Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Background: With respect to the fact that physical and psychological factors affect each other in patients with non-cardiac chest pain:
Objective: The present study was carried out to compare the depression, anxiety, and stress severity in non-coronary patients with mild and severe chest pain.
Patients and Methods: A cross-sectional design was used. The statistical population comprised non-coronary patients who presented to the Heart Emergency Center, Kermanshah city, Iran. Using a matching method, 94 participants were selected and studied in two groups of 47. The instruments of the study comprised comorbidity index, the Brief Pain Index (BPI), and the Depression, Anxiety, and Stress Scale (DASS). The multivariate analysis of variance, chi-squared test, and t-test were used for data analysis.
Results: After adjustment for the effects of age and comorbid conditions, the results showed that there was significant difference among the two groups in terms of depression, anxiety and stress and the severity of these variables was more pronounced in patients with severe chest pain (P < 0.001).Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper
Depression, anxiety, and stress are common psychological occurrences in patients with non-coronary chest pain, and they should be attended to by health professionals, especially in severe non-coronary chest pain. Therefore, paying attention to psychological factors could help the experts choose solutions to decrease pain and side effects of the diseases. It also may facilitate treatment procedures among patients in severe pain. Further investigation to determine the association between these variables and non-coronary chest pain is necessary.
Keywords: Non-coronary; chest pain; depression; anxiety; stress; patients

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1. Background
Chest pain is a common symptom in general population (1) which is regarded as the second cause for which people visit heart hospitals (2,3). However, only 23% of the visiting patients with chest pain have a real coronary disorder (4) and the rest are due to other causes such as pulmonary problems, musculoskeletal issues, gastritis, and psychological factors (5). Specifically, in 66% of patients, the existence of not one clear cause could be approved (6) and the pain cause in 41% of patients is related to psychological factors (4). Psychological factors and psychiatric disorders play significant role in genesis and development of these pains (7,8) and among these factors, anxiety and depression are considered as the most common existing problems (9). Many studies have dealt with the evaluation of stress, anxiety, and depression in patients with non-cardiac chest pain and have shown the effect of these factors on pain development (10-12). However, few researches have studied the effect of these variables on chest pain exacerbation. Therefore, regarding that the frequent visiting of these patients to the clinics takes a lot of time and money for evaluations and examinations which put a high economic pressure on medical system (13):Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

2. Objective
The present study was done to investigate and compare depression, anxiety, and stress severity in non-coronary patients with mild and severe chest pain.

3. Patients and Methods
3.1. Study Design
In this cross-sectional causal-comparative study, the depression, anxiety, and stress of patients with chest pain who presented to the Heart Emergency Department (HED) of Imam Ali Hospital, Kermanshah, Iran in winter 2014, despite having normal angiography, were studied. This treatment center is a state specialized hospital for cardiology in Western Iran.

3.2. Inclusion criteria
Inclusion criteria were (1) educational level higher than elementary school, (2) aged between 30 and 70 years, (3) history of at least 3 months of chest pain, (4) normal coronary angiography, and (5) no evidence of chest pain alleviation for at least 1 month after angiography (14).Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

3.3. Patients and Procedure
Data were gathered using a checklist for demographic variables and the Depression, Anxiety, and Stress Scale (DASS). When the groups were specified, the patients were provided with the DASS and after the clinical psychologist presented the required explanations, they were requested to fill out the forms accurately. In the end, the forms were collected and the information was analyzed using the statistical methods. The statistical population of the present study included 153 patients with non-cardiac chest pain who presented to our hospital. They reported chest pain for at least 1 month after a normal coronary angiography. At first, 32 people were excluded after failing to meet the inclusion criteria. Then, the remaining 121 were requested to participate in the study willingly after providing written informed consent. 12 patients did not agree to participate, and so 109 individuals were included. The Comorbidity Index and Brief Pain Inventory were administered to the 109 subjects in order to gather data about their comorbid conditions and pain intensity. According to the results of a 10-degree pain intensity description, 53 people who obtained scores of 1’5 were included in a mild pain group and 56 patients who scored 6’10 were included in a severe chest pain group. Afterwards, patients in the first group were paired with patients in the second group based on gender and education, and there remained 47 people in each group (15 men and 32 women). Matching was accomplished by excluding 5 patients with severe pain and a high school degree or higher, as there were no counterparts in the group with mild pain. Then, 4 individuals with mild pain and only elementary education, who also did not have counterparts in the other group, were excluded from the study. A man from the group with mild pain and two women from the group with severe pain were excluded from the study due to the lack of a counterpart. Finally, each group included 47 participants. A demographic information checklist and the DASS were used to collect the required data. When the groups were specified, the patients were provided with the DASS, and after the clinical psychologist presented the required explanations, they were requested to fill out the forms accurately. The forms were collected and the information was analyzed using the statistical methods outlined below.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

