Psychiatric Disorders in Medical Outpatients Complaining
of Palpitations
ARTHUR d. BARSKY, MD, PAUL D. CLEARY, PhD, REMY Ft. COEYTAUX, BA.
JEREMY N. RUSKIN, MD
Objective: To determine the prevalence of psychiatric disorders in
ambulatory patients undergoing Holter monitoring to evaluate pal-
pitations.
Design: Patients referred for 24-hour ambulatory electrocardiographic
(ECG) monitoring were studied with a structured diagnostic interview
and self-report questionnaires prior to monitoring.
Setting: Holter laboratory of a large academic medical center.
Patients a n d other participants: One hundred ffJrty-fiveconsecutive
patients complaining of palpitations and 70 asymptomatic non-patient
volunteers.
Outcome measures: DSM-III-Rpsychiatric diagnoses.
Results: Forty-fivepercent (44.8%) of the participants had at least one
lifetime anxiety or depressive disorder and 24.8% had at least one
current (one month) disorder. The lifetime prevalence of panic dis-
order was 27.6%, and that of major depression was 20.8%. Current
prevalence rates showed a similar pattern; the current prevalence of
panic disorder was 18.6%. Panic disorder and somatization disorder
symptoms were significantly more prevalent in the palpitation group
than in the general medical clinic at the same hospital. Patients with
a psychiatric diagnosis were more likely to report cardiac symptoms
during monitoring than were those without psychiatric disorder, and
more commonly described their symptoms as "pounding" and re-
ported faintness, lightheadedness, and vertigo. Although cardiac his-
tories and ECG results were no more serious, the patients with psy-
chiatric diagnoses rated their overall health status as significantlyworse.
Conclgtsions: Almost half of palpitation patients referred for Holter
monitoring have a psychiatric disorder. More than a fourth have life-
time panic disorder and a fifth have had panic attacks in the month
before monitoring.
K ~ uwrds: psychiatric disorders; palpitations; Holter monitoring; panic
disorder; depression; somatization.
d GEN INTERN MED 1994;9:306-313.
SIXTEEN PERCENTo f m e d i c a l o u t p a t i e n t s c o m p l a i n of pal-
pitations. 1 This s y m p t o m is a m o n g t h e t e n m o s t c o m m o n
in general m e d i c a l p r a c t i c e a n d is also e n c o u n t e r e d fre-
quently in cardiology. 2 T h e d i a g n o s t i c e v a l u a t i o n of pal-
pitations often i n c l u d e s 24-hour, c o n t i n u o u s , ambula-
tory e l e c t r o c a r d i o g r a p h i c ( H o l t e r ) m o n i t o r i n g . I n d e e d ,
palpitations are t h e m o s t c o m m o n i n d i c a t i o n for H o l t e r
monitoring, a c c o u n t i n g for 2 1 % - 4 3 % o f s u c h studies
in o u t p a t i e n t s : s-s This has e n o r m o u s e c o n o m i c ramifi-
cations. An e s t i m a t e d 1,700,000 a m b u l a t o r y H o l t e r stud-
ies are p e r f o r m e d annually, at a total c o s t o f $ 4 5 0 - $650
Received from the Departments of Psychiatry (AJB)~Health Care Pol-
icy (PDC), and Medicine (JNR), Harvard Medical School; the Division
of Psychiatry (AJB), Brigham and Women's Hospital; and the Psychiatry
Service (RRC) and the Medical Service and Cardiac Unit (JNR), Mas-
sachusetts General Hospital, Boston, Massachusetts.
Supported by research grant HL43216 from the National Heart,
Lung, and Blood lnstitutc.
Address correspondence and reprint requests to Dr. Barsky:
Brigham and Women's Hospital, Division of Psychiatry, 75 Francis
Street, Boston, MA 02115.
306
million in 1988. Thus, t h e c o s t o f m o n i t o r i n g for pal-
pitations is b e t w e e n $140 and $270 m i l l i o n p e r year,
and is p u t at $250 m i l l i o n by i n d u s t r y estimates.
Clinical e x p e r i e n c e and t h e f e w e x i s t i n g studies
suggest that t h r e e p s y c h i a t r i c d i s o r d e r s - - p a n i c disor-
der, depression, and s o m a t i z a t i o n d i s o r d e r - - a r e rela-
tively c o m m o n causes o f palpitations. Most p a n i c dis-
o r d e r patients p r e s e n t initially w i t h s o m a t i c s y m p t o m s
and b e l i e v e that t h e y h a v e a s e r i o u s m e d i c a l disorder. 6' 7
Palpitations are t h e m o s t c o m m o n s o m a t i c s y m p t o m of
panic anxiety, 6-8 and m a n y s u c h patients are r e f e r r e d
for c a r d i o l o g i c c o n s u l t a t i o n ; p a n i c d i s o r d e r is f o u n d in
1 0 - 1 4 % of patients r e f e r r e d to c a r d i a c clinics. 7 Panic
attacks t h e m s e l v e s are o f t e n m i s t a k e n by t h e p a t i e n t
for a grave m e d i c a l e m e r g e n c y , and b e t w e e n attacks
such patients b e c o m e i n c r e a s i n g l y w o r r i e d a b o u t t h e i r
health, afraid o f disease, and p r e o c c u p i e d w i t h t h e i r
bodies.~,, 9, 10 Depression, a n o t h e r c o m m o n c a u s e of pal-
pitations, is p r e v a l e n t in b o t h g e n e r a l p r a c t i c e and car-
diology. A s o m a t i z e d f o r m o f d e p r e s s i o n c h a r a c t e r i z e d
half of all the d e p r e s s e d p a t i e n t s s e e n in p r i m a r y care
practice, 11-~3 and c o m p l a i n t s o f palpitations, faintness,
and dizziness are a m o n g t h e m o s t c o m m o n a n d char-
acteristic s y m p t o m s lo- 12 o f t h e s e " m a s k e d " depressions.
These patients have m a r k e d l y e l e v a t e d rates o f m e d i c a l
care utilization13-14 and f r e q u e n t l y s e e k c a r d i o l o g i c con-
sultation, is Palpitations are also p r o m i n e n t in somati-
zation disorder. T h e y are a m o n g its d i a g n o s t i c criteria
and are t h e s e c o n d m o s t c o m m o n s y m p t o m in t h e s e
patients)6, 17 In addition, p a l p i t a t i o n s and dizziness are
c o m p o n e n t s of m o s t s e l f - r e p o r t i n s t r u m e n t s m e a s u r i n g
somatization and are f r e q u e n t l y r e p o r t e d by h y p o c h o n -
driacal patients.
T h e aim o f this study w a s to d e t e r m i n e t h e preva-
l e n c e of s e l e c t e d p s y c h i a t r i c d i s o r d e r s in a m b u l a t o r y
patients w h o had b e e n r e f e r r e d f o r H o l t e r m o n i t o r i n g
to evaluate palpitations. W e also s o u g h t to d e t e r m i n e
the clinical features that d i f f e r e n t i a t e d t h e s e p a t i e n t s
from palpitation p a t i e n t s w i t h o u t p s y c h i a t r i c disorder.
METHODS
Subjects and Setting
T h e study p o p u l a t i o n c o n s i s t e d o f c o n s e c u t i v e out-
patients r e f e r r e d to t h e H o l t e r Laboratory of t h e Mas-
sachusetts G e n e r a l Hospital for e v a l u a t i o n o f palpitations
and/or dizziness o v e r I 1 m o n t h s . T h e i n c l u s i o n c r i t e r i a
w e r e English f l u e n c y and availability f o r a f o l l o w - u p in-
t e r v i e w six m o n t h s later. Patients w i t h m a j o r s e n s o r y o r
 JOURNALOF GENERALINTERNALMEDICINE, Volume 9 (June), 1994 307

