Cases That Test Your Skills

An unexplained exacerbation of depression, anxiety, and panic

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The author’s observations

The triad of symptoms in pheochromocytoma results directly from the intermittent release of catecholamines into systemic circulation. Surges of epinephrine and norepinephrine lead to headaches, palpitations, diaphoresis, and (less commonly) gastrointestinal symptoms such as nausea, vomiting, and constipation. Persistent or episodic hypertension may be present, with 13% of patients maintaining a normal blood pressure.5-7 Patients with pheochromocytoma-related anxiety typically have substantial or complete resolution of anxiety and panic attacks after tumor resection.6,8,10

Because of their ability to raise catecholamine levels, several medications, including some psychotropics, can lead to false-positive results on serum and urine metanephrines testing. Tricyclic antidepressants and beta-blockers can cause false-positive results on plasma assays, while buspirone can cause false-positives on urinalysis assays.5 Trazodone, on the other hand, exhibits no catecholaminergic activity and its alpha-1 adrenergic antagonism may actually have some benefit in pheochromocytoma.11 Alpha-1 adrenergic antagonism with doxazosin, prazosin, or terazosin is the first-line of treatment in reducing pheochromocytoma-related hypertension.7 Treatment with a beta-blocker is safe only after alpha-adrenergic blockade occurs. While beta-blockers are useful for reducing the palpitations and anxiety observed in patients with pheochromocytoma, they must not be used alone due to the risk of hypertensive crisis resulting from unopposed alpha-adrenergic agonist activated vasoconstriction.5,7

TREATMENT CBT provides benefit

Mr. P decides against receiving an additional agent for anxiety and instead decides to wait for the outcome of the confirmatory pheochromocytoma testing. He continues to take alprazolam, and both his depressed mood and anxiety improve. His panic attacks continue to lessen, and he appears to benefit from cognitive-behavioral therapy provided during group therapy. Mr. P is advised by his PCP to taper and stop the alprazolam 3 to 5 days before his 24-hour urine metanephrines test because benzodiazepines can lead to false-positive results on a urinalysis assay.7

OUTCOME Remission of anxiety and depression

Mr. P has a repeat serum metanephrines test and a 24-hour urinalysis assay. Both are negative for pheochromocytoma. His PCP refers him to cardiology for management of treatment-resistant hypertension. He is discharged from the PHP and continues psychotherapy for depression and anxiety in an intensive outpatient program (IOP). Throughout his PHP and IOP treatments, he continues to take paroxetine and hydroxyzine. He achieves a successful remission of his anxiety and depression, with partial but significant remission of his panic attacks.

The author’s observations

Although Mr. P did not have pheochromocytoma, it is important to rule out this rare condition in patients who present with treatment-resistant hypertension and/or treatment-resistant anxiety.

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