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Panic Attacks May Be Sign Of Lyme Disease
A Pennsylvania psychiatrist who practices in an endemic area for tick-borne diseases reports that virtually every patient she has treated for new-onset panic attacks in recent years has been diagnosed with Lyme disease.
"In four years, since I've been testing people in my office, I have not found anybody who presented with panic attacks who has not had Lyme disease," says Virginia T. Sherr, M.D., who is in private practice in Holland, Pa. "This is a very controversial finding, but I live in an endemic area."
Sherr presented data on three patients at the 52nd Institute on Psychiatric Services annual meeting in Philadelphia. She says that among referrals for panic attacks, she saw three patients who were nurses in severe panic states. Their symptoms included racing pulse, breathlessness, overwhelming anxiety, a sense of impending doom, sweating, unique pains, headaches, chills and confusion. The patients also complained of hypersensitivity to light and sound. None of the patients was suspected of having, nor were fully evaluated for, tick-borne diseases by their family physicians.
After taking high oral doses of antibiotics, anxiolytic drugs immediately became unnecessary in one patient, and doses were greatly reduced to only rare use in the other two.
Link between panic attacks, Lyme disease
In past research, Brian A. Fallon, M.D., MPH, associate professor of clinical psychiatry at Columbia University and director of the Lyme Disease Research Program at the New York State Psychiatric Institute in New York City, examined the association between neuropsychiatric illness and Lyme disease. Of the patients in his sample group, Fallon found that 17 percent experienced panic attacks. About 9 percent of a control group of patients with lupus and arthritis experienced panic attacks.
"So it looks like there were more panic attacks among the Lyme patients, but not a tremendous amount more," he notes.
Fallon says that in the early stages of Lyme disease - even before it is diagnosed - patients may present with severe panic-like symptoms.
"I use the term 'panic-like,' because they have many of the physical symptoms of panic disorder," he explains. "But unlike a typical panic attack that starts and stops within about 15 minutes, the panic attacks [experienced by] patients with Lyme disease can go on for hours. So it's more like a prolonged, really intense panic attack. That, if anything, is the one feature which distinguishes a possible Lyme-related panic attack from an independent panic attack."
Patients living in nonendemic areas are not likely to have Lyme disease unless they have visited endemic areas and gone into wooded areas, says Fallon. "However, in Lyme-endemic areas, psychiatrists are seeing a lot of patients with Lyme disease," he adds (see related box on this page).
"They have really significant problems," Fallon notes. "They have problems with their mood, with their sleep, with fatigue. Even if the Lyme disease has been picked up, they still have residual symptoms that a psychiatrist can help with."
Fallon doesn't routinely screen for Lyme disease, but he does screen patients if they have panic disorder that is not responding to treatment, or if the patient has a history of other symptoms suggestive of Lyme disease - e.g., joint pain, significant fatigue or atypical, long-lasting panic attacks.
"If the depression or panic attacks are unusual, then you would screen for organic causes. Lyme disease would be one, but you would screen for thyroid problems and B-12 deficiencies too, perhaps."
Other psychiatric disorders most commonly associated with Lyme disease include cognitive disturbances such as short-term retrieval and verbal fluency problems, and disturbances of mood and anxiety, such as irritability and mood swings. Less common disorders associated with Lyme disease include new-onset OCD, tics, autistic-like behaviors, mania, and hallucinations or paranoid delusions, notes Fallon.
"The main disorders people present with would be marked irritability where there is a personality shift and they are a lot more hostile and agitated than they used to be," he notes. "Or, they may have mood swings, where suddenly out of the blue they're agitated or tearful. Cognitive disturbances are the other [problem]. People may suddenly find themselves forgetting things or having word-finding problems or getting extraordinarily distracted and being unable to perform multiple tasks. Less commonly, you might see paranoia, mania or obsessive-compulsive symptoms." Fallon says to keep in mind that psychotropic drugs may not work as well in patients with Lyme disease.
Symptom and testing confusion
Sherr and Fallon both are concerned about the problems of getting an accurate test for the disease and recommend several laboratories that specialize in testing for Lyme disease.
"Labs have developed their own criteria for detecting Lyme disease which are based on more scientific criteria than that of the Centers for Disease Control and Prevention (CDC) in Atlanta, whose guidelines are long outdated," she says.
