Anxiety Due to General Medical Condition

7/29/2019 Anxiety Due to General Medical Condition

1/15

A classic (but easily forgotten)

cause of Anxiety

Katie Anderson

Texas A&M COMMSIII


2/15

Case

51 yo F presented to a breast surgeon w/ historyof nipple discharge.

No PMH volunteered- After breast evaluation-Microdochectomy advised

Day of admission BP was 160/110, tachycardic.Patient mentioned she was anxious about theprocedure and had impending sense of doom.

15 min. after induction of general anesthesia shedeveloped uncontrolable tachycardia and systolicBP >250 mm/Hg

Given 5mg IV labetolol- became hypotensive


3/15

Procedure terminated, transferred to ICU , uneventfulrecovery

On direct questioning - reported 10 year history ofprevious:

panic attacks, pressure on her chest, shallow breathing,palpitations, tremors, severe headaches, difficulty at jobboard meetings with profuse sweating and dizziness

Previously Dx:

Paroxysymal SVT, functional chest pain, migraine, GAD,Depression, and panic attacks

BP never previously elevated


4/15

Further investigation

24 hour urinenormetanephrine/creatinineratio: 639 (26-300)

Metanephrine/creatinineratio: Over 100 times above normal

range

10833 (5-90) CT scan showed 15 cm cystic

tumor localized to rightadrenal


5/15

Treatment

3 week pre-operative blockade with Prazosin

Surgery to remove tumor

Post-op reported complete and dramaticresolution of feelings of anxiety, stress, and

panic.

6month follow up- fully recovered. Previoussymptoms of palpitations and anxiety had

completely disappeared.


6/15

Pheochromocytoma

A neuroendocrine

tumor originating from

chromaffin cells in the

adrenal medulla-

Secretes excess

catecholamines


7/15

Excess Catecholamines

Alpha-Adrenergic Receptors

1:vasoconstriction, intestinal relaxation, uterinecontraction, pupillary dilation

2: presynaptic NE, platelet aggregation,vasoconstriction, insulin secretion

Beta-Adrenergic Receptors

1: HR/contractility, lipolysis, renin secretion 2:vasodilation, bronchodilation, glycogenolysis 3: lipolysis, brown fat thermogenesis


8/15

Signs and Symptoms

The Ps

Classic Triad:

Pain (Headache) 80%

Perspiration 71% Palpitations 64%

Also:

Pressure (hypertension) 90%

Pallor 42%

Paroxysmsspells 10-60 minutes

May have associated HTN, impending sense of doom


9/15

Rule of 10s

10% are extra-adrenal (paragangliomas)

10% are malignant

10% are bilateral

10% are familial

10% occur in children

10% recur

10% are discovered incidentally

10% are not associated with hypertension


10/15

Work-up

24h urine collection: Creatinine, catecholamines, metanephrines,

vanillymandelic acid (VMA), +/-dopamine

Plasma Catecholamines,Metanephrines

CT abdomen Adrenal mass sensitivity 93-100%

Extra-adrenal mass sensitivity 90%

MRI > SEN than CT for extra-adrenal mass

MIBG Scan SEN 80-90% SPEC 95-100%

123 I metaiodobenzylguanidine


11/15

Treatment

Combined + blockade Phenoxybenzamine

Selective 1-blocker -Prazosin Propanolol

Calcium Channel Blocker (CCB) Nicardipine

No Randomized Clinical Trials to compare variousregimens!


12/15

Anxiety d/t GMC Many Causes!

Endocrine: Hyperthyroidism, hypothyroidism,

pheochromocytoma, hypoglycemia,hyperadrenocorticism

Cardiovascular conditions congestive heart failure, Pulmonary embolism,

arrhythmias

Respiratory conditions chronic obstructive pulmonary disease,

pneumonia, hyperventilation, asthma

Metabolic conditions vitamin B12 deficiency, porphyria

Neurological conditions

neoplasms , vestibular dysfunction, encephalitis


13/15

DSM IV- Anxiety due to GMC

A. Prominent anxiety, Panic Attacks, or obsessions or compulsions predominate inthe clinical picture.

B. There is evidence from the history, physical examination, or laboratory findingsthat the disturbance is the direct physiological consequence of a general medicalcondition.

C. The disturbance is not better accounted for by another mental disorder (e.g.

Adjustment Disorder With Anxiety in which the stressor is a serious generalmedical condition).

D. The disturbance does not occur exclusively during the course of a Delirium.

E. The disturbance causes clinically significant distress or impairment in social,occupational, or other important areas of functioning.

Specify if:

With Generalized Anxiety: if excessive anxiety or worry about a number of eventsor activities predominates in the clinical presentationWith Panic Attacks: if Panic Attacks (see p. 395) predominate in the clinicalpresentationWith Obsessive-Compulsive Symptoms: if obsessions or compulsions predominatein the clinical presentation
http://www.behavenet.com/adjustment-disorderhttp://www.behavenet.com/mental-disorderhttp://www.behavenet.com/adjustment-disorderhttp://www.behavenet.com/deliriumhttp://www.behavenet.com/deliriumhttp://www.behavenet.com/adjustment-disorderhttp://www.behavenet.com/adjustment-disorderhttp://www.behavenet.com/mental-disorder


14/15

Main Lessons I Learned:

Importance of HISTORY!

Importance ofpast psychiatric history for

other fields

Dont forget GMC of psychiatric symptoms


15/15

References

J. Edge. Phaeochromocytoma - a classic (but easily forgotten) cause ofanxiety. Afr Journal of Psychiatriy. 2011; 14:154-156.

Koepetsch R, Slisko M, Kilisil A et al. Frequent incidental discovery ofphaeochromocytoma: data from a German cohort of 201phaechromocytoma. European Journal Endocrinology 2009; 1611 (2): 355-361

J.T. Adler, G.Y. Meyer-Rochow, H. Chen et al.Pheochromocytoma: currentapproaches and future directions. Oncologist, 13 (2008), pp. 779793

M. Prokhorova, S. Fritz. Case of a 73-year-old man with dementia and alikely pheochromocytoma mistaken for an anxiety disorder.Psychosomatics, 43 (2002), p. 82

Mohlman J, Bryant C, Lenze EJ, et al. Improving recognition oflate lifeanxiety disorders in Diagnostic and Statistical Manualof Mental Disorders,fifth edition: observations and recommendations of the advisorycommittee to the lifespan disorders workgroup. Int J Geriatric Psychiatry

T. Scholz, G. Eisenhofer, K. Pacak, H. Dralle, H. Lehnert. Clinical review:current treatment of malignant pheochromocytoma. J Clin EndocrinolMetab, 92 (2007), pp. 12171225

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Anxiety Due to General Medical Condition