1
CHAPTER 1 - INTRODUCTION:
1.1 BACKGROUND:
Unexplained chest pain (UCP) is a common reason for emergency hospital
admission and generates considerable health-care costs for society. Previous studies
have often defined UCP as non-cardiac chest pain (NCCP), i.e. chest pain that had not
been diagnosed as acute myocardial infarction (AMI) or ischemic heart disease (IHD)
by a physician. Galmiche et al, has developed three diagnostic criteria for functional
chest pain of presumed esophageal origin,
1) Midline chest pain or discomfort that is not of burning quality.
2) Absence of evidence that gastroesophageal reflux is the cause of the symptom.
3) Absence of histopathology- based esophageal motility disorders". Psychological
factors e.g. anxiety and somatisation disorders will also have an impact on the
functional chest pain.
Terminology "unexplained chest pain", i.e. chest pain, which after
investigation has proven to be unrelated to the heart, might be confusing but is still
preferable to "non-cardiac"[NCCP] or "atypical chest pain". A variety of names have
also been used in describing patients with NCCP. “chest pain of undetermined origin,
unexplained chest pain, functional chest pain, soldier’s heart, irritable heart, sensitive
heart, neurocirculatory asthenia, DaCosta’s syndrome, and chest pain with normal
coronary angiograms”. In patients with NCCP, gastrointestinal, pulmonary,
musculoskeletal, infectious, drug-related, and psychological disorders are considered.
However, esophageal conditions are considered to be the most common contributing
factor for angina-like chest pain of non-cardiac origin.1
Psychiatric conditions are common in NCCP. Several studies have noted a
variable prevalence of panic disorders (24%–70%), anxiety (33%–50%), and major
depression (11%–22%).2 Women with high anxiety sensitivity report more chronic
pain than women with low anxiety sensitivity. No similar relationship was found for
men. Gender differences are also seen in the diagnosis of chest pain, with male
patients more likely than women to be diagnosed with cardiac chest pain instead of
non-cardiac chest pain, in accordance with their higher overall risk of IHD.3 Studies
of patients with a non-cardiac/non-coronary diagnosis of chest pain often include
2
patients with other defined causes of chest pain, e.g. gastro-esophageal, respiratory
and musculoskeletal disorders. However, a considerable number of the patients with a
non-cardiac/coronary diagnosis do not have a clearly defined explanation for their
chest pain.
Atypical chest pain has been reported to account for 49– 60% of all
admissions with chest pain. Such patients are often discharged without follow-up,
though many experience recurrent symptoms, and the lack of a firm diagnosis can
result in depression, anxiety and a decrease in daily activity. Such reactions have been
ascribed directly to the absence of reassurance that symptoms do not indicate lifethreatening disease.4
Chest pain occurs frequently in the community and is usually benign. Despite
this, myocardial ischemia remains important, because it is potentially fatal. This leads
to an understandable tendency to over investigate, so that as few as 11–44% of
patients referred to cardiac outpatient clinics have evidence of organic disease, and up
to 31% of patients receiving coronary angiography are shown to have normal
coronary anatomy (NCA).5
1.2 EPIDEMIOLOGY:
Chest pain is the presenting symptom in about 12% of emergency department
visits in the United States and has a one-year mortality of about 5%. It is possible to
find an organic cause just for 1/3 of patients admitted to hospital with chest pain. For
the other 2/3 we are dealing with Unexplained Chest Pain.
The epidemiology of chest pain differs markedly between outpatient and
emergency settings. Cardiovascular conditions such as myocardial infarction (MI),
angina, pulmonary embolism (PE), and heart failure are found in more than 50% of
patients presenting to the emergency department with chest pain, but the most
common causes of chest pain seen in outpatient primary care are musculoskeletal
conditions, gastrointestinal disease, stable coronary artery disease (CAD), panic
disorder or other psychiatric conditions, and pulmonary disease. Unstable CAD rarely
is the cause of chest pain in primary care, and around 15% of chest pain episodes
never reach a definitive diagnosis. Despite these figures, when evaluating chest pain
in primary care it is important to consider serious conditions such as stable or unstable
3
CAD, PE, and pneumonia, in addition to more common (but less serious) conditions
such as chest wall pain, peptic ulcer disease, gastroesophageal reflux disease (GERD),
and panic disorder. Many studies demonstrated that in a high percentage of people
that suffer of UCP there are mental disorders and unfavorable social and
psychological factors.
The present study will use the term Unexplained Chest Pain (UCP). Most
studies of UCP are concerned without patients with normal coronary angiograms. In
one study, 61% of patients with UCP had psychiatric symptoms on structured
interview (the Clinical Interview Schedule), compared to 23% of patients with
abnormal coronary arteries.6
1.3 CLASSIFICATION OF UCP:
The sources of NCPP can be grouped into esophageal and non-esophageal.
Several studies have shown that approximately 60% or more of patients with NCCP
suffer from esophageal pain (mostly due to acid reflux commonly referred to as
Gastroesophageal Reflux Disease (GERD).
1. Esophageal Sources of NCCP:
a) Gastroesophageal Reflux Disease (GERD) or acid reflux, the most common
cause of esophageal NCCP. In addition to chest pain, patients may complain
of heartburn and or regurgitation or chest pain alone may be due GERD.
b) Esophageal contraction disorders as cause of NCCP, include disorders of
esophagus muscle (esophageal motility disorders) such as uncoordinated
muscle contractions (esophageal spasm), contractions of extremely high
pressure (nutcracker esophagus), and occasionally a disorder characterized by
absence of esophageal muscle contraction due to loss of nerve cells of the
esophagus (achalasia). It is important to recognize particularly achalasia since
is a treatable disorder.
c) Visceral (esophageal) Hypersensitivity in patients with NCCP may have an
esophagus where the smallest change in pressure or exposure to acid may
result in tremendous pain. This is best explained by describing an experiment:
when a small balloon is placed inside the (esophagus) and distended, patients
with NCCP perceive the distension of the balloon at very low volumes. This is
4
unlike healthy control subjects do not experience this pain at all or may only
have pain when the balloon distension reaches very large volumes. Although
the cause of this increased sensitivity to balloon distension is unknown, there
are treatment modalities that can be used to improve this exaggerated pain
perception.
2. Non-esophageal Causes of NCCP:
Non-esophageal sources that can cause NCCP include: Musculoskeletal
conditions of the chest wall or spine, pulmonary (lung) disorders, pleural
illness (the layers of tissue that cover the lungs), pericardial conditions (the
layer of tissue that protects the heart) and even digestive disorders such as
ulcers, gallbladder, pancreatic diseases and rarely tumors (particularly in
patients past age 50).
1.4 DIAGNOSTIC CRITERIA:
Patients with normal or insignificant (50%) coronary artery narrowing were
shown to have a 1% mortality rate from cardiac causes in a 7-yr follow-up study.
Thus, a negative angiogram provides strong evidence to reassure patients that their
recurring chest pains are not life-threatening. Unfortunately, even after cardiac disease
has been ruled out, most patients continue to have recurring chest pain and
compromised lifestyles, and many believe that they still have heart disease.7
Few studies compared the prevalence of lifetime psychiatric disorders and
current psychological distress among three consecutive series of patients with chronic
chest or abdominal pain:
(1) Patients with non-cardiac chest pain and clinically significant upper
gastrointestinal disorders;
(2) Patients with non-cardiac chest pain and no upper gastrointestinal disorders; and
(3) Patients with recurrent biliary colic.
These concluded that Patients with non-cardiac chest pain and no upper
gastrointestinal disease had a higher proportion of panic disorder (15%), obsessivecompulsive disorder (21%), and major depressive episodes (28%) than patients with
gallstone disease (0%, p<0.02; 3%, p<0.02; and 8%, p<0.05, respectively).8
5
1.5 TREATMENT:
Treatment of NCCP is challenging because of the heterogeneous nature of the
disorder.
1. Acid suppression: Several open-label studies have demonstrated efficacy of
acid suppression with either PPIs or histamine H2-receptor antagonists
following the first description by DeMeester et al. in 1982.9 Since the first
double-blind, placebo-controlled study of acid suppression in NCCP by
Achem et al.
10,11
Similar controlled studies have consistently shown efficacy
of PPI treatment in NCCP.
2. Smooth
muscle
relaxants:
Nitrates,
phosphodiesterase-5
inhibitors,
anticholinergic drugs, and calcium channel blockers have been used in the
treatment of NCCP with dysmotility. Most studies included small numbers,
and few were placebo controlled, which prevents us from making any firm
conclusions about the efficacy of these agents.
3. Tricyclic antidepressants (TCAs): A few clinical trials have evaluated the
effect of TCAs in NCCP. In a double-blind, placebo-controlled trial12 in 60
