Psychosomatics 49:543-545, November-December 2008
doi: 10.1176/appi.psy.49.6.543
© 2008 Academy of Psychosomatic Medicine
Non-Fearful Panic Disorder in Gastroenterology
Piero Porcelli, Ph.D., and
Massimo De Carne, M.D.
Received May 6, 2007; revised July 21, 2007; accepted August 1, 2007. From the Psychosomatic Unit; Department of Gastroenterology, IRCCS De Bellis Hospital, Castellana Grotte, Italy. Send correspondence and reprint requests to Dr. Piero Porcelli, Unità di Psicosomatica, IRCCS Ospedale De Bellis, Via della Resistenza, 70013 Castellana Grotte, Bari, Italy. e-mail: porcellip{at}media.it
© 2008 The Academy of Psychosomatic Medicine
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ABSTRACT
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BACKGROUND: Nonfearful panic disorder (NFPD) is a panic condition masked under the appearance of somatic symptoms only, without the component of fear, and it represents a challenging diagnostic task. METHOD: This is the first case report of NFPD in a male patient with acute gastric pain and gastrointestinal disease (atrophic gastritis and H. pylori infection). RESULTS: The patient showed atypical panic symptoms and demoralization on the Diagnostic Criteria for Psychosomatic Research screening. He was successfully treated with anti-panic medication and cognitive–behavioral therapy. DISCUSSION: The case report shows that accurate psychosomatic assessment may help clinicians avoid diagnostic delay, prevent the administration of unnecessary medications, and give patients more appropriate treatment.
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INTRODUCTION
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The DSM–IV approach to medical problems has been criticized for several reasons, and it has been said to lack effectiveness in clinical practice. The main rubric of somatoform disorders may lead clinicians to a false mind–body dichotomy when deciding whether somatic symptoms are due to an underlying medical condition or primary psychopathology while the idea of psychological factors affecting medical condition is not fully integrated into the diagnostic classification. The Diagnostic Criteria for Psychosomatic Research (DCPR) were developed with the aim of providing clinicians with a suitable diagnostic tool for the evaluation of psychological distress in medical patients, and it has recently been proposed that these criteria be incorporated into DSM–V.1,2
Certain somatic symptoms, including gastrointestinal symptoms, may represent a puzzling diagnostic challenge when there are no clear-cut clinical manifestations and significant associations with psychopathology, including panic disorder (PD).3 Some PD patients may show a marked prevalence of somatic symptoms, and few, if any, psychological manifestations of the panic experience, or they may not even report fear of dying or fear of losing control, a condition that has been labeled as nonfearful panic disorder (NFPD; Table 1).4 Here, we report the case of a patient with acute gastric pain, which, however, masked an NFPD condition, for whom the use of DCPR screening was clinically helpful.
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Case Report
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The patient was a 30-year-old man who, in the previous 3 years, had suffered from sudden episodes of intense pain and burning in the upper gut, with accompanying belching, nausea, palpitations, smothering, sweating, and choking. These frequent episodes were particularly troubling because he was a special-unit policeman who was usually engaged in close-surveillance and ambushing actions against criminals and terrorists. Symptom onset occurred shortly after his marriage. He had experienced many problems with his family of origin, which led to a definite rupture with his parents because they did not accept his wife. He felt angry and disappointed, particularly with his mother, with whom he had had a dependent relationship, and isolated because of the weight of perceived responsibility after the birth of his son 1 year after his marriage. Furthermore, about 2 years after the first acute episode of gastric pain, while he was driving with his newborn infant in the car, he witnessed a fatal car crash that frightened him. This event made him avoidant, and, in the last few months, he needed to be accompanied by his wife while driving a car; he experienced some distress in open and crowded places; and he was very concerned at the prospect of soon going back to his dangerous and stressful work. Because of his health condition, he had, in fact, been placed on leave from the police department for some months.
He had been seen three times in various emergency departments before being referred to the Psychosomatic Outpatient Service of our institute. Emergency records showed that standard laboratory tests, including glycemia level, were normal during the acute attacks, and the patient did not have diabetes or other systemic diseases. At the first and follow-up visits, laboratory tests, physical examination for cardiovascular, pulmonary, and neurological functioning, and parameters of abdominal and liver functioning, were normal. Furthermore, because vital signs (blood pressure and heart rate) showed no abnormalities; the patient had no flushing or diarrhea; and symptoms did not occur in the 2 years after the first visit, the presence of unusual conditions such as carcinoid or pheochromocytoma, where episodic symptoms with similar complaints can occur, were considered unlikely. Finally, earlier endoscopy of the upper gastrointestinal tract showed mild atrophic gastritis of the antrum associated with H. pylori infection. Successful eradication of H. pylori and several treatments with proton-pump inhibitors, prokinetics, and benzodiazepines had had very few positive effects. Therefore, from a biomedical viewpoint, the patient’s symptoms were not due to a usual (peptic ulcer, diabetes, or other systemic diseases; cardiovascular disorders) or unusual (carcinoid, pheochromocytoma) condition; that is, symptoms were medically unexplained.
