CLINICAL

AND

sion,

RESEARCH

Am

REPORTS

Behavior, and Psychopathology. Edited by York, Raven Press, 1976, pp 193-224 6. Odell WD, Wilber JG. Utiger RD: Studies of thyrotropin physiology by means of radioimmunoassay. Rec Prog Horm Res 23:47-85, 1967 7. Campuzano AC, Wilkerson JE, Raven PG. et al: A radioimmunoassay for cortisol in human plasma. Biochem Med 7:350-356, 1973 8. Kirkegaard C, Norlem N, Laundsen UB, et al: Protirelin stimu-

BY

Valve

Prolapse

STEPHEN

Syndrome

F. PARISER,

M.D.,

and

EMIL

In recent years, medical reports drawn public attention to syndromes panic

attacks,

Interest numbers

agoraphobia,

and

R.

Anxiety

PINTA,

in the media associated

other

Neurosis/Panic

M.D.,

anxiety

AND

be-

‘

,

‘

with

the

mitral

valve

(MVPS) (1, 3, 4). Patients prone to have extrasystoles, palpitations,

cardiac

prolapse

with this syncope,

awareness,

syndrome

syndrome are tachycardia,

dyspnca,

atypical chest pain. Patients fulfilling recent anxiety neurosis (5) and panic disorder symptoms similar to those found in MVPS. pen, we will elaborate on the association MVPS and anxiety states. The principal anatomic defect in MVPS dance

of myxomatous

valve

(chiefly

the

connective

posterior

leaflet),

tissue

which

fatigue,

and

criteria

for

(6) report

In this pabetween is a redunof the

mitral

causes

the

tissue to billow or prolapse into the left atrium during systole (3, 4). The tissue defect may be idiopathic or associated with other medical disorders such as Mar-

fan’s syndrome, disease (3, 4).

Turner’s We would

syndrome, or ischemic heart like to describe a case of

Dr. Pariser is Assistant Professor, Departments of Psychiatry and Family Medicine, and Clinical Instructor, Department of Obstetrics and Gynecology, Ohio State University College of Medicine, 456 Clinic Dr. , Section 2B. Columbus, Ohio 43210, where Drs. Pinta and Jones are Assistant Professors, Department of Psychiatry. The authors wish to thank Charles F. Wooley, Medicine, Ohio State University, for aiding the mitral valve prolapse syndrome.

246

M.D. , Department their understanding

0002-953X/78/0002-0246$0.35

MVPS

1978

of of

© 1978

M.D.

diagnosed

panic

in a patient

who

first

pre-

attacks.

Report

A 25-year-old

inhib-

‘

tients

A. JONES,

with

Case

tween altered cardiovascular function and anxiety states. Syndromes of historic interest illustrating this relationship include “cardiac muscular exhaustion,” Da Costa’s syndrome, ‘soldier’s heart,’ ‘effort syndrome.’ neurocirculatony asthenia, and the hyperdynamic beta-adrenergic circulatory state (1 2). Recently. cardiologists have emphasized a high incidence of anxiety and “psychoneurotic’ symptoms in pa‘

BRUCE

sented

states.

in these syndromes has surfaced with growing of reports of successful treatment with beta-

‘

February

Disorder

idiopathic

have with

blocking agents, tnicyclic antidepressants, MAO itors, and behavioral therapies. Cardiologists have long noticed a relationship

