Robert W. Hamilton, M.D. Psychiatrist Health Systems
Panic disorder is a fairly common psychiatric problem. It is probably the most frequently reported psychiatric syndrome associated with Mitral Valve Prolapse Syndrome.
Panic disorder is manifested by discrete periods of intense fear or discomfort with associated physical and emotional symptoms. The actual “attacks” tend to be fairly short in duration, lasting typically no more than a few minutes. In most instances, these attacks seem to be unrelated to any specific stress; they seem to come “out of the blue.” As the illness progresses, however, individuals who have suffered an attack in a certain situation may tend to have an anticipatory fear of that situation. After they have developed this kind of anticipatory anxiety about a given situation, they may be at risk to have a recurrence of attacks in that particular situation. As a result, the individual tends to avoid various situations in which they have had panic and their world becomes more and more enclosed. When the person has experienced panic in so many social settings that they become basically housebound, then they are experiencing a condition known as agoraphobia.
Panic disorder typically begins in the last 20s and panic disorder with associated agoraphobia is approximately twice as common in women as in men. Initially, the attacks may be limited in the number of symptoms that are experienced or in the frequency of attacks. However, the tendency is for this disorder to progress. This is in part due to the fact that there is a great deal of anticipatory anxiety in the intervals between attacks. This anticipatory anxiety tends to feed on itself and as a person becomes more fearful of having a panic attacks, they are more at risk to have one. There is a fairly wide variation in the number of symptoms a given individual will experience during an attack. Some of the more commonly reported symptoms include:
?Shortness of breath or smothering
?Dizziness of fainting
?Palpitations or heart racing
?Trembling or shaking
?Nausea or abdominal distress
?Numbness or tingling
?Flushing or chills
?Chest pain or discomfort
?Fear of dying
?Fear of going crazy or losing control
Although experiencing any one of these symptoms is quite distressing, psychiatrists typically find that four of the above noted symptoms are necessary to fully qualify for panic disorder. Fewer than four symptoms would be described as “limited symptom attacks.”
Individuals with MVPS seem to be at higher risk to develop panic disorder than the general population;however, not all individuals with MVPS will develop panic. It is based on biochemical changes and abnormalities in the person’s body, and as such, medications are frequently necessary to adequately treat it.
Panic disorder is a very common illness, particularly in the patient suffering with MVPS. Although it can be extremely debilitating, particularly as it progresses and becomes severe, IT IS QUITE TREATABLE and can be interrupted in its early stages with effective treatment.
Treatment of Symptomatic Mitral Valve Prolapse Syndrome and Dysautonomia
Phillip C. Watkins, MD, FACC
Director and founder of the MVP Center, Birmingham, Alabama
The Patient with symptomatic mitral valve prolapse and dysautonomia can present with multiple symptoms including fatigue, chest pain, increased cardiac awareness, and mood changes. Many of these symptoms are mistaken for other disorders, and the diagnosis is not easily made. The patient should be evaluated carefully with a complete history, as well as a physical exam and appropriate testing including treadmill testing and echocardiography (echo). Treatment should consist of complete education of the patient, stressing the importance of life style changes such as avoiding caffeine and a prescription for regular exercise. Appropriate medications may include a beta-blocker if the patient is hyperadrenergic, and a trycyclic or a benzodiazepine, or a serotonin reuptake inhibitor, if the patient experiences mood swings. The patient who experiences syncope and marked hypotension may require fluorohydrocortisone. Carefully following these life style changes and appropriate use of medication should produce marked improvement of the patients symptomalogy.
Mood swings are quite common in patients with this syndrome. Patients commonly experience anxiety for no apparent reason. This can be manifested by a racing, pounding heartbeat and by becoming sweaty, clammy, and
more anxious. At times this can progress to full-blown panic attacks. These symptoms are experienced by almost
three-quarters of MVPS patients at some time in their lives. Also common are mood swings in which the patient
becomes quite depressed and “down in the dumps.” Either in a premenstrual syndrome setting or in more of a seasonal variation. The so-called “holiday blues,” or seasonal affective disorder is a very common occurrence in patients with this syndrome.
