Objectives: This thesis aims to explore evidence for the effectiveness of cognitive behavioural therapy (CBT) for non-cardiac chest pain (NCCP). Design: The systematic review aimed to evaluate evidence for CBT as an effective intervention for anxiety in the NCCP population. Study one describes the chest pain characteristics, illness beliefs and prevalence of anxiety in a NCCP sample in a cross-sectional design. Study two explores the acceptability and clinical effectiveness of a CBT-based self-help intervention for NCCP patients, using a between subjects, repeated measures design. Methods: A systematic review was completed via a comprehensive literature search for comparative studies examining CBT-based interventions for NCCP including a measure of anxiety. In the empirical study, participants completed measures of anxiety, illness beliefs and indices of chest pain (self-reported frequency, severity and impact on activities) at baseline. Comparisons between illness beliefs and anxiety were undertaken using descriptive statistics and Pearson correlations. Participants were randomised to receive a CBT-based self-help intervention booklet or treatment as usual, with questionnaires re-administered at three-month follow-up. ANOVAs were used to evaluate whether the intervention led to improvements in anxiety levels, or increased belief in participants’ personal control of symptoms. Results: Ten studies met inclusion criteria for the systematic review, with four studies showing evidence regarding the effectiveness of CBT for anxiety. Approximately two thirds of the thesis research sample reported on-going pain following clinic attendance, for the majority this was ‘very mild’ or ‘mild’ pain. Almost half (47%) reported experiencing clinically significant anxiety. Stress was the most common causal attribution advocated by the sample to explain their chest pain. Anxiety scores were significantly associated with psychological attribution scores, but not with personal control or illness coherence beliefs. In study two, 87 participants completed the study and ITT analyses were completed on 119. There were no significant differences between the groups in terms of reduced anxiety or self-reported belief in personal control of symptoms. The intervention booklet was evaluated largely positively by those who reported reading it. Conclusions: CBT-based self-help appears an acceptable intervention for those diagnosed with NCCP. Further research is needed to identify those who are most likely to benefit from such self-help intervention.

Bakgrund: Den psykiska ohälsan ökar i Sverige. Det innebär förändringar inom den prehospitala sjukvården. Ambulanssjuksköterskans arbete riktas ofta initialt mot akuta somatiska problem, men att vårda patienter med psykosomatisk bröstsmärta till följd av ångest är också en viktig del av omvårdnadsarbetet. Detta medför stor potentiell patientnytta då obehandlad, svår ångest indirekt kan bli livshotande med hänseende till suicidrisken. För att öka kunskapen om psykosomatisk bröstsmärta finns det ett behov av att beforska området. Syfte: Att beskriva sjuksköterskors upplevelser av mötet med patienter med psykosomatisk bröstsmärta prehospitalt. Metod: Åtta sjuksköterskor varav sex vidareutbildade inom ambulanssjukvård rekryterades från tre olika ambulansstationer i Norrland. Datan insamlades genom individuella semistrukturerade intervjuer och analyserades genom en kvalitativ innehållsanalys med induktiv ansats. Resultat: Vald analysmetod resulterade i tre huvudkategorier: Samtalet har en viktig roll i mötet, Bedömningen av allvarlighetsgrad är utmanande i mötet, och Ett per- soncentrerat förhållningssätt är viktigt i mötet, med sex tillhörande underkategorier som svarar på syftet. Slutsats: Psykisk ohälsa ses vara ett fullvärdigt problem inom den prehospitala sjukvården. Sjuksköterskor inom prehospital sjukvård utesluter i första hand somatisk orsak, men ser samtalet som ett naturligt nästa steg i bemötandet och behandlingen av patienter som söker vård för psykosomatisk bröstsmärta. Samtalet i kombination med ett personcentrerat förhållningssätt anses vara de bästa verktygen i bemötandet.

