SOMATIZED PSYCHIATRIC-DISORDER PRESENTING AS PALPITATIONS

Background: Psychiatric disorder is underdiagnosed in primary care pra ctice, often because it is somatized and the patient reports only phys ical symptoms. Palpitations are among the symptoms that often are soma tized. Methods: We studied prospectively 125 consecutive medical outpa tients referred for ambulatory electrocardiographic monitoring to eval uate a chief complaint of palpitations. They completed an in-person re search interview at the time of monitoring and a telephone follow-up i nterview 3 months later. The referring physicians completed questionna ires about their patients before receiving the results of the monitori ng and again 3 months later. Results: Forty-three patients had clinica lly significant cardiac arrhythmias. Twenty-four (29%) of the remainin g 82 patients had a current psychiatric disorder, and 20 of these pati ents (83%) had major depression or panic disorder. These patients were significantly younger and more disabled, somatized more, and had more hypochondriacal concerns about their health than did patients who had no psychiatric disorder. Their palpitations were more likely to last longer than 15 minutes, were accompanied by more ancillary symptoms, a nd were described as more intense. At 3-month follow-up, about 90% of the patients in both groups continued to experience palpitations. Symp toms of somatization, hypochondriacal concerns, and impairment of inte rmediate activities had improved in both groups, but remained higher i n patients with psychiatric disorder than in patients without psychiat ric disorder. During the follow-up interval, patients with psychiatric disorder had more emergency department visits. The physicians of pati ents with psychiatric disorder were more likely to ascribe the palpita tions to anxiety or depression, and ordered fewer laboratory tests on them, but few patients who had not already been in psychiatric treatme nt were referred or started on psychotropic medication. Conclusions: P hysicians are aware of a psychiatric component to the clinical present ation of palpitation, but this observation does not result in psychiat ric treatment or referral in most cases.