3.4. Instruments
3.4.1. The Comorbidity Index: This index, designed by Ifudu et al (1998) is a scoring index for evaluating comorbid physical conditions. It evaluates the presence of 14 chronic illnesses. These conditions are 1) ischemic heart disease; 2) other cardiovascular illness; 3) chronic respiratory diseases; 4) autonomic neuropathy; 5) other neurologic problems; 6) muscular-neurologic disorders; 7) infections such as hepatitis; 8) blood disorders; 9) pancreas and bilious diseases; 10) genital and urinary diseases; 11) vision disorder; 12) limbs disorder; 13) backache, spine ache, or joint disorders; and 14) psychiatric illness. Each comorbid condition is scored from 0 to 3 representing the absence of the disease and the presence of severe disease, respectively. The total score ranges from 0 to 42, with a higher score being indicative of a greater comorbidity (15).
3.4.2. The Brief Pain Inventory (BPI): This scale scores pain severity on a ten-degree scale, with zero indicating no pain and ten indicating a high degree of pain. This measurement index has been given validity in Iran and its reliability was reported to be appropriate in Iranian populations (16).
3.4.3. The Depression, Anxiety, and Stress Scale (DASS): this scale, which was developed by Lovibond, and Lovibond, (17), consists of 21 items that measures three mini-scales of depression, anxiety, and stress (each, 7 items). The interviewee answers these items with never, few, many, and too many. The Cronbach’s alpha of this scale was reported as 0.81 for depression, 0.73 for anxiety, and 0.81 for stress. Sahebi (18) obtained Cronbach’s alpha in Iran (N= 400) as 0.70 for depression, 0.66 for anxiety, and 0.76 for stress. Also, Beck Depression Test correlation coefficient was significant for depression (0.66), anxiety (0.67), and stress (0.49).Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

3.5. Statistical Analysis
The data were analyzed by multivariate analysis of variance (MANOVA), t-test, and chi-squared test using SPSS for Windows (v. 20.0). The t-test was used to study the non-significance of the difference between the two groups on quantitative variables, including age and comorbidities. The chi square test was used to investigate the non-significance of the difference between the two groups on nominal variables, including job status and smoking and drinking. The data were analyzed using a multivariate analysis of variance for compare the two groups. Further, significance was determined with p-values less than 0.05, and eta-squared was used to evaluate the effect size for each dependent variable.

4. Results
Each group included 15 men and 32 women. The mean (SD) age for men with severe chest pain was 54.53 (��8.39) years and 54.07 (��9.80) for those with mild chest pain. The mean (SD) age was 52.21 (��7.39) years for women with severe pain and 52.36 (��8.69) for women with mild chest pain. Moreover, the mean (SD) pain severity in the group with mild chest pain was 3.24 (��1.11), and in the group with severe chest pain, it was 7.25 (��1.32). Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Table 1. Comparison of demographic and behavioral factors and comorbidities in the patients

As shown in Table 1, there was no significant difference in any of the variables between the groups. Table 2 presents means and SDs of the variables by group. Table 2 shows the results of the Multivariate analysis of variance comparing the two groups.

Table 2. Multivariate analysis of variance comparing between the two groups

The F-value for group effects when controlling for confounding variables [F(3,92) = 10.56; P < 0.001; eta-squared = 0.26] showed a significant difference for at least one of the dependent variables between the two groups. According to the table, patients with severe pain showed significantly higher scores than did patients with mild pain in depression [F(1,92) = 13.02; P < 0.001; eta-squared = 0.12], anxiety [F(1,92) = 31.83; P < 0.001; eta-squared = 0.25], and stress [F(1,92) = 12.89; P < 0.001; eta-squared = 0.12]. Eta-squared, which shows the effect size for each variable, suggests that the major differences were in anxiety, depression, and stress. Meanwhile, after applying the Bonferroni correction (P = 0.012), because of the three existing dependent variables, and given the significance levels of the variables, the significant difference was confirmed.Generalized Anxiety Disorder is a disorder that I struggle with personally. It is when a person has a tense feeling of stress, and anxiety for long periods of time without any real cause of it. Even though everyone has fears, and has stress from time to time it isn’t harmful unless the anxiety and stress is keeping someone from living their life, and relaxing. Generalized Anxiety Disorder is different from other anxiety disorders because panic attacks rarely occur, and instead an overpowering sense of dread is long lasting. People with GAD, and myself have fears that other people without the disorder have, except the fears are taken to a new level. For example, I am a person with GAD who has an extreme fear of flying on airplanes. I will try to avoid flying on airplanes as much as possible, and even cancel plans or vacations because of my fear. Over spring break I was supposed to fly to Costa Rica for a study abroad class but cancelled a few weeks before because of all the stress of having to fly on a plane. For me, when I’m on an airplane I feel that if I don’t constantly worry, or repeat certain phrases then something bad is going to happen.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

According to the World Health Organization, stress is a significant problem of our times and affects both physical as well as the mental health of people. Stress is defined as a situation where the organism‘s homeostasis is threatened or the organism perceives a situation as threatening. Stress coping methods are the cognitive, behavioral and psychological efforts to deal with stress. Method: After a thorough literature review in major databases (MEDLINE, Scopus, Science Direct) the following techniques were identified and are presented and briefly discussed here: progressive muscle relaxation, autogenic training, relaxation response, biofeedback, emotional freedom technique, guided imagery, diaphragmatic breathing, transcendental meditation, cognitive behavioral therapy, mindfulness-based stress reduction and emotional freedom technique. Conclusion: These are all evidence-based techniques, easy to learn and practice, with good results in individuals with good health or with a disease.

