اختلال هراس غیرترس آور در قفسه سینه بیماران با درد

The prevalence of nonfearful panic disorder (panic attacks without the experience of fear) was estimated in 199 patients consecutively referred to outpatient cardiac investigation for chest pain. Fifty-nine patients met the criteria for panic disorder, and 17 patients fulfilled the criteria for nonfearful panic disorder. The patients with nonfearful panic disorder had lower scores on self-reported panic symptoms and lower frequencies of agoraphobia and comorbid axis I disorders than the patients with panic disorder and had a higher prevalence of somatic disorders than the patients without panic disorder. The patients with nonfearful panic disorder did not differ significantly from the patients with panic disorder in health-related quality of life.

In cardiac settings, panic disorder commonly occurs among chest pain patients, with a reported prevalence of 25%–60%.1., 2., 3., 4. and 5. Beitman et al.6. and 7. recognized a subgroup of patients with panic disorder in medical settings who had panic attacks without the experience of fear. They did not report free-floating anxiety, fear of dying, or fear of going crazy or doing something uncontrolled in conjunction with their panic attacks, but they otherwise met the criteria for panic disorder. Thus, these patients described attacks of intense discomfort and at least four of the 12 remaining symptoms listed in the DSM-III-R definition of panic disorder.8 Beitman et al. used the term “nonfearful panic disorder” to describe the condition of the patients who fulfilled these criteria. Nonfearful panic disorder is an understudied concept that may be clinically important in medical settings where patients with panic disorder are often seen. Three previous studies of patients who were referred for cardiac investigation due to chest pain and who suffered from panic disorder reported that 32%–44% fulfilled the criteria for nonfearful panic disorder.6., 9. and 10. These studies were carried out among selected cardiac patients: patients with atypical angina or nonanginal chest pain,6 patients referred for angiography with a negative result,9 and emergency department patients with acute chest pain.10 We are not aware of any study reporting the prevalence of nonfearful panic disorder in unselected cardiology outpatients referred for investigation of new chest pain. If nonfearful panic disorder is a subcategory of panic disorder, we hypothesize that among the patients with panic disorder referred for cardiac investigation of new chest pain, there will be a subgroup of patients with nonfearful panic disorder. The concept of nonfearful panic disorder is somewhat controversial, as it remains unclear whether nonfearful panic disorder is a subcategory of panic disorder, or a distinct diagnostic entity. Previous studies have so far concluded that it is reasonable to regard nonfearful panic disorder as a subcategory of panic disorder, as there are more similarities than differences between patients who meet the criteria for nonfearful panic disorder and those who meet the criteria for panic disorder. These studies have reported no significant differences between the two groups in demographic characteristics, intensity and frequency of panic attacks,6. and 10. and prevalence of panic disorder in first-degree relatives.9 However, one study found a lower frequency of simple phobia in patients with nonfearful panic disorder, compared to patients with panic disorder.6 Furthermore, a study by Fleet et al.10 reported a lower frequency of generalized anxiety disorder and agoraphobia among patients with nonfearful panic disorder. Considering alternative diagnoses to nonfearful panic disorder, Fleet et al.10 suggested that somatoform disorders or undiagnosed medical diseases could be possible explanations of panic-like symptoms described as nonfearful panic disorder. Based on the idea that nonfearful panic disorder symptoms are more correctly classified as somatoform disorder, we would expect the patients with nonfearful panic disorder to fulfill the diagnostic criteria for such a disease. Similarly, if nonfearful panic disorder symptoms could rather be explained by a somatic disorder, we would expect that a large proportion of patients with nonfearful panic disorder would suffer from a somatic disease characterized by panic-like symptoms. Previous studies have neither diagnosed somatoform disorders through structured diagnostic interviews nor evaluated the presence of medical disorders. Therefore, the relationship between panic disorder, nonfearful panic disorder, and somatoform or somatic disorders is unknown. It has also been emphasized that in future research there is a need to address alexithymia (not having words to express feelings) as a possible explanation for nonfearful panic disorder symptoms. Jones11 described alexithymic panic in a case report in 1984 and Rachman et al.12 reported “noncognitive” panic attacks and suggested that patients with these symptoms were unable to detect, recall, or describe their fearful cognitions. According to this hypothesis, we would expect to find a higher frequency of alexithymia among patients with nonfearful panic disorder than among patients with panic disorder. If this is the case, it may have implications for the treatment of this group of patients. Because patients with nonfearful panic disorder complain solely of somatic symptoms, these patients are less likely to be acknowledged as having an anxiety disorder and thus may not be referred to psychiatric treatment.7 To motivate physicians to identify patients with nonfearful panic disorder, there is a need for further knowledge regarding the extent to which these patients are impaired by their disorder and seek medical treatment for symptoms. Fleet et al.10 conducted a 2-year follow-up study and found no significant differences between patients with panic disorder and those with nonfearful panic disorder in perceived health status and number of chest pain episodes, emergency department visits, and hospitalizations. A number of investigations of health-related quality of life among patients with panic disorder in psychiatric settings have found that patients with panic disorder report their mental and physical health as worse compared to the general population, regardless of the frequency of panic attacks or presence of comorbid psychiatric disorders.13. and 14. We are not aware of any study comparing the health-related quality of life in patients with panic disorder and those with nonfearful panic disorder. However, based on the results of the follow-up study by Fleet et al.,10 we expect the health-related quality of life both in patients with panic disorder and in those with nonfearful panic disorder to be deteriorated. The aims of the present study were to investigate the prevalence of nonfearful panic disorder in patients referred to outpatient cardiac investigation for chest pain and to compare patients with panic disorder, nonfearful panic disorder, and no panic disorder in terms of 1) demographic variables; 2) self-reported anxiety, agoraphobia, and somatization; 3) presence of comorbid axis I disorders, including somatoform disorder; 4) presence of somatic disorders; 5) presence of alexithymia; and 6) health-related quality of life.