The impact of perceived stress and perceived control on anxiety and mood disorders in noncardiac chest pain

Abstract

Chest pain without detectable heart disease, noncardiac chest pain (NCCP), is linked with anxiety and depression. Theory posits stress and perceived control may relate to NCCP. We hypothesized stress would have direct and mediated effects via perceived control on anxiety and mood disorders in NCCP. Patients (N = 113) completed questionnaires and a structured diagnostic interview. Stress and perceived control were associated with anxiety and mood disorder severity. Perceived control fully mediated the relation between stress and mood disorder severity but not anxiety disorder severity. Results are partially supportive of anxiety-based theories of NCCP.

Keywords

anxiety disorders mood disorders noncardiac chest pain perceived control perceived stress

Chest pain without detectable ischemic heart disease is known as noncardiac chest pain (NCCP) (Eslick et al., 2002). This condition is a global health problem linked to high rates of healthcare seeking and interruption of daily activity (Eslick and Talley, 2004). Patients with NCCP typically present to medical settings with symptoms similar to those reported by patients with cardiac problems, such as chest tightness, heart palpitations and numbness (White and Raffa, 2004). While physicians and patients are often comforted by negative cardiac test results, NCCP can present a diagnostic dilemma. In the case of NCCP, diagnostic measures are unable to find evidence to suspect an organic cardiac disease process (e.g. myocardial infarction, acute coronary syndrome), however, this may not reassure many patients with NCCP who continue to experience persistent chest pain for years after their initial presentation (Papanicolaou et al., 1986; Potts and Bass, 1993). These data are complicated by research showing NCCP patients are at an increased risk for future cardiac events compared to general community patients asymptomatic of chest pain (Gulati et al., 2009). Moreover, some data show that NCCP patients have cardiac cause mortality rates similar to those of patients with cardiac chest pain (Eslick and Talley, 2008). Therefore, although NCCP is defined by a short-term diagnosis of exclusion, it may carry some enduring health risks.

Patients with NCCP have disproportionately high rates of anxiety and mood disorders compared to medically ill and community samples (Bass et al., 1983; Kessler et al., 2005; Serlie et al., 1995). In fact, patients with NCCP are two to three times as likely to suffer from anxiety and depression compared to patients with coronary artery disease patients or the general population (Kessler et al., 2005; Serlie et al., 1995). Additionally, they may be characterized as fitting a distressed disposition (i.e. Type D personality) (Kuijpers et al., 2007). Patients with NCCP also exhibit impairments in daily activities (Lau et al., 1996), with particularly limited physical functioning (i.e. hypervigilance toward cardiac-related sensations) (White et al., 2010). Data generally suggest that patients with NCCP exhibit quality of life impairments similar to those with cardiac diagnoses (Eslick, 2008).

Several theories have been proposed to help better understand the development and maintenance of NCCP, many of which suggest physiological arousal may be connected to psychological processes (Eifert et al., 2000; Mayou, 1998; White and Raffa, 2004). NCCP theories and panic disorder theories are similar in their implication of shared psychological vulnerability factors (e.g. low perceived control) and environmental factors (e.g. stress) may lead to increased anxiety and incorrect assumptions regarding heightened physical arousal (Barlow, 1988). In NCCP theories, stress and perceived control may contribute to the development of chest pain as well as worry about cardiac health (White and Raffa, 2004).

Stress may affect the persistence of NCCP, particularly as it relates to anxiety and depression. Perceived stress is correlated with symptoms of depression and anxiety among patients with NCCP (Nezu et al., 2007), and NCCP patients show levels of perceived stress higher than those reported by patients with coronary artery disease (Nezu et al., 2007). The extent of the associations between perceived stress and anxiety and depressive disorders among patients with NCCP remains unclear.

Perceived control is a central factor in understanding anxiety and depression, and may be significant for the syndrome of NCCP. Barlow (1988) suggests that anxiety arises from unpredictable, uncontrollable events and emotions. Empirical data support that low perceived control is critical to the development of anxiety (Barlow, 1988; Rapee et al., 1996). Moreover, low perceived control predicts both anxiety and depression symptoms (Chaney et al., 1996; Frazier and Waid, 1999; Rapee et al., 1996; Rivard and Cappeliez, 2007) and has been suggested as a mediator of anxiety (Ballash et al., 2006), depressive symptoms (Bullers, 2000; Windsor et al., 2007) and stress (Litt, 1988). NCCP theories suggest perceived control may be related to chest pain and anxiety (White and Raffa, 2004).

