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The Clinical Course of Palpitations in Medical Outpatients

The Clinical Course of Palpitations in Medical Outpatients Abstract Objective: The aim of this study was to describe the longitudinal course of patients who were referred for ambulatory electrocardiographic monitoring because of palpitations. Methods: A prospective, follow-up examination was conducted of patients who had been studied 6 months previously when referred for monitoring. The inception cohort consisted of 145 consecutive patients with palpitations and 70 asymptomatic, nonpatient volunteers. At follow-up, the patients completed the same research battery as at inception, consisting of structured interviews and self-report questionnaires. These assessed cardiac symptoms, medical care use, role impairment, somatization, hypochondriacal fears and beliefs, and psychiatric disorder. Results: At 6 months' follow-up, 130 patients with palpitations (89.7% of the original cohort) and 69 nonpatients (98.6%) were reinterviewed. Eighty-four percent of the patients had recurrent palpitations during the 6-month follow-up period. At follow-up, patients with palpitations scored significantly higher than the comparison group on measures of cardiac symptoms and role impairment, and had made more physician visits in the preceding 6 months. They had a higher prevalence of panic disorder and more psychopathologic symptoms, somatized more, and were more hypochondriacal. Psychiatric symptoms and the tendency to amplify bodily sensation, measured at inception, were significant but modest predictors of subsequent palpitations. There was considerable confusion and misunderstanding among patients as to the findings of their ambulatory electrocardiogram and the presence or absence of panic disorder. Conclusions: Patients with palpitations remain symptomatic and functionally impaired and have increased rates of physician visits in the 6 months following Holter monitoring. They also continue to have elevated rates of panic disorder and to evidence some confusion about the cause of their symptoms.(Arch Intern Med. 1995;155:1782-1788) References 1. Kroenke K, Arrington ME, Mangelsdorff AD. The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med . 1990:150: 1685-1689.Crossref 2. Jones GE, Dinoff BL, Jones KR, Leonberger FT. Survey of cardiac awareness in rehabilitated cardiac patients. Psychophysiology . 1983;20:450-451. Abstract. 3. Zeldis SM, Levine BJ, Michelson EL, Morganroth J. Cardiovascular complaints: correlation with cardiac arrhythmias on 24-hour ECG monitoring. Chest . 1980;78:456-462.Crossref 4. Burkhardt D, Luetold BE, Jost MV, Hoffman A. Holter monitoring in the evaluation of palpitations, dizziness and syncope. In: Roelandt J, Hugenholt PG, eds. Long-term Ambulatory Electrocardiography . The Hague, the Netherlands: Martinus Nijhoff; 1982:29-39. 5. Clark PI, Glasser SP, Spoto E. Arrhythmias detected by ambulatory monitoring. Chest . 1980;77:722-725.Crossref 6. Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. JAMA . In press. 7. Mayou RA. Patients' fears of illness, chest pain, and palpitations. In: Creed F, Mayou R. Hopkins A, eds. Medical Symptoms Not Explained by Organic Disease . London, England: The Royal College of Psychiatrists and the Royal College of Physicians; 1992. 8. Knudson M. The natural history of palpitations in a family practice. J Fam Pract . 1987;24:357-360. 9. Channer KS, James MA, Papouchado M, Rees JR. Failure of a negative exercise test to reassure patients with chest pain. 0 J Med . 1987;63:315-322. 10. Lantinga LJ, Sprafkin RP, McCroskery JH, Baker MT, Warner RA, Hill NE. One-year psychosocial follow-up of patients with chest pain and angiographically normal coronary arteries. Am J Cardiol . 1988;62:209-213.Crossref 11. Ockene JS, Shay MJ, Alpert JS, Weiner BM, Dalen JE. Unexplained chest pain in patients with normal coronary arteriograms. N Engl Med . 1980;303:1249-1252.Crossref 12. Pearce MJ, Mayou RA, Klimes I. The management of atypical non-cardiac chest pain. Q J Med . 1990;76:991-996. 13. Papanicolaou MN, Califf RM, Hlatky MA, et al. Prognostic implications of angiographically normal and insignificantly narrowed coronary arteries. Am J Cardiol . 