TABLE 1
SociodemographicCharacteristicsof the Subjects
(1) (2)
Palpitation Patients Palpitation (3)
with Psychiatric Patients without Non-patient
Disorder* Psychiatric Disorder Comparison Subjects p p
(n = 65) (n =80) (n = 70) (1)-(2) (1)-(3)
Age mean _+ SD 39.05 _+ 13.91 years 54.11 _+ 16.56 years 48.80 + 14.58 years 0.000 0,000

Gender--female 39 (60.00/0) 44 (55.09"o) 40 (57.19,0) 0.66 0.87

Social position
I (highest) 8 (12,3%) 10 (12.5%) 14 (20.0%) 0.83 0.33
II 19 (29.2%) 21 (26.3%) 16 (22.9%) 0.83 0.52
II1 16 (24.6%) 23 (28.8%) 13 (18.6%) 0.71 0.52
IV 14 (21.5%) 22 (27.5%) 21 (30.0%) 0.53 0.36
V (lowest) 8 (12.3%) 4 (5,0%) 6 (8.6%) 0.20 0.67

Marital status
Married 25 (38.5%) 46 (57.5%) 37 (52,9%) 0.04 0.13
Divorced,separated,widowed 12 (18.5%) 17 (21.3%) 22 (31,4%) 0.84 0.13
Single 28 (43.I %) 17 (21.39'o) 11 (15.7%) 0.008 0.000

Race
White 58 (89.2%) 69 (86.3%) 68 (97,1%) 0.77 O.14
Nonwhite 7 (10.8%) 11 (13.8%) 2 (2.9%) 0.77 0.14

Religion
Catholic 41 (63.1%) 39 (48,8%) 40 (57.1%) 0.12 0.60
Protestant 9 (13.9%) 25 (31.3%) 18 (25.7%) 0.02 0.13
Jewish 4 (6.2%) 6 (7,5%) 7 (10.0%) 0.99 0.62
No religion 5 (7,7%) 6 (7.5%) 3 (4.3%) 0.79 0,64
Other 6 (9.2%) 4 (5.0%) 2 (2.9%) 0.50 0.23
*Lifetime disorder, excludingphobiaand social phobia.