Introduction: More than half of all patients seeking care for chest pain do not have a cardiac cause for this pain. Despite recurrent episodes of chest pain, many patients are discharged without a clear explanation of the cause for their pain. A lack of explanation may result in a misinterpretation of the pain as being cardiac-related, causing worry and uncertainty, which in turn leads to substantial use of healthcare resources. Psychological distress has been associated with non-cardiac chest pain (NCCP), but there is limited research regarding the relationship between different psychological factors and their association with healthcare utilization. There is a need for interventions to support patients to manage their chest pain, decrease psychological distress, and reduce healthcare utilization and costs. Aim: The overall aim of this thesis was to improve care for patients with  non-cardiac chest pain by describing related psychological distress, healthcare utilization and societal costs, and by evaluating an Internet-delivered cognitive behavioural intervention. Designs and methods: This thesis presents results from four quantitative studies. Studies I and II had a longitudinal descriptive and comparative design. The studies used the same initial cohort. Patients were consecutively approached within 2 weeks from the day of discharge from a general hospital in southeast Sweden. In study I, 267 patients participated (131 with NCCP, 66 with acute myocardial infarction (AMI), and 70 with angina pectoris (AP)). Out of these, 199 patients (99 with NCCP, 51 with AMI, 49 with AP) participated in study II. Participants were predominantly male (about 60 %) with a mean age of 67 years. Data was collected on depressive symptoms (Study I), healthcare utilization (Study I, II), and societal costs (Study II). Study III had a cross-sectional explorative and descriptive design. Data was collected consecutively on depressive symptoms, cardiac anxiety and fear of body sensations in 552 patients discharged with diagnoses of NCCP (51 % women, mean age 64 years) from four hospitals in southeast Sweden. Patients were approached within one month from the day of discharge. Study IV was a pilot randomized controlled study including nine men and six women with a median age of 66 years, who were randomly assigned to an intervention (n=7) or control group (n=8). The intervention consisted of a four-session guided Internet-delivered cognitive behavioural therapy (CBT) program containing psychoeducation, exposure to physical activity, and relaxation. The control group received usual care. Data was collected on chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms. Results: Depressive symptoms were prevalent in 20 % (Study IV) and 25 % (Study I, III) of the patients, and more than half of the patients still experienced depressive symptoms one year later (Study I). There were no significant differences in prevalence and severity of depressive symptoms between patients diagnosed with NCCP, AMI or AP. Living alone and younger age were independently related to more depressive symptoms (Study I). Cardiac anxiety was reported by 42 % of the patients in study III and 67 % of the patients in study IV. Fear of body sensations was reported by 62 % of the patients in study III and 93 % of the patients in study IV. On average, patients with NCCP had 54 contacts with primary care or the outpatient clinic per patient during the two-year study period. This was comparable to the number of contacts among patients with AMI (50 contacts) and AP (65). Patients with NCCP had on average 2.6 hospital admissions during the two years, compared to 3.6 for patients with AMI and 3.9 for patients with AP (Study II). Four out of ten patients reported seeking healthcare at least twice during the last year due to chest pain (Study III). On average, 14 % of patients with NCCP were on sick-leave annually, compared to 18 % for patient with AMI and 25 % for patient with AP. About 11-12 % in each group received a disability pension. The mean annual societal costs for patients with NCCP, AMI and AP were €10,068, €15,989 and €14,737 (Study II). Depressive symptoms (Study I, III), cardiac anxiety (Study III) and fear of body sensations (Study III) were related to healthcare utilization. Cardiac anxiety was the only variable independently associated with healthcare utilization (Study III). In the intervention study (Study IV), almost all patients in both the intervention and control groups improved with regard to chest pain  frequency, cardiac anxiety, fear of body sensations, and depressive symptoms. There was no significant difference between the groups. The intervention was perceived as feasible and easy to manage, with comprehensible language, adequate and varied content, and  manageable homework assignments. Conclusions: Patients with NCCP experienced recurrent and persistent chest pain and psychological distress in terms of depressive symptoms, cardiac anxiety and fear of body sensations. The prevalence and severity of depressive symptoms in patients with NCCP did not differ from patients with AMI and patients with AP. NCCP was significantly associated with healthcare utilization and patients had similar amount of primary care and outpatient clinic contacts as patients with AMI. The estimated cumulative annual national societal cost for patients with NCCP was more than double that of patients with AMI and patients with AP, due to a larger number of patients with NCCP. Depressive symptoms, cardiac anxiety and fear of body sensations were related to increased healthcare utilization, but cardiac anxiety was the only variable independently associated with healthcare utilization. These findings imply that screening and treatment of psychological distress should be considered for implementation in the care of patients with NCCP. By reducing cardiac anxiety, patients may be better prepared to handle chest pain. A short guided Internet-delivered CBT program seems to be feasible. In the pilot study, patients improved with regard to chest pain frequency, cardiac anxiety, fear of body sensations, and depressive symptoms, but this did not differ from the patients in the control group who received usual care. Larger studies with longer follow-up are needed to evaluate both the short and long- term effects of this intervention.