There appears to be a marked variation in serum serotonin levels that causes these mood swings. Where as panic attacks can occur at any time, they appear to be more frequent in the summer months, and conversely, the depressive episodes appear to be more common in the winter months. This has been shown to be due to decreased daylight hours with associated decreased production of melatonin and serotonin.
The increasing ability of the serotonin reuptake inhibitors has made it much easier to treat mood swings in the mitral valve prolapse/dysautonomia patient. They are beneficial not only for the expressive symptoms that occur, but also for the antipanic effects. The antipanic effects of serotonin reuptake inhibitors are beneficial particularly when combined with the appropriate beta-blockers. In general, the longer-acting serotonin reuptake inhibitors medications appear to work the best. Fluoxitine in dosages of 10 to 20 mgs per day, sertraline 25 to 100 mgs. Per day, or paroxetine 10 to 20 mgs per day are efficacious regimens. Some of the side effects associated with serotonin reuptake inhibitors, such as nausea, can be minimized by taking the SSRIs with meals. Some patients may not tolerate the use of SSRIs as they tend to have more anxiety and panic symptoms. If this is the case, they generally will benefit more from the used of a tricyclic rather than the SSRI.
When the physician prescribes an SSRI, he or she must be very patient and not simply advance the dosages of the medications if the patient does not experience improvement in one or two weeks. With these medications, it can take as long as 3 weeks or more to see maximal improvements.
Patients who do not tolerate SSRIs quite often do nicely with the use of imipramine or nortripyline. Imipramine
appears to be efficacious in patients with chest pain as well as panic.
In summary, the appropriate treatment of the patient with MVPS and dysautonomia begins with a high degree of suspicion of the clinical presentation in making the diagnosis. This should be followed up by education and reassurance, with particular emphasis on fluid-loading, aerobic exercise, and avoidance of caffeine and sugar. Appropriate medications are then prescribed for the symptomatic patients, with subsequent follow-up to adjust medications. Later, as the patient becomes asymptomatic, the physician can gradually reduce their medication.
SELECTIVE SEROTONIN REUPTAKE INHIBITORS (SSRIS)
SSRIs INHIBIT A KEY PROCESS THAT IS REQUIRED FOR INACTIVATING AND RECYCLING THE CHEMICAL MESSENGER, SEROTONIN. The process is reuptake of released serotonin back into the nerve terminals that store it. SSRIs are widely used to treat depression, anxiety, and other psychiatric or emotional problems. They are also used to treat some forms of dysautonomia.
David S. Goldstein, M.D., Ph.D Chief, Clinical Neurocardiology Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health
“It makes me truly sad to see some of our patients that are still suffering from panic attacks.” With the medications
we have available today, no one should have to suffer from these disabling attacks.”
Lyn Frederickson, RN, MSN Author of the first book published on MVP Syndrome/Dysautonomia “Confronting Mitral Valve Prolapse Syndrome.” This book, unfortunately is out of print. If you have an old one, keep it.
Lyn Frederickson became our good friend and endorsed our book saying “ The authors clearly did their homework. I suspect that this will become the new Bible for MVP and I send a hearty congratulation.
Debra Doud, M.D. Cardiologist, Midwest Heart Specialists “ Spoke at one of our seminars and said “ I have talked to several people here today that are still having panic attacks, this does not need to happen any more.
Back to panic attacks. Remember the autonomic nervous system operates at the border of the mind and body.
Most people who have dysautonomia exhibit an excessive degree of sympathetic nervous system (Nancy Sawyer M.D.)
If you read about panic you might see it explained simply as a “chemical imbalance” or a “serotonin deficiency. However, it’s not that simple. We really don’t know what causes depression and/or anxiety or how it affects the brain. We don’t even know how antidepressants work.
That said, many researchers believe that the benefits of antidepressants stem from how they affect certain brain circuits and the chemicals (called neurotransmitters that pass along signals from one nerve to another in the brain. These chemicals include serotonin, dopamine, and norepinephrine. In different ways different antidepressants seem to affect how these neurotransmitters behave. Many researchers believe people with mvps/d have an imbalance of serotonin. Therefore they are given an antidepressant that affects the serotonin. They get well, so there’s the proof. Other patients will need a different medication that affects serotonin and norepinephrine