Sighing as an illness marker
Sighing has been described as one member of a group of signs exhibited by depressed or anxiety-ridden patients.1 While Perin et al2 were the first to point out the importance of distinguishing between sighing and respiratory disease, sighing per se has never been identified as a discrete illness marker.
A number of psychiatric disorders are already well known to incorporate breathing and chest symptoms along with widespread somatization. These include globus hystericus, neurocirculatory asthenia, and Tietze syndrome.3-6 As such, the acute pain of precordial catch syndrome stands out as an example of a distinguishable, clear-cut clinical state devoid of any apparent organic basis.7,8
Methods
How we recruited the patients
Data was collected from 3 family practice clinics in Israel from February 2002 to February 2005. We requested that these practices contribute data of consecutive clinical cases presenting with the 10 set symptoms of sigh syndrome (TABLE 1).
Data collected included basic demographics, the circumstances of the onset of symptoms, concurrent medical conditions, and any associated symptoms. We assessed the patients’ education level by asking questions pertaining to their years of schooling and college degrees. Patients rated their own economic status as being below, average, or above-average income.
The main outcome we examined was the clinical course of the sighing episodes during the ensuing months after their visit, in order to determine whether any patients developed a form of significant organic disease or a disorder that led to hospitalization.
Results
40 cases that cut across the socioeconomic spectrum
Forty patients were recruited for this study. Nineteen (47.5%) were male; their ages ranged from 7 to 53 (mean, 31.8; standard deviation, 13.7). Two patients (5%) were Ashkenazi Jews; 34 (85%) were of North African ethnicity (Sephardic Jews); the other 4 were of varied Asian and European ethnicity. The number of patients with North African ethnicity overrepresents that of the population in their communities. Additionally, 3 members of this group were from the same family.
There was no predilection toward any specific education level or socioeconomic status. The occupations of the subjects were diverse.
Their clinical characteristics
The clinical characteristics of the 40 patients are presented in TABLE 2. The subjects’ sighing began at various times of the day, without relationship to eating or any other activity, and disappeared during sleep. All patients reported the same feeling: that of an extra effort demanded to perform full inspiration. In many cases, adult patients were certain their complaints were a sign of cardiac or respiratory disease, and they were very concerned that there was some grave, underlying disorder.
History and examination failed to reveal evidence of any somatic findings related to breathing difficulty. Breathing rate was within normal limits in all cases.
The physicians’ initial encounters with these patients led to further examination in many cases: electrocardiography, blood oxygen saturation, and complete blood counts. However, no abnormalities were found on any of these tests. Medications, if prescribed at all during these consultations, were usually given to alleviate insomnia or anxiety. Further ancillary investigations or referrals were not ordered.
The sole notable finding on physical examination was a typical murmur (which had already been diagnosed) in a young girl with a congenital atrial septal defect. This 7-year-old developed repeated episodes of sigh syndrome just before her annual visit to the pediatric cardiologist; her mother believed that the child was frightened by the thought of possible future surgery.
TABLE 2
Clinical characteristics of the 40 patients studied—One third experienced a traumatic event
| CHARACTERISTIC | YES | NO |
|---|---|---|
| Smoker | 2 (5%) | 38 (95%) |
| History of anxiety or somatoform disorder | 10 (25%) | 30 (75%) |
| Taking prescription medication at time of diagnosis | 4 (10%) | 36 (90%) |
| Recurrence of sighing episodes during follow-up period | 24 (60%) | 16 (40%) |
| Trigger event (eg, exposure to traumatic event 1 month before presentation with syndrome) | 13 (32.5%) | 27 (67.5%) |
Traumatic events, anxiety disorders suggest stress as a cause
Thirteen patient histories disclosed a definite, recent, significant traumatic event that may have triggered the onset of sigh syndrome. Examples of 2 triggering events are the terrorist murder of several members of a neighbor’s family, and a near-miss with a mortar shell. One subject—a teenager—had recently been left alone in the dark with 2 younger siblings during a power blackout; another young woman said that the sighing episodes began when she decided to get married.
Ten patients had previously diagnosed neurotic disorders, mainly generalized anxiety; these included 2 cases of somatization disorder and 1 case of posttraumatic stress disorder. This information from the patients’ histories was documented in their medical files.