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Is the Person or the Event Silent?

Arthur J. Barsky, MD; Barbara Hochstrasser, MD; N.Anthony Coles, MD; Jerome Zisfein, MD; Christopher O'Donnell, MD; Kim A, Eagle, MD

JAMA. 1990;264(9):1132-1135.

Abstract
The symptoms of organic disease vary widely among patients with the same tissue abnormality, because the experience of a symptom is shaped by the patient's perceptual and cognitive style. Thus, the relationship between myocardial ischemia and chest pain is variable in that many patients experience pain without ischemia and many others exhibit ischemia without pain—termed "silent" or "asymptomatic ischemia." Although the nature of the ischemic event may be important in determining the degree of associated pain, we suggest more study of the individual who perceives the event. Myocardial ischemia may not generate a spontaneous report of chest pain because the patient is generally hyposensitive to visceral sensation; because he or she is coping with the threat of heart disease by denying the evidence of it—ie, denying the pain to deny the disease; or because the patient misunderstands the cause and significance of a vague or ambiguous cardiac sensation, normalizing the symptom and misattributing it to a nonpathologic cause.

(JAMA. 1990;264:1132-1135)

Author Affiliations
From the Psychiatry Service (Drs Barsky and Hochstrasser) and General Internal Medicine Unit and Cardiac Unit, Medical Service (Drs Coles, Zisfein, O'Donnell, and Eagle), Massachusetts General Hospital, Boston: and the Departments of Psychiatry (Drs Barsky and Hochstrasser) and Medicine (Drs Coles, Zisfein, O'Donnell, and Eagle), Harvard Medical School, Boston.

Footnotes
Reprint requests to Primary Care Psychiatry Unit, Wang Ambulatory Care Center—807, Massachusetts General Hospital, Fruit Street, Boston, MA 02114 (Dr Barsky).

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