Dr Ruwan M Jayatunge, M.D. PhD
The condition known by several names, including Da Costa's syndrome, effort syndrome, and neurocirculatory asthenia, has been the subject of extensive research by numerous esteemed physicians for over a century (Paul, 1987). During the US Civil War, Dr. Da Costa conducted a thorough evaluation of around 300 soldiers exhibiting a set of symptoms he identified as "irritable heart." Various distressing signs, including shortness of breath, palpitations, a burning sensation in the chest, severe fatigue, headaches, gastrointestinal issues like diarrhea, episodes of dizziness, and disturbances in sleep, characterized this condition (Da Costa, 1871). Da Costa's syndrome mimics heart disease without any physical heart abnormalities (Kubera et al.,2022).
Soldiers diagnosed with Da Costa syndrome experience a variety of symptoms that can profoundly affect their overall health. Lewis (1918) described various symptomatology that is associated with Da Costa syndrome. Notably, chest pain is a common complaint, often described as sharp, stabbing, or burning sensations primarily located on the left side of the chest or near the heart's apex. In addition, individuals may report palpitations, which involve an uncomfortable awareness of a rapid or irregular heartbeat, as well as tachycardia, characterized by an elevated resting heart rate, especially during mild physical exertion or emotional stress. Respiratory and systemic symptoms frequently include shortness of breath, often perceived as a smothering sensation that can trigger hyperventilation and involuntary deep sighing. Extreme fatigue is prevalent, leading to significant physical weakness and a diminished capacity for exercise, where even slight activity can result in exhaustion. Neurological and psychological manifestations may include dizziness, light-headedness, and fainting spells, particularly when changing positions. The condition is further complicated by chronic headaches, excessive sweating often associated with anxiety, and sleep disturbances such as insomnia and frequent awakenings. Gastrointestinal complaints, including nausea, bloating, and diarrhea, are also commonly reported among those affected.
Combatants from Sri Lanka, particularly those involved in the Eelam War from 1983 to 2009, have shown a notable prevalence of Da Costa syndrome. A significant case is that of a soldier from the commando regiment who, after spending over eight years in active combat zones, began to experience cardiac symptoms. Despite thorough evaluations conducted by Brigadier Dr. Nimalka Ariyarahne, a consultant physician for the Sri Lanka Army, which included an ECG, echocardiogram, and CT angiogram—all yielding normal results—the soldier continued to face serious cardiac issues. Consequently, he was referred to Dr. Neil Fernando, visiting psychiatrist of the Sri Lanka Army, for an in-depth psychological evaluation. This assessment indicated that while the soldier had endured traumatic combat experiences, he had not sustained any physical injuries, ultimately leading to a diagnosis that aligned with the clinical profile of Da Costa's syndrome.
The standard treatment for Da Costa’s syndrome is fundamentally non-pharmacological, focusing on a multidisciplinary combination of psychological therapy, autonomic nervous system regulation, and gradual physical reconditioning. Kubera and colleagues (2022) assert that there exists a dynamic and pathophysiological interrelationship between psychological distress and cardiovascular diseases, highlighting the need for a cohesive, multidisciplinary clinical strategy.
The Sri Lankan combatant diagnosed with Da Costa syndrome underwent a comprehensive treatment regimen that included medication, cognitive behavioural therapy (CBT), eye movement desensitization and reprocessing (EMDR), and mindfulness practices such as Anapanasathi breath meditation.
The selective serotonin reuptake inhibitor (SSRI) Fluoxetine was prescribed to address the neurochemical and psychiatric factors contributing to the physical symptoms, particularly by down-regulating the sympathetic nervous system. CBT was employed to disrupt the harmful cycle in which the veteran misinterpreted benign heart palpitations as indicators of a heart attack. EMDR facilitated the reprocessing of combat-related trauma stored in the brain, thereby calming the overactive nervous system. Additionally, mindfulness techniques helped stabilize the autonomic nervous system and alleviate the panic loop associated with hyperventilation. As a result of these interventions, the combatant experienced a reduction in cardiac and other distressing symptoms, ultimately regaining functionality.
References
Da Costa, J. M. (1871). On irritable heart; a clinical study of a form of functional cardiac disorder and its consequences. American Journal of the Medical Sciences, 61(121), 17–52.
Kubera, K. M., Hirjak, D., & Wolf, R. C. (2022). Psychocardiology then and now – the genesis of a discipline. Frontiers in Psychiatry, 13, Article 988393. doi.org
Lewis, T. (1918). The soldier's heart and the effort syndrome. Shaw & Sons.
Paul O. Da Costa's syndrome or neurocirculatory asthenia. Br Heart J. 1987 Oct;58(4):306-15. doi: 0.1136/hrt.58.4.306. PMID: 3314950; PMCID: PMC1277260.
