SPOILER ALERT! ~ Panic disorder (PD) presents with recurrent panic attacks, persistent worry and avoidance behavior. ~ Panic attacks and hyperventilation in PD can cause chest pain ~ Chest pain can be caused by noncardiac events: spasms in the intercostal muscles of the chest wall, difficulty swallowing food , and experiencing anxiety as painful ~ Chest pain can also be caused by cardiac events: spasms in the coronary arteries, and resistance in small coronary vessels. ~ PD has high rates of cardiovascular diseases and high mortality due to unhealthy lifestyles. ~ PD patients who are young and otherwise healthy are not at imminent risk of acute cardiovascular problems.
Panic attacks are associated with an array of somatic symptoms such as abdominal pain, dizziness, headache and most worrisome chest pain. In fact, chest pain has been commonly reported in more than half cases of panic attacks, making it the main reason why patients land in primary care and emergency rooms
Accordingly, patients with panic disorder (PD) frequently visit acute care settings and cardiology departments for evaluation of their chest pain, leaving their condition undiagnosed and untreated. Most concerning is the fact that it can often take years before a diagnosis of panic disorder is made, because the focus is always on panic attack-induced chest pain.
PANIC DISORDER
Panic disorder (PD) is characterized by recurrent panic attacks along with persistent worry and avoidance behavior as a result of the panic attacks. Studies show that these patients have a high risk of developing other psychological disorders, particularly comorbid anxiety (i.e., other anxiety disorder) and medical problems.
They suffer substantial disability and functional impairment. For example, they have high rates of social disability, marital dysfunction, and financial disability due to their difficulty maintaining a job.
CHEST PAIN IN PD DUE TO NONCARDIAC EVENTS
Chest pain is the chief complaint in panic disorder and one of the most disabling symptoms. Patients often undergo expensive cardiac tests, believing that the main condition is cardiac and not psychological.
Studies have identified several noncardiac mechanisms that are responsible for the emergence of chest pain. These involve muscles, the esophagus, and anxiety-related events.
During a panic attack, hyperventilation can cause strain or spasms of the intercostal chest wall muscles leading to the perception of chest pain. Similarly, stress and anxiety can affect the motility of the esophagus (i.e., esophageal dysmotility) making it difficult for food and fluid to go down and resulting in difficulty swallowing (i.e., dysphagia) and chest pain. In addition, some patients may interpret their anxiety symptoms as painful, leading them to also experience chest pain.
By contrast, panic attacks can also cause chest pain through cardiac mechanisms that involve coronary vasculature. For example, panic attacks trigger spasms in the coronary arteries leading to myocardial ischemia (i.e., reduced blood flow to the heart) and cardiac chest pain.
Similarly, strong physiological arousal in PD (i.e., sympathetic activation leading to increased heart rate, blood flow, vigilance, etc…) can lead to ischemic (i.e., reduced blood flow) events in the small coronary vessels. Notably, such arousal contributes to increased resistance in these small cardiac vessels leading to reduced coronary blood flow and chest pain.
HEART DISEASE AND MORTALITY IN PANIC DISORDER
Unsurprisingly, studies reveal high rates of certain cardiovascular disorders among PD patients, including hypertension, heart disease (i.e., cardiomyopathy), chest pain (i.e., microvascular angina), and even sudden cardiac death.
For example, a large community survey reveals that individuals with PD had a greater risk of having a heart attack (myocardial infarction) than those without a psychological problem. They are also more likely to have high cholesterol, a poor diet, a sedentary lifestyle and have high rates of smoking and alcohol consumption.
Treatment options for panic disorder include antidepressants, benzodiazepines, and cognitive behavioral therapy, which have all yielded positive results. It should also be observed that cardiovascular mortality in PD occur in a relatively small number of cases and, when they do they mostly affect older people.
Indeed, patients with PD who are young and otherwise healthy are not at imminent risk of experiencing an acute cardiac event as a result of their panic attacks.
Reference:
Huffman JC, Pollack MH, Stern TA. Panic Disorder and Chest Pain: Mechanisms, Morbidity, and Management. Prim Care Companion J Clin Psychiatry. 2002 Apr;4(2):54-62. doi: 10.4088/pcc.v04n0203. PMID: 15014745; PMCID: PMC181226.