Heart-focused anxiety as a mediating variable in the treatment of noncardiac chest pain by cognitive-behavioral therapy and paroxetine

J Psychosom Res. 2010 Sep;69(3):227-35. doi: 10.1016/j.jpsychores.2010.02.005. Epub 2010 Mar 30.


Objective: We compared the efficacy of cognitive behavior therapy (CBT), paroxetine and placebo in the treatment of noncardiac chest pain (NCCP). We also investigated whether pre- to mid-treatment reduction of (heart-focused) anxiety mediated mid- to post-treatment pain reduction.

Methods: Sixty-nine adults with NCCP were randomly assigned to 16 weeks of outpatient treatment with CBT, paroxetine or placebo. The comparison between placebo and paroxetine was carried out in a double-blind fashion. The main outcome measure was a chest pain index (duration*intensity) as derived from daily pain diaries. Putative mediator measures were general anxiety (HADS:A) and heart-focused anxiety (Cardiac Anxiety Questionnaire).

Results: Eleven patients treated with paroxetine or placebo dropped out prematurely. Intent-to-treat analysis showed that CBT was significantly superior to placebo and to paroxetine in reducing NCCP at posttreatment. Only CBT significantly reduced heart-focused anxiety compared to placebo at mid- and post-treatment. Pre- to mid-treatment reduction of heart-focused anxiety predicted mid- to post-treatment NCCP reduction. The indirect effect of CBT on pain reduction by reducing heart-focused anxiety was significant compared to placebo but not to paroxetine.

Conclusion: CBT is an effective treatment option for patients with NCCP. Paroxetine is not more effective than placebo on the short term. Reduction of heart-focused anxiety by CBT seems to mediate subsequent reduction of NCCP compared to placebo. The results provide further support for cognitive-behavioral models of NCCP and point to the potential benefits of, in particular, cognitive-behavioral interventions to modify heart-focused anxiety.

Publication types

  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adult
  • Aged
  • Analysis of Variance
  • Anxiety / psychology
  • Anxiety / therapy*
  • Anxiety Disorders / psychology
  • Anxiety Disorders / therapy*
  • Chest Pain / psychology
  • Chest Pain / therapy*
  • Cognitive Behavioral Therapy*
  • Double-Blind Method
  • Fear / psychology
  • Female
  • Humans
  • Intention to Treat Analysis
  • Male
  • Middle Aged
  • Pain Measurement
  • Paroxetine / therapeutic use*
  • Psychiatric Status Rating Scales
  • Selective Serotonin Reuptake Inhibitors / therapeutic use
  • Treatment Outcome


  • Serotonin Uptake Inhibitors
  • Paroxetine