The current study seeks to clarify and expand the existing understanding of the relation between stress and perceived control. Research examining their relation in the context of overlapping somatic and psychiatric conditions is needed as it may impact impairment. While perceived control has been shown to mediate perceived stress in other contexts (Ghorbani et al., 2008), this research is novel in that it examines an area about which little published research exists, the role of stress and perceived control in psychiatric impairments among medically unexplained chest pain patients. Further examination of perceived stress and perceived control may contribute to a greater understanding of the development and maintenance of anxiety and depression and help to enhance effective treatments for these impairments among chest pain patients.

The current study tests a mediational model to determine the role of these factors in anxiety and mood disorders in NCCP. Specifically, it is hypothesized that perceived control will mediate (1) the relation between perceived stress and anxiety and (2) the relation between perceived stress and mood disorders.

Method

Participants

Data were collected from patients presenting to an American university-affiliated cardiology department as part of a prospective cohort study of the clinical course and correlates of NCCP. Individuals were excluded if they were: (1) under 18 years of age; (2) unable to demonstrate English fluency; (3) not presenting chiefly for chest discomfort; (4) unable to pass a cardiac evaluation; (5) suffering from an uncontrolled medical illness during the preceding six months; or (6) had a history of cardiac abnormalities. Patients with serious uncontrolled psychiatric illness (e.g. active psychosis) were excluded from the study; however, patients with other psychiatric conditions (e.g. mood and anxiety disorders) were included in the sample. Medical and psychiatric histories, including medications, were assessed through questionnaires and interview procedures to facilitate determination of inclusion criteria.

Questionnaires and a semi-structured clinician administered diagnostic interview (i.e. the Anxiety Disorders Interview Schedule for DSM-IV-Lifetime Version (ADIS-IV-L) (Di Nardo et al., 1994)) were completed by participants (N = 113, M _age = 51 ± 10.5, 61% female). Most participants self-identified their race as Caucasian (90%) or African American (8%). Hispanic ethnic origin was self-identified in 2% of participants. Most participants (91%) completed some post-high school education and were employed (75%).

Measures

Demographics and medical history were assessed via self-report. The ADIS-IV-L (Di Nardo et al., 1994) assessed for current and lifetime anxiety and mood disorders. The ADIS-IV-L is a semi-structured, clinician-administered diagnostic interview based on DSM-IV (American Psychiatric Assocation, 2000) criteria. Clinical severity ratings range from 0 (no interference/distress) to 8 (extreme interference/distress) and facilitate tracking the severity of both clinical ( ≥ 4) and subclinical ( ≤ 3) diagnoses. Factor analysis has demonstrated convergent and discriminant validity for this measure (Brown et al., 1998; Grisham et al., 2003).

ADIS interviews were tape recorded and reviewed in order to facilitate standardized administration procedures. All ADIS interviewers held at least a Master’s degree in clinical psychology and completed a thorough, standardized training protocol that included observation of several administrations of the ADIS-IV-L as well as practice administration of the measure under observation of a senior-level ADIS-IV-L trained clinician. Successful completion of the training protocol also required that the ADIS interviewers and senior-level clinician demonstrated reliability between independently assigned diagnoses and diagnostic severity ratings. In this study, clinicians provided ratings of their confidence in their diagnostic determinations at the conclusion of their assessment. Good diagnostic confidence ratings were obtained (M = 86%) in this study, indicating that the interviewers were assured of their diagnostic ratings because they had obtained sufficient detail and clarity from the patient during the interview (i.e. report of their symptoms, impairment and distress, date of onset).

The Perceived Stress Scale (PSS) (Cohen et al., 1983), was used to assess how overloaded and unpredictable patients felt their lives were over the past month. Ratings used a five-point Likert scale ranging from 0 (never) to 4 (very often). The PSS has concurrent and predictive validity. Both the coefficient alpha reliability for the PSS and test–retest correlation are .85 (Cohen et al., 1983). Cronbach’s alpha in this study was .88.

Perceived control was measured using the Overall Sense of Control scale from the Shapiro Control Inventory (SCI) (Shapiro et al., 1993). Response choices are based on a seven-point Likert format, ranging from 1 (never) to 7 (always). The SCI has demonstrated discriminant, divergent, and incremental validity among various clinical groups (Shapiro et al., 1993). Internal consistency (.75 to .89) and test–retest reliability correlations (.70 to .93) are good (Shapiro, 1994). Cronbach’s alpha in this study was .90.