patients, imipramine (50 mg) significantly reduced chest pain episodes in 52%
of patients. Prakash and Clouse13 demonstrated that 75% of NCCP patients
experience symptomatic relief during long-term use of TCAs for up to 3 years.
4. Selective serotonin reuptake inhibitors: In a double-blind, controlled study of
sertraline versus placebo in 30 NCCP patients for 8 weeks, sertraline
demonstrated a significant reduction in pain score compared with placebo.14
However, another study15 found no differences between paroxetine and
placebo. Serotonin-norepinephrine reuptake inhibitors (SNRIs): Recently, Lee
et al. evaluated venlafaxine vs. placebo in a double-blind controlled study in
NCCP, reporting that 52% of patients experienced symptom improvement in
comparison to 4% of those taking a placebo.16
5. Miscellaneous treatments: Symptomatic improvement has been reported in
NCCP patients taking adenosine intravenously as well as orally. Small-scale
studies have shown improvement with endoscopic injection of botulinum
toxin, cognitive-behavioral therapy, and hypnotherapy.17
6
CHAPTER 2 - REVIEW OF LITERATURE:
 K Y Ho et al.: Non-cardiac, non-oesophageal chest pain: the relevance of
psychological factors.8 In this study, the Diagnostic Interview Schedule and the
28 item General Health Questionnaire were administered to all patients. Patients
with non-cardiac chest pain and no upper gastrointestinal disease had a higher
proportion of panic disorder (15%), obsessive-compulsive disorder (21%), and
major depressive episodes (28%) than patients with gallstone disease (0%, p<0.02;
3%, p<0.02; and 8%, p<0.05, respectively). In contrast, there were no differences
between patients with non- cardiac chest pain and upper gastrointestinal disease
and patients with gallstone disease in any of the DSM-111 defined lifetime
psychiatric diagnoses. Using the General Health Questionnaire, 49% of patients
with non-cardiac chest pain with- out upper gastrointestinal disease scored above
the cutoff point (i.e., more than 4), which was considered indicative of nonpsychotic psychiatric disturbance, whereas only 14% of patients with gall- stones
did so (p<0.005). The proportions of such cases were however similar between
patients with non-cardiac chest pain and upper gastrointestinal disease (27%) and
patients with gallstones. Conclusions—Psychological factors may play a role in
the pathogenesis of chest pain that is neither cardiac nor oesophaglogastric in
origin.
 G. D. Eslick et al.: Non-cardiac chest pain: predictors of health care seeking,
the types of health care professional consulted, work absenteeism and
interruption of daily activities.18 In this study, a total of 212 patients who
presented to a Tertiary Hospital Emergency Department over a 1-year period with
acute chest pain were assessed according to a standard diagnostic protocol and
completed the Chest Pain Questionnaire (CPQ). : In the previous 12 months prior
to presentation to the Emergency Department, 78% of patients had seen a health
care professional for chest pain. The main health care professionals seen were
general practitioners (85%), cardiologists (74%) and gastroenterologists (30%).
Work absenteeism rates because of non-cardiac chest pain were high (29%) as
were interruptions to daily activities (63%). Multiple logistic regression found that
acid regurgitation was the only independent predictive symptom associated with
consulting for non-cardiac chest pain (OR ¼ 3.97, 95% CI: 1.25– 12.63).
7
Conclusions: Consulting for chest pain is common is this group of patients. The
type of health care professional seen appears to be moderated by the frequency
and severity of reflux symptoms among these chest pain patients. Work
absenteeism and interruptions to daily activities is high among chest pain
sufferers.
 Lynette Spalding et al.: Cause and outcome of atypical chest pain in patients
admitted to hospital.19 The study population was 250 patients admitted over five
weeks with chest pain suspected of being cardiac in origin. Initial assessment
included an electrocardiogram and measurement of troponin-T. If neither of these
indicated a cardiac event, the patient was deemed to have ‘atypical’ chest pain and
the cause, where defined, was recorded. Outcomes at one year were determined by
questionnaire and by assessment of medical notes. Of the 250 patients, 142 had
cardiac pain (mean age 79 years, 58% male) and 108 atypical chest pain (mean
age 60 years, 55% male). Of those with atypical pain, 40 were discharged without
a diagnosis; in the remaining 68 the pain was thought to be musculoskeletal (25),
cardiac (21), gastrointestinal (12) or respiratory (10) in origin. 41 patients were
given a follow-up appointment on discharge. At one year, data were available on
103 (96%) patients. The mortality rate was 2.9% (3 patients) compared with
18.3% in those with an original cardiac event. Half of the patients with atypical
pain had undergone further investigations and 14% had been readmitted. The yield
of investigative procedures was generally low (20%) but at the end of the year
only 27 patients remained undiagnosed.
 Cecilia Cheng et al.: Psychosocial Factors in Patients With Noncardiac Chest
Pain.20 A matched case-control design was adopted to compare differences in
psychosocial factors among a target group of patients with NCCP (70), a pain
control group of patients with rheumatism (70), and a community control group of
healthy individuals (70). Results: Compared with subjects from the two control
groups, NCCP patients tended to monitor more, use more problem-focused
coping, display a coping pattern with a poorer strategy-situation fit, and receive
less emotional support in times of stress. Moreover, monitoring perceptual style
and problem-focused coping were associated with higher levels of anxiety and
depression. Coping pattern with a strategy-situation fit and emotional support
were related to lower levels of anxiety and depression. Conclusions: The present
8
new findings suggest that monitoring perceptual style and inflexible coping style
are risk factors that enhance one’s vulnerability to NCCP. Emotional support may
be a resource factor that reduces one’s susceptibility to NCCP.
 Steve R Kisely1 et al.: Psychological interventions for symptomatic
management of non-specific chest pain in patients with normal coronary
anatomy.21 Conducted Randomised controlled trials (RCTs) with standardized
outcome methodology that tested any form of psychotherapy for chest pain with
normal anatomy. Diagnoses included non-specific chest pain (NSCP), atypical
chest pain, syndrome X, or chest pain with normal coronary anatomy (as either
inpatients or outpatients). There was a significant reduction in reports of chest
pain in the first three months following the intervention; fixed-effect relative risk =
0.68 (95% CI 0.57 to 0.81). This was maintained from three to nine months
afterwards; relative risk = 0.59 (95% CI 0.45 to 0.76). This review suggests a
modest to moderate benefit for psychological interventions, particularly those
using a cognitive-behavioral framework, which was largely restricted to the first
three months after the intervention. Hypnotherapy is also a possible alternative.
The evidence for brief interventions was less clear. Further RCTs of psychological
interventions for NSCP with follow-up periods of at least 12 months are needed.
 J Mant et al.: Systematic review and modeling of the investigation of acute
and chronic chest pain presenting in primary care.22 Concluded that for acute
chest pain, no clinical features in isolation were useful in ruling in or excluding an
acute coronary syndrome (ACS), although the most helpful clinical features were
pleuritic pain (LR+ 0.19) and pain on palpation (LR+ 0.23). ST elevation was the
most effective ECG feature for determining MI (with LR+ 13.1) and a completely
normal ECG was reasonably useful at ruling this out (LR+ 0.14). Results from
‘black box’ studies of clinical interpretation of ECGs found very high specificity,
but low sensitivity. In the simulation exercise of management strategies for
suspected ACS, the point of care testing with troponins was cost-effective. Where
an ACS is suspected, emergency referral is justified. ECG interpretation in acute
chest pain can be highly specific for diagnosing MI. Point of care testing with
troponins is cost-effective in the triaging of patients with suspected ACS. Resting
ECG and exercise ECG are of only limited value in the diagnosis of coronary
heart disease (CHD). The potential advantages of rapid access chest pain clinics
9
(RACPCs) are lost if there are long waiting times for further investigation.
Recommendations for further research include the following: determining the
most appropriate model of care to ensure accurate triaging of patients with
suspected ACS; establishing the cost- effectiveness of pre-hospital thrombolysis
in rural areas; determining the relative cost-effectiveness of rapid access chest
pain clinics compared with other innovative models of care; investigating how
rapid access chest pain clinics should be managed; and establishing the long-term
outcome of patients discharged from RACPCs.
10
CHAPTER 3 - AIMS AND OBJECTIVES:
3.1 AIMS:
The major aim of the thesis was to provide a comprehensive assessment of the
UCP experience. Further aims were to determine psychosocial factors associated with
UCP and how the symptom experiences affect everyday life and health-related quality
of life.
3.2 OBJECTIVES OF THE STUDY:
Primary objective:

