In the important article by Flook et al1 on managing undiagnosed chest pain, the authors appropriately stressed the importance of considering gastroesophageal reflux disease (GERD) as one of the most likely diagnoses once potentially life-threatening causes have been excluded. The authors conclude, however, that after a “careful search for symptomatic cardiovascular disease, a clinical assessment for atypical GERD will provide a solid foundation for managing patients with undiagnosed chest pain.”1
We believe that such an approach will lead to many diagnoses of “atypical GERD” in patients with chest pain actually resulting from psychological factors, which can frequently be diagnosed with reasonable certainty by clinical history and “examination of the patient’s emotional system.”2 There are now direct methods to detect the emotional factors that cause symptoms; these factors need not and should not be “diagnosed by exclusion.”2
Delaying appropriate psychological treatment can also be very costly to patients and the system. Several of the causes of chest pain listed in Table 2 of the article by Flook et al,1 such as nutcracker esophagus, diffuse esophageal spasm, nonspecific motility disorder, panic attacks, and depression, can be treated with emotion-focused psychotherapy, such as short-term dynamic psychotherapy.3 In settings other than the inpatient settings in the studies noted by the authors, these other causes are likely to be more common than GERD. In this letter, we focus on one of these problems: panic disorder (PD).
Before consulting their family doctors, many patients with chest pain have already presented “in crisis” to emergency departments (EDs), where, according to common ED practice, life-threatening causes of the pain have been “ruled out,” diagnoses of “chest pain NYD” (not yet diagnosed) have been made,4 and patients have been referred back to their FPs for further investigation. Fleet et al reported that 25% of patients presenting to the ED met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, (DSM-IV) criteria for PD, and that the diagnosis in that setting is missed 98% of the time.5 By the time patients see their FPs, they might, in the security of the consultation room, have less severe symptoms, be less likely in retrospect to associate the pain with symptoms of anxiety, and thus be easier to misdiagnose.
Although some emergency physicians have acknowledged this deficiency in the service they offer,6,7 counterarguments have included the observation that primary care doctors who know their patients well are in a better position to make the diagnosis than an ED doctor who sees them at one point in time.8 In any case, the reality of the situation is that patients with undiagnosed chest pain who have presented in crisis at EDs usually end up in their FPs’ offices.
Panic disorder causes great distress for patients and has the potential to seriously impede psychosocial and occupational functioning. When identified and treated early, however, the outlook is favourable, with 50% to 70% becoming symptom free in acute treatment.9 Undiagnosed and untreated PD can progress to a chronic disabling disease.10 It is vital that FPs screen for and diagnose this condition and explain to patients the biopsychological nature of the disease. Johnson et al found that 84% of primary care patients who met DSM-IV criteria for PD expressed willingness to seek psychiatric care and 95% would have accepted psychological interventions,11 suggesting that physicians need not fear that the diagnosis will offend their patients.
Treatment of PD is often within the realm of family practice. Studies have shown that combination treatments or brief psychotherapy alone might preclude the need for long-term medication use and have lower relapse rates than medications alone.3,9 Misdiagnosis of PD as GERD might sentence a substantial group of patients to prolonged periods of suffering and the health care system to considerable avoidable resource consumption.12
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