Functional heart problems F45.30

Cardiac anxiety has been known since the Middle Ages. It was first described in 1855 by the internist W. Stokes (Stoll 2004).

In 1871, the North American troop physician J. M. da Costa (1857 - 1903) described the symptomatology as "soldier' s heart" (Payk 2007).

The terms "cardiac neurosis" and "cardiac anxiety neurosis" were first used by Richter and Beckmann in 1986 (Machleith 2004).

Probably the most famous patient with functional heart complaints was Sigmund Freud. He initially believed he was suffering from myocarditis. Only in later years did he abandon this diagnosis and himself referred to his condition as "cardiac neurosis" (Stoll 2004).

Functional cardiac complaints are defined as the chronic recurrent occurrence of thoracic complaints without evidence of somatic disease.

However, functional cardiac complaints can also occur frequently in connection with the following somatic diseases:

• Syndrome X
• Mitral valve prolapse
• CHD
• extracardiac diseases such as:
  • thoracic alterations of the spine
  • gastrointestinal diseases
  • peripheral or central nervous diseases
  • pulmonary diseases (Erdmann 2006).

The Diagnostic and Statistical Manual of Mental Disorders = (DSM- 5) recently refers to functional cardiac complaints as "Somatic Stress Disorder" and uses the following diagnostic criteria as a basis:

• A. There are one or more somatic symptoms that are perceived as distressing or lead to significant limitations in daily living.
• B. There are excessive feelings, thoughts, or behaviors regarding the symptomatology or associated concerns about health, manifested in:
• persistent and inappropriate thoughts about the seriousness of the existing symptoms
• persistent and intense anxiety about symptoms and health in general
• excessive expenditure of energy and time on health concerns and symptoms.
• C. None of the somatic symptoms need be consistently present, but the state of symptom distress typically dates back more than 6 months (Herrmann- Lingen 2019)

• Persistent functional cardiac symptoms:

These are described as "persistent" if they last longer than 6 months.

- Mild: One feature from point B (see above) applies.

- Moderate: Two or more characteristics from point B (see above) apply.

- Severe: Two or more features from point B (see above) plus multiple somatic symptoms or very severe symptoms (Herrmann- Lingen 2019).

One differentiates testpsychologically between 2 patient groups:

• Type A:

Type A is characterized by helpless, childlike, clinging, self-sparing behavior. It is found with approx. 70 % clearly more frequently than type B.

• Type B:

Type B, on the other hand, strives to cope with heart fears on his own by acting actively and emphatically independently (Machleith 2004). He denies his fears and insecurities (Stoll 2004). However, this is a so-called "pseudoautonomy" because of the deeply felt dependence (Machleith 2004).

Psychoanalytically, an important educator (usually the mother) has prevented the increasing autonomy occurring during the child's development in order to maintain her influence with the child. The heart represents the last object representation in the later patient (Machleith 2004).

Occurrence /Epidemiology

Functional cardiac complaints are a markedly common disorder (Herrman- Lingen 2019), found in approximately 3% of the general population (Machleith 2004).

Approximately 15% of all patients who see their primary care physician for cardiac complaints suffer from it. Patients < 40 years of age are primarily affected (Herold 2022). Men clearly outnumber women by 60-70% (Machleith 2004).

In cardiology practice, the number of patients with so-called "medically unexplained symptoms" is between 30 - 40 %, but partly comorbid to organic heart disease (Marx 2022).

Initially, it was believed that the prevalence would decrease drastically after the age of 40. Since the beginning of the 1970s, with the introduction of coronary angiography, it became apparent that in 10-50% of (elderly) patients no previously suspected CHD was present and thus functional cardiac symptoms also had to be assumed (Herrmann 1999).

The cause of functional heart complaints lies in the psychogenic / psychosomatic field. In addition to an increased readiness to fear, these patients also have a disturbed fear processing, a vegetative lability and an overcautious personality (Herold 2022).

Likewise, separation conflicts were found to be more frequent in highly ambivalent persons to whom the patients are symbiotically bound (Herrmann 1999).

Functional cardiac complaints arise on the basis of complex interactions between biological, psychological, social and iatrogenic factors:

• Trigger:

The trigger is usually a stressful life event such as separation, loss of partner, professional crisis, etc.

• Increased psychological vulnerability:

Exploration often reveals serious biographical stress factors that impair maturation of physical resilience such as: Neglect, abuse, etc.

• Restriction of affect regulation:

Denial of the connection with the trigger and symptomatology is typical of functional cardiac complaints.

• Cognitive misattribution:

The physical symptoms are physically misvalued by social experiences such as parents' heart disease, own physical diseases, etc.

• Somatosensory amplification:

The patient tends to perceive normal- physiological phenomena such as palpitations amplified, which ultimately activates a vicious cycle of anxiety.

