Case Study: Recurrent Atypical Chest Pain and Health Anxiety in a Young Veteran

Case at a Glance

A 25-year-old male veteran presents with a two-year history of recurrent, episodic chest pain and significant health anxiety. Despite multiple emergency department visits with negative cardiac workups, the patient remains convinced he has an undiagnosed, life-threatening heart condition, leading to a cycle of hypervigilance and distress.

Patient's Story

The patient is a 25-year-old male who completed 5.5 years of military service, including a deployment, and was honorably discharged one year prior to presentation. He reports being in excellent health with no history of anxiety or chronic pain before his final year of service. The onset of his symptoms coincided with his return from deployment. He describes recurrent episodes of chest tightness and a dull, aching pain on the left side of his chest. This pain is often accompanied by radiation to the posterior left jaw and an unusual, dull pain on the dorsum of his left foot. He states these symptoms are indistinguishable from what he understands to be a heart attack, causing immense fear. He expresses a specific concern that his symptoms may be a side effect of a mandatory COVID-19 vaccination he received during his service.

Initial Assessment

Over the past two years, the patient visited the emergency department (ED) on 5-6 separate occasions with a chief complaint of chest pain. During each visit, a standard workup for acute coronary syndrome was performed. This included serial electrocardiograms (ECGs) and high-sensitivity cardiac troponin assays. All ECGs showed normal sinus rhythm with no ischemic changes. All cardiac enzyme tests were within normal limits, effectively ruling out myocardial infarction. Physical examinations were consistently unremarkable. Despite reassurance from ED physicians that his heart was not the source of his pain, the patient's anxiety and conviction of underlying pathology persisted.

The Diagnostic Journey

The patient's journey was characterized by a disconnect between his subjective experience of severe physical symptoms and consistently negative objective medical findings. His insistence on a cardiac etiology, despite multiple negative workups, pointed towards a significant psychological component. The patient's history as a recently discharged veteran raised the clinical suspicion for an underlying anxiety or trauma-related disorder, as these conditions frequently present with somatic (physical) symptoms. Chest pain is a classic manifestation of panic attacks.

The patient struggled to accept a non-cardiac explanation, questioning the thoroughness of the ED evaluations and asking, "how do I know if I have a clogged artery?" This highlighted his profound health anxiety. Clinicians explained that an acute event like a myocardial infarction is reliably detected by ECG and troponin levels. While rare cases of vaccine-associated myocarditis or pericarditis exist, these inflammatory conditions would also typically present with ECG changes or elevated troponin levels, which were absent in his case. The patient expressed extreme frustration, stating, "I almost wish I would just have a heart attack so the doctors would take me seriously." This sentiment underscored his desperation for a diagnosis that validated the reality of his suffering, a common feature in somatic symptom disorders.

Final Diagnosis

1. Panic Disorder: Characterized by recurrent, unexpected panic attacks with prominent somatic symptoms (chest pain, jaw pain).
2. Somatic Symptom Disorder with Predominant Pain: Defined by a significant focus on physical symptoms, leading to major distress and functional impairment.
3. Illness Anxiety Disorder (Health Anxiety): Evidenced by his preoccupation with having a serious, undiagnosed medical illness.

Treatment Plan

A multi-pronged approach was recommended to address both the physical symptoms and the underlying psychological distress:

1. Establish Primary Care: The patient was advised to establish care with a primary care physician (PCP) to create a therapeutic alliance, provide continuity, and serve as a central point for managing health concerns, thereby reducing reliance on the ED.
2. Mental Health Referral: A referral was made to a psychiatrist for a comprehensive evaluation and to discuss potential pharmacotherapy, such as an SSRI, which is first-line treatment for both panic and anxiety disorders.
3. Psychotherapy: A strong recommendation was made for Cognitive Behavioral Therapy (CBT). The goal of CBT is to help the patient identify and challenge catastrophic thoughts about his physical sensations and to develop coping mechanisms for managing anxiety and preventing panic attacks.
4. Patient Education: The treatment plan included educating the patient on the mind-body connection, explaining how psychological distress like anxiety can manifest as real, physical pain, a phenomenon known as somatization.

Outcome and Follow-up

The patient was initially resistant to a psychological diagnosis but agreed to a consultation with a mental health professional specializing in veteran care. Through consistent CBT, he began to recognize the link between his anxiety, hypervigilance, and the onset of his physical symptoms. He was started on a low-dose SSRI, which he tolerated well. Over six months, the frequency and intensity of his chest pain episodes significantly decreased. While he still experienced occasional symptoms, he was better equipped to manage them without resorting to an ED visit. Ongoing follow-up with his PCP and therapist was scheduled to monitor his progress and adjust treatment as needed.