135:2,

lation test and thyroid function during treatment of depression. Arch Gen Psychiatry 32:1115-1118, 1975 9. Loosen PT, Prange AJ Jr. Wilson IC, et al: Thyroid stimulating hormone response after thyrotropin releasing hormone in depressed, schizophrenic and normal women. Psychoneuroendocrinology 2:137-148, 1977 10. Loosen PT, Wilson IC, Lara PP. et al: Beeinflussung depressiver Zustaende in Alkoholentzugsyndrom mit TRH (thyrotropin releasing hormone). Arzneim Forsch 26: 1 164-1 166, 1976

in Hormones,

Sachar E. New

Mitral

J Psychiatry

office

worker

admitted

herself

to a psychiat-

nc hospital for evaluation of anxiety attacks that had occurred over a 2-year period. The patient had been in good health otherwise. She described the attacks as beginning suddenly with rapid pulse and lasting from several minutes to half an hour. Symptoms during the attacks included palpitations, rapid breathing, anxiety, perioral and hand paresthesia, anterior neck discomfort, trembling, lightheadedness, feelings ofunreality, and fear ofdying. Attacks occurred as often as two or three times daily but occasionally disappeared for 3-week periods. The attacks were more common when the patient felt ‘ ‘under pressure.’ ‘ but she could identify no specific precipitating factor. She described

herselfas

“very

anxious”

between

attacks

and “clinging”

to

her husband for security. This patient fulfilled both the Research Diagnostic Criteria (RDC) criteria for panic disorder (6) and the Washington University criteria for anxiety neurosis (5). A cardiology consultation was requested for evaluation of tachycardia. The consultation established a diagnosis of

MVPS

on the basis

of auscultatory,

stress

ECG,

and

echo-

cardiographic findings. Auscultatory findings, typical of MVPS, included a midsystolic click and a ‘ ‘blowing musical’ ‘ apical late systolic murmur that varied with position change. The stress ECG revealed tachycardia (190 beats per minute), sinus arrythmia. and wandering atrial pacemaker.

The

echocardiogram

movement

demonstrated

considered

abnormal

to be diagnostic

mitral

valve

of MVPS.

Discussion

The

constellation

of symptoms

in MVPS

is remark-

ably

similar to the research criteria for anxiety neurosis described by the Washington University group (5) and for panic disorder found in the RDC (6). Both the

RDC

and

the

Washington

University

criteria

contain

many symptoms related to the cardiovascular system, such as dyspnea, palpitations, chest discomfort, choking or smothering sensations, dizziness, vertigo, paresthesias, sweating, and faintness. Wooley concluded that there were striking similarities linking MVPS and American

Psychiatric

Association

Am

J Psychiatry

135:2,

February

1978

CLINICAL

various “cardioanxiety” diagnoses made in the past, including Da Costa’s syndrome and neurocirculatory asthenia (I). There are noteworthy similarities in the epidemiology of MVPS and anxiety neurosis. Both disorders occur more often in females, have an incidence of 5%-10%, begin before age 35 in the majority of cases, and tend to run in families (3-5, 7).

There proaches sis.

are

also

similarities

to MVPS

and

Reassurance,

in the

panic

support,

therapeutic

ap-

disorder/anxiety and

patient

neuroeducation

are

often helpful in these disorders. The patient we have described seemed to benefit from supportive psychotherapy. assertiveness training, and self-taught mcditation. Both anxiety neurosis/panic disorder and

MVPS

tend

to have

a benign

course

(3-5).

Infrequent

complications of MVPS include infective carditis, Severe mitral regurgitations, and sudden death (3, 4). Propranolol has been used in MVPS for its ability to decrease systolic stress on the ballooning mitral leaflet and its antiarrythmic activity, both of which are related to beta-adrenergic blockade (8). Similarly, propranolol is reported to be effective in the treatment of panic disorder and other anxiety states (9). Recently, there has been considerable interest in the treatment of panic states with tnicyclic antidepressants (10). It has been hypothesized that the effectiveness of tnicyclic antidepressants in panic states is also related to betaadrenergic blockade (9). There are many etiologies of anxiety attacks. We suggest that MVPS is one. Patients meeting estab-

Catharsis BY

During

R. JULIAN

Prolonged

HAFNER,

M.D.,

Exposure

for

Snake

(3) claimed

plosive

therapy.

At the time this work trist

and

Senior

that

the reverse

However,

was done

Lecturer

the

is true

during

consensus

Dr. Halner

in Psychiatry,

was Consultant St.

