Psychological treatment of noncardiac chest pain: The cognitive approach

Chest pain often accompanies panic attacks. The success of cognitive therapy in the treatment of panic disorder has led to effective cognitive-behavioral therapy for both anxiety about health and noncardiac chest pain accompanied by anxiety. The cognitive hypothesis proposes that, in vulnerable persons, sensations in the chest region can be misinterpreted as a sign of serious illness, such as an impending heart attack, giving rise to anxiety. A variety of responses can contribute to the problem of such misinterpretations and the associated anxiety. First, anxiety-induced autonomic arousal can generate an increase in symptoms. Second, worried patients are more likely to focus on their bodily reactions and to check their bodily functioning, increasing the likelihood that some changes will be detected. Third, patients may seek medical evaluation or other forms of reassurance, which can lead to further misinterpretation and worry. Each of these reactions can increase the perception of chest pain, contributing to a vicious cycle that exacerbates both the chest pain and the anxiety. In most cases, treatment is straightforward. It starts with identification of the patient's particular fears, followed by education about the role of anxiety in producing physical sensations such as chest pain. Demonstration of the processes that produce and maintain physical sensations usually convinces the patient of the harmless nature of symptoms. Although cognitive therapy avoids giving reassurance by "ruling out" feared diseases, patients are encouraged to take actions to disconfirm their worst fears. Some patients require more specialized treatment, particularly if they remain strongly convinced that their problem is solely physical. Such patients must be engaged in active collaboration with the therapist. © 1992 Reed Publishing USA.