From a psychiatric viewpoint, although the clinical manifestation of the patient’s symptoms did not meet DSM–IV criteria for PD (or other psychopathologies that were ruled out with the use of the Structured Clinical Interview for DSM–IV Axis I Disorders), the acute episodes of pain had abrupt onset, were unexpected, were not associated with a situational trigger, and peaked very quickly. However, unlike typical panic manifestations, no fears of imminent death or losing control were associated with episodes of gastric pain—which remained his only subjectively-perceived core symptom. Furthermore, the avoidant behavior pattern, although developed some time after the onset of somatic symptoms, was strongly suggestive of one of the most frequent aspects of the panic experience (agoraphobia). Finally, the patient did not report PD or hypochondriasis in the past, and there was no family history of PD. The clinical characteristics of symptoms raised the suspicion of a panic syndrome "masked" by the report of somatic symptoms only; that is, a condition meeting the criteria of NFPD (Table 1). From the structured interview for DCPR,2 the patient met the three criteria for demoralization: namely, helplessness (the patient’s sense of personal failure to meet his expectations at work, to become independent from his mother without anger and guilt, to accomplish the expected tasks as a new father, and to cope with his health status), prolonged duration (>1 month), and close association with somatic symptoms.
The patient was treated with venlafaxine 75 mg daily and alprazolam 1.5 mg daily for 8 months, and, simultaneously, short-term cognitive–behavioral therapy (CBT) for 16 sessions once weekly. CBT addressed three clinical aspects. Psychoeducational interventions were aimed at making him aware of mechanisms and symptoms of panic. Fear of driving alone was addressed with techniques of gradual exposure and response-prevention. Demoralization constituted a specific target of CBT, and it was addressed with cognitive restructuring aimed at improving autonomy and ego-strength. After CBT, the patient returned to work and was followed up every month until the end of the drug-tapering period, 4 months later. At 2 years after the end of treatment, recovery from NFPD and gastric pain was maintained, and the patients no longer met DCPR criteria for demoralization.
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Discussion
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To our knowledge, this is the first case report in gastroenterology of a male patient with NFPD who was successfully treated with a combination of anti-panic medication and CBT. NFPD represents a diagnostic challenge for clinicians because of the "masked" presentation of panic as somatic symptoms only. The present case was particularly challenging because, even though other medical conditions were excluded, atrophic gastritis and H. pylori infection made the patient’s acute symptoms quite plausible within a medically-based framework, although both gastrointestinal conditions may present asymptomatically.
Previously, a few studies showed successful treatment of NFPD in cardiology and neurology settings;5,6 however, so far, no treatment study has been reported in gastroenterology.
The DCPR assessment of demoralization was particularly helpful in the diagnostic and treatment-planning process of this case. Demoralization is characterized by feelings of hopelessness, helplessness, sense of incompetence in coping with pressing life or health problems, and loss of control. Demoralization, which is distinct from depression, is likely to represent the most common reason why subjects seek psychotherapeutic treatment;7 it is one of the most frequent psychological syndromes in medically ill patients;8 and, even though it did not differentiate functional gastrointestinal disorder patient responders from nonresponders to treatment-as-usual,9 somatic patients with demoralization were found to respond positively to CBT.10 Despite its clinical and prognostic relevance, demoralization has not been adequately recognized by traditional diagnostic classifications, and DCPR criteria provide a useful tool for its identification in medical patients.
This case report shows that NFPD may occur in gastroenterology settings and that a comprehensive assessment of medical symptoms and psychosomatic syndromes could help clinicians avoiding delays in diagnosis and prevent unnecessary medication in medical patients with particularly challenging clinical presentation.
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REFERENCES
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- Fava GA, Fabbri S, Sirri L, Wise TN: Psychological factors affecting medical conditions: a new proposal for DSM-V. Psychosomatics 2007; 48:103–111[Abstract/Free Full Text]
- Porcelli P, Sonino N (eds): Psychological Factors Affecting Medical Condition. A New Proposal for DSM-V. Advances in Psychosomatic Medicine, 2007; No. 28. Basel, Switzerland, Karger
- Jones MP, Sharp LK, Crowell MD: Psychosocial correlates of symptoms in functional dyspepsia. Clin Gastroenterol Hepatol 2005; 3:521–528[CrossRef][Medline]
- Beitman BD, Basha I, Flaker G, et al: Non-fearful panic disorder: panic attacks without fear. Behav Res Ther 1987; 25:487–492[CrossRef][Medline]
- Mayou RA, Bryant BM, Sanders D, et al: A controlled trial of cognitive-behavioral therapy for non-cardiac chest pain. Psychol Med 1997; 27:1021–1031[CrossRef][Medline]
- Russell JL, Kushner MG, Beitman BD, et al: Nonfearful panic disorder in neurology patients validated by lactate challenge. Am J Psychiatry 1991; 148:361–364[Abstract/Free Full Text]
- Frank JD: Psychotherapy: the restoration of morale. Am J Psychiatry 1974; 131:271–274[Abstract/Free Full Text]
- Mangelli L, Fava GA, Grandi S, et al: Assessing demoralization and depression in the setting of medical disease. J Clin Psychiatry 2005; 66:391–394[Medline]
- Porcelli P, De Carne M, Todarello O: The prediction of treatment outcome of patients with functional gastrointestinal disorders by the Diagnostic Criteria for Psychosomatic Research (DCPR). Psychother Psychosom 2004; 73:166–173[CrossRef][Medline]
- Griffith JL, Gaby L: Brief psychotherapy at the bedside: countering demoralization from medical illness. Psychosomatics 2005; 46:109–116[Abstract/Free Full Text]
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ABSTRACT
INTRODUCTION
