CASE: Stress and chest pain
A primary care physician refers Mr. J, age 40, to our mental health clinic for evaluation of anxiety symptoms. Almost a decade ago Mr. J presented to his primary care physician with anxiety and panic attacks that included chest pain and shortness of breath. Various pharmacologic treatments, including paroxetine, were only moderately successful until 4 years ago, when Mr. J began nighttime continuous positive airway pressure (CPAP) therapy and pramipexole, 0.25 to 0.5 mg/d, for obstructive sleep apnea (OSA), at which point his anxiety completely resolved.
Mr. J reported no anxiety for many years, but when shortness of breath, palpitations, and chest pain re-emerge, he consults his primary care physician. After a negative workup for myocardial infarction, Mr. J is started on short-term beta-blocker therapy and restarted on paroxetine, 20 mg/d. A sleep medicine specialist repeats polysomnography and makes slight adjustments to Mr. J’s CPAP therapy. Mr. J relocates to our city and his new primary care physician refers Mr. J to our mental health clinic.
In addition to OSA, Mr. J has mild anemia, hyperlipidemia, and vitamin D deficiency. Mr. J was adopted and has no knowledge of his family psychiatric or medical history. His mental status is normal. Mr. J is not obese, exercises regularly, and has slight micrognathia. His current medications include paroxetine, 20 mg/d, modafinil, 200 mg/d, and ergocalciferol, 50,000 units/week for vitamin D deficiency.
Mr. J says he experienced a single panic attack 7 months ago, but none since then. However, he complains of chronic chest pressure and mild intermittent anxiety associated with the stress of his new job and recent relocation.
The authors’ observations
Mr. J’s anxiety resolved fully only after receiving treatment for OSA, which is characterized by episodes of blocked breathing during sleep (Table 1).1 Multiple studies show a significant association between OSA and panic attacks.2-5 In a survey of 301 sleep apnea patients, Edlund et al6 demonstrated that OSA may cause nocturnal panic attacks. Untreated OSA can worsen anxiety symptoms. In a study of 242 OSA patients, those who were not compliant with CPAP therapy had significantly higher anxiety scores as measured on the Hospital Anxiety and Depression Scale.7
OSA treatment options include CPAP, oral appliance, and surgery; weight loss and positional therapy may help. Thyroid function, B12, folate, ferritin, and iron studies, and complete blood count can rule out secondary causes of OSA.
Table 1
Obstructive sleep apnea risk factors, symptoms, and features
| Established risk factors | Obesity, craniofacial abnormalities, upper airway soft tissue abnormalities, male sex |
| Potential risk factors | Heredity, smoking, nasal congestion, diabetes |
| Symptoms | Daytime sleepiness; nonrestorative sleep; witnessed apneas by bed partner; awakening with choking; nocturnal restlessness; insomnia with frequent awakenings; impaired concentration; cognitive deficits; mood changes; morning headaches; vivid, strange, or threatening dreams; gastroesophageal reflux |
| Common features in patients with obstructive sleep apnea | Obesity, large neck circumference, systemic hypertension, hypercapnia, cardiovascular or cerebrovascular disease, cardiac dysrhythmias, narrow or ‘crowded’ airway, pulmonary hypertension, cor pulmonale, polycythemia |
| Source: Reference 1 | |
HISTORY: A succession of diagnoses
Approximately 9 years ago, Mr. J experienced several episodes of waking in the middle of the night from a bad dream with severe shortness of breath and chest pain. He also reported increasing fatigue, anxiety, and stress regarding work, graduate school, and his wife’s recent miscarriage. After negative cardiac workups, his primary care physician diagnosed panic attacks. He referred Mr. J to stress management classes and prescribed clonazepam, 1.5 mg/d, which was discontinued after 2 months.
One week after discontinuing clonazepam, Mr. J experienced chest pain, shortness of breath, and anxiety while awake. A cardiologist ruled out cardiac pathology. Mr. J’s primary care physician prescribed sertraline, 25 mg/d, and propranolol, 60 mg/d and 10 mg as needed, for anxiety.
Shortly after, Mr. J moved to a different city. His new primary care physician discontinued sertraline and propranolol and started paroxetine, titrated to 20 mg/d. A psychiatrist diagnosed Mr. J with panic disorder without agoraphobia, continued paroxetine, and added alprazolam, 1 mg/d as needed. Mr. J’s anxiety symptoms were moderately controlled for several years.
After his son was diagnosed with attention-deficit/hyperactivity disorder (ADHD), Mr. J also was evaluated and found to have ADHD and major depressive disorder, single episode. Mr. J received methylphenidate, 54 mg/d, and paroxetine was titrated to 40 mg/d, with moderate results.
Approximately 6 years before presenting to our clinic, Mr. J reported worsening daytime fatigue, which was treated with modafinil, 200 mg/d. He experienced significant improvement. The next year methylphenidate was switched to amphetamine/dextroamphetamine, then discontinued because of side effects. His physician started Mr. J on atomoxetine, which also was discontinued because of side effects.