A Patient With Mental Retardation and Possible Panic Disorder

Case report

Ms. X was initially brought to the attention of the emergency psychiatric service in June 1990 at age 58. She had mild mental retardation (an IQ of 56) and was experiencing new-onset paranoid delusions and auditory hallucinations precipitated by the death of her long-time caregiver. She was given a diagnosis of major depressive episode with psychotic features and was admitted to inpatient psychiatric care three times in the next six months. Each time she was discharged back to her own home, where she now lived alone.

After the depression remitted, she occasionally called 911 for emergency medical service with the vague complaint of "I feel bad." Emergency medical service personnel would routinely transport her to the local general medical emergency department, where she was often given intramuscular haloperidol and then discharged.

Over the next three years, Ms. X developed frequent somatic complaints, including chest pain, shortness of breath, and gastrointestinal distress, and fear. At times she would not leave her home—or even her room—for days or even weeks. Although she was unable to read or tell time, she called the emergency medical service more frequently, and at times she threatened to commit suicide if she were not brought to the emergency department. She persisted with chief complaints of "I feel bad," "I need to go to the hospital," or "I'll suicide." However, she never harmed herself. When she was evaluated by the psychiatric consultants in the emergency department, she denied depressed mood or neurovegetative symptoms of depression.

Emergency medical service records revealed that Ms. X had made up to 40 calls to 911 in one year and that her calls had resulted in total charges of $6,396 in 36 months. In almost all instances, emergency clinicians could find no medical condition, although they sometimes recorded a diagnosis of heat exhaustion or mental retardation.

The department of psychiatry's emergency service and mobile crisis program began to visit Ms. X, usually prompted by requests from the emergency medical service or from attending physicians in the emergency department after a series of 911 calls.

During 1993 we conducted a research study in which all adult patients seen by the psychiatric emergency service were administered a questionnaire on panic symptoms that was adapted from the Structured Clinical Interview for DSM-III-R (SCID). The questionnaire was given five times to Ms. X, who was seen in consultation four times for suicidal ideation and once for somatic symptoms. Ratings on the initial two questionnaires were inconsistent. She was unable to complete the third due to anxiety and dysphoria. However, her answers to the fourth and fifth questionnaires suggested that she had experienced eight of 13 symptoms associated with a DSM-III-R diagnosis of panic disorder.

In November 1993 a psychiatrist associated with the psychiatric emergency service prescribed clonazepam .5 mg twice a day. Records showed that Ms. X had less contact with all emergency services after that time. Ms. X's outpatient psychiatrist, who had been treating her since June 1990, added nortriptyline and soon documented a marked decrease in her symptoms of anxiety and panic.

Ms. X called the emergency medical service several times in late February and early March 1994, which led to a hospital admission for hyponatremia of unknown etiology. Her serum sodium level ranged from 115 to 120 mEq/L early in the admission. As nortriptyline may have contributed to her hyponatremia, her medication was changed to paroxetine 20 mg a day. The hyponatremia resolved.

Until a diagnosis of panic disorder was considered, emergency physicians and Ms. X's outpatient psychiatrist had treated her symptoms of dysphoria and anxiety by increasing doses of neuroleptics. She had been taking loxapine for many years. After her panic symptoms were identified, she was tapered off loxapine with no recurrence of psychotic symptoms. As of June 1994, Ms. X had little contact with the emergency medical service. She was stabilized on paroxetine and clonazepam and was free of panic symptoms.