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Hidden harm
Case Report
Hidden harm Masahiro Suzuki, Chisato Konno, Sakae Takahashi, Makoto Uchiyama Lancet 2011; 377: 874 Department of Psychiatry, Nihon University School of Medicine, Tokyo, Japan (M Suzuki MD, C Konno MD, S Takahashi MD, M Uchiyama MD) Correspondence to: Makoto Uchiyama, Department of Psychiatry, Nihon University School of Medicine, 30-1 Oyaguchi- Kamicho, Itabashi-ku, Tokyo 173-8610, Japan uchiyama.makoto@nihon-u. ac.jp
In April, 2009, a 46-year-old woman was referred to us with a history of repetitive self-harming. She had no previous psychiatric history. She had a 3-year history of diabetes mellitus, and a systolic blood pressure of 200 mm Hg twice during the previous 4-months. In 2007, after starting a divorce procedure, she developed a lack of energy, anxious restlessness, and hypersensitivity to external noises. A local clinic gave her anxiolytics and paroxetine, but her symptoms worsened. In January, 2009, she was fired from her job, and she started self-harming, which included wrist cutting, strangling her neck with a rope, and hitting her head against a chest of drawers. She was then referred to our department. Her self-harming behaviour was triggered by intense anxiety. She reported that only the painful sensations from self-harming could relieve the restlessness associated with her feelings of intense anxiety. Her blood pressure was 138/88 mm Hg. Blood tests showed hyperglycaemia (fasting glucose 10⋅7 mmol/L), but other investigations including full blood count, liver and renal function tests, and a thyroid function test were normal. We suspected that she had adjustment disorder, and administered anxiolytics, antidepressants, mood stabilisers, and antipsychotics sequentially with psychotherapy. However, she continued self-harming almost every day. No complaints or behaviours related to anxiety were reported between the episodes of self-harm. In July, 2009, our patient was admitted to hospital with profuse vomiting. Laboratory tests showed diabetic ketosis (blood glucose 15⋅5 mmol/L and blood ketones 1647 μmol/L). After admission, she frequently had hypertensive episodes, with blood pressure readings up to 200/110 mm Hg. She had extremely high urine norepinephrine 22 775 nmol/day, [normal 287–996], urine
normetanephrine 60 060 nmol/day, [491–1802], and plasma norepinephrine 78⋅2 nmol/L [0⋅6–2⋅7]. CT of the abdomen showed a 8⋅7×8⋅8×7⋅3 cm left-sided adrenal mass with peripheral enhancement and a central area of low density (figure). A meta-iodobenzylguanidine (MIBG) scan revealed increased uptake in the left adrenal gland with no evidence of abnormal extra-adrenal uptake. In August, 2009, laparoscopic adrenalectomy and histological analysis of the tumour confirmed the diagnosis of phaeochromocytoma. After the operation, her blood glucose, blood pressure, and plasma norepinephrine were normal. Furthermore, her mental state became stable and the anxiety attacks no longer occurred. When last seen in March, 2010, she was well with no further history of self-harm. Anxiety is the fourth most common symptom of phaeochromocytoma, after palpitations, headaches, and sweating, and it occurs in approximately 30% of patients.1 In patients with phaeochromocytoma, prominent anxiety or a sense of doom occurs during a hypertensive crisis that is caused by episodic secretion of catecholamines.2 Selfharming is an unusual way of coping with anxiety in primary anxiety disorders; our patient self-harmed to relieve the restlessness associated with her anxiety. Although her clinical course seemed to be related to life stress, the anxiety attacks improved after removing the adrenal mass. Therefore, we concluded that her anxiety symptoms could predominantly be attributed to phaeochromocytoma. That the plasma and urine norepinephrine concentrations of our patient were very high compared with a previous study on phaeochromocytoma,3 might explain why she experienced such intense anxiety. Selective serotonin reuptake inhibitors can precipitate hypertensive crises.4 Our patient had taken paroxetine before starting self-harming, which might have exacerbated her phaeochromocytoma. Anxiety occurs in various physical conditions. This case report suggests that organic causes should be considered when psychiatric symptoms are atypical and resistant to conventional therapy. Contributors All authors looked after the patient and wrote the report. Written consent to publish was obtained. Acknowledgments We thank K Kanazawa, M Hatano, A Minagawa and H Yanaihara for contributing to patient management and providing clinical data.
Figure: CT of the abdomen: showing a left-sided adrenal mass (arrow)
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References 1 Mannelli M, Ianni L, Cilotti A, Conti A. Pheochromocytoma in Italy: a multicentric retrospective study. Eur J Endocrinol 1999; 141: 619–24. 2 Pacak K, Keiser H, Eisenhofer G. Pheochromocytoma. In: DeGroot LJ, Jameson JL, eds, Endocrinology, 5th edn. Philadelphia: Elsevier Saunders, 2005: 2501–34. 3 Lenders JW, Pacak K, Walther MM, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA 2002; 287: 1427–34. 4 Seelen MA, de Meijer PH, Meinders AE. Serotonin reuptake inhibitor unmasks a pheochromocytoma. Ann Intern Med 1997; 126: 333.