Anxiety is a reaction to things that stress you. It is normal to have some anxiety at work, school, or home. It is when anxiety becomes a daily occurrence with no known cause that it is categorized as a disorder. Anxiety, panic, and depression often begin with normal stress that gets out of control. Hectic lifestyles lead to poor eating habits, less restful sleep, deficiencies in vitamins and minerals the body needs, and higher levels of stress. You don’t have to work outside the home to experience stress, anxiety, and/or depression. It can happen to stay-at-home parents, working parents, students, young working adults, children, and senior citizens alike. Anxiety isn’t exclusive to any age or gender group. Natural anxiety remedies are better for you than conventional treatments like medications that dull the senses and cause a number of side effects ranging from mild to life-threatening. A good rule of thumb to follow is that if the medication has more side effects than you have symptoms, consider going with natural means of treatments.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Anxiety can be defined as “distress or uneasiness of the mind caused by fear of danger or misfortune” (Anxiety, 1). Many individuals struggle with anxiety. As an individual dealing with anxiety, a person may explore their past situations to get to the bottom on their anxiety. Do they ever stop to think of what the root cause of anxiety may be? The motivation of anxiety can fluctuate depending on what the root cause is. Biblically speaking, the Bible has a great deal to say about anxiety and how to deal with anxiety as it arises. It is important to explore what motivates anxiety and what the Bible has to say about anxiety. Anxiety can usually be found paired with another psychological disorder, such as depression or ADHD (Attention Deficit Hyperactivity Disorder). The feelings of anxiety generally stem from having a lack of activity in the nucleus accumbens, which is found in hippocampus. The nucleus accumbens “plays a critical role in the experience of pleasure from naturally occurring reinforcers” (Reeve, 58). Although the nucleus accumbens is where your pleasure and reinforcers are found, “your brains natural anti-anxiety chemicals are endorphins” (Reeve, 59).

Life exists through the maintenance of a complex dynamic equilibrium, termed homeostasis, that is constantly challenged by internal or external adverse forces, termed stressors, which can be emotional or physical in nature. Thus, stress is defined as a state of threatened or perceived by the individual as threatened homeostasis and it is re-established by a complex repertoire of behavioural and physiologic adaptive responses of the organism [1] . Neuroendocrinic hormones have a crucial role in coordinating basic as well as threatened homeostasis; also, they intervene in pathogenesis of dyshomeostatic or cacostatic situations of disease [1].

The Stress System located both in the central and peripheral nervous system, generically activated whenever a threshold of any stressor is exceeded, plays a major coordinator role in the re-establishment of homeostasis by eliciting a complex behavioral and physical adaptive response. This response is defined as the stress syndrome and represents the unfolding of a relatively stereotypic, innate program of the organism that has evolved to coordinate homeostasis and protect the individual during stress [1].Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Stress, health and illness

According to the World Health Organization [2] stress, especially that relating to work, is the second most frequent health problem, impacting one third of employed people in the European Union.

There is a substantial body of research connecting stress to cardiovascular disease [3] , the future manifestation of hypertension related to the individual‘s response to stress [4] , metabolic syndrome [5] , obesity [6] , emotional overeating [7] , while stress fuels approximately 50% of depression cases through disturbance of the HPA axis [8] and increased cortisol levels.

Furthermore, biological markers associate the immunoendocrinological disturbance brought by stress to infertility [9] . There are also research data pin pointing the role of stress in infectious disease [10] and cancer [11] . Given the negative impact of stress at intrapersonal and somatic level, it is important for healthcare professionals to master a repertoire of stress management techniques and teach them to their patients.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

It should be noted that stress management techniques are applicable not only to people who manifest a disease or disorder, but also to healthy people, when added to daily routine practice as an effective tool for health enhancement and protection over the life span, serving thus as a valuable intervention for the ―healthy population‖ as well. Health promotion, as one of the main approaches to health enhancement, can serve this multiple role by designing and applying interventions to reduce or prevent distress and adequately contribute to future health and wellness.

Evidence-based stress management techniques

Progressive Muscle Relaxation (PMR)

Origins: Progressive muscle relaxation (PMR) is a technique for reducing stress and anxiety by alternately tensing and relaxing the muscles [12] . It was developed by American physician Edmund Jacobson in the early 1920s. Jacobson argued that since muscle tension accompanies anxiety, one can reduce anxiety by learning how to relax the muscular tension. PMR entails a physical and mental component [13].

Method/Pathophysiology: The physical component involves the tensing and relaxing of muscle groups over the legs, abdomen, chest, arms and face. In a sequential pattern, with eyes closed, the individual places a tension in a given muscle group purposefully for approximately 10 seconds and then releases it for 20 seconds before continuing with the next muscle group. The mental component requires that the individual focuses on the distinction between the feelings of the tension and relaxation. With practice, the patient learns how to effectively relax in a short period of time.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Relaxation must be attempted in order to reduce pain or pain perception and tension, create a pleasant mental state, reduce anticipatory anxiety, reduce anxiety as a response to stress, increase parasympathetic activities, increase knowledge concerning muscle tension and autonomous stimuli, improve concentration, increase the feeling of control, improve the ability to block inner talk, energize and improve sleep, decrease the cardiac index, lower blood pressure, warm or cool body parts, enhance performance of physical activities and help in the relationship with others [14] . Therefore, the individual is taught by a trained professional, manual or audio how to progressively relax major muscle groups and performs the sequence 2-3 times daily for 15-20 minutes per session.

