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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.

This article describes a reanalysis of seven studies on heart beat perception (HBP) in panic disorder. The pooled sample had 709 participants from eight diagnostic categories. Accurate HBP was uncommon, but more prevalent among panic disorder patients than among healthy controls, depressed patients, patients with palpitations and individuals with infrequent panic attacks. No differences were found between panic disorder patients and patients with other anxiety disorders. Accurate perceivers had higher anxiety sensitivity scores than inaccurate perceivers. The data remain inconclusive as to whether perceived heart rate is correlated with anxiety in inaccurate perceivers. Physical exercise, distraction, variations in instructions and treatment each influenced HBP. However, the influence was different than previously thought. Finally, it is suggested that HBP may be understood in terms of schema-guided information processing.

Objective: To develop a laboratory paradigm for assessing the tendency to amplify somatic symptoms and report bodily distress., Method: Reports of four different cardiopulmonary symptoms were obtained during standardized, treadmill exercise, while the physiological parameters which induce these symptoms were simultaneously measured. Two indices were developed to compare symptom reporting across patients: symptom severity after reaching 80% of predicted, maximal exercise capacity; and the magnitude of physiological arousal necessary to induce an initial sensation of discomfort., Results: Fifty-one medical outpatients with a chief complaint of palpitations were studied. Symptom distress at 80% of maximal exercise capacity was significantly associated with state anxiety and daily life stress. The complaint of "heart racing" first occurred at a significantly lower heart rate for patients who were older, more anxious, and reported more daily life stress. Measures of hypochondriasis, somatization, bodily amplification, and bodily absorption were not significantly associated with either symptom measure., Conclusions: Standardized exercise testing may provide a suitable paradigm with which to study the tendency to amplify symptoms and to somatize. The distress reported by different subjects at 80% of maximal exercise capacity may be considered an index of the discomfort engendered by a standardized stimulus, whereas the point of onset of discomfort may be a measure of the patient's threshold for becoming symptomatic. These findings are not conclusive, but do suggest that patients who are more anxious and under more stress tend to report more intense cardiopulmonary symptoms at comparable levels of physiological arousal, and to have a lower threshold for experiencing discomfort.

We measured the accurate awareness of resting heartbeat in a sample of medical out-patients meeting DSM-III-R criteria for hypochondriasis (n = 60), and in a comparison group of non-hypochondriacal patients (n = 60) from the same general medical clinic. Patients also completed subjective self-report ratings of their sensitivity to benign bodily sensation and of functional somatic symptoms. Hypochondriacal patients did not differ significantly from non-hypochondriacal patients in their accurate awareness of heartbeat. They did, however, consider themselves more sensitive to benign bodily sensation and report more functional somatic symptoms. Within each sample, the only statistically significant association found was a negative correlation (r = -0.32, p = 0.025) between heartbeat awareness and the severity of hypochondriacal symptoms among the hypochondriacal patients. These results suggest that hypochondriacs may not be more accurately aware of normal cardiac activity, and therefore that hypochondriacal somatic complaints may not result from an unusually fine discriminative ability to detect normal physiological sensations that non-hypochondriacal individuals do not perceive.

Objective: To determine the prevalence of psychiatric disorders in ambulatory patients undergoing Holter monitoring to evaluate palpitations., Design: Patients referred for 24-hour ambulatory electrocardiographic (ECG) monitoring were studied with a structured diagnostic interview and self-report questionnaires prior to monitoring., Setting: Holter laboratory of a large academic medical center., Patients and Other Participants: One hundred forty-five consecutive patients complaining of palpitations and 70 asymptomatic non-patient volunteers., Outcome Measures: DSM-III-R psychiatric diagnoses., Results: Forty-five percent (44.8%) of the participants had at least one lifetime anxiety or depressive disorder and 24.8% had at least one current (one month) disorder. The lifetime prevalence of panic disorder was 27.6%, and that of major depression was 20.8%. Current prevalence rates showed a similar pattern; the current prevalence of panic disorder was 18.6%. Panic disorder and somatization disorder symptoms were significantly more prevalent in the palpitation group than in the general medical clinic at the same hospital. Patients with a psychiatric diagnosis were more likely to report cardiac symptoms during monitoring than were those without psychiatric disorder, and more commonly described their symptoms as "pounding" and reported faintness, lightheadedness, and vertigo. Although cardiac histories and ECG results were no more serious, the patients with psychiatric diagnoses rated their overall health status as significantly worse., Conclusions: Almost half of palpitation patients referred for Holter monitoring have a psychiatric disorder. More than a fourth have lifetime panic disorder and a fifth have had panic attacks in the month before monitoring.

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)

This article reviews and appraises a variety of studies on panic disorder, visceral sensitivity, and cardiac disease. The literature reviewed includes descriptive surveys, small-scale experimental manipulations, and clinical interventions. Instruments have included structured diagnostic interviews, clinical observation, self-report inventories, direct measures of perceptual sensitivity, and cognitive tests. The subjects in these studies have ranged from community residents to carefully defined samples of designated patients with psychiatric or cardiac disease. We then outline a prospective investigation to examine the prominence of palpitations in panic anxiety and speculate on the importance of sensitivity to cardiac sensation in several other clinical conditions characterized by marked discrepancies between cardiac activity and cardiac symptoms.