The CDC states that in order to be diagnosed with chronic Lyme disease, patients must have five positive Western blot IGG bands on blood tests. However, Sherr says she has seen many patients with clear evidence of Lyme disease who have had fewer than five positive bands "and plenty of positive spirochetal DNA of the blood [whose] symptoms disappeared with the right antibiotic."
"Tragically, I've even seen very disabled people come into my office. They have been tested, and they've had four [positive] Western Blot Lyme bands. But they've been told they don't have Lyme disease because they don't have five [positive] bands."
In addition, Sherr says the CDC "promotes the idea" that in order to be diagnosed with Lyme disease, patients must have swollen joints.
"But most people [with Lyme disease] don't have a swollen joint," Sherr says. "They have pains in their joints, and they're migrating pains. When you see patients with so-called 'typical psychiatric problems,' who [also] have all these physical symptoms, you should check these people for tick-borne diseases. Anxiety and depression do not cause hypersensitivity to light and sound, nor does the usual panic attack last for hours, as do those in Lyme patients."
Sherr says that Lyme disease should be "the first cause" considered in patients with panic attacks who live in endemic areas, especially in the Northern East Coast.
"I think any person with a panic attack deserves a full workup for Lyme disease," she says.
Sherr, like Fallon, also has seen patients with Lyme disease who have been diagnosed with other psychiatric disorders, such as obsessive-compulsive disorder (OCD) and depression that began at the outset of their physical complaints. If those patients have symptoms of Lyme disease, she recommends conducting a workup on them as well.
Fallon prefers to test patients for Lyme disease himself in order to send the blood tests to specific laboratories. He does refer patients to internists or infectious disease physicians for antimicrobial therapy.
"I think it's very helpful for the psychiatrist to do the evaluation and present a solid case to the internist or infectious disease doctor so the antibiotic treatment can be initiated," he notes. "Because when you have a patient with a lot of psychiatric symptoms, the obvious conclusion would be it's a psychiatric disorder. You can understand that from an internist or an infectious disease doctor. But if you as the psychiatrist think there's something unusual, you're probably going to be the only one to know that, so you need to buttress your argument with as much hard data as possible."
Once patients with Lyme disease are on antibiotics from a treating Lyme specialist, Sherr says she occasionally uses typical psychotropic drugs, often short-term, to treat panic disorder and other psychiatric disorders in patients with Lyme disease. However, she says that in her experience, patients tend to be "hypersensitive" to medications, and may require lower doses.
"You may use the same psychotropic medicines, but you may have to use pediatric doses for some of these patients," she notes.
For example, with paroxetine (Paxil) she may start patients on 10 mg daily.
"But even this may be too much and make the person extraordinarily anxious or jittery," Sherr says. "In that case, I have them break [the tablet] in half and or quarters and take those small amounts until they get used to them. Then I build up the dose from there."
[Editor's Note: Starting doses of SSRIs, such as paroxetine, should be very low when used for panic disorder and it is not obvious that this is different in patient's with Lyme disease and panic disorder. I have had to start some panic disorder patients on as little as 1 mg/d of fluoxetine to allow them to tolerate the initial doses and titrate them very slowly to therapeutic doses. - SRS]
For new cases of panic disorder, she prefers to use very small divided doses of alprazolam (Xanax), such as 0.25 mg, one-half to a full tablet up to three times daily as needed in conjunction with the antibiotics.
"It seems to be the most user-friendly," Sherr says.
She also usesclonazepam (Klonopin) at bedtime in patients who have racing thoughts, difficulty sleeping or who have Lyme-related restless legs syndrome. For patients with what she calls "typical severe insomnia," Sherr prefers to use zolpidem (Ambien).
"Those patients have, Lyme-related brainstem dysfunction, and the resulting insomnia can be total," she says.
Sherr adds to keep in mind that if patients improve, and then their symptoms return, they may require another round of antibiotics, a different type of antibiotic or a combination ofantimicrobials from their Lyme disease specialist physician.
Sherr also says that strains of spirochetes vary, and that in some geographical areas, panic disorder may present as the predominant symptom in a majority of patients, while in other areas, memory loss or arthritis may be the predominant symptoms.