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Denial and Silent Ischemia: Which Comes First?-Reply

Arthur J. Barsky, MD; N. Anthony Coles, MD; Christopher O'Donnell, MD; Kim A. Eagle, MD
JAMA. 1991;265(2):213. doi:10.1001/jama.1991.03460020067024.
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In Reply. —  We thank Drs Janne, Reynaert, and Decoster for directing our attention to their work on denial; more such research is needed. The phenomenon of denial is particularly knotty to conceptualize and especially difficult to study. Does denial refer to the disavowal of perceptions, eg, pain, or to the disavowal of knowledge and information, eg, the fact that one is ill? How are we to measure denial, and how do we distinguish it from simply refusing to admit something to an interviewer or researcher?If patients with silent ischemia show more denial than symptomatic patients, how do we know whether they're denying their illness because they experience no symptoms of it, or whether they report no symptoms because they are denying that they feel them? The work of Dr Janne and colleagues suggests that patients with silent myocardial ischemia do indeed exhibit more denial of serious disease, and


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