1986;58:1181-1187.Crossref 14. Wielgosz AT, Fletcher RH, McCants CB, McKinnis RA, Haney TL, Williams RB. Unimproved chest pain in patients with minimal or no coronary disease: a behavioral phenomenon. Am Heart J . 1984;108:67-72.Crossref 15. Wielgosz AT, Earp J. Perceived vulnerability to serious heart disease and persistent pain in patients with minimal or no coronary disease. Psychosom Med . 1986;48:118-124.Crossref 16. Barsky AJ, Cleary PD, Barnett MC, Christiansen CL, Ruskin JN. The accuracy of symptom reporting in patients complaining of palpitations. Am J Med . 1994; 97:214-221.Crossref 17. Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. Psychiatric disorders in medical outpatients complaining of palpitations. J Gen Intern Med . 1994:9:306-313.Crossref 18. Barsky AJ, Cleary PD, Brener J, Ruskin JN. The perception of cardiac activity in medical outpatients. Cardiology . 1993;83:304-315.Crossref 19. Derogatis LR, Lipman RS, Covi L, Rickels K, Uhlenhuth EH. The Hopkins symptom checklist (HSCL): a self-report symptom inventory. Behav Sci . 1974;19: 1-15.Crossref 20. Lipman RS, Covi L, Shapiro AK. The Hopkins symptom checklist (HSCL): factors derived from the HSCL-90. Psychopharmacol Bull . 1977;13:43-45. 21. Barsky AJ, Wyshak G, Klerman GL. Hypochondriasis: an evaluation of the DSM-III criteria in medical outpatients. Arch Gen Psychiatry . 1986;43:493-500.Crossref 22. Barsky AJ, Cleary PD, Spitzer RL, Williams JBW. Wyshak G, Klerman GL. A structured diagnostic interview for hypochondriasis: a proposed criterion standard. J Nerv Ment Dis . 1992;180:20-27.Crossref 23. Pilowski I. Dimensions of hypochondriasis. Br J Psychiatry . 1967;113:89-93.Crossref 24. Pilowski I. A general classification of abnormal illness behaviors. Br J Med Psychol . 1978;51:131-137.Crossref 25. Robins LN, Helzer JE, Croughan J, Ratcliff KS. National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and face validity. Arch Gen Psychiatry . 1981;38:381-389.Crossref 26. Helzer JE, Robins LN. The Diagnostic Interview Schedule: its development, evolution, and use. Soc Psychiatry Psychiatr Epidemiol . 1988;23:6-16.Crossref 27. Barsky AJ, Goodson JD, Lane RS, Cleary PD. The amplification of somatic symptoms. Psychosom Med . 1988;50:510-519.Crossref 28. Barsky AJ, Wyshak G. Hypochondriasis and somatosensory amplification. Br J Psychiatry . 1990;157:404-409.Crossref 29. Barsky AJ, Wyshak G, Klerman GL. The Somatosensory Amplification Scale and its relationship to hypochondriasis. J Psychiatr Res . 1990;24:323-334.Crossref 30. Jette AM, Davies AR, Cleary PD, et al. The Functional Status Questionnaire: reliability and validity when used in primary care. J Gen Intern Med . 1986;1: 143-149.Crossref 31. Bass CM. Functional cardiorespiratory syndromes. In: Bass CM, ed. Somatization: Physical Symptoms and Psychological Illness . Boston, Mass: Blackwell Scientific Publications Inc; 1990:171-206. 32. Cadoret RJ, Widmer RB, Troughton EP. Somatic complaints: harbinger of depression in primary care. J Affect Dis . 1980;2:61-70.Crossref 33. Sharpe M, Hawton K, Seagroatt V, Pasvol G. Follow-up of patients presenting with fatigue to an infectious diseases clinic. BMJ . 1992;305:147-153.Crossref 34. Barsky AJ. Amplification, somatization, and the somatoform disorders. Psychosomatics . 1992;33:28-34.Crossref 35. Simon GE, Katon WJ, Sparks PJ. Allergic to life: psychological factors in environmental illness. Am J Psychiatry . 1990;147:901-906. 36. Vandiver T, Sher KJ. Temporal stability of the Diagnostic Interview Schedule. J Consult Clin Psychol . 1991;3:277-281. 37. Rogler LH, Malgady RG, Tryon WW. Evaluation of mental health: issues of memory in the Diagnostic Interview Schedule. J Nerv Ment Dis . 1992:180: 215-222.Crossref 38. Helzer JE. Spitznagel EL, McEvoy L. The predictive validity of lay Diagnostic Interview Schedule diagnoses in the general population: a comparison with physician examiners. Arch Gen Psychiatry . 1987;44:1067-1077.Crossref 39. Wells KB, Burnam MA, Leake B, Robins LN. Agreement between face-to-face and telephone administered versions of the depression section of the NIMH Diagnostic Interview Schedule. J Psychiatr Res . 1988;22:207-220.Crossref 40. Barsky AJ, Wyshak G, Klerman GL. Transient hypochondriasis. Arch Gen Psychiatry . 1990;47:746-752.Crossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

The Clinical Course of Palpitations in Medical Outpatients

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Publisher
