Repeatedly telling a patient “your heart is fine” after emergency testing may sound reassuring to the clinician and dismissive to the patient. But treating every recurrence as an entirely new cardiac question, without reviewing what has already been assessed, can leave care fragmented. Psychiatry’s task is to validate the symptoms, describe what the prior evaluation established, and agree on a next step—while diagnosing panic only when the history supports it.
Consider an illustrative case: a 27-year-old woman with several emergency visits over two months for sudden palpitations, chest tightness, shortness of breath, and fear of dying. Records show normal ECGs and serial troponins; clinicians did not identify an acute myocardial infarction during those visits. She says, “They told me the tests were fine, but I know something is being missed.” Some episodes occur in elevators or on crowded trains, which she now avoids.
The referral does not establish whether her attacks are recurrent and unexpected, what her cardiac risk history is, or whether her avoidance meets criteria for a separate disorder. Those gaps matter. The useful question is not simply whether to reassure her again; it is how to make a careful, connected plan without either dismissing risk or leaving her in a cycle of disconnected evaluations.
Say what the tests show—and what they do not
Start with the patient’s experience, not a psychiatric label. The pounding heart and chest tightness are real sensations, even when a panic response may be contributing. A normal result does not mean she imagined them.
Be equally precise about the medical evidence. An ECG and troponin results are interpreted in context, as part of an evaluation for a particular problem at a particular time. A prior evaluation that did not find an acute heart attack is reassuring about that encounter; it is not a blanket guarantee about every possible cause of chest symptoms or every future episode. A single ECG, in particular, cannot settle every question about an intermittent rhythm problem.
| Finding | What it can support | What it does not establish |
|---|---|---|
| Prior emergency evaluation found no acute myocardial infarction | No acute MI was identified during those evaluated episodes | That all cardiac or noncardiac causes have been excluded, or that future symptoms never need reassessment |
| Abrupt episodes with intense fear and bodily symptoms | Panic attacks are one possibility to assess | Panic disorder, especially if it is unclear whether attacks are unexpected or better explained by another cause |
| Avoidance of elevators or crowded transit | Significant fear-related behavior and functional impact worth exploring | A specific diagnosis without assessing the broader pattern, feared outcome, duration, and impairment |
A panic attack is not, by itself, panic disorder. The formulation should establish whether there are recurrent unexpected panic attacks and whether at least one is followed for a month or more by persistent concern or worry about further attacks or their consequences, or a significant maladaptive behavior change related to attacks. Assess functional impact and relevant medical, medication, and substance explanations. If attacks are consistently tied to particular situations, clarify that pattern rather than assuming they are unexpected. Repeated negative tests do not supply missing diagnostic criteria.
Validate without promising certainty
A concise, collaborative response can hold both truths:
“I don’t doubt that your heart was pounding and your chest felt tight. The emergency evaluations did not find an acute heart attack during those visits, which is reassuring about those episodes. It doesn’t make the sensations imaginary. Let’s review what was checked, agree on what changes should prompt medical reassessment, and address how these episodes are affecting your life.”
This approach avoids two opposite errors. “It’s all anxiety” implies that the physical symptoms are not real and may damage trust. “We can’t rule out everything” followed by a long list of rare diseases can intensify threat without clarifying what to do next. Acknowledge uncertainty in proportion to the evidence, then identify who will follow up and what that follow-up is for.
If the patient asks for a guarantee, do not offer one. Explain what the prior assessment found, ask what still feels unanswered, and check whether there is relevant history the referral missed. A record describing someone as “healthy” is not a substitute for a targeted history of baseline function, family and personal cardiac history, medications, caffeine or stimulant exposure, and the actual timing and pattern of symptoms.
Turn separate visits into a shared plan
The psychiatrist’s role is not to repeat a cardiac workup or overrule the clinicians who performed it. It is to understand the available records, assess the psychiatric pattern, and help the patient and medical team coordinate next steps.
- Review the record rather than relying on a summary. Confirm which symptoms were present, what testing was done, and what conclusions the treating team documented. Avoid recording “cardiac causes excluded” if the records only show that no acute MI was found.
- Clarify what has changed. Ask whether the current episode resembles prior ones or differs in timing, severity, duration, or associated symptoms. New, persistent, worsening, or exertional symptoms, fainting, or other concerning changes warrant medical reassessment according to the patient’s circumstances and the relevant clinical pathway. A psychiatric formulation does not cancel that need.
- Make responsibility and follow-up explicit. With the patient’s permission, coordinate with primary care or the relevant medical clinician. Specify who will review ongoing physical symptoms, who will treat anxiety, and when the patient should seek urgent care. “Follow up with someone” is less useful than naming a clinician, purpose, and timeframe.
- Offer treatment for the problem that is established. If the history supports panic disorder and the symptoms are impairing, discuss appropriate evidence-based care, including CBT and other suitable options. Explain that treating panic is not a claim that symptoms are fabricated or that medical follow-up is forbidden.
The aim is not to stop all reassurance. It is to replace repeated, short-lived reassurance with a clear account of what is known, an agreed route back to medical care if the picture changes, and a continuing plan for the fear and avoidance that are already limiting the patient’s life.
Common traps
- Calling the symptoms imaginary: Panic-related physiology is still physical experience.
- Treating a prior negative test as lifetime clearance: Results answer a defined clinical question; they do not certify every future episode.
- Diagnosing from normal tests alone: A medical evaluation may inform the differential, but it does not establish panic disorder.
- Repeating the same reassurance without a plan: Reassurance can calm the moment while leaving the patient unsure what to do at the next episode.
- Letting psychiatric care compete with medical care: A coordinated plan can address both without reflexively repeating tests or dismissing new symptoms.
Practical takeaways
- Validate the bodily experience before offering a psychiatric explanation.
- Describe prior cardiac results in terms of what was assessed and when; avoid blanket statements that the heart is “fine.”
- Establish the attack pattern, baseline history, functional impact, and relevant medical, medication, and substance context before formulating panic disorder.
- Agree on who will provide medical follow-up, who will address panic symptoms, and what changes warrant reassessment.
- Treat panic symptoms when supported by the assessment; do not use the diagnosis to close the door on appropriate medical care.