To investigate the effect of psychosocial risk factors in men and women
with non-cardiac chest pain.
Secondary Objective:

To assess the risk factors of chest pain in men and women.

Age wise and gender wise distribution of Unexplained Chest Pain.

To assess the effect of UCP on everyday life.
3.3 OUTCOMES OF THE STUDY:

The differential effects of psychosocial factors in between patient group
and reference group.

The differential effects of psychosocial factors in between men and
women.
11
CHAPTER 4 - MATERIALS AND METHODS:
4.1 STUDY SITE:
The study was conducted in the General Medicine and Surgery departments of SVS
Medical College Hospital, Mahabubnagar which is a Tertiary Care Teaching Hospital
which has 900 beds with Multi specialty departments.
4.2 STUDY DESIGN:
The study was an observational study.
4.3 STUDY PERIOD:
The study was conducted over a period of six months starting from March 2014 to
August 2014.
4.4 STUDY APPROVAL:
This study was approved by the Institutional Ethical Committee (IEC).
4.5 SAMPLES:
4.5.1 The patient group:
The study was conducted in Out-Patient Department of General Medicine. 60 patients
between 16–69 years of age, who were,
1) Evaluated for acute chest pain and judged by a physician to have no organic cause
of their chest pain and
2) Free from any history of heart disease were considered for inclusion in the study.
They were asked about participation by the investigators, thereafter written and verbal
information about all the steps in the study was provided. After written informed
consent was obtained, the patients filled in a questionnaire providing background
characteristics and data on psychosocial factors, before being discharged.
4.5.2
The Reference Group:
General population was taken under Reference group. 60 reference participants were
assessed according to the protocol. The psychological assessment was conducted after
the basic examination.
12
4.6 STUDY CRITERIA:
4.6.1 Inclusion Criteria:

Inpatients and Outpatients.

Patients of either sex with age between 16- 69 years.

Patients who were evaluated by the physician to have no organic
cause for their chest pain.

Patients free from any history of heart disease.
4.6.2 Exclusion Criteria:

Patients who are not willing to give the consent.

Pregnant/lactating women.

