Educating Patients About Symptoms of Anxiety in the Wake of Neurological Illness

SIR: It is not uncommon for individuals suffering from serious neurological disorders to experience symptoms of panic that mimic the symptoms of the original illness, especially during and after recovery from the illness.^1,2 This is particularly so in the case of cerebrovascular disorders and postinfectious polyneuritis. Because some of the symptoms of anxiety disorders, particularly panic, may overlap with symptoms of neurological disorders, patients who experience symptoms during or soon after recovery may become confused as to whether they are experiencing residual symptoms of the illness, anticipatory effects of anxiety related to the possibility of relapse, or symptoms of a coexisting condition. The anxiety sensitivity theory of Reiss et al.³ posits that individuals vulnerable to panic and anxiety are prone to become particularly concerned with physical symptoms or threat. Additional research indicates that symptoms of anxiety disorders may bias individuals toward selectively attending to seemingly ominous information, which in turn contributes to the escalation of their anxiety symptoms.⁴

In the typical incident described below, symptoms of panic disorder developed in the wake of an acute inflammatory demyelinating polyneuropathy.

Case Report

Ms. A., a 34-year-old dance instructor, suffered an acute inflammatory demyelinating polyradiculoneuropathy following an upper respiratory illness. In this illness, a postinfectious polyneuritis affects the myelin sheaths of the peripheral nerves and nerve roots. The central features are symmetrical progressive motor weakness, areflexia, and ataxia. In this case (but not in every case), painful paresthesias and dysautonomia with loss of tactile sensitivity occurred, although the patient fortunately did not experience respiratory failure.

Ms. A. first experienced bilateral paresthesias in her feet after a dance recital. She dismissed her tingling sensations as consequences of “overdoing it.” However, over the next several weeks her symptoms intensified, soon spreading to her upper extremities and her abdomen. Her symptoms progressed to ataxia that seriously affected her gait and eventually rendered her completely immobile.

After consultation with a neurologist, Ms. A. was hospitalized, and the results of an electromyogram and lumbar puncture led to a diagnosis of acute demyelinating polyneuropathy. During several weeks' hospitalization she received intravenous immune globulin over a period of 5 days. She was discharged and referred to a rehabilitation hospital for 2 weeks, where she received intensive physical therapy and was then released to light duties.

Several months after her physical rehabilitation, Ms. A. began to experience paresthesias in her fingertips. She immediately became distraught, anticipating that she would soon experience a recurrence of her polyneuritis. Even though the chance of relapse is less than five percent,⁵ she promptly contacted her neurologist to ask for a reevaluation. In the absence of symptoms or signs of a neurologic disorder, it was determined that she was experiencing anxiety. She was placed on lorazepam 0.25 mg, 1 tab tid prn. Within one day she reported that her symptoms had abated, along with her fear of relapse. It was subsequently explained to her that anxiety is common with postneurological illnesses and that the attendant feelings may be mistaken by patients for symptoms of their original illness.

Comment

It is important that patients be alerted to the possibility of anxiety symptoms that may be confused with characteristics of their original neurological illness. Such information is important over and above the administration of anxiolytic compounds. Paresthesias, tightness in the chest, and body weakness may be especially distressing soon after a debilitating neurological illness. Many patients experience posttraumatic symptoms, and these too may contribute to their anxiety.

Patients such as Ms. A. need to be educated about the properties of anxiety as well as the symptoms of their illness. Further, they must learn methods for restructuring their thinking and reducing potential symptoms of anxiety. These patients may also benefit from being taught to interpret body sensations as benign rather than catastrophic, unless, of course, criteria are met that raise concern about a reoccurrence of the neurological illness. Mental health professionals and neurologists can support patients by helping them construct a specific list of criteria for concern, to include likely duration of numbness and tingling in the extremities as well as a clear delineation of ataxia and/or awkward motor movements, in order to differentiate their symptoms.

Although there is no guarantee of success, an attempt must be made to better prepare patients to cope with benign physical sensations, particularly in the early stages of serious neurological illnesses. Aside from the stress that confusion about such symptoms causes patients, it also may lead to false alarms, unnecessarily burdening health care providers and negatively affecting the patient's follow-up medical care. Psychoeducation provides the individual with the means to better differentiate symptoms, something that anxiolytic medication cannot achieve alone.