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Anxiety and Chest Pain

Paul Musey, MD, Rob Orman, MD, and Jeff Kline, MD
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Nurses Edition Commentary

Lisa Chavez, RN and Kathy Garvin, RN

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EM:RAP 2017 May Written Summary 839 KB - PDF

Many of our chest pain patients have anxiety. It may or may not be the principal cause of the pain, but it’s there. Jeff Kline and Paul Musey present the argument that it’s something we should address with patients in the ED.

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Donald W. C., M.D. -

I listened with interest to this segment about the association between anxiety and chest pain and more specifically the unwillingness of many ep's to "make the diagnosis " of anxiety in the ed setting. After hearing the segment I was left with the impression that my colleagues are afraid to explore the possible an association between anxiety and their patient's symptoms for a variety of reasons. Some seemed to focus on the implications of suggesting that a patient's anxiety played a role in their symptoms . If the patient were subsequently diagnosed with a "real disease" this then would make them legally liable for misdiagnosis. The implication of this excuse is that we must make a specific diagnosis in all our patients. This is clearly not our role , not to mention an impossibility. Another justification for not addressing anxiety seemed to be that it was somehow not our role to discuss such purely psychiatric matters. Hogwash. Our job is to 1) rule out disaster (and initiate treatment if found), 2) relieve symptoms, 3) provide reassurance and 4) provide guidance- a reasonable approach for care after the emergency department. If I simply throw our hands up and say "you're not having a heart attack and I don't know what's causing your pain, now its time to go home and good luck", I am not providing optimal care for my patients.

I have long been fascinated by the "invisible disease " that we ep's see every shift .. By this I mean the phenomena of physical symptoms without recognizable signs of a known medical disorder. Chest pain with no etiology after a comprehensive evaluation is probably the prototype but is only one example . Most of us with any depth of clinical experience recognize that anxiety is recognizable in many who present to the ed with chest pain and end up with a completely negative work up. It is absurd that we are reluctant to acknowledge this association as we try to help our patient deal with their symptoms.
I believe that the biggest impediment to better understanding the origin of our patient's symptoms is that most emergency physicians have difficulty explaining the pathophysiogic connection between stress and the development of physical symptoms. I know I used to be very frustrated by my inability to explain this phenomena, that I saw daily, to either myself or my patient's. So I spent a good deal of time devising a plausible theory to connect stress and disease. It sprang from my experience of seeing hundreds of thousands of ed patients rather than from a synthesis of the scientific literature because , as of now there is essentially no emergency medicine literature addressing the subject of how stress results in symptom development.

In 2010 I spoke at the guest speakers panel on the last day of the Essentials meeting in San Francisco. I presented my framework for understanding patients with distressing symptoms but no physical signs to explain them. I sought to characterize a phenomena I termed sensory dysattenuation. My goal was to generate discussion as an initial step towards research and perhaps validation of the theory. Now, the work done by Dr Kline and colleagues highlights the vacuum of ideas emergency physicians have for dealing with symptoms like chest pain that aren't explainable by the pathophysiology they have been taught thus far. Perhaps the time is right to once again revisit my theory to explain this "invisible disease" or any other explanations being advanced address this problem. If you are interested, I believe you could still find a link to the 2010 talk I gave at Essentials (titled :Sensory attenuation disorder -a new understanding of the invisible disease we see every day) or I could dig up the PowerPoint and resurrect the presentation.

Donald Crowe, MD
Ocala, Florida

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Red, Hot, and Shot Full episode audio for MD edition 237:30 min - 331 MB - M4AEMRAP 2017 May Aussie Edition Australian 22:03 min - 30 MB - MP3EM:RAP 2017 May Canadian Edition Canadian 12:11 min - 17 MB - MP3EM:RAP 2017 May Spanish Edition Español 77:25 min - 106 MB - MP3EM:RAP 2017 May French Edition Français 23:24 min - 32 MB - MP3EM:RAP 2017 May German Edition Deutsche 73:18 min - 101 MB - MP3EM:RAP 2017 May Board Review Answers 211 KB - PDFEM:RAP 2017 May Board Review Questions 171 KB - PDFEM:RAP 2017 May MP3 Individual Segments 316 MB - ZIPEM:RAP 2017 May Written Summary 839 KB - PDF

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