George’s

im-

suggests

Dr. George

lished criteria for panic disorder merit evaluation and history to determine the murmur-click syndrome. If there cultatony findings, an echocardiogram

REPORTS

a careful cardiac the presence of are positive ausis indicated.

REFERENCES 1 . Wooley CF: Where are the diseases of yesteryear? Da Costa’s syndrome, soldier’s heart, the effort syndrome, neurocirculatory asthenia and the mitral valve prolapse syndrome. Circulation

53:749-751,

1976

2. Frohlich ED, Tarazi RD. Dustan HP: Hyperdynamic f3-adrenergic circulatory state. Arch Intern Med 123:1-7, 1969 3. Barlow lB. Pocock WA: The problem of non-ejection systolic clicks and associated mitral systolic murmurs: emphasis on the billowing mitral leaflet syndrome. Am Heart I 90:636-655. 1975 4. Hancock EW, Cohn K: The syndrome associated with midsystolic 1966

click

and

late

systolic

murmur.

Am

J Med

41:183-196,

Woodruff RA, Goodwin DW, Guze SB: Psychiatric Diagnosis. New York, Oxford University Press, 1974, pp 45-57, 199-212 6. Spitzer RL, Endicott I, Robins E: Research diagnostic cri5.

teria. sion

New York, of Biometrics

New York Research,

7. Markiewicz N, Stoneri, in one hundred presumably 473,

State 1975

Psychiatric

Institute,

London E, et al: Mitral valve healthy females. Circulation

Divi-

prolapse 53:464-

1976

8. Shappell SD, Marshall EC. Brown RD. et al: Sudden death and the familial occurrence of mid-systolic click, late systolic murmur syndrome. Circulation 48:1128-1134, 1973 9. HeiserJF, Dc Francisco D: The treatment ofpathological states with propranolol. Am I Psychiatry 133:1389-1394, 1976 10. Klein DF, Davis JM: Diagnosis and Drug Treatment of Psychiatric

Disorders.

Baltimore,

Williams

& Wilkins

Co.

1974,

413-

414, 438-439

Phobia:

An

Agent

of Change?

PsychiaHospital

Hs#{252} for his assistance

0002-953X/78/0002-0247$0.35

that

anxiety

reduction

is

exposure

therapies.

and

in the

© 1978

the

change

during

illustrates emotions phobic

that anxiety is only that may be experienced objects.

Case The

basis

of

The one

therapeutic

following

case

of several intense during exposure to

Report patient,

Ms.

A. was

a 25-year-old

unmarried

school-

teacher. Her life had been severely restricted for over 10 years by a profound fear of snakes. She was unable to watch movies for fear that a snake would appear on the screen and required her friends and relatives to telephone her in the

morning to warn her if there newspaper; she also avoided

Medical School, London, England. He is now Staff Specialist and Senior Lecturer in Psychiatry, Flinders Medical Centre, Bedford Park, South Australia 5042. The author wishes to thank treatment of this patient.

RESEARCH

M.R.C.PSYCH.

Watson and associates (1) have shown that in vivo exposure to phobic objects or situations during two or three sessions lasting a total of 4-5 hours is an effective and acceptable treatment for patients with circumscribed phobias. Such procedures seem inevitably anxiety provoking for patients, and there has been much debate about the role of anxiety in the behavioral treatment of phobias. Wolpe (2) has claimed that the presence of anxiety hinders or prevents symptom relief during systematic desensitization, whereas

Stampfl

AND

was a picture objects made

of a snake in the of snake skin as

much as possible and had recurrent nightmares about snakes. Her treatment was precipitated by an incident at her school when she panicked and burst into tears in front of a class because one of the children had given her a magazine containing a picture ofa snake. Subsequently she was unable

to include

magazines

materials,

which

American

Psychiatric

and

interfered

certain with

Association

books her

work

among

her teaching

to such

an extent 247