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Psychological and Perceptual Factors Associated With Arrhythmias and Benign Palpitations

From the Department of Psychiatry (A.E., R.A.M.), Oxford University, Oxford, and Department of Cardiology (D.C.S., J.B.), Northampton General Hospital, Northampton, United Kingdom.

Address reprint requests to: Anke Ehlers, PhD, Department of Psychiatry, University of Oxford, Warneford Hospital, Oxford OX3 7JX, UK. Email: anke.ehlers{at}psych.ox.ac.uk

OBJECTIVE: Little is known about how patients who seek medical help for benign palpitations can be distinguished from those with clinically significant arrhythmias. This study tested whether patients with arrhythmia can be distinguished from those who are aware of sinus rhythm or extrasystoles on the basis of sex, prevalence of anxiety disorders, and heartbeat perception.

METHODS: A consecutive sample of patients referred to a cardiology clinic participated in the study. Patients were diagnosed as having either arrhythmia (N = 62), extrasystoles (N = 75), or awareness of sinus rhythm (N = 47). They were assessed with use of the anxiety disorders and hypochondriasis modules of the Structured Clinical Interview for DSM-IV. Both patients and control subjects (N = 35) answered questionnaires measuring anxiety, fear of bodily sensations, and depression and underwent a heartbeat perception test. The present report focuses on patients who had palpitations but no comorbid cardiovascular disease.

RESULTS: Patients with awareness of sinus rhythm could be distinguished from those with arrhythmia by several variables: female sex, higher prevalence of panic disorder, poor performance on the heartbeat perception test, report of palpitations when doing the test, higher heart rates, lower levels of physical activity, and (as trends) a greater prevalence of panic attacks, fear of bodily sensations, and depression. In contrast, patients with arrhythmias rarely reported palpitations when doing the test but were more likely to perceive their heartbeats accurately than patients with sinus rhythm and control subjects. Performance on the heartbeat perception test was intermediate in patients with extrasystoles; these patients also had an intermediate prevalence of panic disorder and intermediate depression scores.

CONCLUSIONS: Measures of panic disorder and a simple heartbeat perception test could complement medical assessment in the diagnosis of patients who seek medical help for palpitations. The results also have implications for the treatment of patients with benign palpitations.

Key Words: palpitations • arrhythmia • panic attacks • sex differences • heartbeat perception

Abbreviations: BDI = Beck Depression Inventory; BSQ = Body SensationsQuestionnaire; DSM-IV = Diagnostic and Statistical Manualof Mental Disorders, fourth edition; FQ = FearQuestionnaire; SCID = Structured Clinical Interview for DSM-IVAxis I Disorders—Patient Edition; STAI = State-Trait Anxiety Inventory.

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