Symptoms utilized in the clinical care of heart failure as markers of disease severity include, dyspnea, insomnia, low energy, fatigue, poor appetite, and diminished memory. This is despite the fact that physiologic variables such as cardiac ejection fraction and oxygen consumption do not accurately predict functional state in individuals with congestive heart failure (CHF). Distress (anxiety and depression) may amplify symptom complaints without associated physiologic aberration. Personality traits and psychiatric illness, such as mood, anxiety, and psychotic illnesses may also alter perception of somatic symptoms that are associated with this chronic illness. The impact of distress and its treatment on functional performance and CHF symptom reporting deserve additional attention. The need to screen for distress in all with serious symptomatic heart failure is certain.