• Neurobiological activation of pain experience:

Pain perception is tied to complex cognitive and emotional processes and is always subjective. Thus, negative emotions can be augmented into a sensation of pain by otherwise subliminal somatosensory stimuli.

• Deconditioning:

To avoid the distressing symptoms, physical sparing behavior often occurs. This favors the onset of symptoms during mild physical exertion and creates a vicious circle.

• Iatrogenic factors:

Iatrogenic factors can contribute significantly to the chronification of the condition, such as cardiological medication of convenience, uncritical multiple diagnoses, hasty sick leave or recommendation for retirement, but also premature or inappropriate confrontation with the functional genesis of the disease.

(Marx 2022)

The predominant age of manifestation is between 30 - 40 years (Machleith 2004).

Patients complain of:

• thoracic pain, sometimes radiating to the (left) arm, but typically unrelated to exertion
• Occurrence of so-called "heart attacks" with:
  • Anxiety attacks
  • Tachycardias
  • Globus sensation
  • panic feeling
  • the feeling of dying
  • trembling
  • sweating
  • feeling of fainting (Herold 2022)
  • palpitations (Herrmann 1999)
• Symptoms of hyperventilation (see d.) with:
  • Paresthesias of the acras
  • Pawing
  • Shortness of breath
  • Dizziness
  • Drowsiness
  • Syncope possible with low pCO2 (Tunnessen 2019)
• constant preoccupation with the possibility of cardiac disease by e.g.:
  • excessive need for control
  • close doctor-patient relationship
  • Fear that something could be overlooked
  • Tendency to spare patients
  • Pedantic adherence to medical instructions (Herold 2022)

• Anamnesis, including the biopsychosocial anamnesis. Only this can ultimately provide clues to the trigger. It should include the following questions:
• psychological sensation
• the psychosocial trigger
• the subjective theory of the disease
• family history
• heart disease in the family or circle of friends (Marx 2022)
• Which examinations have been performed so far? Repeated investigations or special examinations should be avoided if possible (Herrmann 1999).
• Exclusion of organic diseases after critical weighting (Marx 2022) by e.g.:
  • Physical examination
  • Blood pressure measurement
  • resting ECG
  • stress ECG
  • X-ray thorax
  • Screening laboratory examination including TSH basal
  • possibly cardiological examination with long-term ECG and echocardiography etc. (Herold 2022)

Often the first contact is emergency. After somatic clarification with exclusion of a serious heart disease, the patient is initially relieved, but a short time later he often appears again in an emergency with the same symptoms. If there are indications of a psychosomatic cause, the patient almost always reacts angrily and the so-called "doctor hopping" begins (Marx 1999).

• Organic diseases such as:
  • Myocardial infarction
  • CHD
  • Cardiac arrhythmia
  • Hyperthyroidism
  • Cervical spine / or BWS syndrome
  • Pulmonary embolism (Herold 2022)
  • Motility disorder of the esophagus (Herrmann 1999)

The patient should be informed in a conversation about the harmlessness of his complaints (Herold 2022), but not before an alternative clinical picture such as neurobiology of pain, general stress model, etc. has been explained to the patient (Marx 2022). The patient needs a positive explanation of his or her complaints along with the feeling that his or her form of the disease is known to the physician (Marx 2022).

It should be noted that because of the specific disorder characteristics, the patient does not have primary insight into the psychogenesis of his or her disorder (Marx 2022).

Techniques of basic psychosomatic care have often proven helpful in this regard (Marx 2022).

Other supportive measures:

• Learning relaxation techniques such as autogenic training, biofeedback procedures, progressive muscle relaxation, etc. (Stoll 2004).
• physical training
• psychotherapy
• psychosomatic treatment
• in case of tachycardia, possibly prescription of a beta-blocker
• in case of pronounced symptoms short-term use of tranquilizers (caution: dependence)

(Herold 2022)

• Beta-blockers:

There is no scientific evidence regarding an improvement of the clinical picture in functional cardiac complaints (Marx 2022).

• For atypical chest pain, the following medications may have a moderate effect:
  • Selective serotonin reuptake inhibitors (SSRIs).
  • serotonin-norepinephrine reuptake inhibitors (SNRI)
  • tri- or tetracyclic antidepressants such as amitriptyline (Marx 2022)

In about 50% of cases, the condition becomes chronic, with constant visits to the doctor (so-called "doctor hopping" [Marx 2022]), unnecessary medication, and unnecessary hospitalization (Herold 2022).

Although the rate of myocardial infarction and death was low during an 11-year study, the subjective course was largely unsatisfactory (Herrmann 1999). Some studies even showed an inverse relationship between (cardiac) anxiety and the risk of dying from cardiac disease (Marx 2022).

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