Procedure

The institutional review boards at the University of Missouri – St Louis, Boston University, and Beth Israel Deaconess Medical Center at Harvard Medical School approved this study. Participants presenting with primary complaints of chest discomfort without cardiac abnormalities and with a negative cardiac history (i.e. no personal lifetime history of heart disease, myocardial infarction; no history of cardiac-repair procedures such as pacemaker, stent or CABG surgery) were considered to have NCCP. All eligible patients showed negative evaluations on medical exams with clinicians who specialized in the identification of cardiac conditions and did not show any changes on ECG monitoring during an exercise tolerance test. Eligible participants were invited to take part in a research study regarding the medical and psychological features of chest pain after the above-mentioned evaluation determined that the patient’s chest pain was noncardiac in nature. Prior to recruitment, all patients were informed that the results of their evaluation did not indicate cardiac abnormalities. The majority of study assessment procedures were conducted within a few weeks of their medical evaluation.

After informed consent was discussed and obtained, participants were scheduled to complete the ADIS-IV-L interviews with a doctoral-level psychologist or doctoral-level clinical psychology student. Participants were compensated $25 for their participation, which took approximately two to three hours. Participants were not provided with feedback regarding their psychiatric diagnostic status, however appropriate treatment referrals were provided if participants presented any current or imminent risks to safety or if patients requested a referral for services.

Data analysis

The Statistical Package for the Social Sciences (SPSS, version 14.0) was used to examine all data analyses for this study (SPSS for Windows). Hierarchical regression analyses were carried out following Baron and Kenny’s (1986) recommendations for mediation. Regression assumptions were verified. To facilitate interpretation of effects, interaction terms and independent variables were mean centered and plotted prior to their entry into the models. Additional analyses were conducted using Preacher and Hayes’ (2004, 2008) bootstrapping procedure. Bootstrapping is a method of testing for indirect effects using resampling techniques and is recommended for meditational analyses. In our analyses we performed 3000 resamples, obtained confidence intervals (CI) at 95%, and determined statistical significance for the indirect effect using the Sobel test.

Results

Descriptive analyses

Approximately 41% of participants were determined to have a clinically significant anxiety disorder and 64% of participants evidenced anxiety symptoms at a sub-clinical level.¹ The most common anxiety disorder diagnoses were Social Phobia (16%), Specific Phobia (14%), Generalized Anxiety Disorder (13%) and Panic Disorder (12%). Other principle diagnoses included Agoraphobia (11%), Posttraumatic Stress Disorder (6%), Anxiety Disorder Not Otherwise Specified (6%) and Obsessive Compulsive Disorder (5%). Clinically significant mood disorders were diagnosed in approximately 13% of participants. Approximately 5% of participants evidenced mood disorder symptoms at a sub-clinical level. The most common mood disorder diagnosis was Major Depressive Disorder (8%), however Dysthymic Disorder (5%) and Mood Disorder Not Otherwise Specified (3%) were also present in the sample. On average, most patients reported mild to moderate anxiety (M = 2.72 SD = 2.03, range = 0–7) and mood disorder (M = 0.74, SD = 1.7, range = 0–7) symptoms. This study did not control for treatment for psychological conditions at the time of data collection, suggesting that these clinical severity ratings could be an underestimate of distress and impairment.

Participants had similar levels of perceived control (M_SCI = 5.2 ± .97) and perceived stress (M _PSS = 21.97 ± 9.44) to those found among other medical populations used in previous research (M _SCI = 5.1 ± .80, M _PSS = 18.92 ± 7.45) (Lackner et al., 2010; Surgenora et al., 2000). A negative correlation was observed between age and perceived stress (r = −.23, p < .05), indicating less stress with increasing age among this sample. A positive correlation was observed between age and perceived control (r = .16, p < .05). Perceived stress t(175) = 1.1, p > .05 and perceived control t(189) = −1.6, p > .05 did not differ by sex.

Mediational analyses

All regression assumptions were examined and verified prior to the model building stage of mediation analysis. Although perceived stress and perceived control were correlated (see Table 1 for correlation matrix) multicollinearity (tolerance = .49, variance inflation factor = 2.0) was not apparent. Relations among variables of interest (i.e. perceived stress, perceived control, anxiety disorder severity, and mood disorder severity) and demographic factors were examined in order to safeguard against omitted variable bias in the regression analyses. Younger participants had more severe anxiety disorder ratings; the relevant analysis was adjusted to control for age.

Table 1.

