Psychosomatics 42:81-82, February 2001
© 2001 The Academy of Psychosomatic Medicine
Anxiety and Position-Dependent Neurologic Findings Due to Autonomic Dysreflexia
Oliver Freudenreich, M.D., and
George B. Murray, M.D.
Received July 12, 2000; accepted July 31, 2000. From the Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts. Address correspondence and reprint requests to Dr. Freudenreich, Department of Psychiatry, Massachusetts General Hospital, Warren 605, Boston, MA 02114.
Key Words: Anxiety • Autonomic Dysreflexia
The phenomenon of autonomic dysreflexia is well-known to physicians working with patients with spinal cord-injuries but might be less known to other physicians. Autonomic dysreflexia can occur in quadriplegic patients with spinal cord injuries above the level of T5.1,2 Such an injury effectively disconnects the entire sympathetic nervous system from supraspinal modulation. Certain stimulations then, most often bladder distension or rectal distension, can lead to an overwhelming discharge of the sympathetic nervous system. Severe headaches are quite common. Its most dangerous manifestations are marked blood pressure elevations that can cause seizures, cerebral hemorrhage, or a myocardial infarction. A plethora of symptoms have been observed, including chest tightness and dyspnea, anxiety, pupillary dilation, penile erection, cold limbs, flushing, nasal congestion, slow pulse, and profuse sweating. Patients may only have one or two symptoms.
We present a case of anxiety due to autonomic dysreflexia to illustrate that it remains important to rule out physiological causes of anxiety, regardless of how well psychological explanations fit. Moreover, we describe a previously unreported phenomenon due to autonomic dysreflexia, that is, position-dependent anisokoria with half-sided hyperhidrosis.
Case Report
Mr. A. is a 38-year-old man who had his spinal cord severed at age 17 in a car accident, leaving him with an incomplete C4 spinal cord injury. Neurologically, he had enough use of his left hand to operate a joystick on his wheelchair but otherwise he had no motor control of his extremities; his sensory deficits were incomplete. Mr. A. was admitted to the hospital for elective correction of a urethrocutaneous fistula and coverage with a flap of a deep sacral decubitus ulcer. He had never seen a psychiatrist or required psychotropic medications. At home, Mr. A. usually wore a Texas catheter, but he had an indwelling Foley catheter in the hospital.
Mr. A. underwent two procedures separated by several days. In his initial surgery, the fistula was corrected by urethroplasty and scrotoplasty and he had a debridement of the sacral decubitus ulcer in preparation for a skin flap to cover the decubitus. The second procedure, a gluteal rotation skin flap, left him with a horizontal 25-cm scar on his back extending from side to side at the level of the os ilia. After his second operation, the indwelling Foley catheter was briefly clamped and Mr. A. started sweating profusely but this was rectified.
Two days after Mr. A.'s second operation, a psychiatry consult was called as he complained about anxiety; Mr. A. was afraid of "going crazy." He described a sense of uneasiness as well as ruminating and restless thinking after surgery. He had no concerns about heart function and denied palpitations. He had no shortness of breath, chest pain, nausea or vomiting. Mr. A. did not have the feeling that his anxiety was fluctuating or had the character of episodes. The only somatic complaint that he had was several bad headaches that he developed while in the hospital.
A chart review was replete with references to anxiety and needing reassurance, which was uncharacteristic for him. Thyrotropin was normal and other laboratory values were uninformative as well.
Mr. A.'s physical exam showed normal blood pressures and pulses over the hospital course. He was lying on his left side and had a left pupil of 8 mm and a right of 6 mm, as well as prominent, large sweat pearls strictly on his left forehead and on his left upper arm, although less pronounced. On the next visit, Mr. A. was lying on his right side, and the neurological findings were reversed, with a larger pupil on his right side and sweat pearls on his right forehead. On subsequent visits, this pattern was confirmed and the eye findings and sweating were predictable depending on Mr. A.'s position; he would always have half-sided sweating and mydriasis on the side that he lay on. Despite the persistence of the neurological findings while in the hospital, the anxiety abated over the course of several days and Mr. A.'s blood pressures remained normotensive. He had no further headaches.
Discussion
Even though anxiety is clearly recognized to be a symptom of autonomic dysreflexia, few clinical descriptions have been published. Marshall and Sperling described a patient with complete T1 transsection who developed autonomic dysreflexia postinjury that resolved and who several years later developed panic disorder that could not be related to autonomic dysreflexia.3 Marshall and Sperling argued for central-psychic anxiety in their case as their patient could not perceive (and thus interpret) somatic signals. This might be related to a feeling close to what Gorman had termed "preverbal" anxiety: anxiety that is perceived as vague and thought to arise in limbic areas.4
Mr. A. was different in that he had neurological findings that pointed to an aberrant physiological state, even if the pathophysiological details are unclear. Because he had only a partial transsection, he might have felt something that he interpreted as anxiety. We are reminded here of the James-Lange idea of the peripheral-origin theory of emotions.5 In 1890, William James stated, "my theory, on the contrary, is that the bodily changes follow directly the perception of the exciting fact, and that our feeling of the same changes as they occur is the emotion" (emphasis in the original). Clearly, though, any theory about the origin of Mr. A.'s anxiety is speculative.
Mr. A. readily agreed with the staff's psychological interpretation that he was suffering from the "beached whale syndrome": he was literally on his back, more helpless in the hospital than at home. Karl Jaspers, father of German existentialism and psychiatric descriptive phenomenology, drew a distinction between "explaining" or making causal connections and "understanding" or making meaningful connections.6 In this sense, Mr. A.'s symptoms were "understandable," one could put oneself in his shoes, or in the bed paralyzed, and understand his anxiety.
There were two signs in this case, however, that made Mr. A.'s anxiety "explainable" once conceptualized as part of autonomic dysreflexia: he had severe headaches, even though he was not usually prone to succumbing to headaches, and he had new anisokoria and position-dependent half-sided hyperhidrosis of the upper body. Although somewhat speculative, his position-dependent anisokoria and sweating could be related to the position-dependent irritation of the skin flap scar because his scar runs on his lower back fully from side to side.
Mr. A.'s treatment was supportive but only after a clearer understanding of the pathophysiology of his symptoms, reassurance that there was no psychiatric disorder, and improved monitoring of Mr. A. with regard to blood pressure. If this patient had elevated blood pressures, he would have been treated aggressively with antihypertensives.
Occam's razor does indeed apply to consult psychiatry. If there is a medical disorder, see if psychological phenomena can be embraced by it. Or in this case one might say that the sensation of the anxious body created an anxious mind: in corpore anxie, mens anxia.
REFERENCES
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McGuire TJ, Kumar VN: Autonomic dysreflexia in the spinal cord injured. What the physician should know about this medical emergency. Postgrad Med 1986; 80:81–84
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Zejdlik CP: Management of Spinal Cord Injury, Second Edition. Boston, MA, Jones and Bartlett Publishers, 1992
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Marshall JR, Sperling KB: Panic disorder in a paraplegic patient. Psychosomatics 1991; 32:346–349[Free Full Text]
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Gorman JM, Liebowitz MR, Fyer AJ, et al: A neuroanatomical hypothesis for panic disorder. Am J Psychiatry 1989; 146:148–161[Abstract/Free Full Text]
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James W: The Principles of Psychology, Volume II, Dover Publications, 1950(1890), p 449
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Jaspers K: General Psychopathology (translated from 7th Edition by Hoenig J, Hamilton MW). Manchester, UK, Manchester University Press, 1963
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