American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinte.1995.00430160124012
Publisher site
See Article on Publisher Site

Abstract

Abstract Objective: The aim of this study was to describe the longitudinal course of patients who were referred for ambulatory electrocardiographic monitoring because of palpitations. Methods: A prospective, follow-up examination was conducted of patients who had been studied 6 months previously when referred for monitoring. The inception cohort consisted of 145 consecutive patients with palpitations and 70 asymptomatic, nonpatient volunteers. At follow-up, the patients completed the same research battery as at inception, consisting of structured interviews and self-report questionnaires. These assessed cardiac symptoms, medical care use, role impairment, somatization, hypochondriacal fears and beliefs, and psychiatric disorder. Results: At 6 months' follow-up, 130 patients with palpitations (89.7% of the original cohort) and 69 nonpatients (98.6%) were reinterviewed. Eighty-four percent of the patients had recurrent palpitations during the 6-month follow-up period. At follow-up, patients with palpitations scored significantly higher than the comparison group on measures of cardiac symptoms and role impairment, and had made more physician visits in the preceding 6 months. They had a higher prevalence of panic disorder and more psychopathologic symptoms, somatized more, and were more hypochondriacal. Psychiatric symptoms and the tendency to amplify bodily sensation, measured at inception, were significant but modest predictors of subsequent palpitations. There was considerable confusion and misunderstanding among patients as to the findings of their ambulatory electrocardiogram and the presence or absence of panic disorder. Conclusions: Patients with palpitations remain symptomatic and functionally impaired and have increased rates of physician visits in the 6 months following Holter monitoring. They also continue to have elevated rates of panic disorder and to evidence some confusion about the cause of their symptoms.(Arch Intern Med. 1995;155:1782-1788) References 1. Kroenke K, Arrington ME, Mangelsdorff AD. The prevalence of symptoms in medical outpatients and the adequacy of therapy. Arch Intern Med . 1990:150: 1685-1689.Crossref 2. Jones GE, Dinoff BL, Jones KR, Leonberger FT. Survey of cardiac awareness in rehabilitated cardiac patients. Psychophysiology . 1983;20:450-451. Abstract. 3. Zeldis SM, Levine BJ, Michelson EL, Morganroth J. Cardiovascular complaints: correlation with cardiac arrhythmias on 24-hour ECG monitoring. Chest . 1980;78:456-462.Crossref 4. Burkhardt D, Luetold BE, Jost MV, Hoffman A. Holter monitoring in the evaluation of palpitations, dizziness and syncope. In: Roelandt J, Hugenholt PG, eds. Long-term Ambulatory Electrocardiography . The Hague, the Netherlands: Martinus Nijhoff; 1982:29-39. 5. Clark PI, Glasser SP, Spoto E. Arrhythmias detected by ambulatory monitoring. Chest . 1980;77:722-725.Crossref 6. Weber BE, Kapoor WN. Evaluation and outcomes of patients with palpitations. JAMA . In press. 7. Mayou RA. Patients' fears of illness, chest pain, and palpitations. In: Creed F, Mayou R. Hopkins A, eds. Medical Symptoms Not Explained by Organic Disease . London, England: The Royal College of Psychiatrists and the Royal College of Physicians; 1992. 8. Knudson M. The natural history of palpitations in a family practice. J Fam Pract . 1987;24:357-360. 9. Channer KS, James MA, Papouchado M, Rees JR. Failure of a negative exercise test to reassure patients with chest pain. 0 J Med . 1987;63:315-322. 10. Lantinga LJ, Sprafkin RP, McCroskery JH, Baker MT, Warner RA, Hill NE. One-year psychosocial follow-up of patients with chest pain and angiographically normal coronary arteries. Am J Cardiol . 1988;62:209-213.Crossref 11. Ockene JS, Shay MJ, Alpert JS, Weiner BM, Dalen JE. Unexplained chest pain in patients with normal coronary arteriograms. N Engl Med . 1980;303:1249-1252.Crossref 12. Pearce MJ, Mayou RA, Klimes I. The management of atypical non-cardiac chest pain. Q J Med . 1990;76:991-996. 13. Papanicolaou MN, Califf RM, Hlatky MA, et al. Prognostic implications of angiographically normal and insignificantly narrowed coronary arteries. Am J Cardiol . 