Search

Somatic and visceral symptoms have a surprisingly weak relationship to objective measures of tissue pathology. This is exemplified by the poor correlation found between palpitations and cardiac arrhythmias. Many factors other than extent of disease influence symptomatic distress, and since symptoms are such a crucial feature of illness and of medical practice, much more investigation of these nonbiomedical influences is needed. Although experimental laboratory paradigms facilitate such investigation, there are problems involved in generalizing from laboratory findings to the reporting of the symptoms of disease in daily life. In studying the awareness of cardiac arrhythmias and of resting heartbeat, we have found that the palpitations of patients who somatize more and have more health-related anxiety and more psychiatric distress are significantly less likely to be related to demonstrable cardiac arrhythmias than are the palpitations of other patients. The accurate awareness of arrhythmias, however, is not associated with the accurate awareness of resting heartbeat. Even more surprising, a relatively large proportion of heart transplant recipients are accurately aware of their resting heartbeat. This work poses more questions than it answers. In so doing, it underscores some of the technical difficulties of conducting research in this area and shows how little is known about symptom perception, processing, and reporting.

Objective: To develop a self-report screening instrument to assist in the differential diagnosis of medical outpatients complaining of palpitations., Design: Patients completed self-report questionnaires assessing somatization, cardiac symptoms, and hypochondriacal concerns about health. Principal components analysis was performed to identify a subset of questions that could be used to distinguish patients with palpitations who have panic disorder from those with palpitations who do not have panic disorder., Patients: Sixty-seven medical outpatients referred for Holter monitoring because of a complaint of palpitations., Main Outcome Measures: Patients with palpitations were classified into 2 groups, those with and those without current panic disorder (established with a structured, diagnostic interview). The sensitivity, specificity, and posttest probability of the screening instrument were determined., Results: A reliable, stable, 10-item instrument was derived. It seems to tap diffuse, vague, or generalized somatic complaints and worry about physical illness. With the use of a criterion cutoff score of 21, this instrument had a sensitivity of 0.81, a specificity of 0.80, and a post-test probability of.57 in detecting current panic disorder in patients with palpitations., Conclusions: A psychometrically sound and brief self-report instrument was developed to assist in the differential diagnosis of palpitations. It can be used to identify patients whose symptoms are more likely to result from panic disorder and in whom ambulatory monitoring might be deferred.

Background: Psychiatric disorder is underdiagnosed in primary care practice, often because it is somatized and the patient reports only physical symptoms. Palpitations are among the symptoms that often are somatized., Methods: We studied prospectively 125 consecutive medical outpatients referred for ambulatory electrocardiographic monitoring to evaluate a chief complaint of palpitations. They completed an in-person research interview at the time of monitoring and a telephone follow-up interview 3 months later. The referring physicians completed questionnaires about their patients before receiving the results of the monitoring and again 3 months later., Results: Forty-three patients had clinically significant cardiac arrhythmias. Twenty-four (29%) of the remaining 82 patients had a current psychiatric disorder, and 20 of these patients (83%) had major depression or panic disorder. These patients were significantly younger and more disabled, somatized more, and had more hypochondriacal concerns about their health than did patients who had no psychiatric disorder. Their palpitations were more likely to last longer than 15 minutes, were accompanied by more ancillary symptoms, and were described as more intense. At 3-month follow-up, about 90% of the patients in both groups continued to experience palpitations. Symptoms of somatization, hypochondriacal concerns, and impairment of intermediate activities had improved in both groups, but remained higher in patients with psychiatric disorder than in patients without psychiatric disorder. During the follow-up interval, patients with psychiatric disorder had more emergency department visits. The physicians of patients with psychiatric disorder were more likely to ascribe the palpitations to anxiety or depression, and ordered fewer laboratory tests on them, but few patients who had not already been in psychiatric treatment were referred or started on psychotropic medication., Conclusions: Physicians are aware of a psychiatric component to the clinical presentation of palpitation, but this observation does not result in psychiatric treatment or referral in most cases.

