21 de noviembre de 2011

Coincidence of paroxysmal supraventricular tachycardia and panic disorder: two case reports


Coincidence of paroxysmal supraventricular tachycardia and panic disorder: two case reports

Katharina Domschke1*, Paulus Kirchhof2, Peter Zwanzger1, Alexander L Gerlach3, Günter Breithardt2 and Jürgen Deckert4

* Corresponding author: Katharina Domschke katharina.domschke@ukmuenster.de

Author Affiliations

1 Department of Psychiatry, University of Münster, Münster, Germany 2 Department of Cardiology and Angiology, and German Competence Network on Atrial Fibrillation (AFNET), University of Münster, Münster, Germany 3 Institute of Psychology, University of Münster, Münster, Germany 4 Department of Psychiatry, University of Würzburg, Würzburg, Germany

FUENTE: Annals of General Psychiatry 2010, 9:13 doi:10.1186/1744-859X-9-13

Abstract



Panic disorder (PD) is characterised by sudden attacks of intense fear with somatic symptoms including palpitations and tachycardia. Reciprocally, palpitations caused by paroxysmal supraventricular tachycardia (PSVT) are commonly associated with anxiety and may therefore be misdiagnosed as PD. As demonstrated by two case reports, PSVT and PD can occur comorbidly in a chronological sequence, with PSVT possibly precipitating and maintaining PD via interoceptive processes or, alternatively, with PD increasing the risk for PSVT by elevating stress levels. As both PSVT and PD require different treatments, potentially helpful differential clinical diagnostic criteria are proposed.



Background



Panic disorder (PD) is characterised by a lifetime prevalence of 1% to 3% and sudden attacks of intense fear accompanied by somatic, particularly cardiac symptoms such as palpitations, chest pain, and tachycardia: 89% of patients with PD complain of palpitations, with up to 25% of patients initially referred to cardiac clinics with atypical chest pain or palpitations being later diagnosed with PD [1]. Reciprocally, palpitations caused by paroxysmal supraventricular tachycardia (PSVT) are associated with anxiety in approximately 20% of patients and may therefore be misdiagnosed as PD [2-4]. In patients with PSVT, radiofrequency ablation offers a curative therapy and can reduce anxiety symptoms dramatically. After successful catheter ablation, a minority of patients has been reported to still suffer from panic symptoms, pointing to a possible true comorbidity in at least 4% of cases [5].



Based on two case reports of patients with comorbid PSVT and PD, neuropsychophysiological processes potentially driving this comorbidity will be discussed. Additionally, as both PSVT and PD require different treatments, potentially helpful differential clinical criteria will be proposed.

Conclusions



The present cases demonstrate that PSVT and PD can co-occur as two different diagnostic entities. Both patients could clearly differentiate between PD and PSVT symptoms: Differential diagnostic clues were that in contrast to panic attacks PSVT attacks were not accompanied by symptoms such as feelings of derealisation/depersonalisation or a fear of losing control, going crazy or dying. Conversely, panic attacks were not terminable by vagal manoeuvres. The possibility of true comorbidity of PSVT and panic disorder thus necessitates reciprocal inclusion of both nosological entities in the diagnostic evaluation of the respective diseases.



Given the chronological sequence of onset of the two comorbid diseases in the present cases, two different neuropsychophysiological interactions of PSVT symptoms and specific PD symptoms may be postulated.



Firstly, as in patient 1, PD might trigger PSVT as has previously been shown for ventricular premature beats or arrhythmias possibly via chronic mental and somatic stress [7].



Secondly, as in patient 2 and also in patient 1 after ablation, PSVT might initiate or aggravate anxiety states as an internal cue of panic and anxiety. This latter hypothesis is in line with anxiety disorder patients exhibiting increased interoceptive sensitivity, particularly to heart beat [8,9], as mirrored by elevated BSQ mean scores in both cases presented here. Also, elevated ASI scores as in both cases here have been shown to be associated with more accurate heart rate estimation suggesting an interaction of physiological arousal and state anxiety in interoceptive accuracy [10,11]. In anxiety disorders, not only has increased self-report of somatic sensations been observed, but also a subsequent dysfunctional cognitive appraisal of these sensations with a significant bias towards a danger-related and catastrophising interpretational style (for example, [12,13]). Consistently, self-rated fears of specific physical and psychological symptoms in PD patients as measured by the BSQ are primarily related to the catastrophising idea of having a heart attack [14]. Thus, increased cardiac awareness as precipitated by PSVT and further influenced by increased anxiety sensitivity may be a factor for the development and maintenance of panic disorder.



Assuming a reciprocal neuropsychophysiological interaction between PSVT and PD via either chronic mental and somatic stress or interoceptive processes, immediate and focused differential treatment such as radiofrequency ablation in PSVT or cognitive behavioural psychotherapy, if necessary in combination with pharmacological treatment (for example, with serotonin reuptake inhibitors (SSRI) or noradrenaline and selective serotonin agonists (NaSSA)) in PD is warranted in order to possibly avoid the precipitation of the respective other disorder.

Yo podría aportar un tercer caso pero el paciente no me da la autorización