Anxiety

Brain Facts

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Panic disorder/agoraphobia and thyroid disease

Matsubayashi et al report on two patients with Graves' disease who initially presented while euthyroid with a panic disorder. Four and five years after the panic disorder began, these patients developed hyperthyroidism. Antithyroid drug treatment reduced psychiatric symptoms. The authors suggest that panic disorder may not only be a consequence of Graves' disease but may precede its onset and potentially predispose to its development.

Orenstein et al interviewed 144 consecutive female psychiatric patients and found that those with a lifetime history of either panic disorder or agoraphobia with panic attacks were more likely than the other patients to report a history of hyperthyroidism or goiter in themselves or in their first degree relatives. This personal history of hyperthyroidism or goiter was found almost exclusively in the subgroup of patients who presented with symptoms of panic/agoraphobia who also had a lifetime history of major depression.

Lesser et al measured indices of thyroid function in 165 subjects who had a DSM-III diagnosis of panic disorder with or without phobic avoidance. These investigators noted that the patients with these conditions reported a higher prevalence of thyroid illness by history compared to that encountered in the general population. However, less than one percent had current thyroid dysfunction. Patients who also had a history of a major depressive episode had a higher prevalence of thyroid disease by history. Indices of thyroid functions, however, were not correlated with severity of panic attacks or phobias.

Lesser et al47 noted a low order of occurrence of active thyroid disease in patients with panic disorder. In an eight-center drug treatment study of 165 consecutively recruited panic disorder patients, there was a higher reported incidence of thyroid disease than would have been expected in the general population. However, when specific thyroid testing was undertaken by T3, T4, TSH and free thyroxine index, fewer than one percent of these patients had any laboratory evidence of current thyroid disease. Rag also noted a low incidence of thyroid disease in the panic disorder patients that they evaluated. Matuzas et al reported significantly different findings in their study of 65 self-referred patients with panic attacks, examining them for cardiac defects and thyroid abnormalities. Fifty percent of these patients evidenced mitral valve prolapse on both cardiac auscultation and echocardiography. Twenty-six percent of the women had thyroid abnormalities. Seventeen percent had elevated thyroid microsomal antibodies. There was no relationship between those patients who had mitral valve prolapse and those who evidenced thyroid abnormalities. The authors suggested that panic attacks, mitral valve prolapse, and autoimmune thyroid disorders, are associated. Forty-six of these 65 patients also met criteria for agoraphobia and would have been classified as agoraphobic with panic attacks. The 50% prevalence of mitral valve prolapse was approximately ten times higher than the 5% to 7% estimated in the general population. Twenty-five percent of the women ages, 30 to 40, had positive antithyroid antibodies, compared to 5% to 13.8% of women of similar age in the general population. The authors suggested that the prevalence of thyroid antibody titers was elevated in patients with panic attacks.

Nemeroff et al had previously noted that 8 of 53 patients (15%) suffering from depression had elevated thyroid microsomal antibody titers. Orenstein et al46 noted that of 144 consecutive female psychiatric patients interviewed, that those with a life-time history of either panic disorder or agoraphobia with panic attacks were more likely than other patients to report a history of hyperthyroidism or goiter in themselves or in their first degree relatives. A personal history of hyperthyroidism or goiter was found almost exclusively in the subgroup of patients with panic/agoraphobia who also had a lifetime history of major depression. These investigators noted a 13% prevalence of hyperthyroidism among patients who had a history of depression/panic/agoraphobia. Their data was very similar to the 11% prevalence for a history of hyperthyroidism and agoraphobia/panic disorder reported by Lesser.

Emanuele et al reported on four cases of coexistent agoraphobia and hyperthyroidism, where the patients reported a fear of crowded or confined spaces, difficulty traveling away from home or places of safety, and the development of panic attacks. All of their patients had typical signs and symptoms of Graves' disease and unequivocal laboratory evidence of hyperthyroidism at the time of their psychiatric diagnosis. The agoraphobia preceded the onset of thyrotoxicosis in all of these patients. They noted that the anxiety experienced by their hyperthyroid patients was unrelenting, whereas the panic attacks that occurred with agoraphobia tended to be intermittent and provoked by readily identifiable situations. Their hyperthyroid patients experienced a constant tachycardia that persisted during sleep. While the rapid heartbeat seen in the primary anxiety and panic disorder patients was intermittent. They noted that the hyperthyroid patients had warm moist skin rather than the cold clammy skin associated with primary anxiety disorders. The tremor that they experienced was high frequency and low amplitude in contrast to the course tremor that is often seen with primary anxiety disorders. The hyperthyroid patients also complained of the proximal myopathy commonly seen with thyrotoxicosis. These authors noted that with appropriate treatment of the hyperthyroidism, the agoraphobia rapidly improved. Restoration of a euthyroid state, without concomitant psychotherapy, resulted in the cessation of agoraphobia with restoration of the patient's ability to function normally in the community. The investigators noted, however, that the diagnosis of agoraphobia delayed the diagnosis of hyperthyroidism in all the patients in this study and made it impossible for one patient to comply with therapeutic recommendations until advanced thyrotoxicosis developed and was diagnosed and treated two and a half years later.

Noyes et al compared 41 subjects with generalized anxiety disorder who had never experienced panic attacks with 71 subjects who presented with panic disorder. They found that among the general anxiety disordered subjects, co-existing major depression was associated with the presence of simple phobia and thyroid disorders.

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