1986;58:1181-1187.Crossref 14. Wielgosz AT, Fletcher RH, McCants CB, McKinnis RA, Haney TL, Williams RB. Unimproved chest pain in patients with minimal or no coronary disease: a behavioral phenomenon. Am Heart J . 1984;108:67-72.Crossref 15. Wielgosz AT, Earp J. Perceived vulnerability to serious heart disease and persistent pain in patients with minimal or no coronary disease. Psychosom Med . 1986;48:118-124.Crossref 16. Barsky AJ, Cleary PD, Barnett MC, Christiansen CL, Ruskin JN. The accuracy of symptom reporting in patients complaining of palpitations. Am J Med . 1994; 97:214-221.Crossref 17. Barsky AJ, Cleary PD, Coeytaux RR, Ruskin JN. Psychiatric disorders in medical outpatients complaining of palpitations. J Gen Intern Med . 1994:9:306-313.Crossref 18. Barsky AJ, Cleary PD, Brener J, Ruskin JN. The perception of cardiac activity in medical outpatients. Cardiology . 1993;83:304-315.Crossref 19. Derogatis LR, Lipman RS, Covi L, Rickels K, Uhlenhuth EH. The Hopkins symptom checklist (HSCL): a self-report symptom inventory. Behav Sci . 1974;19: 1-15.Crossref 20. Lipman RS, Covi L, Shapiro AK. The Hopkins symptom checklist (HSCL): factors derived from the HSCL-90. Psychopharmacol Bull . 1977;13:43-45. 21. Barsky AJ, Wyshak G, Klerman GL. Hypochondriasis: an evaluation of the DSM-III criteria in medical outpatients. Arch Gen Psychiatry . 1986;43:493-500.Crossref 22. Barsky AJ, Cleary PD, Spitzer RL, Williams JBW. Wyshak G, Klerman GL. A structured diagnostic interview for hypochondriasis: a proposed criterion standard. J Nerv Ment Dis . 1992;180:20-27.Crossref 23. Pilowski I. Dimensions of hypochondriasis. Br J Psychiatry . 1967;113:89-93.Crossref 24. Pilowski I. A general classification of abnormal illness behaviors. Br J Med Psychol . 1978;51:131-137.Crossref 25. Robins LN, Helzer JE, Croughan J, Ratcliff KS. National Institute of Mental Health Diagnostic Interview Schedule: its history, characteristics, and face validity. Arch Gen Psychiatry . 1981;38:381-389.Crossref 26. Helzer JE, Robins LN. The Diagnostic Interview Schedule: its development, evolution, and use. Soc Psychiatry Psychiatr Epidemiol . 1988;23:6-16.Crossref 27. Barsky AJ, Goodson JD, Lane RS, Cleary PD. The amplification of somatic symptoms. Psychosom Med . 1988;50:510-519.Crossref 28. Barsky AJ, Wyshak G. Hypochondriasis and somatosensory amplification. Br J Psychiatry . 1990;157:404-409.Crossref 29. Barsky AJ, Wyshak G, Klerman GL. The Somatosensory Amplification Scale and its relationship to hypochondriasis. J Psychiatr Res . 1990;24:323-334.Crossref 30. Jette AM, Davies AR, Cleary PD, et al. The Functional Status Questionnaire: reliability and validity when used in primary care. J Gen Intern Med . 1986;1: 143-149.Crossref 31. Bass CM. Functional cardiorespiratory syndromes. In: Bass CM, ed. Somatization: Physical Symptoms and Psychological Illness . Boston, Mass: Blackwell Scientific Publications Inc; 1990:171-206. 32. Cadoret RJ, Widmer RB, Troughton EP. Somatic complaints: harbinger of depression in primary care. J Affect Dis . 1980;2:61-70.Crossref 33. Sharpe M, Hawton K, Seagroatt V, Pasvol G. Follow-up of patients presenting with fatigue to an infectious diseases clinic. BMJ . 1992;305:147-153.Crossref 34. Barsky AJ. Amplification, somatization, and the somatoform disorders. Psychosomatics . 1992;33:28-34.Crossref 35. Simon GE, Katon WJ, Sparks PJ. Allergic to life: psychological factors in environmental illness. Am J Psychiatry . 1990;147:901-906. 36. Vandiver T, Sher KJ. Temporal stability of the Diagnostic Interview Schedule. J Consult Clin Psychol . 1991;3:277-281. 37. Rogler LH, Malgady RG, Tryon WW. Evaluation of mental health: issues of memory in the Diagnostic Interview Schedule. J Nerv Ment Dis . 1992:180: 215-222.Crossref 38. Helzer JE. Spitznagel EL, McEvoy L. The predictive validity of lay Diagnostic Interview Schedule diagnoses in the general population: a comparison with physician examiners. Arch Gen Psychiatry . 1987;44:1067-1077.Crossref 39. Wells KB, Burnam MA, Leake B, Robins LN. Agreement between face-to-face and telephone administered versions of the depression section of the NIMH Diagnostic Interview Schedule. J Psychiatr Res . 1988;22:207-220.Crossref 40. Barsky AJ, Wyshak G, Klerman GL. Transient hypochondriasis. Arch Gen Psychiatry . 1990;47:746-752.Crossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: Sep 11, 1995

References