Results/Benefits: Among PMR long-term benefits the following are included: reduction of salivary cortisol levels and generalized anxiety [13] , decreased blood pressure [13,15] and heart rate [15] , decreased headaches [16] better management of cardiac rehabilitation [17] , improvement of quality of life of patients after bypass surgery [18] and improvement of quality of life of patients with multiple sclerosis [19].

Αutogenic Training (AT)

Origins: Autogenic training (AT) is a self-relaxation procedure by which a psychophysiological determined relaxation response is elicited. This relaxation technique was developed by Johannes Heinrich Schultz [20] . AT aims to achieve deep relaxation and reduce stress.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Method/Pathophysiology: In AT the individual learns a set of directions/exercises that command the body to relax and control breathing, blood pressure, heartbeat, and body temperature. AT consists of six standard exercises that -with the use visual imagination and verbal cues- make the body feel warm, heavy, and relaxed. The person learns each exercise by reading about it or watching a teacher, then practicing it for a few minutes several times a day. Mastering the exercises, either from an instructor or on one‘s own, usually requires 4 to 6 months.

Results/Benefits: A meta-analysis of clinical outcome studies in AT found that it is useful in a range of diverse disorders including tension headache/migraine, mild-to-moderate essential hypertension, coronary heart disease, asthma bronchiale, somatoform pain disorder (unspecified type), Raynaud’s disease, anxiety disorders, mild-to-moderate depression/dysthymia, and functional sleep disorders [21].

Relaxation Response (RR)

Origins: In the 1960’s, Herbert Benson of Harvard University found that there is a counterbalancing mechanism to the stress response: just as stimulating an area of the hypothalamus can cause the stress response, so activating other areas of the brain results in its reduction. He defined this opposite state the “relaxation response.” [22-24].Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Method/Pathophysiology: RR is a simple practice that once learned takes 10 to 20 minutes a day to achieve relaxation. The important characteristics of a relaxation program are: α) repetition of a word, sound, prayer, thought, phrase or muscular movement, through which concentration is achieved β) passive return to the repetition when other thoughts intrude.

When an organism is stressed its physiological response is the fight-or-flight response, whereas when the body is no longer in perceived danger, and the autonomic nervous system functioning returns to normal, the relaxation response (RR) occurs. During RR, the body moves from a state of physiological arousal, including increased heart rate and blood pressure, slowed digestive functioning, decreased blood flow to the extremities, increased release of stress hormones, and other responses preparing the body to fight or flight, to a state of physiological relaxation, where blood pressure, heart rate, digestive functioning and hormonal levels return to their normal state.

Results/Benefits: The RR can reduce systolic hypertension [25] , improve cardiac rehabilitation [26] and relieve medical symptoms [27].

There is compelling evidence that the RR elicits specific gene expression changes in people who practice either short-term or long-term. The study results suggest consistent and constitutive changes in gene expression resulting from RR. These changes may relate to long term physiological effects [28].Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper


History: Biofeedback has its roots in the concept of homeostasis and cybernetic theory, proposing that systems are controlled by monitoring their resultsits. A team of researchers in a landmark conference in 1969 at the Surfrider Inn in Santa Monica coined the term biofeedback from Weiner’s feedback. The conference resulted in the founding of the Bio-Feedback Research Society, which permitted normally isolated researchers to contact and collaborate with each other, as well as making the term ―biofeedback‖ popular [29].

Training/Psychophysiology: Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance. Precise instruments measure physiological activity such as brainwaves, heart function, breathing, muscle activity, and skin temperature. These instruments rapidly and accurately ‘feed back’ information to the user. The presentation of this information — often in conjunction with changes in thinking, emotions, and behavior — supports desired physiological changes. Over time, these changes can endure without continued use of an instrument [30].

Biofeedback training is done in the presence of qualified biofeedback therapists. The therapists work with their patients and explain to them the process of reading and then responding to the physiological information relating to their body using various biofeedback devices. When patients understand and practice this concept, after several sessions spanned in 3-6 months, they are then able to take control of their physiological functions like heart beat rate, blood pressure, etc. They can also learn to observe the changes that happen when they apply the learning from the training. Sensor modalities include: the electromyograph, feedback thermometer, electrodermograph, electroencephalograph, electrocardiograph, pneumograph, capnometer, and the hemoencephalographyv [30].

Results/Benefits: Biofeedback has been used successfully for the treatment of headaches [31] , the control of high blood pressure [32-34] and type II diabetes [34,35] and cardiac disease [36] .Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Guided Imagery (GI)

History: GI is not a new approach to helping, but is well established in Native American and other indigenous traditions, in Hinduism, Judeo-Christian, and other religious traditions as well as traditional Chinese medicine [37] . In the late 1960s, Joseph Wolpe introduced several imagery-related techniques in behaviour-modification therapy: systematic desensitization, aversive-imagery methods, symbolic-modelling techniques and implosive therapy. Since that time there have been many advocates of guided imagery [37] . In 1982, Drs. Bresler and Rossman presented their initial findings at a conference sponsored by Marquette University and the University of San Francisco called The Power of Imagination. During this conference, leading clinicians and researchers introduced more than 1,400 health professionals nationwide to the practical applications of imagery work [38].