Relationships between anxiety and mood disorder severity, stress, perceived control and demographic factors (N = 113)

	Ethnicity	Sex	Race	Age	Perceived stress	Perceived control	Mood disorder severity	Anxiety disorder severity
Anxiety disorder severity	−.11	−.01	.10	−.30**	.53**	−.49**	.36**	–
Mood disorder severity	.05	.12	.14	−.13	.28**	−.31**	–
Perceived control	.12	.13	.13	−.17*	−.73**	–
Perceived stress	−.14	−.01	.07	−.22**	–
Age	.05	−.09	−.14	–
Race	−.14	−.05	–
Sex	−.15*	–
Ethnicity	–

Note: *p < .05 (two-tailed test); **p < .01 (two-tailed test).

A hierarchical multiple regression analysis was conducted with anxiety disorder severity entered as the outcome variable (see Table 2). To control for age, this variable was entered first to block one of the model (β = −.33, p < .05, f² = .12). Perceived stress was entered in block two of the model (β = .53, p < .05, f² = .58) with age. Perceived stress (β = .40, p < .05) and perceived control (β = −.18, p > .05) were entered in the third block to test for mediation. The overall model was statistically significant, F(3, 105) = 21.17, p < .05. Eleven percent of the variance was explained by the model in block one with an additional 26% of the variance explained by perceived stress in block two, and an additional 1% of the variance explained by perceived control in block three. The overall model explained 38% of the variance. The final model containing perceived stress and perceived control provided a good fit to the data (f² = .62, large effect size), but the meditational role of perceived control between perceived stress and anxiety disorder severity was not supported by the bootstrap test for indirect effects (M_{indirect effect} = .029, 95% CI = −.01 −.08) or the Sobel test (Z = 1.65, p > .05). A post-hoc power analysis indicated sufficient power to detect a medium-sized effect.

Table 2.

Hierarchical regression analyses for stress and perceived control on anxiety disorder severity (adjusted for age) (N = 106)

Variables	B	SE B	β	R²	ƒ²
Step 1				.11**	.12**
Age	−.07**	.02	−.33**
Step 2				.37**	.58**
Age	−.04*	.02	−.19*
Stress (PSS)	.12**	.02	.53**
Step 3				.38**	.62**
Age	−.04*	.02	−.19*
Stress (PSS)	.09**	.02	.40**
Perceived control (SCI)	−.38	.23	−.19

Note: *p < .05; **p < .01.

A hierarchical multiple regression analysis was conducted to test for mediation with mood disorder severity entered as the dependent variable (see Table 3). Perceived stress was entered into block one of the model (β = .28, p < .05, f² = .09), and perceived stress (β = .09, p > .05) and perceived control (β = −.28, p < .05) were entered in the second block to test for mediation. Block one of the model accounted for 8% of the variance. At block two, an additional 4% of the variance was explained by perceived control (f² = .14, medium effect size). The overall model was statistically significant and provided a good fit to the data, F(2, 106) = 6.87, p < .05 and explained 12% of the variance. The reduction of significance and beta weight of perceived stress in the second block after the addition of perceived control supports mediation. Mediation was confirmed by the bootstrap test for indirect effects (M_{indirect effect} = .033, 95% CI = −.01 −.08) and the Sobel test (Z = 2.05, p < .05).

Table 3.

Hierarchical regression analyses for stress and perceived control on mood disorder severity (N = 107)

Variables	B	SE B	β	R²	ƒ²
Step 1				.08**	.09**
Stress (PSS)	.05**	.02	.28**
Step 2				.12**	.14**
Stress (PSS)	.02	.02	.09
Perceived control (SCI)	−.46*	.22	−.28*

Note: *p < .05; **p < .01.

Discussion

The results from this study contribute to greater understanding of anxiety and mood disorders, and factors related to their severity, among patients with NCCP. While previous studies have reported prevalence rates of anxiety and mood disorders among NCCP patients, this study extends the literature in its examination of factors associated with severity of psychiatric impairment, specifically, stress and perceived control. The results of the current study suggest perceived control and perceived stress are important factors in further understanding psychiatric morbidity among this population. Additionally, these factors may be implicated in changes in levels of functioning.