communication deficits or with significant organic brain
disease w e r e excluded. A convenience sample of non-
patients without cardiac symptoms served as the com-
parison group: Volunteers w e r e recruited from church-
sponsored bingo games and Rotary Club meetings.
Subjects with known cardiac disease, cardiac symptoms,
or the use of cardiac medications w e r e excluded.
The data gathered in the current study w e r e also
compared with the findings from a previous study of the
general internal medicine clinic of this hospital, details
of which are available elsewhere. 18-2° That study em-
ployed a random sample of consecutive clinic attenders
who did not have DSM-III-R* hypochondriasis.
Design and Procedure
The patients w e r e contacted after referral to the
Holter Laboratory. Those consenting to the study came
to the hospital before their Holter electrocardiogram
(ECG) appointments to c o m p l e t e the research battery,
which took approximately one and three quarter hours.
The patients w e r e then given specially designed diaries
for recording symptoms during monitoring. Due to
scheduling constraints, some patients c o m p l e t e d the
battery immediately after, rather than immediately be-
*Diagnostic and Statistical Manual of Mental Disorders, third edition,
revised. Washington, DC: American Psychiatric Association, 1987.
fore, receiving the monitor. (This was long before they
learned their Holter ECG results, however.) The com-
parison subjects underwent the same research proce-
dure as did the patients. The patients received $50 for
their participation, and the comparison subjects re-
ceived $75.
A continuous, 24-hour ECG was r e c o r d e d in the
standard fashion with a dual-channel recorder (Del Mar
Avionics Electrocardiocorder, Model 453A, Irvine, CA),
with five leads placed in a modified cardiac monitor lead
convention. The patients w e r e given a clock to deter-
mine the exact time of all symptoms, and taught h o w
to mark the ECG recording at the onset of each symp-
tom. Recordings w e r e scanned and analyzed with a
Holter analysis unit (Del Mar Avionics, Model 750), and
then interpreted by a trained cardiologist.
Variables and Their Measurement
Psychiatric Status. Psychiatric disorder was as-
sessed with the Diagnostic Interview Schedule (DIS),
version 3-R. 21 This is a widely used, highly structured
interview that generates most of the major Axis I diag-
noses, both current and lifetime, and is scored by com-
puter using operationalized DSM-III-R criteria. We em-
ployed only the modules covering anxiety disorders (panic
disorder, generalized anxiety disorder, and phobias), de-
pressive disorders (major depression and dysthymia),
308 Barsky et al., PSYCHIATRICDISORDERSIN MEDICALOUTPATIENTS
and somatoform disorders (somatization disorder and
somatoform pain disorder). The panic disorder section
was slightly modified, as discussed by Katon, 6 to mini-
mize false negatives among highly somatizing patients.
Somatization was measured with the Somatic Symp-
tom Inventory (SSI). It consists of 26 somatic symptoms
common to both the somatization subscale of the Hop-
kins Symptom Checklist-90 and the hypochondriasis
subscale of the Minnesota Multiphasic Personality In-
ventory (MMPI). 22,23 In previous work, this question-
naire displayed excellent intrascale consistency and t e s t -
retest reliability. 24-26
Hypochondriacal symptoms were assessed with the
Whitely Index (WI), which is composed of 14 hy-
pochondriacal attitudes and beliefs. It contains three
factors: disease conviction (the unfounded belief one
has a serious disease), disease fear, and bodily preoc-
cupation. It has excellent t e s t - r e t e s t and intrascale re-
liability, as well as discriminant and convergent valid-
ity. 27-31
State anxiety was measured with the Spielberger
State-Trait Anxiety Inventory (STAI), a 20-item self-re-
port questionnaire of demonstrated internal consistency
and construct, concurrent, and convergent validity. Z" It
has been used extensively in studies of cardiac disease
and of transient anxiety induced by experimental pro-
cedures and surgery. 33-3~
Cardiac S y m p t o m s a n d Status. A one-month his-
tory of cardiorespiratory symptoms was obtained with
a nine-item questionnaire, using a five-point ordinal re-
sponse format. The same questionnaire was incorpo-
rated into the Holter diaries. A history of known cardiac
disease and treatment was obtained from the patient.
Medical Utilization. The patients were asked about
all scheduled physician visits, walk-in and emergency
