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Panic disorder masquerading as pre-eclampsia
European Journal of Obstetrics & Gynecology and Reproductive Biology 51 (1993) 81-82
Panic disorder masquerading Jonathan
as pre-eclampsia
Benjamin”“, Miriam Benjaminb
aDivision of Psychiatry, bDivision of Obstetrics and Gynecology, Ben Gurion University of the Negev, Beer-sheba, Israel
(Accepted 3 June 1993)
Abstract Panic disorder is a specific psychiatric entity with specific and successful treatments. A parturient patient with sudden hypertension, hyperreflexia and headache was diagnosed with pre-eclampsia and treated with magnesium sulphate. Further attacks after discharge were recognized as panic attacks, and resolved with the anti-depressant imipramine. Key worak
Panic disorder; Pre-eclampsia; Imipramine; Anxiety
1. Introduction
Panic disorder is a discrete psychiatric entity [ 11, consisting of recurrent attacks of panic without apparent cause. During an attack, which typically lasts seconds or minutes, an indefinable feeling of impending doom, sometimes together with a fear of dying or going crazy, is attended by physical symptoms and signs, such as dizziness, palpitations, hypertension, and paresthesias. The main differential diagnosis is general anxiety. A central feature of the pathophysiology is episodic hyperactivity of the locus ceruleus, the principal noradrenergic brain stem nucleus, and a candidate ‘fear center’. Three percent of the population expe* Correspondingauthor, Laboratory of Clinical Science, NIMH, NIH Clinical Center lo-3D41, Rockville, MD 20892, USA.
0028-2243/93/$06.00 0 1993 Elsevier Scientific SSDlOO28-2243(93)01645-A
Publishers
Ireland
rience a panic attack, and 1% the full disorder. There is evidence for a genetic etiology. The standard treatments, which are highly successful, are behavioral (relaxation training) and pharmacological (‘tri-cyclic’ antiand other depressants). Benzodiazepines, useful for general anxiety, do not prevent panic attacks. Here we report a case with an initial diagnosis of preeclampsia after delivery, which was subsequently considered to have been the third in a series of panic attacks. 2. Case report MS A, 27 years old, consulted the psychiatric emergency room 6 days after her fourth delivery, because of attacks of panic. There were no previous medical, psychological or gynecological illnesses. In the recent pregnancy, Ltd. All rights reserved.
82
J. Benjamin, M. Benjamin/Eur.
regular attendance at an ante-natal care unit revealed no pathology. Repeated sonographic examinations from the 16th week to term showed a stable discrepancy of 2 weeks between ultrasonic gestational age and age by last menstrual period. Since hearing the result of the first ultrasound scan, the patient began to fear for the fetus in a way uncharacteristic of previous pregnancies, and this escalated at each visit. Two weeks before delivery she complained of reduced fetal movements. An oxytocin challenge test (OCT) was negative. During it, the patient had a feeling ‘unlike any she had ever known’, together with headache and weakness, and believed herself about to die. Blood-pressure was 120/70. Subsequently she had a spontaneous anxiety attack at home, but did not inform her obstetrician. Blood-pressure rose to 160/100 2.5 h after a normal spontaneous term delivery. Headache and weakness did not respond to intravenous diazepam. (She afterwards reported to the psychiatrist that her subjective feelings were identical to those in previous and subsequent attacks.) After another 2 h, blood-pressure had not fallen, the headache was worse, and there were epigastric pain and hyperreflexia, without edema or proteinuria. Appropriate laboratory tests were normal. She received 2 g magnesium sulphate intravenously, followed by 1 g/h. Seven hours later, blood pressure was 120170, and the symptoms had resolved. After discharge further attacks and secondary phobias led her to consult a psychiatrist. Imipramine 150 mg/day brought about a complete resolution of the disorder, and she was weaned from the medication uneventfully 3 months later. 3. Comment In retrospect, the first signs of anxiety early, when an ultrasound examination discrepancy between gestational age and We speculate that this played some part