Method/Pathophysiology: The GI method is taught by a trained professional, an audio or written script in the course of 4-8 weeks, requiring 10 minutes practice per day. GI utilizes the subject‘s personalized images to promote health through several standardized, yet adaptable, techniques, including relaxation/stress reduction. The GI facilitator‘s goal is to enable the subject to engage his/her own images that are symbolic of his/her specific health or life issues, in order to develop health-directed insights, health-promoting behaviour changes, or direct physiologic changes. A facilitated exploration of an image of a safe, comfortable place specific to the participant is involved including sensory recruitment (visual, auditory, olfactory, tactile, and kinesthetic), particularly focusing on linking elements of relaxation in the image to the physiologically relaxed state simultaneously being experienced by the subject [39].Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Results/Benefits: GI has been used successfully in stress reduction [40] , in the prevention of smoking relapse [41] , in the treatment of depression [42] , as an adjuvant cancer therapy [43] , as an anxiety treatment prior to diagnostic cardiac catheterization [44] on surgical stress and wound healing [45] and in patients undergoing coronary artery bypass graft surgery [46] , in the management of patients undergoing bone marrow transplantation [47] , for cancer pain and management [48,49] , for asthma management [50] , for pain management [51,52] , for overweight adolescents [53].

The main types of immune cells are white blood cells. There are two types of white blood cells – lymphocytes and phagocytes.

When we’re stressed, the immune system’s ability to fight off antigens is reduced. That is why we are more susceptible to infections.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

The stress hormone corticosteroid can suppress the effectiveness of the immune system (e.g. lowers the number of lymphocytes).

Stress can also have an indirect effect on the immune system as a person may use unhealthy behavioral coping strategies to reduce their stress, such as drinking and smoking.

Stress is linked to: headaches; infectious illness (e.g. ‘flu); cardiovascular disease; diabetes, asthma and gastric ulcers.

Stress and Illness


Stress responses have an effect on digestive system. During stress digestion is inhibited. After stress digestive activity increases. This may affect the health of digestive system and cause ulcers.  Adrenaline released during a stress response may also cause ulcers.

Stress responses increase strain upon circulatory system due to increased heart rate etc. Stress can also affect the immune system by raising blood pressure.

Hypertension (consistently raised blood pressure over several weeks) is a major risk factor in coronary heart disease (CHD) However, CHD may be caused by eating too much salt, drinking too much coffee or alcohol.

Stress also produces an increase in blood cholesterol levels, through the action of adrenaline and noradrenaline on the release of free fatty acids. This produces a clumping together of cholesterol particles, leading to clots in the blood and in the artery walls and occlusion of the arteries.

In turn, raised heart rate is related to a more rapid build-up of cholesterol on artery walls. High blood pressure results in small lesions on the artery walls, and cholesterol tends to get trapped in these lesions (Holmes, 1994).Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Since the 1970s, meditation and other stress-reduction techniques have been studied as possible treatments for depression and anxiety. One such practice, yoga, has received less attention in the medical literature, though it has become increasingly popular in recent decades. One national survey estimated, for example, that about 7.5% of U.S. adults had tried yoga at least once, and that nearly 4% practiced yoga in the previous year.

Yoga classes can vary from gentle and accommodating to strenuous and challenging; the choice of style tends to be based on physical ability and personal preference. Hatha yoga, the most common type of yoga practiced in the United States, combines three elements: physical poses, called asanas; controlled breathing practiced in conjunction with asanas; and a short period of deep relaxation or meditation.

Natural anxiety relief

Available reviews of a wide range of yoga practices suggest they can reduce the impact of exaggerated stress responses and may be helpful for both anxiety and depression. In this respect, yoga functions like other self-soothing techniques, such as meditation, relaxation, exercise, or even socializing with friends.

By reducing perceived stress and anxiety, yoga appears to modulate stress response systems. This, in turn, decreases physiological arousal — for example, reducing the heart rate, lowering blood pressure, and easing respiration. There is also evidence that yoga practices help increase heart rate variability, an indicator of the body’s ability to respond to stress more flexibly.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Stress response

A small but intriguing study done at the University of Utah provided some insight into the effect of yoga on the stress response by looking at the participants’ responses to pain. The researchers noted that people who have a poorly regulated response to stress are also more sensitive to pain. Their subjects were 12 experienced yoga practitioners, 14 people with fibromyalgia (a condition many researchers consider a stress-related illness that is characterized by hypersensitivity to pain), and 16 healthy volunteers.

When the three groups were subjected to more or less painful thumbnail pressure, the participants with fibromyalgia — as expected — perceived pain at lower pressure levels compared with the other subjects. Functional MRIs showed they also had the greatest activity in areas of the brain associated with the pain response. In contrast, the yoga practitioners had the highest pain tolerance and lowest pain-related brain activity during the MRI. The study underscores the value of techniques, such as yoga, that can help a person regulate their stress and, therefore, pain responses.

Benefits of yoga

Although many forms of yoga practice are safe, some are strenuous and may not be appropriate for everyone. In particular, elderly patients or those with mobility problems may want to check first with a clinician before choosing yoga as a treatment option.