Patients with previous MI/Angina.
4.7 STUDY MATERIALS:
4.7.1 Informed consent form, an informed consent form was prepared for
patients’ understanding and agreeing to participate in the study.
4.7.2 Patient data collection form, contains the socio-demographic
details of the patient like age, sex, education, occupation, and annual income,
social and family history, stress periods, marriage or cohabilitation.
4.7.3 Social interaction and communication skills Questionnaire:
It contains a total of 20 questions. Each question is given 1-5 options. 1- not able to
perform with assistance, 2- able to perform with two or more verbal prompts, 3- able
to perform with less than two verbal prompt, 4- Able to perform with minimal
assistance (Gesture) 5- Able to perform independently. At last all the scores of
questions are added to obtain final score. Severity is assessed.
− 90: Social Interaction skills exceed expectations
− 70-89: Social Interaction skills meet expectations
− 50-69: Social Interaction skills sub standard to expectations
− 30-49: Social Interaction skills below expectations
− < 29: Social Interaction skills far below expectations
13
4.7.4 Zung-self rating depression scale:
It contains a total of 20 questions. Each question is given options as A little of time,
some of the time, Good part of the time, Most of the time. At last all the scores of
questions are added to obtain final score. Severity is assessed.
− 20-44 – Normal Range
− 45 – 59 – Mildly depressed
− 60 – 69 – Moderately depressed
− ≥70 – Severely depressed.
4.7.5
Triat- anxiety scale:
It contains a total of 20 questions. Each question is given options as 1-almost never;
2- sometimes; 3- often; 4- almost always. . At last all the scores of questions are
added to obtain final score. Severity is assessed.
− 20 – 44 – Normal.
− 45 – 59 – Mild.
− 60 – 69 – Moderate.
− ≥70 – sever.
4.7.6
SF-36(tm) Health Survey:
This contains 12 sub-scales which have a total of 36 questions, each question caries 0
– 100 marks. Averages of the sub-scales are taken into consideration.
4.8 STUDY PROCEDURE:

A consecutive sample of patients with chest pain, who presented to SVS
Medical Hospital, General Medicine Department (a tertiary teaching and
referral hospital) over a 4months period was enrolled in the study.

Patients were followed through to general admission in the outpatient (OP)
department of General Medicine.

On presentation, all subjects were invited to participate in the study. An
information package was provided.
14

This included a letter describing the study, and a patient consent form
(requiring a signature), which gives permission to access the patient’s medical
records and the Chest Pain Questionnaire Annexures (CPQA).

The CPQA incorporates several existing validated and widely used
instruments including Social interaction and attachment scales, Anxiety and
Depression Scale (used to assess anxiety and depression), the SF-36 (used to
assess general health status),

Data is collected using patient data collection based on the inclusion and
exclusion criteria.

Two groups are required for this study of which one is patient group the other
is reference group.

Patients from the patient group and reference participants from the reference
group are assessed accordingly.

The psychological assessment was conducted after the basic examination.

