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Anxiety Disorders: Aortic Aneurysm in the Differential?

(PSYCHIATRIC TIMES) - Anxiety disorders, including panic attacks, may have multiple cardiovascular causes, such as congestive heart failure, arrhythmias, angina, and mitral valve prolapse.1 A literature search of several databases (PsycINFO, PubMed, Medline, Biomedical Reference Collection, and Psychology & Behavioral Science Collection) revealed only 1 report of panic attack symptoms possibly related to an enlarging thoracic aortic aneurysm (TAA).2 However, possible connections have been noted between aneurysmal dissection and both weight lifting3 and extreme emotional states.4 These initial and varied findings further support a possible connection between emotional symptomatology and aortic aneurysms.

In an attempt to further expound on this minimally researched topic, we present 2 cases in which anxiety symptoms may be associated with an aortic aneurysm. We also briefly review aortic aneurysms.

This patient is a 51-year-old man with a long history of posttraumatic stress disorder (PTSD), alcohol dependence (in full sustained remission), hypertension, gastroesophageal reflux disease, atypical chest pain, hepatitis C, bladder cancer (in remission), and chronic back pain related to degenerative joint disease.

He presented with worsening anxiety and panic symptoms a few months before his TAA diagnosis. Worsening symptoms included sleep-onset insomnia, worrying, difficulties with concentrating, tremors, tingling in his fingers, and palpitations. He denies any recent psychosocial stressors or medication changes to account for these symptoms. He has been taking alprazolam, 1 mg tid, for the past 15 years. In addition, he has been taking citalopram, 60 mg at bedtime; doxepin, 50 mg at bedtime; and hydrocodone-APAP, as needed for pain.

A routine chest radiograph taken 2 years earlier, and a follow-up CT scan, confirmed the dilatation of the ascending fusiform aorta, which measured 5 cm in diameter. Cardiac catheterization also showed a moderately severe dilatation of the ascending thoracic aorta. Surgical resection ensued; the patient remains stable.

This patient is a 54-year-old man with a history of PTSD, schizophrenia (residual), hypertension, dyslipidemia, obesity, chronic renal failure, and coronary artery disease that required a 5-vessel coronary artery bypass graft 10 years earlier and coronary stent placement 4 years earlier. He also has a 20-year history of chronic low back and lower extremity numbness and pain as a result of a work-related injury.

He was stable on a regimen of diazepam, 5 mg bid, until 4 years ago, when he noted worsening of his nightmares, anxiety, and panic symptoms; these worsening symptoms resulted in the doubling of his diazepam dose. His new-onset panic symptoms included tremors, chest pain, sweats, shortness of breath, dizziness, choking sensations, and feelings of impending doom and were not consistent with his typical PTSD-related anxiety. His schizophrenia remained in full remission.

At the time of his aneurysm diagnosis, his medication regimen included diazepam, 10 mg bid; thiothixene, 20 mg at bedtime; and benztropine, 2 mg once daily. His nonpsychotropic medications included allopurinol, 200 mg once daily; aspirin, 325 mg once daily; felodipine extended-release, 10 mg in the morning and 5 mg in evening; hydrochlorothiazide, 25 mg in the morning; lisinopril, 40 mg in the morning; methocarbamol, 500 mg bid; naproxen, 500 mg bid; nitroglycerin sublingual, 0.4 mg as needed; and simvastatin, 20 mg once daily. There were no changes in his medication regimen that would account for his increased anxiety symptoms.

Based on the patient's complaints of increased back and shoulder pain, a CT scan was ordered; it showed a TAA of 3 cm in diameter. The most recent CT scan showed slight expansion of the aneurysm to 3.3 cm.

Later onset or worsening of anxiety symptoms is often a sign of a concomitant or worsening medical condition. Disorders such as chronic obstructive pulmonary disease or thyroid dysfunction are commonly considered in the differential diagnosis of anxiety disorders, but aneurysms are not.

In the cases presented, both patients have numerous medical conditions that can result in anxiety symptoms. Both patients also have risk factors for an aortic aneurysm, but this diagnosis was not considered during either patient's initial presentation for worsening symptoms. This is especially critical when situational, laboratory, and medication or illicit substance effects have been ruled out as a cause of worsening anxiety, as was the case in both patients.

Currently, there are no data to support a causal effect. In the cases presented here, there was no documentation of a causal or direct temporal relationship between aneurysmal formation and anxiety. Therefore, we propose a relational connection between stress and aneurysm and possibly aneurysm and increased emotional distress.

Proposed mechanisms for this connection are 2-fold. The first mechanism may be that an enlarging aneurysm may physically have a "mass effect on the nearby sympathetic ganglion."2 This neurohormonal effect may produce panic or generalized anxiety symptoms. The other mechanism, which was suggested by Elef-teriades, is that extreme emotional or physical states may lead to sudden sharp increases in blood pressure that might result in aneurysmal dissection in those who may be genetically vulnerable.4 Genetic vulnerability is important to assess during history taking, because studies suggest that there are higher familial prevalence rates of aneurysm.5 This hypertension connection may also reflect on the hypothesis that the hypertension resulting as part of an anxiety state may worsen or increase the risk of an aortic aneurysm or aortic dissection.

Aortic aneurysm--the dilation, bulging, or ballooning out of part of the wall of the aorta--is a silent and often instant killer. About 15,000 Americans die suddenly each year of an abdominal aortic aneurysm (AAA) rupture; this phenomenon is the ninth leading cause of death in men older than 55 years.6 Rupture occurs because of many risk factors, including atherosclerosis, hypertension, Marfan syndrome, and chronic infections such as syphilis and tuberculosis.

There are 2 types of aortic aneurysms: abdominal and thoracic. At diagnosis, about 78% of persons with AAAs7 and 40% of those with TAAs8 are asymptomatic. Symptoms generally occur because of growth of the aneurysm, leading to increased pressure on surrounding organs, or because of rupture of the aneurysm.

The symptoms of an aortic aneurysm rupture include sudden severe pain, an extreme drop in blood pressure, and signs of shock. It is important to remember that the diagnostic triad of abdominal or back pain, a pulsatile abdominal mass, and hypotension characterizes rupture of an AAA. Immediate medical treatment is required, or death will occur within minutes.
Abdominal aortic aneurysms

In the United States, 5% to 7% of persons older than 60 years have an AAA. About 48% of AAAs are found clinically, 37% are found incidentally, and 15% are found during an unrelated abdominal operation.7 Symptoms, often vague and general complaints of abdominal pain or discomfort or a feeling of fullness, can be easily overlooked. Persons younger than 50 are more likely to have symptoms than are persons older than 50. Specific symptoms of an AAA may include the following:

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