visits, days hospitalized, and outpatient mental health
visits in the preceding 12 months, at both the study
hospital and other sites.
Causal Attributions f o r Somatic Symptoms.
Attributional style was assessed with the Symptom Inter-
pretation Questionnaire ( S I Q ) . 36'37 The respondent is
asked how much he or she suspects each of three pos-
sible causes (psychological, medical, and environmental/
circumstantial) for 13 c o m m o n and ambiguous symp-
toms. Factor analysis confirms the presence of three
attributional tendencies: psychologizing, somatizing, and
normalizing. These three subscales have acceptable in-
ternal consistency and moderate t e s t - r e t e s t reliability.
Among family practice patients, a somatizing attribu-
tional style has been associated with hypochondriacal
concerns and somatic symptoms without a medical cause.
A psychologizing tendency has been associated with
dcprcssion, introspection, and a history of chronic psy-
chiatric disorder. 36, 37
Statistical Analyses
Comparisons between sample pairs on continuous
variables were made using a t-test for equality of means.
Comparisons of categorical variables were made using
the chi-square test. In situations in which any expected
cell frequency was less than 5, Fisher's exact test was
used.
RESULTS
During the period of study, 238 patients underwent
Holter monitoring for palpitations and/or dizziness. Thirty-
five of these patients (14.7%) were ineligible. An ad-
ditional eight patients (3.4%) could not be contacted.
Fifty patients (21.0%) refused to participate. Thus, a
total of 145 patients (71.4% of those eligible to partic-
ipate) were examined. Two of these patients complained
only of dizziness, and the rest had palpitations or pal-
pitations and dizziness.
In the comparison sample, there were 111 eligible
volunteers (59.5% from bingo games and 40.5% from
Rotary meetings). Forty-one of them (36.9%) could not
be contacted or ultimately declined participation. The
remaining 70 individuals (75.3% of the eligible subjects
who were contacted) were studied.
Table 1 outlines the sociodemographic character-
istics of the samples. The palpitation patients with psy-
chiatric disorders were significantly younger and more
often single than the patients without psychiatric dis-
order.
The prevalences of selected DSM-III-R disorders are
shown in Tables 2 and 3. Comparable rates in the general
medical clinic of the study hospital, determined in pre-
vious work,~8-zo are included for comparison. The most
striking finding is that the palpitation patients had sig-
nitlcantly higher rates of lifetime panic disorder and more
symptoms of somatization disorder than did those in the
comparison group. The lifetime prevalence of all psy-
chiatric disorder was high in palpitation patients: 44.8%
had at least one of the disorders assessed, and 18.6%
had two or more. Lifetime prevalence rates in the sample
of palpitation patients were generally comparable to those
in the random sample of nonhypochondriacal medical
outpatients, except for an elevated rate of panic disorder
(28% vs 3% ) and a lower rate of generalized anxiety
disorder.
Current (one m o n t h ) prevalence rates for these
disorders showed the same pattern (Table 3). The most
striking finding was the high prevalence of panic dis-
order, with almost one in five palpitation patients having
panic attacks in the month preceding the Holter mon-
itoring.
Table 4 compares the clinical characteristics of those
with and without current psychiatric disorders. The pre-
senting symptom was chronic ( 4 . 5 - 5 years in duration)
in both groups. The patients with psychiatric disorders
did not have a significantly higher prevalence of serious,
 JOURNALOF GENERALINTERNALMEDICINE,Volume 9 (June), 1994 309

clinically significant arrhythmias (ventricular or atrial
tachycardia, atrial fibrillation, c o m p l e x ventricular ec-
topy, or bradycardia) than did the palpitation patients
without psychiatric disorder. They also reported lower
rates of known heart disease. The patients with a psy-
chiatric diagnosis w e r e significantly m o r e likely to re-
port palpitations during monitoring. Among the patients
with at least one symptom, those with a psychiatric di-
agnosis had m o r e s y m p t o m s per 24 hours than did those
without a psychiatric diagnosis, but this difference was
not statistically significant. Certain types of palpitations
were significantly m o r e c o m m o n among the patients
with a psychiatric diagnosis: "pounding," faintness, light-
headedness, and "rotating" sensations.