They were asked about participation by the investigators, thereafter written
and verbal information about all the steps in the study was provided. After
written informed consent was obtained, the patients filled in a questionnaire
providing background characteristics and data on psychosocial factors, before
being discharged.
4.9 STATISTICAL ANALYSIS:
Patient demographic and clinical characteristics have been reported as mean and S.D.
or confidence interval (CI) for numeric-scaled features and percentages for discrete
characteristics. All psychological and quality of life scores are presented as a mean ±
S.D.
15
CHAPTER 5 – RESULTS AND DISCUSSIONS
During the study a total of 60 patients with UCP visited Emergency
Department (ED), of which, 33 were male and 27 were female. 60 participants from
general population were considered as referents of which 22 were male and 38 were
female.
TABLE 5.1: GENDER WISE DISTRIBUTION IN PATIENT GROUP AND
REFERENCE GROUP:
Total
Males
Females
Patient group
60
33
27
Reference group
60
22
38
70
60
60
No. of people
60
50
40
38
33
27
30
22
20
10
0
Patient group
Total
Reference group
Males
Females
Figure 5.1: Gender wise distribution in patient group and reference group.
The total number of people participated are 120. In which 60 are patients suffering
from UCP and the other group of 60 are from the general population, considered as
referents. Patient group consisted of 33 males and 27 females, while referents group
consisted of 22 males and 38 females (Figure 5.2).
The incident rate of UCP is more in males 55%, than in females 45%.
16
TABLE 5.2: AGE WISE DISTRIBUTION IN PATIENT GROUP AND
REFERENCE GROUP:
Reference group
Age
Patient group (n=60)
10-20yrs
8
9
21-30yrs
18
34
31-40yrs
18
12
41-50yrs
7
2
51-60yrs
9
3
61-70yrs
0
0
(n=60)
40
34
35
No. of people
30
Patient
group
25
18
20
15
10
18
12
8
9
5
Referen
ce group
9
7
2
3
0
0
0
10-20yrs
21-30yrs
31-40yrs
41-50yrs
51-60yrs
61-70yrs
Figure 5.2: Age wise distribution in patient group and reference group.
When it comes to the age group the highest number participants are found to be in
between 21-30yrs then by 31-40yrs, 10-20yrs, 51-60yrs, 41-50yrs with a number of
52, 30, 17, 12 and 9 respectively (Figure 5.2).
17
TABLE 5.3: AGE WISE DISTRIBUTION OF MALES IN PATIENT GROUP
AND REFERENCE GROUP:
Age
Patient group (n=60)
Reference group (n=60)
10-20yrs
6
0
21-30yrs
9
13
31-40yrs
8
8
41-50yrs
6
1
51-60yrs
4
0
61-70yrs
0
0
14
13
12
No. of people
10
9
8
Patient
group
8
8
6
6
6
4
Referenc
e group
4
2
1
0
0
0
0
0
10-20yrs 21-30yrs 31-40yrs 41-50yrs 51-60yrs 61-70yrs
Figure 5.3: Age wise distribution of males in patient group and reference
group.
18
TABLE 5.4: AGE WISE DISTRIBUTION OF FEMALES IN PATIENT
GROUP AND REFERENCE GROUP:
Age
Patients group
Reference group
10-20yrs
2
9
21-30yrs
9
2
31-40yrs
10
4
41-50yrs
1
1
51-60yrs
5
3
61-70yrs
0
0
12
10
No. of people
10
9
9
Patient
group
8
6
5
4
4
Reference
group
3
2
2
2
1 1
0 0
0
10-20yrs 21-30yrs 31-40yrs 41-50yrs 51-60yrs 61-70yrs
Figure 5.4: Age wise distribution of females in patient group and
reference group.
People of 21-30yrs (30%) and 31-40yrs (30%) group are the more prone to UCP, in
which males of 21-30yrs are 27.27% while females of 31-40yrs are 37.03% with
highest rate of UCP. Lowest rate in males was found in age group of 51-60yrs
(12.12%), while in females its 41-50yrs (3.70%) (Figure 5.3, 5.4).
19
TABLE 5.5: COMPARISON OF NUMBER OF PEOPLE SMOKING IN
No. of people
PATIENT GROUP AND REFERENCE GROUP:
Males
Females
Patient group (n=02)
2
0
Reference group (n=03)
3
0
3.5
3
2.5
2
1.5
1
0.5
0
0
0
Females
3
2
Patient group (n=02)
Males
Reference group (n=03)
Figure 5.5: Comparison of number of people smoking in patients and
reference group.
TABLE 5.6: COMPARISON OF NUMBER OF PEOPLE DRINKING
ALCOHOL IN PATIENT GROUP AND REFERENNC GROUP:
Males
Females
Patient group (n=24)
15
9
Reference group (n=12)
9
3
30
No. of people
25
20
9
Females
15
3
10
5
Males
15
9
0
Patient group (n=24)
Reference group (n=12)
Figure 5.6: Comparison of number of people drinking alcohol in patient
group and reference group.
20
TABLE 5.7: COMPARISON OF NUMBER OF PEOPLE WHO SMOKE AND
DRINKING ALCOHOL IN PATIENT AND REFERENCE GROUP:
Males
Females
Patient group (n=10)
8
2
Reference group (n=04)
4
0
12
10
2
8
No. of people
6
4
Females
8
0
2
Males
4
0
Patient group (n=10)
Reference group (n=04)
Figure 5.7: Comparison of number of people who smoke and drinking
alcohol in patient group and reference group.
Social factors like smoking did not affect UCP but consumption of alcohol is more in
patients group (56%) than in referents group (26%). Indeed males consume more
amount of alcohol than females (Figure 5.5, 5.6, 5.7).
21
TABLE 5.8: COMPARISON OF PEOPLE HAVING DIABETES IN PATIENT
GROUP AND REFERENCE GROUP:
Males
Females
Patient group (n= 4)
2
2
Reference group (n= 3)
3
0
5
4
No. of people
3
2
0
Females
2
Males
3
1
2
0
Patient group (n=4)
Reference group (n=3)
Figure 5.8: Comparison of people having diabetes in Patient group and
Reference group.
TABLE 5.9: COMPARISON OF PEOPLE HAVING HYPERTENSION IN
No. of people
PATIENT GROUP AND REFERENCE GROUP:
Males
Females
Patient group (n=15)
5
10
Reference group (n=8 )
6
2
16
14
12
10
8
6
4
2
0
10
2
Females
Males
5
6
Patient group (n=15)
Reference group (n=8 )
Figure 5.9: Comparison of people having hypertension in Patient group
and Reference group.
22
TABLE 5.10: COMPARISON OF PEOPLE HAVING BOTH DIABETES AND
HYPERTENSION IN PATIENT GROUP AND REFERENCE GROUP:
Males
Females
Patient group (n=16 )
10
6
Reference group (n=8 )
3
5
18
16
No. of prople
14
12
6
10
Females
8
6
4
5
10
2
Males
3
0
Patient group (n=16 )
Reference group (n=8 )
Figure 5.10: Comparison of people having both diabetes and hypertension
in Patient group and Reference group.
Incidence of diabetes is same in men and women while incidence of hypertension is
75% in total and is much high in women (66%) suffering with UCP. UCP patients
showed more number of diabetes and hypertension cases (26%) than referents (Figure
5.8, 5.9, 5.10)
23
TABLE 5.11: COMPARISON OF SOCIAL AND COMMUNICATION SKILLS
BELOW EXPECTATION BETWEEN PATIENT GROUP AND REFERENCE
GROUP:
Males
Females
Patients group (n=43 )
23
20
Reference group (n=15 )
11
04
50
45
40
No. of people
35
30
20
25
Females
20
Males
15
10
23
4
11
5
0
Patient group (n=43 )
Reference group (n= 15)
Figure 5.11: Comparison of social and communication skills below
expectation between Patient group and Reference group.
Social and communication skills are below expectation in males (53%) than in
females (46%) in patients group while 73% males and 26% females are below
expectation in referents group. When compared UCP patients have very low levels of
social and communication skills than referents (Figure 5.11).
24
TABLE 5.12: COMPARISON OF NUMBER OF PEOPLE HAVING ONLY
ANXIETY IN PATIENT GROUP AND REFERENCE GROUP:
Males
Females
Patients group (n= 14)
6
8
Reference group (n= 34)
7
27
No. of people
40
30
Females
27
20
10
Males
8
6
7
Patient group (n= 14)
Reference group (n= 34)
0
Figure 5.12: Comparison of number of people having only anxiety in
Patient group and Reference group.
TABLE 5.13: COMPARISON OF NUMBER OF PEOPLE HAVING ONLY
DEPRESSION IN PATIENT GROUP AND REFERENCE GROUP:
Males
Females
Patient group (n=06)
5
1
Reference group (n=07)
6
1
No. of people
8
1
6
1
Females
4
5
2
6
Males
0
Patient group (n=06)
Reference group (n=07)
Figure 5.13: Comparison of number of people having only depression in Patient
group and Reference group.
25
TABLE 5.14: COMPARISON OF NUMBER OF PEOPLE HAVING BOTH
ANXIETY AND DEPRESSION IN PATIENT GROUP AND REFERENCE
GROUP:
Males
Females
Patient group (n=40)
22
18
Reference group (n= 09)