But for many patients dealing with depression, anxiety, or stress, yoga may be a very appealing way to better manage symptoms. Indeed, the scientific study of yoga demonstrates that mental and physical health are not just closely allied, but are essentially equivalent. The evidence is growing that yoga practice is a relatively low-risk, high-yield approach to improving overall health.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Acute chest pain accounts for approximately 700,000 emergency department (ED) attendances each year in England and Wales (Goodacre et al., 2005), but between 30 and 60% of these patients do not receive a cardiac diagnosis for their pain (Eken et al., 2010; Mayou & Thompson, 2002). Current guidelines recommend that staff merely explain the non-cardiac nature of the pain to these patients (National Institute for Health and Clinical Excellence, 2010), based on the assumption that the rapid diagnosis of non-cardiac chest pain (NCCP) will alleviate any distress. However, cardiac testing itself may lead some patients to believe they are suffering from a cardiac problem, and so the unclear diagnosis, along with a lack of follow-up, may cause psychological distress (Nijher, Weinman, Bass, & Chambers, 2001). Furthermore, reassurance that test results are negative is often not sufficient to calm patients’ concerns (McDonald, Daly, Jelinek, Panetta, & Gutman, 1996). Despite having excellent long-term cardiac survival (Papanicolaou et al., 1986), patients with NCCP have been found to experience elevated levels of anxiety, reduced quality of life (QoL), further episodes of chest pain, and high use of health care services (e.g. Eslick & Talley, 2008; Goodacre, Mason, Arnold, & Angelini, 2001; Hadlandsmyth, Rosenbaum, Craft, Gervino, & White, 2013; Smeijers et al., 2013; Webster, Norman, Goodacre, & Thompson, 2012), thus placing a burden on health care costs and resources (Eslick, Coulshed, & Talley, 2002). Furthermore, indirect economical costs may also result from chronic chest pain through lost work days (Eslick et al., 2002). Psychological morbidity associated with NCCP may initiate, maintain or worsen chest pain (Bass & Mayou, 2002; Potts & Bass, 1995). In particular, anxiety-related disorders are often proposed as a cause for NCCP (Beitman et al., 1987; Jonsbu et al., 2009), and higher levels of anxiety have been related to increased health care use in NCCP patients (Hadlandsmyth, Rosenbaum, Craft, Gervino, & White, 2013). These findings suggest that it may be important to address not only the NCCP, but also the psychological distress associated with it.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

In order to develop effective interventions for this population, it is important to identify factors that are associated with both psychological distress and continued chest pain. However, research to date has focused on a limited range of mainly demographic variables and has lacked a strong theoretical focus (Webster et al., 2012). The common sense model of illness representations (CSM, Leventhal, Meyer, & Nerenz, 1980) provides an appropriate theoretical framework for examining the correlates of poor psychological outcomes in patients with NCCP (Webster et al., 2012). The CSM proposes that when faced with a health threat or illness, such as the experience of chest pain, people form a representation of the health threat based around the perceived causes of the illness, consequences of the illness, identity (i.e. the label given to the illness and the symptoms associated with it), expected timeline of the illness, cure/controllability of the illness (personal and treatment), one’s emotional response to the illness and one’s perceived understanding of the illness (coherence). Illness representations have been found to explain both psychological and physical outcomes for a range of conditions (e.g. Hagger & Orbell, 2003), including medically unexplained symptoms (MUS) (Frostholm et al., 2007) and cardiac chest pain (Aalto et al., 2006).

To date, four studies have applied the CSM to patients with NCCP. Robertson, Javed, Samani, and Khunti (2008) found that those with NCCP had more negative illness representations than those with cardiac chest pain. Donkin et al. (2006) found that illness representations (i.e. stronger illness identity, the perception of more severe consequences and a longer timeline, increased illness concern and stronger emotional representations) assessed at baseline were related to lower levels of reassurance following a negative exercise stress test. Jonsbu, Martinsen, Morken, Moum, and Dammen (2012) found that more negative illness representations assessed prior to cardiac stress testing were related to increased depression, worse QoL and chest pain, both prior to testing and six months later. Schroeder et al. (2012) found that more negative consequences, more chronic timeline, stronger illness identity, and greater concern and emotional representations were related to more severe chest pain prior to diagnostic testing. However, these studies suffer from a number of important limitations. First, the studies used the brief Illness Perceptions Questionnaire (IPQ, Broadbent, Petrie, Main, & Weinman, 2006), which only uses single items to measure each dimension. Second, none of these studies assessed perception of possible causes of NCCP. Given that NCCP patients do not receive a diagnosis, this dimension may be very important in understanding NCCP patients’ psychological reactions. Third, Jonsbu et al. did not assess anxiety. Given that anxiety has previously been shown to be strongly associated with NCCP (Smeijers et al., 2013; White, Craft, & Gervino, 2010), this may be an important factor to assess. Fourth, previous studies have employed cross-sectional designs (Schroeder et al., 2012) or have assessed patients pre-diagnosis (before they were aware that their pain was non-cardiac), which may have impacted on their responses (Jonsbu et al., 2012; Robertson et al., 2008; Schroeder et al., 2012). Fifth, previous studies have been conducted in outpatient departments (Donkin et al., 2006; Jonsbu et al., 2012; Robertson et al., 2008; Schroeder et al., 2012), and therefore the patients may differ from those who are examined in an ED.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

The present study therefore sought to address the above limitations by using a full version of the IPQ to assess illness representations, including perceived causes, in patients recruited in an acute setting (ED) who have been informed of their NCCP diagnosis, and then relate these perceptions to a range of measures of psychological distress and continued chest pain at one-month follow-up. In line with the CSM (Leventhal et al., 1980) and previous research on NCCP (e.g. Jonsbu et al., 2012; Schroeder et al., 2012; Webster et al., 2012), it was hypothesised that (i) illness representations would be associated with levels of psychological distress and QoL at baseline (i.e. after being informed of a NCCP diagnosis in an ED) and that (ii) baseline illness representations, psychological distress and QoL would be related to chest pain at one month.

