Panic disorder and pregnancy

LETTERS TO THE EDITORS

Panic disorder and pregnancy

Isabella Nascimento; Fabiana L Lopes; Alexandre M Valença; Marco A Mezzasalma; Antonio E Nardi

Laboratory of Panic & Respiration. Institute of Psychiatry. Federal University of Rio de Janeiro. Rio de Janeiro, RJ, Brazil

Dear Editor,

Some case reports suggest that pregnancy protects against panic disorder (PD) but the worsening or no change of PD during pregnancy are also reported.^1-2 We describe two PD (DSM-IV) women with severe panic attacks during pregnancy efficaciously and safely treated with a tricyclic antidepressant – nortriptyline, in the Laboratory of Panic & Respiration of the Federal University of Rio de Janeiro.

Case A:

Ms. A., Afro-Brazilian, 29 year-old. At the age of 24 year-old she started with spontaneous panic attacks. She was treated with nortriptyline (75 mg/day). After 20 months she was asymptomatic and started to decrease the dosage. She got her first pregnancy following one-year without medication. However during the fourth month of pregnancy she developed intense, almost daily panic attacks. A severe agoraphobic pattern developed and she also presented intense anticipatory anxiety disturbing her quality of life. She was initially treated with nortriptyline, 10 mg daily. After 5 weeks, at the dosage of 75 mg/day, she achieved full remission of her attacks. During the last two weeks of her pregnancy the nortriptyline was taken out. The asymptomatic period persisted after a two-year follow-up without medication.

Case B:

Ms. C., Afro-Brazilian, 29 year-old. She started to have panic attacks when she was 24 years old. She was treated with imipramine, 200 mg daily. After 6 months of treatment she was panic-attack free. During the next 12 months she was asymptomatic but still taking imipramine. During the first month of her first pregnancy she stopped imipramine but the panic attacks returned. She started cognitive behavioral psychotherapy but she had only a mild improvement. The disabling consequences of her high anxiety level and panic attacks frequency worsened her agoraphobic symptoms. Nortriptyline was started on the fourth month of her pregnancy and with 100 mg/day a complete remission was achieved. The drug was maintained during the last month of her pregnancy. She had no panic attacks after one-year follow-up with nortriptyline.

Discussion

Pregnancy may prevent panic by decreasing the reactivity of the sympathetic nervous system, by facilitating GABAergic activity through progesterone's effect on adenosine, or by diminishing arterial CO₂ plasma levels through minute ventilation.³ Klein⁴ hypothesized that the increase in progesterone associated with pregnancy stimulates breath and lowers pCO₂; therefore pregnancy would protect patients by increasing the distance of their pCO₂ levels from panic threshold. Klein also suggested that lactation protects against PD because oxytocin may be active against anxiety. During pregnancy, nonpharmacologic strategies, such as cognitive behavioral therapy, are preferable to antipanic medications. These strategies, however, may not always suffice, and clinicians may need to use medications for pregnant women who remain severely symptomatic. Our cases suggest that some subgroups of PD women may be particularly vulnerable to persistence of symptoms during pregnancy. Tricyclic antidepressants are a reasonable choice, because the data on their use in pregnancy show they do not seem to be associated with teratogenic effects.⁵

References

1. Northcott CJ, Stein MB. Panic disorder in pregnancy. J Clin Psychiatry. 1994;55:539-42.

2. Villeponteaux VA, Lydiard RB, Laraia MT, Stuart GW, Ballenger JC. The effects of pregnancy on preexisting panic disorder. J Clin Psychiatry. 1992;53:201-3.

3. Costei AM, Kozer E, Ho T, Ito S, Koren G. Perinatal outcome following third trimester exposure to paroxetine. Arch Pediatr Adolesc Med. 2002;156:1129-32.

4. Klein DF. False suffocation alarms, spontaneous panics, and related conditions: an integrative hypothesis. Arch Gen Psychiatry. 1993;50:306-17.

5. American Academy of Pediatrics. Use of psychoactive medication during pregnancy and possible effects on the fetus and newborn. Committee on Drugs. Pediatrics. 2000;105:880-7.

Sponsoring: Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq). Grant 304671/2003-7.

Publication Dates

• Publication in this collection
  23 Feb 2005
• Date of issue
  Sept 2004