4
5
50
No. of people
40
30
18
Females
20
10
Males
22
5
4
0
Patient group (n=40)
Reference group (n=09 )
Figure 5.14: Comparison of number of people having both anxiety and
depression in Patient group and Reference group.
In the level of only anxiety, females (29.62%) are having higher ratio when compared
to males (18.18%) in UCP patients, they have the same result in referent group. The
scores of patients with depression show that the ratio of males (15.15%) is higher than
females (3.70%) in both patient as well as referent groups. While people with both
anxiety as well as depression the ratios are very high (66%) in both men and women
compared to individual risk factors. When compared patients suffering with UCP
showed high percentage of anxiety and depression scores (Figure 5.12, 5.13, 5.14).
26
TABLE 5.15: COMPARISON OF PERCENTAGES OF VARIOUS SUBSCALES IN HEALTH RELATED QUALITY OF LIFE (HRQOL) INBETWEEN PATIENT GROUP AND REFERENCE GROUP:
Sub-scales
Patient group
Reference group
Physical functioning (%)
31
62
Role physical (%)
52
53
Vitality (%)
49
58
Bodily pain (%)
59
33
General health (%)
33
69
Social functioning (%)
38
66
Role emotional (%)
54
78
Mental health (%)
41
75
Patients group
Referents group
90%
Sum of the averages
80%
70%
60%
50%
40%
30%
20%
10%
0%
Figure 5.15: Comparison of percentages of various sub-scales in HealthRelated Quality of Life (HRQOL) in-between Patient group and Reference
group.
27
Comparing all the sub-scales of health related quality of life (HRQOL),
Physical functioning, bodily pain, general health, social functioning, emotional role
and mental health showed a significant difference in patient group and the reference
group with a percentage of 31%, 59%, 33%, 38%, 54%, 41% and 62%, 33%, 69%,
66%, 78%, 75% respectively.
Physical functioning and general health was very low in patients suffering
from UCP and the referents. Physical role and vitality are almost equal in both but
emotional role, mental health and social functioning are more in general population
than UCP patients. UCP patients suffered with high bodily pains than the referents
(Figure 5.15).
28
CHAPTER 6 - SUMMARY:
Results from both the qualitative and quantitative analyses showed that the
UCP patients were often worried about stress at work, experienced stress at home, and
experienced negative life events.
Treatment with a double-dose PPI for a period of 2–4 months should be
considered in those with GERD- related NCCP. In patients with nutcracker
esophagus, GERD should be first excluded by initiating treatment with a potent
antireflux medication.10 In patients with non-GERD-related NCCP, smooth muscle
relaxants have demonstrated very limited efficacy in ameliorating symptoms. In
contrast, pain modulators such as tricyclic antidepressants, trazodone, and SSRIs have
become the mainstay of treatment, regardless of the presence or absence of
esophageal dysmotility (except achalasia).23 Psychological comorbidity is very
common in patients with NCCP and thus should not be overlooked. Pharmacologic or
nonpharmacologic approaches have been used with varied success. Future therapy for
NCCP will likely include new pain modulators and possibly more potent antireflux
medications.
Based on the literature in psychology and psychosomatic medicine, three
psychosocial factors were proposed to be associated with NCCP. First, NCCP patients
were hypothesized to differ from individuals without NCCP in having a unique
perceptual style. This hypothesis was derived from two lines of findings that suggest
their hypersensitivity to stress and bodily conditions, respectively. Although there
were no differences in the number of stressful life events experienced between NCCP
subjects and healthy controls, NCCP subjects gave higher negative life-change scores
to stressful life events than did their counterparts.20
Psychiatric reviews of somatization
24-27
have emphasized the notion of mind-
body connection, but the mechanisms of how psychological and physical factors
interact remain unknown. The present results may provide insights to the mind-body
connection for NCCP. Psychodynamic28,29 and cognitive-behavioral30-33 theories
emphasize the close relationship between the mind (eg, unresolved psychological
conflicts, maladaptive cognitions) and feelings of tension. Enhanced tension in the
thoracic muscles elicited by anxiety might explain the mechanism of chest pain. This
29
study suggests that one way in which psychological factors may interact with chest
pain is through the cognitive pathway. This type of perceptual style predisposes a
person to be hypersensitive to normal bodily functioning.34 Monitoring perceptual
style is related to high anxiety levels. Because an autonomic and hormonal sequel of
anxiety can influence esophageal and cardiac functioning,
35
NCCP patients’
persistent chest pain may be due to their monitoring perceptual style and anxiety
associated with this perceptual style.
The psychological therapies include: (1) CBT; (2) Relaxation therapy; (3)
Hyperventilation control; (4) Hypnotherapy; (5) Other psychotherapy/talking
/counseling therapy; (6) Standard care, ’attention’ placebo, waiting list controls, or no
intervention as the control conditions.
Hypnotherapy has been recently evaluated in the treatment of NCCP patients.
Jones and colleagues reported an 80% improvement in symptoms, with a significant
reduction in pain intensity, among patients who were receiving 12 sessions of
hypnotherapy, compared to only a 23% symptom improvement in the control group.
The study concluded that hypnotherapy appears to have a role in treating NCCP and
that further studies are needed.36,37
30
CHAPTER 7 - CONCLUSIONS:
The pr``esent study is a comparative study using two sample groups namely
patient group suffering with UCP and referents group from the general healthy
population,
60memebers
in
each
group.
Various
parameters
like
stress,
communication skills, anxiety, depression as well as health related quality of life are
been assessed.
The present study concludes that:
− A large proportion of those patients who present with acute chest pain to hospital
emergency departments have sought healthcare for UCP presentation and that the
type of health care professional consulted is influenced by the severity and
frequency of reflux symptoms.
− High rates of absenteeism from work were reported by those patients with UCP
along with considerable interruption to daily activities.
− A larger proportion of the UCP patients was immigrant and had a sedentary
lifestyle.
− Likewise, UCP patients were more often worried about stress at work, perceived
more stress at home, more often had sleep problems and had experienced more
negative life events than the referents.
− Thus UCP patients used cognitive coping strategies in managing stress, but
emotional reactions to stress seemed to increase the intensity of the chest pain.
− The incident rate of UCP is more in males (55%), than in females (45%).
− People of 21-30yrs (30%) and 31-40yrs (30%) group are more prone to UCP, in
which highest rate occurred in males of 21-30yrs (27.27%) and in females of 3140yrs (37.03%).
− Social and communication skills are below expectation in males (53%) than in
females (46%) in patients group, while 73% males and 26% females are below
expectation in referents group.
− Patients showed atleast one stress factor in their life.
− Risk of occurrence of UCP is more in people having both anxiety and depression
than individual components. This had a significant effect on their daily life.
31
− The ratio of people with both anxiety as well as depression is very high in patient