Background: The aim of this study was to determine the predictors of persistent palpitations and continued medical utilization in a sample of medical patients referred for ambulatory electrocardiographic monitoring., Methods: A prospective telephone follow-up was conducted with patients who had undergone ambulatory electrocardiographic monitoring 3 months earlier. At inception, patients completed in-person interviews and self-report questionnaires, assessing somatization, hypochondriacal attitudes, bodily amplification (high degree of sensitivity to bodily sensations), and two types of life stress (minor daily irritants and major life changes). At follow-up, patients completed a structured interview about their clinical course, palpitations, and utilization of medical care during the interval., Results: At 3-month follow-up, 55 of the inception cohort of 67 patients were interviewed again. The mean severity of palpitations for the entire sample declined significantly, but 46 (83.6%) patients continued to experience their presenting symptoms. Stepwise multiple linear regression revealed that the interaction of bodily amplification and daily life stress at inception uniquely explained 10.0% of the variance in palpitation severity at follow-up. A four-step model composed of these two interaction terms and age and education level accounted for 21.4% of the variance in palpitations. The medical utilization findings are complementary in that the interaction of amplification and daily irritants at baseline predicted the number of unscheduled medical visits over the subsequent 3 months. The total number of ventricular premature contractions occurring during ambulatory monitoring was not a significant predictor of palpitations., Conclusions: Palpitations are more persistent in persons who are both highly sensitive to bodily sensations and who experience a greater number of minor daily irritants. The existence of either predictor alone is not sufficient to perpetrate this functional somatic symptom; it requires the combination of these predictors.

Purpose: To examine the relationship between patients' reports of palpitations and documented arrhythmias., Patients and Methods: Consecutive patients complaining of palpitations and referred for 24-hour ambulatory electrocardiographic monitoring were studied using self-report questionnaires and a structured diagnostic interview. Electrocardiographic results were subsequently analyzed in conjunction with symptom diaries. Positive predictive value was used to estimate the likelihood that a reported symptom coincided with a documented arrhythmia. Sensitivity was calculated as a measure of the likelihood that an arrhythmia would be detected and reported as a symptom., Results: Positive predictive value was inversely related to somatization, hypochondriacal attitudes, and psychiatric symptoms. It was not related to chronicity of palpitations, previously diagnosed heart disease, more extensive medical care utilization, or clinically significant arrhythmias. Patients were generally insensitive to their arrhythmias, failing to note the vast majority., Conclusions: Somatizing and hypochondriacal patients are not more sensitive to or accurately aware of subtle changes in cardiac activity, but rather may be expressing a response bias toward reporting somatic and psychologic distress in general. Apparently, patients do not learn to discriminate and detect cardiac activity more accurately as a result of having more medical care or suffering longer with their symptoms.

One hundred forty-five consecutive patients referred for ambulatory electrocardiographic monitoring for the evaluation of palpitations were studied just before monitoring. They were compared with 75 asymptomatic, nonpatient volunteers. The research battery included a structured diagnostic interview, self-report questionnaires, and perceptual tasks measuring awareness of cardiac activity. After monitoring, symptom reports were compared with concurrent electrocardiographic recordings to determine their accuracy. Forty palpitation patients (27.6%) had DSM-III-R lifetime panic disorder, and 27 (18.6%) had current (1-month) panic disorder. Panic patients were significantly more likely to describe their palpitations as "racing" or "pounding" and to have been awakened from sleep by them. They did not have more cardiac arrhythmias during 24-hour, electrocardiographic monitoring, and their symptom reports were significantly less likely to be due to demonstrable cardiac irregularities. They were not more accurately aware of resting heartbeat than nonpanic palpitation patients. They did score higher on self-report measures of somatization, hypochondriasis, and bodily amplification.

This study compared several measures of cardiac perception and related them to patient' spontaneous reports of palpitations. One hundred and forty-five ambulatory patients referred for Holter monitoring for the evaluation of palpitations were compared with 70 asymptomatic nonpatients. Reports of palpitations during monitoring were compared with the ECG to determine whether they coincided with an arrhythmia. Subjects also completed a heartbeat detection task to determine whether they were accurately aware of cardiac systole while at rest. 20.7% of palpitation patients and 4.7% of asymptomatic controls demonstrated an accurate awareness of resting heartbeat (p = 0.01). Performance was unrelated to bodily amplification, somatization, hypochondriacal symptoms, ECG findings, or psychiatric morbidity. 34.3% of palpitation patients reported symptoms that consistently coincided with arrhythmias on ECG. These accurate patients had significantly lower levels of amplification, somatization, hypochondriacal symptoms, and psychiatric morbidity. Accuracy of symptom reporting and accuracy of heartbeat awareness were not statistically associated.(ABSTRACT TRUNCATED AT 250 WORDS)