Psychosomatics 41:74-75, February 2000
© 2000 The Academy of Psychosomatic Medicine
Panic Disorder With Agoraphobia in Reaction to Gastroenteritis
Nicole Mainguy, M.D., C.S.P.Q.,
Pierre Landry, M.D., Ph.D., F.R.C.P.C., Department of Psychiatry, Louis-H. Lafontaine Hospital, University of Montréal, Canada, and
André Marchand, Ph.D., Fernand-Seguin Research Center, Louis-H. Lafontaine Hospital, University of Quebec at Montréal, Canada
Key Words: Panic Disorder • Agoraphobia • Gastroenteritis • Letters to the Editor
TO THE EDITOR: Panic disorder is a syndrome in which medical disorders may possibly mimic, precipitate, or complicate the diagnosis. Moreover, panic disorder with agoraphobia is the most frequently reported of the anxiety disorders in association with medical illness. The syndrome has been reported to occur alone or together, secondary to a number of medical illnesses, such as cardiomyopathy, Parkinson's disease, chronic pulmonary disease, chronic pain, postinfarction heart failure, and primary biliary cirrhosis.1,2 We present two cases in which both agoraphobia and panic disorder occurred following gastroenteritis.
Case Report
Case 1. Ms. AL, a 32-year-old woman, was seen in consultation for a panic disorder present for the past 3 years. The medical examination and laboratory findings were negative. She did not take alcohol or drugs. There was no personal or family history of panic disorder. At age 29, she described being sick for 4–5 days with severe gastroenteritis. While still sick, she had an episode of fecal incontinence in a telephone booth while waiting in a subway station. No other symptoms of a panic attack were present previous to or during this incident. Although her medical illness improved in the following days, she started feeling the same abdominal symptoms whenever she entered a subway station, leading eventually to a panic attack with palpitations, difficulty in breathing, hyperventilation, sweating, and fear of dying. Gradually, the symptoms were felt in other public areas, such as theaters, waiting lines, and in her automobile during heavy traffic. The symptoms were less severe if she was accompanied by someone, and they disappeared immediately whenever a bathroom was available. These panic symptoms occurred once or twice a week. The patient responded well to 14 sessions of cognitive–behavioral therapy (CBT). The therapist and client worked though the material covered in the MAP (Mastery of Anxiety and Panic) Workbook.3 The patient remained asymptomatic 1 year after treatment.
Case 2.Ms. NL is a 20-year-old patient. She was hospitalized because of dehydration following severe diarrhea. The patient had no history of panic attacks, and family history for psychiatric illnesses was negative. She took neither drugs nor alcohol. The patient suffered from abdominal cramps and discomfort, accompanied by dizziness, nausea, and frequent vomiting. The medical investigation lead to the identification of an enterotoxin produced by a bacteria. Following remission of the symptoms, she remained cautious, fearing to induce the abdominal symptoms if she ate food. Progressively, the mere sight of food would induce gastrointestinal cramps, palpitations, sensations of shortness of breath, dizziness, chest pain, and fear of dying. Gradually, the symptoms occurred spontaneously, and she then started avoiding shopping centers, public transportation, and waiting lines, as well as situations in which she was exposed to food, such as in restaurants or at meals with friends. She was offered CBT but did not attend the sessions.
DISCUSSION
The two patients we presented had symptoms indicative of panic disorder with agoraphobia, characterized by panic attacks and generalized avoidance to a number of situations or places after severe gastroenteritis. This observation supports the findings made by other researchers that the onset of a panic-like syndrome with agoraphobia can be precipitated by a medical illness not known to have a physiological relationship with panic disorder. In both patients, the panic-like syndrome with agoraphobia is different from the one observed in other general medical conditions, such as thyroid disorders,4 vestibular dysfunctions, and cardiac conditions,1 because the symptoms persisted beyond resolution of the medical illness. Similar observations have been made in a few geriatric patients who developed late-onset agoraphobic fears with or without panic disorder in reaction to physical illnesses.2 With our patients, there was no previous indication that before or during the initial phase of their gastroenteritis, gastrointestinal discomfort had been related to a panic disorder, as has been reported by others.5 Also, the symptoms were not compatible with a diagnosis of irritable bowel syndrome that can occur after infectious diarrhea.6 The first case indicates that these patients may respond to CBT, as suggested by others.7
We conclude that more attention should be given to panic-like syndrome with agoraphobia that may develop after a medical illness.
REFERENCES
- Cassem EH: Depression and anxiety secondary to medical illness. Psychiatr Clin North Am 1990; 13:597–612[Medline]
- Lindesay J: Phobic disorders in the elderly. Br J Psychiatry 1991; 159:531–541[Abstract/Free Full Text]
- Craske MG, Barlow DH: Therapist's Guide for Mastery of Your Anxiety and Panic. Albany, NY, Graywind Publications, 1990
- Stein MB: Panic disorder and medical illness. Psychosomatics 1986; 27:833–838[Abstract/Free Full Text]
- Lydiard RB, Greenwald S, Weissman MM, et al: Panic disorder and gastrointestinal symptoms: findings from the NIMH Epidemiologic Catchment Area Project. Am J Psychiatry 1994; 151:64–70[Abstract/Free Full Text]
- Gwee KA, Graham JC, McKendrick MW, et al: Psychometric scores and persistence of irritable bowel after infectious diarrhoea. Lancet 1996; 347:150–153[CrossRef][Medline]
- Bishay NR, Tarrier N, Roberts AP: Cognitive therapy of agoraphobia in reaction to physical illness: an uncontrolled study. Irish Journal of Psychological Medicine 1995; 12:135–138
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