velopment of the psychiatric disorder. The first actual panic attack occurred during an OCT. Oxytocin is not considered anxiogenic, but can cause palpitations, hypertension and water intoxication. This patient had a clear sensorium, pulse = 60, serum sodium = 140 mEquiv./l, and received less than 1 1 of fluids, virtually excluding the possibility of water intoxication. The cognitive psychological approach to panic attacks suggests that any physiological change may trigger a first attack in vulnerable (hypochondriacal) individuals. Thereafter, attacks may recur on the basis of a ‘kindling’ phenomenon, as in epilepsy [ 11. So an OCT in an already anxious mother may have finally precipitated the syndrome, which then became autonomous. The patient did not report her anxiety attacks to her obstetrician, so the sudden rise in blood pressure after delivery was not considered a psychiatric problem, and pregnancy-induced-hypertension was diagnosed. However, in retrospect, neither the hyperreflexia, which is a non-specific concomitant of anxiety, nor the response to magnesium, which is a non-specific neuro-muscular inhibitor, seems sufficient keys to diagnose pre-eclampsia rather than panic in this case. If this is so, optimal management would have included (1) confident reassurance by the obstetrician and a psychiatrist that panic disorder is a recognized, benign entity, (2) relaxation training during pregnancy, and (3) imipramine after delivery if necessary. Imipramine is not recommended late in pregnancy because of possible toxic (not teratogenic) effects on the fetus [2]. 4. References 1
appeared showed a fetal size. in the de-
J. Obstet. Gynecol. Reprod. Biol. 51 (1993) 81-82
2
Kaplan HI, Sadock BJ. Synopsis of psychiatry, Baltimore, MD: Williams and Wilkins, 1986: Baldessarini RJ. Drugs and the treatment of disorders. In: Gilman AG, Goodman LS, eds. The Pharmacological Murad F, Therapeutics, 7th edn. New York: Macmillan,
5th edn. 316. psychiatric Rail TW, Basis of 1985: 875.
Panic disorder masquerading Jonathan
as pre-eclampsia
Benjamin”“, Miriam Benjaminb
aDivision of Psychiatry, bDivision of Obstetrics and Gynecology, Ben Gurion University of the Negev, Beer-sheba, Israel
(Accepted 3 June 1993)
Abstract Panic disorder is a specific psychiatric entity with specific and successful treatments. A parturient patient with sudden hypertension, hyperreflexia and headache was diagnosed with pre-eclampsia and treated with magnesium sulphate. Further attacks after discharge were recognized as panic attacks, and resolved with the anti-depressant imipramine. Key worak
Panic disorder; Pre-eclampsia; Imipramine; Anxiety
1. Introduction
Panic disorder is a discrete psychiatric entity [ 11, consisting of recurrent attacks of panic without apparent cause. During an attack, which typically lasts seconds or minutes, an indefinable feeling of impending doom, sometimes together with a fear of dying or going crazy, is attended by physical symptoms and signs, such as dizziness, palpitations, hypertension, and paresthesias. The main differential diagnosis is general anxiety. A central feature of the pathophysiology is episodic hyperactivity of the locus ceruleus, the principal noradrenergic brain stem nucleus, and a candidate ‘fear center’. Three percent of the population expe* Correspondingauthor, Laboratory of Clinical Science, NIMH, NIH Clinical Center lo-3D41, Rockville, MD 20892, USA.
0028-2243/93/$06.00 0 1993 Elsevier Scientific SSDlOO28-2243(93)01645-A
Publishers
Ireland
rience a panic attack, and 1% the full disorder. There is evidence for a genetic etiology. The standard treatments, which are highly successful, are behavioral (relaxation training) and pharmacological (‘tri-cyclic’ antiand other depressants). Benzodiazepines, useful for general anxiety, do not prevent panic attacks. Here we report a case with an initial diagnosis of preeclampsia after delivery, which was subsequently considered to have been the third in a series of panic attacks. 2. Case report MS A, 27 years old, consulted the psychiatric emergency room 6 days after her fourth delivery, because of attacks of panic. There were no previous medical, psychological or gynecological illnesses. In the recent pregnancy, Ltd. All rights reserved.