TABLE 2
Prevalence of Lifetime DSM-III-R* Psychiatric Disorders

(2)
(1) Non-patient Comparison (3)
Palpitation Patients Group General Medicine Clinict p P
(n = 145) (n = 70) (n = 100) (1)-(2) (1)-(3)
Anxiety disorder
Panic disorder 40 (27.6%) 3 (4.3%) 2 (2.0%) 0.0001 0.000
Generalized anxiety disorder 9 (6.2%) 3 (4.3%) 29 (29.0%) 0.80 0.000
Agoraphobic without panic 5 (3.4%) 1 (1.4%) 3 (3.0%) 0.69 0.86
Simple phobia 17 (11.7%) 11 (15.7%) 18 (18.0%) 0.55 0.23
Social phobia 15 (10.3%) 5 (7.1%) 1 (1.0%) 0.61 0.008

Depression
Major depression 30 (20.8%) 9 (12.9%) 16 (16.0%) 0.22 0.43
Dysthymia 16 (11.0%) 2 (2.9%) 13 (13.0%) 0.08 0.79

Somatoform disorder
Somatizationdisorder 3 (2.1%) 0 (0%) 0 (0%) 0.55 0.39
Number positive somatization
disorder symptoms--mean
_+ SD 4.0 _+ 3.1 1.8 _+ 1.5 3.0 _+ 2.8 0.000 0.01

Any psychiatric disorder

One or more lifetime diag-
noses* 65 (44.8%) 15 (21.4%) 36 (36.0%) 0.002 0.21
Mean number lifetime psychi-
atric symptoms 15.7 _+ 12.9 8.9 _+ 8.6 15.8 _+ 11.2 0.0001 0.97
*Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Washington, DC: American Psychiatric Association, 1987.
tPsychiatric diagnoses based on DSM-III instead of DSM III-R criteria.
*Excluding simple, social phobias.

TABLE 3
Prevalence of Current (One Month) DSM-III-R* Psychiatric Disorders
(z)
(1) Non-patient Comparison (3)
Palpitation Patients Group General Medicine Clinict p P
(n = 145) (n = 70) (n = 100) (1)-(2) (1)-(3)
Anxiety disorder
Panic disorder 27 (18.6%) 1 (1.4%) 1 (1.0%) 0.001 0.00
Generalized anxiety disorder 6 (4.1%) 1 (1.4%) 7 (7.0%) 0.52 0.19
Agoraphobia without panic 1 (0.7%) 1 (1.4%) 1 (1.0%) 0.82 0.65
Simple phobia 12 (8.3%) 9 (12.9%) 14 (14.0%) 0.42 0.22
Social phobia 9 (6.2%) 2 (2.9%) 1 (1.0%) 0.48 0.10

Depression
Major depression 8 (5.6%) 2 (2.9%) 8 (8.0%) 0.59 0.62
Dysthymia 2 (1.4%) 1 (1.4%) 13 (13.0%) 0.55 0.001

Somatoform disorder
Somatizationdisorder 3 (2.1%) 0 (0%) 0 (0%) 0.55 0.39

Any psychiatric disorder

One or more current diag-
noses* 36 (24.8%) 4 (5.7%) 21 (21.0%) 0.001 0.59
*Diagnostic and Statistical Manual of Mental Disorders, third edition, revised. Washington, DC: American Psychological Association, 1987.
tPsychiatric diagnoses based on DSM-III instead of DSM IIIR criteria.
;tExcluding simple, social phobias.
310 Barsk3, et aL, PSYCHIATRICDISORDERSIN MEDICALOUTPATIENTS