group (70%) than the reference group (15%) compared to individual risk factors.
− In comparison with a random population sample, most the sub-scales of health
related quality of life (HRQOL) like Physical functioning, bodily pain, general
health, social functioning, emotional role and mental health showed a significant
difference in patient group.
32
CHAPTER 8 - LIMITATIONS AND FUTURE
DIRECTIONS:
8.1 LIMITATIONS OF THE STUDY
 Sample size was low;
 Duration of the study 6months was insufficient to gather the required
outcomes;
 We couldn’t follow few UCP cases as the occurrence was more during night
times;
 Lack of time to interact fully as most of the cases are reported in the outpatient
department.
 Our study was not an interventional study.
8.2 FUTURE DIRECTIONS
 These should Include a larger number of participants with explicit sample size
and power analysis;
 Have follow-up periods of atleast 12 months and preferably longer;
 Further RCTs of psychological interventions for UCP are needed;
 Use interventions that are explicitly described manualised and monitored for
treatment accuracy.
33
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46 Mora G. Mind-body concepts in the Middle Ages. Part I. J Hist Behav Sci Vol
14, 1978;, Pg.344–61.
37
47 Mora G. Mind-body concepts in the Middle Ages. Part II. The Moslem
influence, the great theological systems, and cultural attitudes toward the
mentally ill in the late middle Ages. J Hist Behav Sci Vol 16, 1980, Pg.58–72.
48 Ron Schey, MD, Autumn Villarreal, MS, and Ronnie Fass, MD, FACP,
FACG, Noncardiac Chest Pain: Current Treatment, Gastroenterology &
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49 Van Peski-Oosterbaan A, Spinhoven P, van Rood Y, et al. Cognitive-behavioral therapy for noncardiac chest pain: a randomized trial. Am J Med. Vol
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39
CHAPTER 10 - ANNEXURES:
PATIENT CONSENT FORM
I have read/ been briefed on “Investigating the effect of psychosocial risk
factors on non-cardiac chest pain” and I voluntarily agree to participate in the
project. I understand that participation in this study may or may not benefit me. Its
general purpose, potential benefits and inconveniences have been explained to me up
to my satisfaction. I have the option to withdraw from the study at any stage. I hereby
give my consent for this study.
Name of the patient:
Impression
Date:
Signature/ Thumb
40
PATIENT DATA COLLECTION FORM
DEMOGRAPHIC DETAILS:
Name:
Height:
Weight:
Age/gender:
Date:
BMI:
OP/ IP:
Department:
Consultant Dr:
Contact no:
Address:
Marital status: Single/ Married (or) cohabitating/ divorced/ widower.
Education: Primary/ Secondary school/ University.
Work Status: Employed (full time/ part time)/ early retirement/ disability pension/
retired/ unemployed.
Immigrant status: Local/ non-local.
Physical activity in leisure time:
1) Sedentary in leisure time.
2) Moderate exercise in leisure time (walking, riding bicycle, light
gardening).
3) Regular exercise and training (strenuous activity for a minimum of
3hrs/week).
4) Intense training or competitive sport.
Physician conformed diabetes: YES/ NO
Physician conformed hypertension: YES/ NO
Current smoker: YES/ NO
Alcohol consumption: YES/ NO
month.
C/O:
Ex-Smoker: YES/ NO
Frequency/ amount each day-week-
41
PREVIOUS MEDICAL HISTORY:
PREVIOUS MEDICATION HISTORY:
PHYSICAL EXAMINATION:
VITALS:
Previous stress at work:
1) Never perceived stress.
2) Some period of stress.
3) Some period of stress during last 5yrs.
4) Several periods of stress during last 5yrs.
5) Permanent stress during the last 1 year.
6) Permanent stress during the last 5yrs.
Perception of their marriage or cohabitation:
I] “How do you perceive your marriage or cohabitation?”
1) Very happy.
2) Fairly happy.
3) Difficult to say.
4) Rather unhappy.
5) Very unhappy.
II] “How often do you have difficulty getting along with your wife or husband or
cohabitant?”
42
1) Never.
2) Seldom.
3) Sometimes.
4) Very often.
5) Almost all the time.
LAB INVESTIGAGTIONS:
Rx:
43
SOCIAL INTERACTION AND COMMUNICATION SKILLS
CHECKLIST:
Please rate the items on the following scale:
1 = Not able to perform even with assistance
2 = Able to perform with two or more verbal prompts
3 = Able to perform with less than two verbal prompts
4 = Able to perform with minimal assistance (Gesture)
5 = Able to perform independently
1. Respond when called by name.............................1..........2..........3..........4..........5
2. Follow verbal instructions in 1:1 setting..............1..........2..........3..........4..........5
3. Follow verbal instructions in small group............1..........2..........3..........4..........5
4. Appropriately gain attention from others.............1..........2..........3..........4..........5
5. Ability to take turns in conversation....................1..........2..........3..........4..........5
6. Ability to initiate conversation.............................1..........2..........3..........4..........5
7. Respond appropriately to praise...........................1..........2..........3..........4..........5
8. Ability to accept supervision ...............................1..........2..........3..........4..........5
9. Recognize and respond to non-verbal cues .........1..........2..........3..........4..........5
10. Give simple instructions to others
..................1..........2..........3..........4..........5
11. Ability to consistently communicate needs/wants..1..........2..........3..........4..........5
12. Ability to solve basic social problems ..............1..........2..........3..........4..........5
13. Ability to ask for help/assistance ......................1..........2..........3..........4..........5
44
14. Ability to follow simple visual instructions ......1..........2..........3..........4..........5
15. Ability to work as part of a team .......................1..........2..........3..........4..........5
16. Ability to express lack of understanding or ask questions when appropriate
…………………………………………...................1..........2..........3..........4..........5
17. Ability to request a break when needed ............1..........2..........3..........4..........5
18. Respond appropriately to criticism/correction.....1..........2..........3..........4..........5
19. Follow social cues in a group ..............................1..........2..........3..........4..........5
20. Ability to learn a task through modeling …..........1..........2..........3..........4..........5
TOTAL SCORE = _____
Reference:
>90
– social interaction skills exceed expectations.
70-89 - social interaction skills meet expectations.
50-69 - social interaction skills substandard to expectations.
30-49 - social interaction skills below expectations.
<29
- social interaction skills far below expectations.
45
ZUNG SELF-RATING DEPRESSION SCALE
Please read each statement and decide how much of the time the statement
describes how you have been feeling during the past several days.
Make check mark (✓) in appropriate
column.
1. I feel down-hearted and blue
A little of
Some of
Good
Most of
the time
the time
part
the time
1
2
Morning is when I feel the best
I have crying spells or feel like it
I have trouble sleeping at night
I eat as much as I used to
4
1
1
4
6.
7.
8.
9.
10.
11.
I still enjoy sex
I notice that I am losing weight
I have trouble with constipation
My heart beats faster than usual
I get tired for no reason
My mind is as clear as it used to be
12.
13.
14.
15.
16.
17.
18.
19.
2.
3.
4.
5.
4
3
2
2
3
of the3
time 2
3
3
2
4
1
1
1
1
4
3
2
2
2
2
3
2
3
3
3
3
2
1
4
4
4
4
1
I find it easy to do the things I used to
I am restless and can’t keep still
