Unexplained chest pain: A review of psychological conceptualizations and treatment efficacy

Abstract

This review critically considers psychological theories and models used to understand unexplained chest pain, and efficacy of treatment strategies. It discusses the strengths and limitations of current perspectives, and highlights implications for future research and interventions. A comprehensive range of literature examining unexplained chest pain, and published over the last three decades, was thus reviewed finding that, although unexplained chest pain has been examined as a psychological phenomenon for over 100 years, explanatory models have emerged only in the last two decades. Neither psychophysiological nor psychodynamic models have been significantly advanced. Only cognitive-behavioural models have been explicitly derived to explain and manage the condition, and require further refinement to address conceptual and methodological limitations. Studies assessing treatment efficacy suggest cognitive-behavioural therapy as a first-line therapy, but have failed to establish whether the approach is acceptable and effective in routine care. Comprehensive psychological understanding of unexplained chest pain, and its management, is therefore developing but is far from complete. Cognitive-behavioural interventions show promise but are likely to be enhanced by greater theoretical clarity and understanding of resistance to their implementation.

Psychodynamic Psychiatry in the General Medical Setting

“…He comments that while the randomized controlled trial using CBT has been the most studied therapeutic modality, the results have not shown efficacy. He suggests that, given patient hesitation to engage in psychiatric treatment for chest pain, that the "means of introducing and delivering" such treatment needs further elucidation (Robertson, 2006). This issue suggests that psychodynamic techniques may be very useful in conjunction with traditional CBT in engaging the patient, understanding the various aspects of meaning of the chest pain, and that the psychodynamic elements should be further studied and may improve efficacy.…”

Experiences of unexplained chest pain and physical activity: A Meta‐Ethnography

“…Chest pain with a normal coronary angiogram implies that the chest pain is unexplained. The expression “unexplained chest pain” has often been used when referring to chest pain without obvious organic causes (Garroni & Fragasso, 2018; Ockene et al, 1980; Robertson, 2006). It is sometimes called a “puzzling condition.” Unexplained chest pain constitutes a diagnostic and therapeutic challenge, and in addition to the illness experience, it challenges patients' daily life.…”

“…Chest pain with a normal coronary angiogram implies that the chest pain is unexplained. The expression "unexplained chest pain" has often been used when referring to chest pain without obvious organic causes (Garroni & Fragasso, 2018;Ockene et al, 1980;Robertson, 2006). It is sometimes called a "puzzling condition.…”