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“Connective tissue” between panic disorder and dysautonomia

      To the Editor:
      We were very interested in the paper by Gazit et al (
      • Gazit Y.
      • Nahir A.M.
      • Grahame R.
      • Jacob G.
      Dysautonomia in the joint hypermobility syndrome.
      ) which concluded that patients suffering from joint hypermobility syndrome also suffer from dysautonomia. These results are similar to previously published psychiatric findings in patients with joint hypermobility syndrome (
      • Bulbena A.
      • Duró J.C.
      • Mateo A.
      • Porta-Serra M.
      • Vallejo J.
      Joint hypermobility syndrome and anxiety disorders.
      ). Panic disorder has been found to be almost seven times more likely among patients with joint hypermobility syndrome than among other rheumatologic outpatients (

      Bulbena A, Duró JC, Porta-Serra M, et al. Anxiety disorders in the joint hypermobility syndrome. Psychiatry Res. 1993;46:59-68

      ). Moreover, joint hypermobility has been found to be 16 times more probable in patients with panic disorder than in other age- and sex-controlled outpatients (
      • Martín-Santos R.
      • Bulbena A.
      • Porta-Serra M.
      • Gago J.
      • Molina L.
      • Duró J.C.
      Association between joint hypermobility syndrome and panic disorder.
      ). Both conditions have been related to a duplication of chromosome 15 (
      • Gratacós M.
      • Nadal M.
      • Martín-Santos R.
      • et al.
      A polymorphic genomic duplication on human chromosome 15 is a major susceptibility genetic factor for panic and phobic disorders.
      ). Mitral valve prolapse, a condition briefly commented on in Gazit et al's introduction, is a syndrome found both in joint hypermobility syndrome and in panic disorder and might also be related to dysautonomic symptoms.
      Although the authors did not identify any psychiatric condition, in Table 2 they include the results of a “questionnaire designed to determine the type, extent, and duration of clinical symptoms related to the autonomic nervous system” (
      • Gazit Y.
      • Nahir A.M.
      • Grahame R.
      • Jacob G.
      Dysautonomia in the joint hypermobility syndrome.
      ). Nine of the 13 modern clinical criteria to diagnose a panic episode (
      American Psychiatric Association
      Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision (DSM-IV®-TR).
      ) were included in the questionnaire and most of them were found to be substantially higher among patients with joint hypermobility syndrome. This finding could explain why most of these patients are quite familiar with panic disorder symptoms. Although the authors state that none of the subjects had a primary psychiatric disorder, it does not guarantee that some patients did not have or had previously had panic disorder. Detecting panic disorder is not easy because these patients adopt an illness behavior that is difficult to predict (
      • Goodwin R.
      • Andersen R.M.
      Use of the behavioral model of health care use to identify correlates of use of treatment for panic attacks in the community.
      ), and most of them consult their physician about somatic complaints, especially cardiac (tachycardia, chest pain), gastrointestinal (epigastric pain or irritable bowel syndrome), and neurological complaints (headaches, dizziness, or presyncope) (
      • Katon W.J.
      • Von Korff M.
      • Lin E.
      Panic disorder relationship to high medical utilization.
      ). On the other hand, pharmacological challenges with isoproterenol in panic disorder have produced uneven results. Nevertheless, there is evidence that tricyclic antidepressant treatment may abolish isoproterenol-induced increases in systolic blood pressure, but may not affect diastolic blood pressure response (
      • Pohl R.
      • Yeragani V.K.
      • Balon R.
      Effects of isoproterenol in panic disorder patients after antidepressant treatment.
      ).
      Panic disorder is a proper medical condition, not merely a reaction caused by another illness. In fact, nowadays it is considered to be one of the most biologically based psychiatric conditions. Its association with joint hypermobility syndrome also contributes to this view, as stated in a recent editorial (
      • Collier D.
      FISH, flexible joints and panic are anxiety disorders really expressions of instability in the human genome?.
      ).
      Although dysautonomia and panic disorder are not in the same spectrum, they probably overlap. It is not uncommon to find different names overlapping in similar multisystemic medical conditions according to the different medical specialties that deal with them. This overlap is not a burden, provided that the different medical views actively converge both to enhance the knowledge of the illness and to enable better diagnosis and treatment for patients suffering from these complex disorders.

      References

        • Gazit Y.
        • Nahir A.M.
        • Grahame R.
        • Jacob G.
        Dysautonomia in the joint hypermobility syndrome.
        Am J Med. 2003; 115: 33-40
        • Bulbena A.
        • Duró J.C.
        • Mateo A.
        • Porta-Serra M.
        • Vallejo J.
        Joint hypermobility syndrome and anxiety disorders.
        Lancet. 1988; II: 694
      1. Bulbena A, Duró JC, Porta-Serra M, et al. Anxiety disorders in the joint hypermobility syndrome. Psychiatry Res. 1993;46:59-68

        • Martín-Santos R.
        • Bulbena A.
        • Porta-Serra M.
        • Gago J.
        • Molina L.
        • Duró J.C.
        Association between joint hypermobility syndrome and panic disorder.
        Am J Psychiatry. 1998; 155: 1578-1583
        • Gratacós M.
        • Nadal M.
        • Martín-Santos R.
        • et al.
        A polymorphic genomic duplication on human chromosome 15 is a major susceptibility genetic factor for panic and phobic disorders.
        Cell. 2001; 106: 367-379
        • American Psychiatric Association
        Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Text Revision (DSM-IV®-TR).
        American Psychiatric Press, Washington, D.C2000
        • Goodwin R.
        • Andersen R.M.
        Use of the behavioral model of health care use to identify correlates of use of treatment for panic attacks in the community.
        Soc Psychiatry Psychiatr Epidemiol. 2002; 37: 212
        • Katon W.J.
        • Von Korff M.
        • Lin E.
        Panic disorder.
        Am J Med. 1992; 92: 7S-11S
        • Pohl R.
        • Yeragani V.K.
        • Balon R.
        Effects of isoproterenol in panic disorder patients after antidepressant treatment.
        Biol Psychiatry. 1990; 28: 203-214
        • Collier D.
        FISH, flexible joints and panic.
        Br J Psychiatry. 2002; 181: 457-459

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