Is It Panic Disorder or PSVT?

Lessmeier TJ, et al. Unrecognized paroxysmal supraventricular tachycardia. Potential for misdiagnosis as panic disorder. Arch Intern Med 1997;157:537-543.

In this interesting study, investigators performed a retrospective survey of 107 consecutive patients with documented reentrant PSVT referred for electrophysiologic studies. Assessments of symptoms were made, including the application of criteria for panic disorder from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Sixty-seven percent of patients met the criteria for panic disorder according to the DSM-IV. PSVT was unrecognized after initial medical evaluation in 59 patients (55%), including 13 of 32 (41%) patients with ventricular preexcitation by electrocardiogram; it remained unrecognized for a median of 3.3 years. Prior to eventual identification of PSVT, over half of nonpsychiatrist physicians attributed the symptoms to panic, anxiety, or stress. The investigators concluded: "The clinical characteristics of patients with PSVT referred for electrophysiologically guided therapy can mimic panic disorder. Diagnosis of PSVT is often delayed by inappropriate rhythm detection techniques (Holter instead of event monitoring) and failure to recognize ventricular preexcitation in the sinus electrocardiogram; symptoms due to unrecognized PSVT are often ascribed to psychiatric conditions."

Commentary

This paper features some important points. Remember, though, that it deals with a somewhat skewed population -- patients who have been referred for electrophysiologic studies. Nonetheless, physicians often missed preexcitation and used inappropriate diagnostic techniques. Event monitoring is far more effective than Holter monitoring for patients with symptoms -- they push a button and trigger the recorder only when an event is present. It would be interesting to perform a variant of this study and put event monitors on people with panic disorder symptoms and no history of cardiac problems.