In terms of medical care utilization (Table 4), the DISCUSSION

patients with a psychiatric diagnosis had m o r e outpa-
tient visits, more days in the hospital, and m o r e emer-
gency ward visits, but only the latter attained statistical
significance.
Finally, we c o m p a r e d the three groups on several
psychological characteristics (Table 5). Those with psy-
chiatric disorders had significantly higher levels of so-
matization, hypochondriacal attitudes (fear of disease,
belief in the presence of occult medical disease, and
bodily preoccupation), and state anxiety. They also rated
their health status as significantly w o r s e than did those
without a psychiatric diagnosis. On the SIQ, those with
a psychiatric diagnosis m o r e often endorsed psycholog-
ical explanations for c o m m o n symptoms, but the two
groups did not differ significantly in the tendency to
attribute symptoms to medical disease or to external
circumstances.
Palpitation patients have a high prevalence of anx-
iety and depressive disorder; almost haft have a lifetime
diagnosis and a fourth have a current disorder. Panic
disorder in particular is found among 28% of palpitation
patients, and 19% have had panic attacks in the preced-
ing month. These are significantly higher than the prev-
alence rates among asymptomatic non-patients. The other
anxiety disorders, while generally m o r e prevalent in the
Holter monitor patients than in the non-patient com-
parison group, are not significantly m o r e so. When the
palpitation patients are c o m p a r e d with a random sample
of nonhypochondriacal patients from the general med-
ical clinic, panic again emerges as the disorder that is
most strikingly elevated in the palpitation group.
Both lifetime major depression and lifetime dysthy-
mia are more prevalent in the Holter patients than in

TABLE 4
Clinical Characteristics of the Palpitation Patients with and without Current Psychiatric Disorders
(1) (2) (3)
Patients with One Patients with Non-patient Comparison
or More Diagnoses No Diagnosis Group p p
(n = 36) (n = 109) (n = 70) (1)-(2) (1)-(3)
Duration of chief complaint 55.21 months 61.00 months N/A 0.78 N/A

Total no. symptoms in diary 5.42 3.53 0.63 0.08 0.000

Cardiac symptoms (mean rat-

ing per patient, 1-5)
Racing heart 3.19 2.77 1.35 0.09 0.000
Irregular heartbeat 2.64 2.38 1.12 0.29 0.000
Heart pounding 3.06 2.51 1.17 0.04 0.000
Flip-flopping or fluttering 2.11 2.04 1.10 0.75 0.000
Heart jumping 2.14 1.82 1.01 O.16 0.000
Heart stopping 1.47 1.18 1.00 0.05 N/A
Feeling faint 2.78 1.56 1.07 0.000 0.000
Feeling lightheaded 2.83 1.83 1.23 0.000 0.000
Rotating sensation 2.11 1.27 1.10 0.000 0.000

Utilization of medical care (no.

in preceding 12 months)
Physician visits--mean 6.19 5.31 2.21 0.55 0.001
Psychiatry visits--mean 0.28 0.16 0.16 0.11 0.14
Emergency ward visits--
mean 2.06 1.22 0.47 0.01 0.000
Days hospitalized-- mean 0.53 0.29 0.03 0.20 0.005
Prior cardiac catheteriza-
t i o n - no. patients 2 (5.6°,6) 11 (10.1%) 0 (0°/6) 0.62 0.22
Prior stress testing--no.
patients 13 (36.1%) 48 (44.0%) 16 (22.9%) 0.52 0.22
Prior Holter monitoring--
no. patients 8 (22.2%) 31 (28.4%) 5 (7.1%) 0.61 0.05
Prior ultrasonography--no.
patients 12 (33.3%) 44 (40.4%) 9 (12.99/o) 0.58 0.03

Cardiac status
Significant finding on elec-
trocardiogram- no. pa-
tients 5 (13.9%) 23 (21.1%) 3 (4.3%) 0.48 0.17
Prior myocardial infarc-
t i o n - n o , patients 0 (0%) 6 (5.5%) 0 (0%) 0.34 N/A
Known cardiacdisease-- no.
patients 6 (16,7o/6) 41 (37.6%) 2 (2.9%) 0.03 0.03
 JOURNALOF GENERALINTERNALMEDICINE,Volume 9 (June), 1994 311

TABLE 5
PsychologicalCharacteristics of the Palpitation Patients with and without Current Psychiatric Disorders
(1)
Patients with One (2) (3)
or More DIS* Patients with No Non-patient
Diagnoses DIS Diagnosis Comparison Group p p
(n = 36) (n = 109) (n = 70) (1)-(2) (1)-(3)
Psychological status--mean
rating per patient
Hypochondriacal attitudes
(Whiteley Index, 1-5) 2.28 1.78 1.44 0.000 0.000
Somatization (SSIt, 1-5) 2.46 1.79 1.41 0.000 0.000
Anxiety (STAI*, 1 4) 1.95 1.56 1.39 0.001 0.000
Global Self-rating of Health
(1-5) 3.28 3.85 4.33 0.001 0.000