Our findings extend previous examinations of stress in NCCP. Consistent with others (Nezu et al., 2007; Tulley et al., 2008; Ye et al., 2008), our data showed stress was associated with anxiety and depression. Our study extended this literature to show that perceived control may function as a mediator for mood disorders but not for anxiety disorders in this population. To our knowledge, this is the first published study to examine the role of perceived control in NCCP patients. These results regarding the association between perceived control and anxiety are similar to those found in an examination of individuals seeking treatment for anxiety disorders (McLaren and Crowe, 2003). These data support theories that propose perceptions of stress and control may be related to anxiety (Barlow, 1988), however, these factors may be independently related to anxiety within NCCP. Perceived control may be of secondary importance to stress in understanding anxiety in patients who do not self-identify as a psychiatric population.

The relation of stress to mood disorder severity was partially accounted for by perceived control. These findings add important information to the literature, as previous research of NCCP patients has not focused extensively on mood disorders or their relation with other psychological factors. Our finding of an association between stress and depressive symptoms is supported by comparable results among similar patients (Nezu et al., 2007; Tulley et al., 2008; Ye et al., 2008). Based on the findings of this study, the relation of perceived control is more salient than perceived stress to mood disorders among patients with NCCP. Future research is needed to replicate this finding.

In general, this sample endorsed similar levels of stress as other NCCP samples (Nezu et al., 2007; Zachariae et al., 2001). Of note, because the patients in this study were informed of their negative cardiac evaluation results prior to their recruitment, it may be expected that their level of stress and worry might be lower than those found among cardiac patients as they experience the relief of receiving benign results. Alternatively, failure to return a definitive cardiac diagnosis may contribute to increased stress and anxiety for those that continue to experience chest pain symptoms after negative cardiac evaluation. This may be a more common response for those who are particularly vigilant to cardiac sensations, or who have higher levels of premorbid anxiety. Similarly, the occurrence of physiological symptoms without a medical diagnosis may impact levels of perceived control, particularly in regard to somatic functioning. It is unknown whether the level of perceived control found within this sample is commensurate among NCCP patients, as few studies have examined perceived control in patients with NCCP. Unique vulnerability factors may contribute to the high rates of psychiatric diagnoses among this population. Factors such as early life stress and resilience may impact adult perceptions of stress and the development of anxiety and mood disorders; this may be an area for future research.

Study limitations are evident. First, although participants underwent a thorough cardiac evaluation prior to their recruitment for this study, a chance remains that some may have experienced chest pain whose cardiac origin may be detectable with more sophisticated diagnostic technology available in the future. Additionally, this study did not address the relation of perceived stress and perceived control on shared factors of depression and anxiety, such as negative affect. While this may be an area for future study, the authors chose to examine depression and anxiety independently as research continues to demonstrate support for their unique symptom profiles (Craske et al., 2009). Also, because this sample was mostly comprised of Caucasian participants, these data may not be generalizable to more diverse populations. In addition, we did not collect information on individuals who were eligible for this study but declined to participate. As such, we cannot rule out the possibility that various factors (e.g. psychiatric factors) may have influenced participation rates. Finally, while it is notable that approximately one-half of participants experienced chest pain syndrome lasting six months or more at the time of data collection, this study is cross-sectional in nature, and inferences regarding causality are not warranted. Future research is needed to establish if relations between perceived stress, perceived control, anxiety and mood disorders persist over time, and to determine whether temporal relations with chest pain may exist.

Clinical implications and future research

These data suggest that stress and perceived control may serve differential roles for patients with anxiety and mood disorders in this population. Our results have some clinical implications. Although anxiety and mood disorders are prevalent among NCCP patients, these symptoms may not be assessed upon their immediate presentation for care in medical settings. Given that chest pain remains a chief complaint for many patients across international healthcare systems, referral for psychological assessment and treatment may be important after a noncardiac origin is established as this may be associated with a shorter course of chest pain.

Development of effective stress management techniques may be important for NCCP patients. Social support may help shape perceptions of stress, facilitate coping and mitigate symptoms of anxiety (Ye et al., 2008) and warrants additional study in NCCP. In addition, future study should examine associations between perceived stress and severity of NCCP.

It may be that NCCP persists for years after initial diagnosis (Papanicolaou et al., 1986) partly because NCCP is conceptualized as frightening and uncontrollable. Research indicates treatment may help with adjustment to NCCP (Olden, 2006). Our data suggest that cognitive and behavioral techniques to promote perceived control may be useful in NCCP. Future research is warranted to investigate whether high perceived control functions as a protective factor to help buffer against depressogenic tendencies in this group. Additionally, future research examining positive dispositional characteristics (e.g. optimism, resilience) within the context of NCCP may provide more information regarding the relation between effective coping and patients’ evaluations of their diagnosis.

Footnotes

Competing Interests

None declared.

Notes

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