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Chronic Obstructive Pulmonary Disease and Panic Disorder: Their Interrelationships and a Unique Utilization of Beta-Receptor Agonists

TO THE EDITOR:  Previous data from clinical samples suggest that anxiety disorders, especially panic attacks, occur more often than would be expected by chance among individuals with chronic obstructive pulmonary disease (COPD).¹ The hypercapnia and acid–base disturbances that accompany COPD may be causal in the development of "anxiety" in this population. We present a case of a patient with COPD and comorbid panic disorder who had a surprisingly "panico-lytic" response to albuterol.

Case Report
Mr. R is an 87-year-old gentleman with a medical history significant for COPD, congestive heart failure (CHF), and coronary artery disease (CAD). He was admitted to the hospital because of COPD/CHF exacerbation. We were consulted to evaluate Mr. R for "panic attacks."

Mr. R reported that he has had at least a 1-year history of discrete episodes of shortness of breath, dyspnea, chest discomfort, lightheadedness, dizziness, sweating, feelings of loss of control, and fear of dying, lasting for less than 30 minutes and relieved within 30 seconds by albuterol. According to the nursing staff, the patient had numerous similar episodes while in the hospital. On several occasions, the respiratory therapy department was notified, and, despite the patient’s complaints, there were no physiologic signs of respiratory difficulties, (no cyanosis; oxygen saturation and breath sounds within normal limits).

Discussion
Although the exact etiology of panic disorder is unknown, one theory involves CO₂ sensitivity and abnormalities in lactate metabolism.¹ It has been proposed that one possible "trigger" for the activation of the panic-disorder neuronal circuit is an abnormal sensitivity to disturbances of acid–base balance in the brainstem.² This sensitivity is supported by the panicogenic actions of CO₂ inhalation and lactate infusion, which also induce changes in acid–base balance.² Papp et al.³ concluded that panic attacks occur when a "suffocation monitor" erroneously signals a decrease in oxygenation and maladaptively triggers an evolved "suffocation alarm" system.³ This "false suffocation alarm" theory seems to account for the prominent symptoms of dyspnea during a panic attack. Bailey et al.⁵ add that hypercapnia caused a rapid increase in the firing rate of locus coeruleus neurons, which resulted in the release of norepinephrine. This could explain the high frequency of panic in patients with respiratory insufficiency (states characterized by increased by hypercapnia).

Several studies have reported a high comorbidity between panic disorder and COPD.⁴ We postulate that repetitive experiences with hypoxia and hypercapnia may sensitize neural circuits that control fear responses (i.e., in the locus coeruleus) to overreact to subsequent episodes of hypoxia or hypercapnia or to fearful perceptions of conditioned stimuli such as the sensation of breathlessness.

Surprisingly, our patient experienced "panico-lysis" from albuterol. Studies have shown, in patients without COPD/CHF, that bronchodilators may trigger a panic attack.⁴ In our patient, albuterol may have been "panico-lytic" simply because it reduced hypercapnia, thus reducing the stimulating effects of CO₂ that may precipitate a panic attack. Although we do not advocate the routine use of bronchodilators in the treatment of panic disorder, adjunctive use of bronchodilators with traditional panicolytic therapy may be helpful in patients with COPD and panic disorder.

REFERENCES

1. Roy-Byrne PP, Cowley DS: Search for pathophysiology of panic disorder. Lancet 1998; 352:9142–9147
2. Griez E, Schruers K: Mechanisms of CO₂ challenges. J Psychopharmacol 2003; 17:260–262[Free Full Text]
3. Papp LA, Martinez JM, Klein DF, et al: Respiratory psychophysiology of panic disorder: three respiratory challenges in 98 subjects. Am J Psychiatry 1997; 154:1557–1565[Abstract/Free Full Text]
4. Coffman K: Psychiatric issues in pulmonary disease. Psychiatr Clin N Am 2002; 25:89–118[CrossRef][Medline]
5. Bailey JE, Argyropoulos SV, Lightman SL, et al: Does the brain noradrenaline network mediate the effects of CO₂ challenge? J Psychopharmacol 2003; 17:252–259[Abstract/Free Full Text]

Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Email this article to a Colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to My Articles & Searches Download to citation manager Citing Articles via Google Scholar Articles by Harvey, H. Articles by Speigel, D. R. Search for Related Content PubMed Citation Articles by Harvey, H. Articles by Speigel, D. R. Panic Disorder Syndromes Secondary to General Medical Disorders

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