Attributional style (SIQ§)--

mean rating per patient
Somatizing (1-4) 1.87 1.75 1.73 0.21 0.14
Psychotogizing (1-4) 2.15 1.88 1.95 0.008 0.06
Normalizing (1-4) 2.32 2.15 2.49 0.09 O.16
*Diagnostic Interview Schedule.
tSomatic Symptom Inventory.
*State-Trait Anxiety Inventory.
§Symptom Interpretation Questionnaire.

the asymptomatic non-patients, but not significantly so.
These rates are comparable to those found in the medical
clinic as a whole, and thus the patients referred for Hol-
ter monitoring have approximately as m u c h depressive
disorder as do the patients in the medical setting from
which most are referred.
Somatization disorder symptoms are significantly
more prevalent in the palpitation patients than in the
other two samples. Diagnosed somatization disorder is
rare (2%), but the full DSM-III-R diagnostic criteria may
be excessively stringent, 38" 39 and more than a third of
the palpitation patients meet the diagnostic criteria sug-
gested for "abridged somatization disorder" (six func-
tional somatic symptoms for w o m e n and four for men). ~8
While the incidences of clinically significant ar-
rhythmias do not differ for palpitation patients with and
without psychiatric disorder, some other clinical char-
acteristics do distinguish the two groups. Patients who
report no symptom during monitoring are more likely
to be free of psychiatric disorder. Among those w h o are
symptomatic during monitoring, there is a trend sug-
gesting that the more palpitations the patient reports,
the more likely he or she is to have an anxiety or a
depressive disorder: when patients with and without
lifetime psychiatric disorder are compared, the former
report significantly more (p = 0.03) symptoms during
monitoring; however, when those with and without cur-
rent psychiatric disorder are compared, this difference
fails to attain statistical significance (p = 0.08). In ad-
dition, psychiatric patients are more likely to charac-
terize their symptom as "pounding" and to report feeling
faint, lightheaded, and vertiginous at the same time.
Anxious and depressed palpitation patients and those
without psychiatric disorder have undergone similar
amounts of prior cardiac evaluation, yet the former are
less likely to give a history of cardiac disease. One might
expect that these patients would have undergone even
more extensive evaluation, since their symptoms would
likely have persisted undiagnosed and untreated. How-
ever, their significantly higher rates of psychiatric care
suggest that at least some of their psychiatric morbidity
was in fact recognized by their physicians. In addition,
the psychiatric patients were younger and therefore may
have been presumed by their physicians to be generally
healthier. The psychiatric patients' higher use of emer-
gency rooms and walk-in clinics may be attributable to
their panic attacks, since such attacks characteristically
precipitate emergency room visits in the mistaken belief
that the sufferer is having a heart attack or other medical
emergency.
Palpitation patients with psychiatric disorder also
somatize more and are more hypochondriacal. They
consider themselves to be in poorer health, although
their relative youth and the medical morbidity measures
suggest that they are no sicker than other palpitation
patients. Finally, they are more likely to attribute com-
mon somatic symptoms to psychological causes, but not
to medical causes. Thus, although these patients soma-
tize in the sense of reporting functional somatic symp-
toms (including palpitations), they do not appear to
somatize in the sense of repressing all emotional symp-
toms and all psychological distress; while seeking med-
ical care for a functional somatic symptom, they none-
theless also o b t a i n p s y c h i a t r i c c a r e and e n d o r s e
psychological explanations for their somatic discomfort.
This might indicate that these patients would admit their
psychiatric distress if explicitly questioned about it by
their medical physicians.
Several cautions are necessary in interpreting these
findings. First, the mere presence of a psychiatric dis-
312 Barsk7 et aL, PSYCHIATRICDISORDERSIN MEDICALOUTPATIENTS
o r d e r d o e s n o t m e a n t h a t it is t h e c a u s e o f t h e p a t i e n t ' s
