Anxiety Due to General Medical Condition
-
Upload
katie-anderson -
Category
Documents
-
view
215 -
download
0
Transcript of 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
-
7/29/2019 Anxiety Due to General Medical Condition
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
-
7/29/2019 Anxiety Due to General Medical Condition
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
-
7/29/2019 Anxiety Due to General Medical Condition
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
-
7/29/2019 Anxiety Due to General Medical Condition
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.
-
7/29/2019 Anxiety Due to General Medical Condition
6/15
Pheochromocytoma
A neuroendocrine
tumor originating from
chromaffin cells in the
adrenal medulla-
Secretes excess
catecholamines
-
7/29/2019 Anxiety Due to General Medical Condition
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
-
7/29/2019 Anxiety Due to General Medical Condition
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
-
7/29/2019 Anxiety Due to General Medical Condition
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
-
7/29/2019 Anxiety Due to General Medical Condition
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
-
7/29/2019 Anxiety Due to General Medical Condition
11/15
Treatment
Combined + blockade Phenoxybenzamine
Selective 1-blocker -Prazosin Propanolol
Calcium Channel Blocker (CCB) Nicardipine
No Randomized Clinical Trials to compare variousregimens!
-
7/29/2019 Anxiety Due to General Medical Condition
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
-
7/29/2019 Anxiety Due to General Medical Condition
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 -
7/29/2019 Anxiety Due to General Medical Condition
14/15
Main Lessons I Learned:
Importance of HISTORY!
Importance ofpast psychiatric history for
other fields
Dont forget GMC of psychiatric symptoms
-
7/29/2019 Anxiety Due to General Medical Condition
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