82
J. Benjamin, M. Benjamin/Eur.
regular attendance at an ante-natal care unit revealed no pathology. Repeated sonographic examinations from the 16th week to term showed a stable discrepancy of 2 weeks between ultrasonic gestational age and age by last menstrual period. Since hearing the result of the first ultrasound scan, the patient began to fear for the fetus in a way uncharacteristic of previous pregnancies, and this escalated at each visit. Two weeks before delivery she complained of reduced fetal movements. An oxytocin challenge test (OCT) was negative. During it, the patient had a feeling ‘unlike any she had ever known’, together with headache and weakness, and believed herself about to die. Blood-pressure was 120/70. Subsequently she had a spontaneous anxiety attack at home, but did not inform her obstetrician. Blood-pressure rose to 160/100 2.5 h after a normal spontaneous term delivery. Headache and weakness did not respond to intravenous diazepam. (She afterwards reported to the psychiatrist that her subjective feelings were identical to those in previous and subsequent attacks.) After another 2 h, blood-pressure had not fallen, the headache was worse, and there were epigastric pain and hyperreflexia, without edema or proteinuria. Appropriate laboratory tests were normal. She received 2 g magnesium sulphate intravenously, followed by 1 g/h. Seven hours later, blood pressure was 120170, and the symptoms had resolved. After discharge further attacks and secondary phobias led her to consult a psychiatrist. Imipramine 150 mg/day brought about a complete resolution of the disorder, and she was weaned from the medication uneventfully 3 months later. 3. Comment In retrospect, the first signs of anxiety early, when an ultrasound examination discrepancy between gestational age and We speculate that this played some part
velopment of the psychiatric disorder. The first actual panic attack occurred during an OCT. Oxytocin is not considered anxiogenic, but can cause palpitations, hypertension and water intoxication. This patient had a clear sensorium, pulse = 60, serum sodium = 140 mEquiv./l, and received less than 1 1 of fluids, virtually excluding the possibility of water intoxication. The cognitive psychological approach to panic attacks suggests that any physiological change may trigger a first attack in vulnerable (hypochondriacal) individuals. Thereafter, attacks may recur on the basis of a ‘kindling’ phenomenon, as in epilepsy [ 11. So an OCT in an already anxious mother may have finally precipitated the syndrome, which then became autonomous. The patient did not report her anxiety attacks to her obstetrician, so the sudden rise in blood pressure after delivery was not considered a psychiatric problem, and pregnancy-induced-hypertension was diagnosed. However, in retrospect, neither the hyperreflexia, which is a non-specific concomitant of anxiety, nor the response to magnesium, which is a non-specific neuro-muscular inhibitor, seems sufficient keys to diagnose pre-eclampsia rather than panic in this case. If this is so, optimal management would have included (1) confident reassurance by the obstetrician and a psychiatrist that panic disorder is a recognized, benign entity, (2) relaxation training during pregnancy, and (3) imipramine after delivery if necessary. Imipramine is not recommended late in pregnancy because of possible toxic (not teratogenic) effects on the fetus [2]. 4. References 1
appeared showed a fetal size. in the de-
J. Obstet. Gynecol. Reprod. Biol. 51 (1993) 81-82
2
Kaplan HI, Sadock BJ. Synopsis of psychiatry, Baltimore, MD: Williams and Wilkins, 1986: Baldessarini RJ. Drugs and the treatment of disorders. In: Gilman AG, Goodman LS, eds. The Pharmacological Murad F, Therapeutics, 7th edn. New York: Macmillan,
5th edn. 316. psychiatric Rail TW, Basis of 1985: 875.