Journal of Psychosomatic Research
Volume 69, Issue 3 , Pages 227-235, September 2010

Heart-focused anxiety as a mediating variable in the treatment of noncardiac chest pain by cognitive-behavioral therapy and paroxetine

  • Philip Spinhoven

      Affiliations

    • Institute of Psychology, Leiden University, Leiden, The Netherlands
    • Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
    • Corresponding Author InformationCorresponding author. Leiden University, Institute of Psychology, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands. Tel.: +31 71 527 3377; fax: +31 71 527 4678.
    • Shared first authorship.
    • ,
  • A.J. Willem Van der Does

      Affiliations

    • Institute of Psychology, Leiden University, Leiden, The Netherlands
    • Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
    • Shared first authorship.
    • ,
  • Eduard Van Dijk

      Affiliations

    • Institute of Psychology, Leiden University, Leiden, The Netherlands
    • ,
  • Yanda R. Van Rood

      Affiliations

    • Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands

Received 10 October 2009; received in revised form 9 February 2010; accepted 9 February 2010. published online 31 March 2010.

Abstract 

Objective

We compared the efficacy of cognitive behavior therapy (CBT), paroxetine and placebo in the treatment of noncardiac chest pain (NCCP). We also investigated whether pre- to mid-treatment reduction of (heart-focused) anxiety mediated mid- to post-treatment pain reduction.

Methods

Sixty-nine adults with NCCP were randomly assigned to 16 weeks of outpatient treatment with CBT, paroxetine or placebo. The comparison between placebo and paroxetine was carried out in a double-blind fashion. The main outcome measure was a chest pain index (duration*intensity) as derived from daily pain diaries. Putative mediator measures were general anxiety (HADS:A) and heart-focused anxiety (Cardiac Anxiety Questionnaire).

Results

Eleven patients treated with paroxetine or placebo dropped out prematurely. Intent-to-treat analysis showed that CBT was significantly superior to placebo and to paroxetine in reducing NCCP at posttreatment. Only CBT significantly reduced heart-focused anxiety compared to placebo at mid- and post-treatment. Pre- to mid-treatment reduction of heart-focused anxiety predicted mid- to post-treatment NCCP reduction. The indirect effect of CBT on pain reduction by reducing heart-focused anxiety was significant compared to placebo but not to paroxetine.

Conclusion

CBT is an effective treatment option for patients with NCCP. Paroxetine is not more effective than placebo on the short term. Reduction of heart-focused anxiety by CBT seems to mediate subsequent reduction of NCCP compared to placebo. The results provide further support for cognitive–behavioral models of NCCP and point to the potential benefits of, in particular, cognitive-behavioral interventions to modify heart-focused anxiety.

Keywords: Noncardiac chest pain, Randomized controlled trial, Cognitive behavior therapy, Paroxetine, Placebo, Anxiety, Mediation

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PII: S0022-3999(10)00077-2

doi:10.1016/j.jpsychores.2010.02.005

Journal of Psychosomatic Research
Volume 69, Issue 3 , Pages 227-235, September 2010

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