People often associate a heavy feeling in the chest with heart problems, but this discomfort can be a sign of anxiety or depression.

A feeling of heaviness is one way that a person may describe chest pain or discomfort. Other sensations that a person with chest pain may experience include:

  • tightening
  • crushing
  • squeezing
  • aching
  • burning
  • stabbing

This article explores 13 causes of a heavy feeling in the chest and ways to treat them.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper


1. Anxiety

Anxiety disorder is a mental healthcondition that causes a person to feel worried, apprehensive, and tense. It can also cause many physical symptoms.

Experiencing anxiety can lead to a heavy or tight feeling in the chest. Other physical symptoms of anxiety include:

  • muscle tension
  • sweating
  • shaking
  • a rapid heartbeat
  • fast breathing
  • dizziness
  • nausea
  • pins and needles

A panic attack involves experiencing many of these symptoms at once. Panic attack symptoms feel intense and overwhelming.

If a person has not had a panic attack before, they may mistake their symptoms for those of a heart attack.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Experiencing a panic attack can make a person feel like they are in physical danger, but these attacks are not physically harmful. Symptoms usually pass after 10–20 minutes.

If a person has panic attacks often, they may have a type of anxiety disorder called panic disorder.


2. Depression

Depression is another psychological cause of a heavy feeling in the chest. A 2017 study found a link between having depression and experiencing recurrent chest pain.

A person with depression may experience physical symptoms because depression affects how people feel pain. One theory is that this is because depression affects the neurotransmitters that govern both pain and mood.

People with depression may also experience chest heaviness due to an increase in perceived stress.

Unexplained aches and pains accompanied by feeling low, hopeless, guilty, or worthless may be a sign of depression.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper


3. Muscle strain

Chest pain may result from intercostal muscle strain, which can happen when a person overstretches and pulls the muscle that holds the ribs in place.

Straining the intercostal muscles may put pressure on the ribs and cause a heavy feeling in the chest.



Gastroesophageal reflux disease (GERD) is a digestive disorder that can cause chest pain.

GERD occurs when stomach acid comes back up into a person’s throat. As well as chest pain, it may cause:

  • excessive saliva
  • pain when swallowing
  • a sore throat


5. Pericarditis

Pericarditis is a heart problem that may cause chest pain.

The pericardium is the name of the layers of tissue surrounding the heart. Pericarditis occurs when the pericardium becomes infected and swells.

When swollen, the pericardium may rub against the heart, causing chest pain. The pain typically gets better when a person sits upright and worse when they lie down.


6. Angina

Angina can cause a feeling of pressure in the chest. It happens when the heart muscle does not get enough blood, and it is a symptom of coronary artery disease.

As well as chest pain, angina may cause pain in the:

  • back
  • neck
  • arms
  • shoulders
  • jaw


7. Heart attack

Chest discomfort is one symptom of a heart attack. During a heart attack, a person’s chest may feel:Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

  • heavy
  • pressurized
  • squeezed
  • full
  • painful

Other heart attack symptoms include:

  • pain in the neck, jaw, arms, back, or stomach
  • shortness of breath
  • a cold sweat
  • dizziness
  • nausea

A heart attack is a medical emergency, so anyone who suspects that they are having one should seek immediate medical care.


Pneumonia can cause chest pain that worsens when a person coughs or breathes deeply.

It is a complication of the flu and other respiratory infections. Other symptoms of pneumonia include:

  • shortness of breath
  • a cough
  • fever
  • chills


9. Collapsed lung

A partial or completely collapsed lung may cause a person’s chest to feel heavy and painful.

Known as pneumothorax, a collapsed lung happens when air collects in the space between the lungs and chest wall. Pneumothorax can occur on its own or as a complication of lung disease.

As well as chest pain, a person with a collapsed lung may experience shortness of breath.


10. Pulmonary embolism

A heavy or painful feeling in the chest may be a sign of a pulmonary embolism. This is when a blockage occurs in the pulmonary artery, or the artery in the lung.

The blockage is usually a blood clot, but in rare cases, it can be made up of other substances, such as fat.

The blockage will cause other symptoms, such as:

  • lightheadedness
  • severe difficulty breathing
  • a fast heartbeat
  • passing out

A pulmonary embolism is a medical emergency and can be life-threatening without treatment.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper


11. Costochondritis

If a person has pain where their breastbone meets their ribs, they may have costochondritis.

Also known as chest wall pain, costochondritis occurs when the cartilage between the rib and the breastbone becomes inflamed. The pain may feel worse when a person touches the area.


12. Gallstones

A buildup of cholesterol or bilirubin can form masses, known as gallstones, in the gallbladder.

Gallstones do not always cause symptoms, but if they block a person’s bile ducts, they can cause chest pain. Doctors refer to this as a gallbladder attack.

A person usually feels gallbladder attack pain in the upper right abdomen. The pain is often sharp and sudden, but it can feel like dull, heavy cramping.