I feel hopeful about the future
I am more irritable than usual
I find it easy to make decisions
I feel that I am useful and needed
My life is pretty full
I feel that others would be better
4
1
4
1
4
4
4
3
2
3
2
3
3
3
2
3
2
3
2
2
2
1
4
1
4
1
1
1
off if I were dead
1
2
3
4
4
3
2
1
20. I still enjoy the things I used to do
TOTAL SCORE =__________
1
4
4
1
46
Reference:
20-44 – Normal Range
45 – 59 – Mildly depressed
60 – 69 – Moderately depressed
≥70 – Severely depressed.
47
TRAIT ANXIETY SCALE
Please rate the items on the following scale:
1-almost never; 2- sometimes; 3- often; 4- almost always.
1) I fell pleasant…………………………………………..…..1…..2…..3…..4
2) I feel nervous and restless……………………………...….1…..2…..3…..4
3) I feel satisfied with myself…………………………………1…..2…..3…..4
4) I wish I could be as others seem to be……………….…….1…..2…..3…..4
5) I feel like a failure…………………………..…………...…1…..2…..3…..4
6) I feel rested……………………………………………...…..1…..2…..3…..4
7) I am “calm, cool and collected”………………………..….. 1…..2…..3…..4
8) I feel that difficulties are piling up so that I cannot overcome them..1..2..3..4
9) I worry too much over something that really doesn’t matter….1….2….3....4
10) I am happy………………………………………………..…1…..2…..3…..4
11) I have disturbing thoughts………………………….………1…..2…..3…..4
12) I lack self-confidence………………………………………..1…..2…..3…..4
13) I feel secure……………………………………..………..…1…..2…..3…..4
14) I make decisions easily…………………………….……….1…..2…..3…..4
15) I feel inadequate………………………………………..…..1…..2…..3…..4
16) I am content…………………………………………..…….1…..2…..3…..4
17) Some unimportant thoughts runs through my mind and bothers
me………………………………………………………….1…..2…..3…..4
18) I take disappointments so keenly that I can’t put them out of my mind
……………………………………………………….……1…..2…..3…..4
48
19) I am a steady person………………………………………1…..2…..3…..4
20) I get in a state of tension or turmoil as I think over my recent concerns and
interests…………………………………………………….1…..2…..3…..4
TOTAL SCORE =__________
Reference:
20 – 44 – Normal.
45 – 59 – Mild.
60 – 69 – Moderate.
≥70 – sever.
49
SF-36 HEALTH SURVEY:
1.
In general, would you say your health is:
□ Excellent
2.
□ Very good
□ Good
□ Fair
□Poor
Compared to one year ago, how would you rate your health in general now?
□ Much better now than a year ago
□ Somewhat better now than a year ago
□ About the same as one year ago
□ Somewhat worse now than one year ago
□ Much worse now than one year ago
3. The
following items are about activities you might do during a typical day.
Does your health now limit you in these activities? If so, how much?
a. Vigorous
activities, such as running, lifting heavy objects, participating in
strenuous sports.
□ Yes, limited a lot.
b. Moderate
□ Yes, limited a little. □No, not limited at all.
activities, such as moving a table, pushing a vacuum cleaner,
bowling, or playing golf?
□ Yes, limited a lot.
c. Lifting
or carrying groceries.
□ Yes, limited a lot.
d. Climbing
e. Climbing
□ Yes, limited a little.
□No, not limited at all.
□ Yes, limited a little.
□No, not limited at all.
□ Yes, limited a little.
□No, not limited at all.
□ Yes, limited a little.
□No, not limited at all.
□ Yes, limited a little.
□No, not limited at all.
several blocks.
□ Yes, limited a lot.
i. Walking
□No, not limited at all.
more than one mile.
□ Yes, limited a lot.
h. Walking
□ Yes, limited a little.
kneeling or stooping.
□ Yes, limited a lot.
g. Walking
□No, not limited at all.
one flight of stairs.
□ Yes, limited a lot.
f. Bending,
□ Yes, limited a little.
several flights of stairs.
□ Yes, limited a lot.
one block.
□ Yes, limited a lot.
j. Bathing
□ Yes, limited a little. □No, not limited at all.
or dressing yourself.
□ Yes, limited a lot.
□ Yes, limited a little.
□No, not limited at all.
50
4. During
the past 4 weeks, have you had any of the following problems with your
work or other regular daily activities as a result of your physical health?
a.
Cut down the amount of time you spent on work or other activities? Yes
b.
Accomplished less than you would like?
c.
Were limited in the kind of work or other activities
d.
Had difficulty performing the work or other activities
(for example, it took extra time)
5. During
Yes
Yes
No
No
Yes
No
No
the past 4 weeks, have you had any of the following problems with your
work or other regular daily activities as a result of any emotional problems (such
as feeling depressed or anxious)?
a.
Cut down the amount of time you spent on work or other activities? Yes No
b.
Accomplished less than you would like
c.
Yes
No
Didn't do work or other activities as carefully as usual
6. During
Yes
No
the past 4 weeks, to what extent has your physical health or emotional
problems interfered with your normal social activities with family, friends,
neighbors, or groups?
□ Not at all
7. How
□ slightly
□ moderately
□ Quite a bit
□ extremely
much bodily pain have you had during the past 4 weeks?
□ Not at all
8. During
□ slightly
□ moderately
□ Quite a bit
□ extremely
the past 4 weeks, how much did pain interfere with your normal work
(including both work outside the home and housework)?
□ Not at all
9. These
□ slightly
□ moderately
□ Quite a bit
□ extremely
questions are about how you feel and how things have been with you
during the past 4 weeks. For each question, please give the one answer that comes
closest to the way you have been feeling. How much of the time during the past 4
weeks.
a. Did you feel full of pep?
□ All of the time
□ Most of the time
□A good bit of the time
□ Some of the time
□ A little of the time
□ None of the time
a. Have
you been a very nervous person?
51
□ All of the time
□ Most of the time
□A good bit of the time
□ Some of the time
□ A little of the time
□ None of the time
b. Have
c.
□ All of the time
□ Most of the time
□A good bit of the time
□ Some of the time
□ A little of the time
□ None of the time
Have you felt calm and peaceful?
□ All of the time
□ Most of the time
□A good bit of the time
□ Some of the time
□ A little of the time
□ None of the time
d. Did
you have a lot of energy?
□ All of the time
□ Most of the time
□A good bit of the time
□ Some of the time
□ A little of the time
□ None of the time
e.Have
f.
you felt so down in the dumps nothing could cheer you up?
you felt downhearted and blue?
□ All of the time
□ Most of the time
□A good bit of the time
□ Some of the time
□ A little of the time
□ None of the time
□ All of the time
□ Most of the time
□A good bit of the time
□ Some of the time
□ A little of the time
□ None of the time
Did you feel worn out?
g. Have
h.
10. .
you been a happy person?
□ All of the time
□ Most of the time
□A good bit of the time
□ Some of the time
□ A little of the time
□ None of the time
□ All of the time
□ Most of the time
□A good bit of the time
□ Some of the time
□ A little of the time
□ None of the time
Did you feel tired?
During the past 4 weeks, how much of the time has your physical health or
emotional problems interfered with your social activities (like visiting friends,
relatives, etc.)?
11. .
□ All of the time
□ Most of the time
□ A little of the time
□ None of the time
□ Some of the time
How TRUE or FALSE is each of the following statements for you?
52
a. I
b. I
seem to get sick a little easier than other people
□ Definitely true
□ Mostly true
□ Mostly false
□ Definitely false
am as healthy as anybody I know
□ Definitely true
□ Mostly false
c. I
□ Don't know
□ Mostly true
□ Don't know
□ Definitely false
expect my health to get worse
□ Definitely true
□ Mostly true
□ Mostly false
□ Definitely false
d. My health
□ Don't know
is excellent
□ Definitely true
□ Mostly true
□ Mostly false
□ Definitely false
TOTAL SCORE =__________
□ Don't know