www.thelancet.com Vol 377 March 5, 2011
Hidden harm Masahiro Suzuki, Chisato Konno, Sakae Takahashi, Makoto Uchiyama Lancet 2011; 377: 874 Department of Psychiatry, Nihon University School of Medicine, Tokyo, Japan (M Suzuki MD, C Konno MD, S Takahashi MD, M Uchiyama MD) Correspondence to: Makoto Uchiyama, Department of Psychiatry, Nihon University School of Medicine, 30-1 Oyaguchi- Kamicho, Itabashi-ku, Tokyo 173-8610, Japan uchiyama.makoto@nihon-u. ac.jp
In April, 2009, a 46-year-old woman was referred to us with a history of repetitive self-harming. She had no previous psychiatric history. She had a 3-year history of diabetes mellitus, and a systolic blood pressure of 200 mm Hg twice during the previous 4-months. In 2007, after starting a divorce procedure, she developed a lack of energy, anxious restlessness, and hypersensitivity to external noises. A local clinic gave her anxiolytics and paroxetine, but her symptoms worsened. In January, 2009, she was fired from her job, and she started self-harming, which included wrist cutting, strangling her neck with a rope, and hitting her head against a chest of drawers. She was then referred to our department. Her self-harming behaviour was triggered by intense anxiety. She reported that only the painful sensations from self-harming could relieve the restlessness associated with her feelings of intense anxiety. Her blood pressure was 138/88 mm Hg. Blood tests showed hyperglycaemia (fasting glucose 10⋅7 mmol/L), but other investigations including full blood count, liver and renal function tests, and a thyroid function test were normal. We suspected that she had adjustment disorder, and administered anxiolytics, antidepressants, mood stabilisers, and antipsychotics sequentially with psychotherapy. However, she continued self-harming almost every day. No complaints or behaviours related to anxiety were reported between the episodes of self-harm. In July, 2009, our patient was admitted to hospital with profuse vomiting. Laboratory tests showed diabetic ketosis (blood glucose 15⋅5 mmol/L and blood ketones 1647 μmol/L). After admission, she frequently had hypertensive episodes, with blood pressure readings up to 200/110 mm Hg. She had extremely high urine norepinephrine 22 775 nmol/day, [normal 287–996], urine
normetanephrine 60 060 nmol/day, [491–1802], and plasma norepinephrine 78⋅2 nmol/L [0⋅6–2⋅7]. CT of the abdomen showed a 8⋅7×8⋅8×7⋅3 cm left-sided adrenal mass with peripheral enhancement and a central area of low density (figure). A meta-iodobenzylguanidine (MIBG) scan revealed increased uptake in the left adrenal gland with no evidence of abnormal extra-adrenal uptake. In August, 2009, laparoscopic adrenalectomy and histological analysis of the tumour confirmed the diagnosis of phaeochromocytoma. After the operation, her blood glucose, blood pressure, and plasma norepinephrine were normal. Furthermore, her mental state became stable and the anxiety attacks no longer occurred. When last seen in March, 2010, she was well with no further history of self-harm. Anxiety is the fourth most common symptom of phaeochromocytoma, after palpitations, headaches, and sweating, and it occurs in approximately 30% of patients.1 In patients with phaeochromocytoma, prominent anxiety or a sense of doom occurs during a hypertensive crisis that is caused by episodic secretion of catecholamines.2 Selfharming is an unusual way of coping with anxiety in primary anxiety disorders; our patient self-harmed to relieve the restlessness associated with her anxiety. Although her clinical course seemed to be related to life stress, the anxiety attacks improved after removing the adrenal mass. Therefore, we concluded that her anxiety symptoms could predominantly be attributed to phaeochromocytoma. That the plasma and urine norepinephrine concentrations of our patient were very high compared with a previous study on phaeochromocytoma,3 might explain why she experienced such intense anxiety. Selective serotonin reuptake inhibitors can precipitate hypertensive crises.4 Our patient had taken paroxetine before starting self-harming, which might have exacerbated her phaeochromocytoma. Anxiety occurs in various physical conditions. This case report suggests that organic causes should be considered when psychiatric symptoms are atypical and resistant to conventional therapy. Contributors All authors looked after the patient and wrote the report. Written consent to publish was obtained. Acknowledgments We thank K Kanazawa, M Hatano, A Minagawa and H Yanaihara for contributing to patient management and providing clinical data.
Figure: CT of the abdomen: showing a left-sided adrenal mass (arrow)
874
References 1 Mannelli M, Ianni L, Cilotti A, Conti A. Pheochromocytoma in Italy: a multicentric retrospective study. Eur J Endocrinol 1999; 141: 619–24. 2 Pacak K, Keiser H, Eisenhofer G. Pheochromocytoma. In: DeGroot LJ, Jameson JL, eds, Endocrinology, 5th edn. Philadelphia: Elsevier Saunders, 2005: 2501–34. 3 Lenders JW, Pacak K, Walther MM, et al. Biochemical diagnosis of pheochromocytoma: which test is best? JAMA 2002; 287: 1427–34. 4 Seelen MA, de Meijer PH, Meinders AE. Serotonin reuptake inhibitor unmasks a pheochromocytoma. Ann Intern Med 1997; 126: 333.
www.thelancet.com Vol 377 March 5, 2011