13. Aortic dissection

Sudden chest pain may result from an aortic dissection.

The aorta is the main artery that comes from the heart. An aortic dissection occurs when the wall of the aorta tears.

This is a medical emergency and requires immediate treatment.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper



The treatment for a heavy-feeling chest varies, depending on the cause. We explore treatments for the mental and physical causes of chest pain below.

Treating psychological causes

When chest heaviness or tightness is a symptom of anxiety or depression, it is important to get help for the underlying condition.

People can often manage depression and anxiety through a combination of medication and talk therapy.

Lifestyle changes and stress-management techniques can also help. These include:

  • regular exercise
  • yoga, mindfulness, or meditation
  • eating a healthful, balanced diet
  • getting enough sleep
  • journaling
  • seeking emotional support from family and friends Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

Treating physical causes

Each of the following causes of chest heaviness or pain may have a different treatment:

  • Muscle strain: Pain-relieving medication, rest, and compresses can heal the strain over time.
  • GERD: Lifestyle and dietary changes can often prevent symptoms.
  • Pericarditis: A doctor may prescribe medication to reduce inflammation.
  • Angina: Medication and lifestyle changes can often reduce symptoms. Sometimes surgery is necessary.
  • Heart attack: This requires emergency treatment, which may include medication and surgery.
  • Pneumonia: Rest and medication can help treat the infection. A person may require hospital treatment if symptoms are severe.
  • Collapsed lung: Treatment focuses on releasing the trapped air
  • Pulmonary embolism: A person may receive blood-thinning drugs, oxygen, and pain relief in the hospital.
  • Costochondritis: Pain-relieving medication, compresses, and rest can relieve symptoms.
  • Gallstones: Gallbladder attacks may require hospital treatment.
  • Aortic dissection: This may require emergency surgery.


When to see a doctor

People who have anxiety or depression may recognize a heavy feeling in the chest as a symptom of their condition. In this case, it is not usually necessary to see a doctor every time symptoms occur.

However, as chest heaviness and pain have many causes, it is best to see a doctor when new symptoms happen for the first time.

Anyone experiencing sudden, unexplained, severe chest pain should contact emergency services.

The present study was carried out to compare the depression, anxiety, and stress in non-coronary patients with severe and mild chest pain. In line with (7,10,12), the results showed that there was significant difference between the two groups in terms of depression, anxiety, and stress. The severity of these variables was higher in patients with severe pain chest. There is a mutual relationship between the physical and psychological factors and as probably psychological factors play important role in development of non-cardiac chest pain, chest pains are the underlying cause for genesis of agitation (19). One of the findings showed that the degree of depression in patients with severe chest pain is higher than patients with mild chest pain. Apart from the fact that the heart examination process causes the patients to feel that they suffer from a heart problem and receiving a vague diagnosis from the doctor may lead to agitation and psychological distress of the patient (20), the primary depression may also affect the intensity of the pain (10).Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper

According to the reports (21), nearly 97% of the depressed patients complain about the loss of energy as a barrier to perform their tasks and 80% of them complain about insomnia. Based on cognitive model, depression is caused by certain cognitive distortions which are called depressing schemas and are cognitive models that cause the person to perceive the internal and external data in a changed manner by the impact of the initial experiences (21). In this viewpoint, the assumption is that the depressed people distort environmental data that are consistent with their negative inner thoughts, and in this way, they eliminate and distort information which are inconsistent with the dominant cognitive system (22). Therefore, the pain intensity of this group of patients may increase due to these cognitive distortions. Other findings showed that the degree of anxiety in patients with severe chest pain is higher than in patients with mild chest pain. Anxiety often creates confusion and distortion in perception of time and space, recognition of people and the importance of incidences. These distortions can create disorder in correct perception of incidences by decreasing concentration and reminding power, and by upsetting the power of relating things to each other (21). Anxious people often report thoughts and imaginations which indicate the feeling of high danger in the present situations and it seems that this anxiety is an understandable response to their distorted perceptions (23). The distorted perceptions led anxiety can ultimately intensify chest pain in these patients. However, sever pain in chest probably improves the concern about seriousness of the disease and outbreak of fatal consequences, which definitely leads to higher levels of anxiety.
To explain this finding that the degree of stress in patients with severe chest pain is higher than in patients with mild pain, Kuijpers et al, (10) point out patients who experience negative emotions as well as having anxiety and depression reported to have higher degrees of chest pain. Stress is one of those negative emotions in which the persons see their physical and psychological wellbeing in danger. Stressed people often are stricken with fear, avoiding behavior, depression, and anger and induce reactions in others which cause the disharmonious and non-adaptive models to be preserved. As individuals evaluate the incidents based on their own cognitive schemas and orientations, an internal self-approval process is created (24). Therefore, patients may feel the pain higher than before.Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper
A limitation to the present study was a lack of consideration of variables that might affect the severity of noncardiac chest pain. In fact, there are many conditions that are comorbid with severity of pain, so future studies should at��tempt to control for these potentially confounding variables. In addition, regarding the sample size that we recruited and the probable loss of many patients because of careful matching, it is recommended to consider the following items in future studies: family history of chest pain, kinds of drugs taken, and history of cardiovascular disease in first-degree relatives. Comparison of Depression, Anxiety, and Stress in Non-Coronary Patients with Mild and Severe Chest Pain Essay Paper


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