palpitations. S e c o n d , t h e m e d i c a l status o f t h e s e p a t i e n t s
is i n c o m p l e t e l y k n o w n ; c a r d i a c d i a g n o s e s w e r e estab-
lished o n l y b y q u e s t i o n i n g t h e p a t i e n t s t h e m s e l v e s , a n d
w e w e r e n o t a b l e to v a l i d a t e t h e i r c l i n i c a l h i s t o r i e s w i t h
a m e d i c a l r e c o r d audit. T h u s , s o m e o f t h e a s s o c i a t i o n s
r e p o r t e d h e r e c o u l d b e m e d i a t e d o r c o n f o u n d e d by dif-
f e r e n c e s in m e d i c a l m o r b i d i t i e s . T h i r d , p a l p i t a t i o n s
t h e m s e l v e s are a d i a g n o s t i c c r i t e r i o n for s o m e o f t h e s e
p s y c h i a t r i c d i s o r d e r s . If in s o m e c a s e s t h e p a l p i t a t i o n s
are d u e to c a r d i a c d i s e a s e , t h e n t h e y are c o n t r i b u t i n g
falsely t o w a r d t h e p s y c h i a t r i c diagnosis. W e d o k n o w ,
h o w e v e r , that c l i n i c a l l y s i g n i f i c a n t a r r h y t h m i a s a r e rel-
atively u n c o m m o n in t h e p a l p i t a t i o n g r o u p as a w h o l e .
In addition, e l i m i n a t i n g p a l p i t a t i o n s as a d i a g n o s t i c
s y m p t o m y i e l d e d o n l y v e r y s l i g h t c h a n g e s in p a n i c dis-
o r d e r p r e v a l e n c e rates. F o u r t h , t h e p r e v a l e n c e r a t e s in
the g e n e r a l m e d i c i n e c l i n i c s a m p l e a n d in t h e H o l t e r
s a m p l e are n o t p r e c i s e l y c o m p a r a b l e . T h e f o r m e r c o m -
p l e t e d an e a r l i e r v e r s i o n o f t h e d i a g n o s t i c i n t e r v i e w a n d
w e r e classified a c c o r d i n g to DSM-III n o s o l o g y , w h i l e t h e
latter r e c e i v e d DIS-III-R d i a g n o s e s . Finally, it m u s t b e
remembered that we assessed only a limited number of
p s y c h i a t r i c d i s o r d e r s a n d c a n say n o t h i n g a b o u t t h e p r e v -
a l e n c e of s u b s t a n c e o r a l c o h o l a b u s e , d i s o r d e r s t h a t a r e
relatively c o m m o n in m e d i c a l p o p u l a t i o n s .
In g e n e r a l , h o w e v e r , t h e s e f i n d i n g s a d d w e i g h t to
a growing body of literature on the high prevalence of
p s y c h i a t r i c d i s o r d e r in v a r i o u s g r o u p s o f m e d i c a l pa-
tients. T h e y a r e also c o m p a t i b l e w i t h t h e r e s u l t s o f stud-
ies o f p a t i e n t s w h o u n d e r g o a n g i o g r a p h y f o r a n g i n a - l i k e
chest pain but are found to have negative coronary artery
results, oo/o 220/ - 440//o o f w h o m h a v e p a n i c d i s o r d e r . 6,~°-42
This h i g h f r e q u e n c y o f p s y c h i a t r i c d i s o r d e r s in pa-
tients c o m p l a i n i n g o f p a l p i t a t i o n s has b o t h c l i n i c a l im-
portance and public health implications, Many of these
d i s o r d e r s are e m i n e n t l y t r e a t a b l e (e.g., p a n i c d i s o r d e r ,
m a j o r d e p r e s s i o n ) , b u t as l o n g as t h e y g o u n d i a g n o s e d ,
p a t i e n t s w i l l r e m a i n d i s t r e s s e d a n d d i s a b l e d . In a d d i t i o n ,
extensive medical and financial resources are consumed
in m o n i t o r i n g t h e s e p a t i e n t s , a n d w h i l e m o n i t o r i n g is
n o t i n v a s i v e a n d c a r r i e s l i t t l e i a t r o g e n i c risk, it is n o n e -
theless e x p e n s i v e a n d u n r e v e a l i n g . It also m a y f o s t e r o r
confirm some patients' mistaken suspicions that they do
in fact h a v e a s e r i o u s c a r d i a c disease. M o n i t o r i n g is un-
d o u b t e d l y i n d i c a t e d in s o m e o f t h e s e cases, s i n c e s e r i o u s
arrhythmias and psychiatric disorder are not mutually
e x c l u s i v e . But in m a n y o t h e r cases, a c c u r a t e p s y c h i a t r i c
diagnosis a n d a r a p i d r e s p o n s e to t r e a t m e n t o f t h e psy-
chiatric disorder would obviate the need for ambulatory
electrocardiography and avoid fruitless and unnecessary
m e d i c a l utilization.
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must be postmarked by June 30, 1995.

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