Dear Editor:
Bipolar disorder (BD) is a chronic psychiatric syndrome with frequent comorbidity with other psychiatric disorders, including anxiety disorders such as panic disorder (PD). In this case report, low-dose quetiapine (Seroquel®) effectively treated panic disorder with agoraphobia (PDA) and obsessive-compulsive disorder (OCD) in a patient with bipolar depression.
Case example and clinical data. Mr. A is a 30-year-old single, white man who satisfied DSM-IV-TR criteria for bipolar disorder, current episode depressed with mood-incongruent psychotic features, PDA, and OCD. His bipolar disorder was characterized by episodes of decreased need for sleep, flight of ideas, racing thoughts, irritability, agitation, distractibility, and impulsivity. These episodes alternated with periods of depressed mood, anhedonia, frequent crying, decreased sleep, feelings of hopelessness, impaired concentration, suicidal ideations, ideas of reference, and paranoid ideations.
His PDA was characterized by episodes of palpitations, sweating, tremors, shortness of breath, abdominal discomfort, fear of losing control, going crazy, and dying, numbness, paresthesias, and anxiety around and avoidance of crowds, lines, buses, and restaurants. Mr. A's OCD symptoms comprised spending several hours per day checking (e.g., to see if the doors were locked), washing his hands, changing his clothes, and counting. His mental status examination was remarkable for fidgeting and a depressed and anxious mood.
His blood chemistry, complete with blood cell count and thyroid stimulating hormone levels, was noncontributory.
Mr. A was started with risperidone (Risperdal®) 0.5mg daily, citalopram (Celexa™) 5mg daily, and trazodone (Desyrel®) 50 to 100mg at night. A few days later, he found that these medications did not treat his symptoms and unilaterally discontinued all of them. Quetiapine 50mg at night was initiated, followed the next day by sertraline (Zoloft®) 25mg daily. All of Mr. A's symptoms improved two days after starting the quetiapine. Believing that quetiapine adequately controlled all of his symptoms, he unilaterally discontinued the sertraline. Within approximately one week, he noted that all of his symptoms had resolved, except for his frequent changing of clothes. Twenty days after starting quetiapine, his mental status examination was within normal limits; specifically, his motor activity was normal and his mood euthymic.
Discussion
The sertononin receptor affinity of atypical antipsychotics may explain their effectiveness in anxiety disorders. Accordingly, the literature supports the use of atypical antipsychotics in the treatment of panic attacks and PD. A case report found that a schizophrenic patient switched from haloperidol to risperidone experienced a complete remission of panic attacks.1 Another case report of three patients treated with quetiapine for schizophrenia noted marked improvement in their panic attacks.2 Likewise, an eight-week study observed that olanzapine (Zyprexa®) significantly improved or resolved panic attacks.3
Although SSRIs are a first-line treatment for OCD and PDA, quetiapine may have a role in patients who fail to respond to adequate SSRI treatment or who have a comorbid bipolar disorder. The potential for hyperglycemia, tardive dyskinesia, and weight gain may limit the use of atypical antipsychotics in patients with these disorders. Therefore, large scale trials may be warranted to help define the role of atypical antipsychotics in treating OCD and PDA.
With regards,
Michael Menaster, MD
Private Practice
2107 Van Ness Ave., #102A
San Francisco, CA94109
Phone: (415) 204-2344
Fax: (415) 648-7554
E-mail: Menaster@yahoo.com
References
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