "two-step" exercise: A test of cardiac function and coronary insufficiency. Am. J. M. Sc. 207:435, 1944. MILES, H. H. W., and COBB, S.

Neuro-

circulatory asthenia, anxiety and neuroses. New England ]. Med. 245:711, 1951. METTENLEITER,

M. W.,

and LUST, F. J.

Angina pectoris simulated by chronic peripancreatitis and pancreatitis. Am. ]. Digest. Dis. 17:11, 1950. OILLIE, J. A., and OILLIE, W. A.

Pain or

distress wrongly attributed to the heart. M. Clin. North America 36:501, 1952. PECKHAM, R. H. Determination of the statistically minimum number of cases. Am. ) . M. Sc. 224:131, 1952. REISER, M. F., BRUST, A. A., and FERRIS,

E. B., JR. Life situations, emotions and the course of patients with arterial hypertension. Psychosom. Med. 13:133, 1951. RINZLER, S. H. Cardiac Pain. Springfield, 111., Thomas, 1951. RISEMAN, J. E. F., and BROWN, M. G.

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analysis of the diagnostic criteria of angina pectoris: A critical study of 100 proved cases. Am. Heart ) . 14:331, 1937. 26. SCHNUR, S. Cardiac neurosis associated with organic heart disease: Am. Heart ]. 18:153, 1939. SUCKLE, E., and WHARTON, G. K.

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relationship between cardiovascular function and gastro-intestinal disease. Am. ]. Digest. Dis. 18:153, J939VIKO, L. E. Cardiac neurosis associated with rheumatic valvular heart disease. Am. Heart ]• i:539, 19^529. WALTERS, M. B., and MASTER, A. M.

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relationship between biliary tract and coronary artery disease. Surg., Gynec. & Obst. 94: 152, 1952. 30. WEISS, E. Emotional Factors in Cardiovascular Disease. Springfield, 111., Thomas, 1951. VOL. XVII, NO. 2, 1955

31. WEISS, E. Neurocirculatory asthenia. Psychosom. Med. 14:150, 1952. 32. WENCKEBACH, K. F. Herzkranke; die es nicht sind. Wien. med. Wchnschr. 84:621, 1934. 33.

34. 35. 36. 37. 38.

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Discussion DR. EDWARD WEISS, Philadelphia, Pa.: This paper is concerned with one of the most important and most difficult subjects in clinical medicine—the problem of anxiety and the heart. An anxious person with a normal heart can often be reassured and told to go about his business; an anxious person with a diseased heart cannot. When he is told to rest and is surrounded with other precautions he often becomes an invalid, more from the fear of heart disease than from the heart disease itself. Moreover, tension of emotional origin can be as burdensome to the cardiovascular system as effort of physical origin, so that for both reasons one has to try to reduce anxiety in order to make such patients, within the capacity of their cardiovascular systems, useful citizens again. Now and again such patients develop a coronary occlusion, or a cerebral vascular accident occurs, and the physician is criticized for overlooking or giving insufficient attention to the organic disease. This poses a very difficult question because the problems of psychosomatic relationships in cardiovascular disease may be very complicated, and depend as much upon an analysis of the personality structure as upon the evaluation of the cardiovascular disease. Therefore, as the authors have pointed out, one has to try to determine the degree of psychological impairment as carefully as the degree of organic heart damage, and judgment must be based on both. This means that the physician must have one foot planted as firmly in psychopathology as the other is in tissue pathology in order to stand on safe ground

138 in the diagnosis and treatment of cardiovascular cases. Any pain, from nose to navel, must be taken seriously and the various physical studies outlined by the authors must be done. Then, if one can safely exclude physical disease, the question of reassurance arises. Most physicians attempt to reassure such patients on the basis that they do not have organic heart disease, but the authors tell us that reassurance alone may prove to be more troublesome to the patient by robbing him of his defenses. They recognize, of course, that one must do more than reassure these patients. We must try to understand the background of the anxiety so that symptom formation may not be necessary. Under these circumstances, I have not seen harm come to patients with cardiac neurosis who have been reassured; indeed, the individual usually tolerates anxiety better in relation to some other organ or system than when it is localized in the heart. And in turn I think one might say that other organs and systems usually tolerate anxiety—or the tension arising from it—better than the heart, because tension of emotional origin may provoke cardiac breakdowns in cardiovascular disease that might not otherwise occur. When one deals with anxious people with diseased hearts the question often arises of whether the physician, psychiatrist, or both should be responsible for the patient. There is always the question of whether we ought to ask our colleagues in psychiatry and psychoanalysis to assume responsibility for such patients; yet so often

CHEST PAIN the psychiatric problems are beyond the capacity of the average physician or cardiologist. Certainly under such circumstances the cooperation that is necessary requires that each have considerable understanding of the other's discipline. So often after myocardial infarction the heart heals but the patient remains an invalid because of anxiety. Here, the analysis of the personality will permit the physician to judge whether the individual is one who accepts dependency, thinks in terms of retirement, and becomes an invalid (perhaps subsisting on insurance benefits) or whether he will fight against dependency, perhaps erring in the other direction by refusing suggestions and indulging in rash behavior. One may have to deal with guilt and hostile feelings; nor should we forget that the coronary age is also the period of diminishing potency and many sexual problems arise that are capable of causing great tension. These too have to be considered in relation to the coronary circulation. Finally, depression is often masked by heart symptoms; it must be recognized and dealt with appropriately. While the authors absolve the medical profession from responsibility for the precipitation of many of these disorders, I think that the over-all picture cannot be viewed so optimistically. In other words, the general lack of appreciation of the importance of the emotional factor in all disorders and diseases of the circulation leads to many difficulties of iatrogenic origin. When the medical profession generally is as well prepared and sympathetic to this point of view as the authors are, most of these troubles can be avoided.

PSYCHOSOMATIC MEDICINE