Psychosomatic Medicine 67:616-617 (2005)
© 2005 American Psychosomatic Society
Colon Motility During a Panic Attack
Paul E. Hyman, MD and
Jose Cocjin, MD
From the Department of Pediatrics, University of Kansas School of Medicine, Kansas City, Kansas.
Address correspondence and reprint requests to Paul E. Hyman, MD, Department of Pediatrics, 3901 Rainbow Blvd, Kansas City, KS 66160. E-mail: phyman{at}kumc.edu
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ABSTRACT
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Objective: To document the temporal relationship between a panic attack and high amplitude propagating contractions.
Methods: Colon manometry was used to discriminate between functional defecation problems and colon neuromuscular disease. By chance, the patent developed a panic attack during the test session.
Results: Coincident with the panic attack, there was a continuous series of high amplitude propagating contractions. There were 15 high amplitude propagating contractions over 45 minutes, initially at a rate of 4 per 10 minutes, gradually slowing to 1.5 per 10 minutes.
Conclusions: These data may explain the cause for gastrointestinal distress and diarrhea in some patients with panic attacks.
Key Words: colon manometry • high amplitude propagating contraction • corticotropin releasing factor
Abbreviations: HAPC = high amplitude propagating contraction; CRF = corticotropin releasing factor.
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INTRODUCTION
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When the cause for constipation is uncertain, colon manometry discriminates between functional fecal retention (1) and colon neuromuscular disease, providing convincing data for clinicians and families (2). In this report, a 12-year-old boy with a long history of constipation suffered a panic attack during colon manometry. During the panic attack there were continuous high amplitude propagating contractions, a unique pattern indicating a disappearance of inhibitory colon neural tone or an overpowering stimulation of coordinated colon motility. High amplitude propagating contractions were defined by increases in luminal pressure >60 mm Hg that did not overlap with other contractions, with duration >10 seconds and <30 seconds, and propagating aborally across 30 cm or more (3,4).
Panic attacks are characterized by at least four of the following symptoms: (a) palpitations, pounding heart, or accelerated heart rate, (b) chest discomfort, (c) choking sensations, (d) feeling faint or dizzy, (e) feelings of unreality or depersonalization, (f) numbness and tingling in the extremities, (g) hot or cold flashes, (h) sweating, (i) shaking or trembling, (j) nausea or abdominal distress, (k) fear of dying, or (l) fear of going crazy or losing control (5). Panic attacks may be precipitated by a variety of anxiety provoking events, including medical procedures.
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CASE REPORT
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A 12-year-old male referred for evaluation because of nearly lifelong problems with constipation and 7 years of fecal incontinence underwent colon manometry to assess the physiology associated with his symptoms. Hard, painful stools began during weaning from breast milk midway through the first year. As a toddler he exhibited retentive posture, contracting his gluteal muscles during each urge to avoid defecation. Over the years he was treated by many clinicians with a variety of stool softeners, stimulant laxatives, and enemas. Anorectal manometry was normal at 3.5 years of age. A barium enema at 5 years of age was normal. He required hospitalization because of bowel obstruction secondary to fecal impaction at 8 years of age. Neuron cell bodies (ganglion cells) were found in rectal biopsy at 9 years of age. For 3 years preceding the evaluation he took 17 g polyethelene glycol (Miralax, Braintree Laboratories, Braintree, MA) twice daily. Treatment resulted in soft stools but daily episodes of fecal incontinence.
The past medical history and review of systems were negative except for four or five episodes in the preceding several years of intense fear, hyperventilation, dizziness, loss of truncal tone, lasting about 20 minutes, always associated with a medical intervention such as venipuncture. There were no reports of other emotional or behavior problems.
Physical examination was normal. Weight was 39 kg, height 152.7 cm, blood pressure 114/64 mm Hg, pulse 88/minute, and temperature 36°C. There were no subcutaneous tongue nodules.
With intravenous propofol for sedation, we used colonoscopy to facilitate manometry catheter placement to the ascending colon. When the child awoke, we studied colon motility by standard techniques (6–8). It was normal. We studied fasting motility for 55 minutes and then asked the subject to eat. There was a gastrocolonic response beginning 20 minutes after the meal and spontaneous high amplitude propagating contractions (HAPCs) that prompted defecation. There were no discrete abnormalities.
During 55 minutes of fasting, recording there were no spontaneous HAPCs. There were scattered isolated low amplitude tonic and phasic contractions throughout the colon. The patient ate half of a personal pizza and drank a few sips of chocolate milk. Fifteen minutes after starting the meal, colon motility increased: tonic and phasic contractions became higher in amplitude and increased in frequency. Beginning 20 minutes after the meal, the patient complained of a hot sensation over his body, though his skin was cool to the touch. Thirty minutes after eating, there was a high amplitude contraction propagating over 20 cm, associated with a defecatory urge. The skin on the patient’s legs turned from white to red, and his mother became alarmed and went to his side. He felt frightened as if something terrible was about to happen. Then he began hyperventilating and lost tone in his trunk and neck. He maintained consciousness, but felt faint. Coincident with the symptoms, there began a series of HAPCs, beginning in the most proximal recording site and propagating through the sigmoid. There were 15 spontaneous HAPCs over the next 45 minutes, many associated with defecation. HAPCs began at a rate of 4 per 10 minutes, and gradually slowed to 1.5 per 10 minutes. His mother attended to his discomfort, trying to sooth him with each of his complaints, but she was anxious and her speech was tense. The physician reassured them both that the patient was in the middle of a panic attack and that he would be OK. Over the next 15 minutes, hyperventilation resolved and hypotonia abated, but the patient continued to be dysphoric for 45 minutes. Colon manometry recording continued through the episode (Figure 1).
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Figure 1. Colon manometry showing 15 high amplitude propagating contractions over 45 minutes. Time is on the x-axis. Recording sites were 15 cm apart.
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DISCUSSION
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After more than 500 colon manometries in our lab over 10 years, the patient described in this report was the first to have a panic attack. The coincidence of panic attack during colon manometry permitted documentation of a unique motility pattern of repeating HAPCs, suggesting factors that either stimulate colon motility or inhibit inhibitory tone. HAPCs are the marker for neuromuscular health of the colon. An HAPC occurs once or twice daily in healthy adults (3,4) and more often in infants (6). After cecal instillation of bisacodyl, a stimulant laxative, there were two to seven HAPCs/subject (7). During the panic attack, there were 15 HAPCs, a number unequalled in any other study.
The pathophysiology of panic attacks is still under study. Corticotropin releasing factor (CRF) is implicated in the stress response in both animals and humans (9) and may have mediated the increased colon motility documented above. CRF may act independently of the hypothalamic-pituitary-adrenal axis response to fear. Moreover, CRF increased colon motility in rodents (10,11) and man (12). CRF1 receptors mediate the stimulation of colon transit induced by CRF, urocortins1 and 2 and "restraint stress." Although a surge in secretion of autonomic neurotransmitters may mediate the physical effects of panic on heart and lungs, while causing sweating and cerebral vasoconstriction (13), CRF has actions that may override the inhibitory effects of circulating catecholamines on the colon. Although sympathetic activation decreases colon motility in a fight/flight response, the colon has increased motility in panic attacks, which may be attributable to CRF.
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NOTES
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Received for publication August 13, 2004; revision received October 4, 2004.
DOI:10.1097/01.psy.0000170950.33024.b4
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ABSTRACT
INTRODUCTION
