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Potential for Misdiagnosis as Panic Disorder

Timothy J. Lessmeier, MD; Deborah Gamperling, LPN; Vicki Johnson-Liddon, C-CVT; Barbara S. Fromm, MA; Russell T. Steinman, MD; Marc D. Meissner, MD; Michael H. Lehmann, MD

Arch Intern Med. 1997;157(5):537-543.

Abstract
Background
The diagnostic criteria for panic disorder include symptoms commonly experienced by patients with paroxysmal supraventricular tachycardia (PSVT). Since electrocardiographic documentation of PSVT can be elusive, symptoms may be ascribed to other conditions.

Objective
To systematically evaluate the potential for PSVT to simulate panic disorder.

Methods
A retrospective survey of 107 consecutive patients with reentrant PSVT was conducted. Objective and subjective assessments of PSVT symptomatology were made, including the application of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), panic disorder criteria.

Results
The criteria for panic disorder according to DSM-IV were fulfilled by 67% of patients. Paroxysmal supraventricular tachycardia was unrecognized after initial medical evaluation in 59 patients (55%), including 13 (41%) of 32 patients with ventricular preexcitation by electrocardiogram, and remained unrecognized for a median of 3.3 years. Prior to eventual identification of PSVT, physicians (nonpsychiatrists) attributed symptoms to panic, anxiety, or stress in 32 (54%) of the 59 patients. When PSVT was unrecognized, women were more likely than men to have symptoms ascribed to psychiatric origins (65% vs 32%, respectively; P<.04). Paroxysmal supraventricular tachycardia was detected in only 6 (9%) of 64 patients undergoing Holter monitoring vs 8 (47%) of 17 patients who wore an event monitor (P<.001). During a 20-month median follow-up, electrophysiologically guided therapy (ablation in 81% of patients) resolved symptoms in 86% of patients; only 4% continued to meet DSM-IV panic disorder criteria without evidence of PSVT recurrence.

Conclusions
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 on the sinus electrocardiogram; symptoms due to unrecognized PSVT are often ascribed to psychiatric conditions.

Arch Intern Med. 1997;157:537-543

Author Affiliations
From the Division of Cardiology, Department of Internal Medicine, Wayne State University and Harper Hospital, Detroit, Drs Lehmann and Steinman and Mss Gamperling and Johnson-Liddon are now with the Arrhythmia Center, Sinai Hospital, Detroit, and Dr Lessmeier is now with the Heart Clinics Northwest, Spokane, Wash.

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