Medically Unexplained Syncope: Relationship to Psychiatric Illness MARK LINZER, M.D., Boston,Massachuseffs, INDIRA VARIA, M.D., MICHELE PONTINEN,M.A., GEORGE W. DIVINE, Pm., Durham, North Carolina, BLAIR P. GRUBB, M.D., Toledo, Ohio, N. A. MARK ESTES, III, M.D. ~osfon, Massachusetfs
The purpose of this article is to review the literature and present new data concerning the relationship between psychiatric disorders and unexplained syncope. Several case series are presented of patients with syncope in whom psychiatric structured interviews were undertaken, tilt-table (physiologic) testing was performed, and health-related quality of life was measured. Patients seen in a syncope specialty clinic underwent structured psychiatric interviews in addition to in-depth medical evaluations. Tilt-table testing was performed on a separate series of patients to determine susceptibility to syncope during the orthostatic challenge of head-up tilt; in some cases, tilt studies included simultaneous electroencephalographic (EEG) monitoring and cerebral blood flow measurements. Formal functional status assessment was carried out using the Sickness Impact Profile, the Symptom Check List 90, and the Medical Outcomes Study Short-Form 36. Psychiatric disorders (in particular, panic disorders and major depression) were a common cause of syncope (24-31% of syncope patients). Tilt table studies showed several physiologic profiles in syncope: (a) a typical vasovagal (hypotension-bradycardia) response, (b) a “psychosomatic” response (fainting with normal vital signs), and (c) a gradual decline in blood pressure (dysautonomic response). EEG and cerebral blood flow measurements in three patients with the psychosomatic response
From the Syncope Evaluation Center, the Division of General Medicine (M.L.) and the Cardiac Arrhythmia Service (N.A.M.E.), Department of Medicine, New England Medical Center, Boston, Massachusetts, the Drvisron of General Internal Medicine (M.P., G.W.D.), the Department of Medicine, Department of Psychiatry (I.V.), and the Drvrsion of Biometry (G.W.D.), Department of Community and Family Medicine, Duke University Medical Center, Durham, North Carolina, and the Arrhythmia Service (B.P.G.), Department of Medicine, Medical College of Ohio, Toledo, Ohlo. This work was presented in part at the Symposium on Somatization Panic Disorders and Anxiety, the University of Washington, Seattle, Washington, May 30, 1991. Requests for reprints should be addressed to Mark Lrnzer, M.D., NEhC Box 1042, New England Medical Center, 750 Washington Street, Boston, Massachusetts 02111.
lA-18s
January 24, 1992
The Amerrcan Journal of Medtcine
to tilt were normal during fainting. Functional status measurements showed serious impairment in two series of syncope patients. Conclusions were as follows: (a) Psychiatric disorders are common in syncope. (b) Tilt-table methodology may elucidate underlying mechanisms of syncope in these subjects. (c) Syncope can seriously disrupt a patient’s life and result in important psychosocial sequelae. (d) There is an intimate relationship between unexplained syncope and psychiatric illness, mandating a combined medical and psychiatric approach to such patients. yncope is a transient loss of consciousness with loss of postural tone. Psychiatric syncope is a syncopal disorder that, in the opinion of a consulting psychiatrist, is likely to have resulted from the psychiatric condition [l]. Alternatively, psychiatric syncope may be viewed as a syncopal disorder occurring in the setting of a psychiatric illness, with no other apparent cause for syncope [Z]. Psychiatric causes of syncope have, in the past, been felt to be uncommon [2,3], occurring in l-7% of patients with syncope. However, recent work from our laboratories [1,5] and from that of Kapoor et al [4, 61 suggests that the prevalence of psychiatric disorders responsible for syncope and presyncope (near loss of consciousness) may be as high as 26%. Furthermore, the psychosocial sequelae of recurrent syncope have not, until recently, been evaluated. Data accumulated in the Syncope Clinic at Duke University between 1988 and 1989 have shown that the psychosocial impairment that results from recurrent syncope is considerable [7], and comparable to the physical and psychosocial impairment seen in several other chronic diseases. These studies suggest that there is an important relationship between psychiatric illness and syncope. This article will (a) introduce the concept of psychiatric syncope, describing the patients, their symptom complex, their treatment, and how they differ from nonpsychiatric syncope patients; (b) discuss the range of psychiatric disorders seen in syncope patients; (c) discuss new diagnostic modalities
S
Volume 92 (suppl 1A)
SYMPOSIUM
(in particular, loop electrocardiogram (ECG) recorders and tilt-table studies), as well as bedside maneuvers (such as hyperventilation) useful in the diagnosis of psychiatric syncope patients; (d) describe the pathophysiology of the three types of tilttable induced syncope, and specifically, the “psyehosomatic” type of syncope; and (e) delineate the physical and psychosocial impairment that results from recurrent syncope. Last, this article will present the “vicious cycle” of psychiatric distress and syncope, and discuss the problems that this cycle poses for clinicians, patients, and researchers.
PSYCHIATRICSYNCOPE: THE ORIGINALCASESERIES In 1990 we published a series of 72 patients seen in the Syncope Clinic at Duke University. These patients underwent a standardized evaluation, with a loo-item intake questionnaire, a thorough history and physical examination, and a series of bedside maneuvers to provoke syncope. A subgroup of these patients, which for the most part consisted of patients whose syncope remained unexplained after a diagnostic workup, were referred to a psychiatrist for evaluation. Psychiatric diagnoses were made by the psychiatrist on the basis of a semistructured clinical interview as well as strict criteria from the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-IIIR). Patients in whom a psychiatric diagnosis was made, but where the psychiatrist did not feel that this diagnosis was responsible for syncope, were excluded from the psychiatric syncope category. Also, vasovagal syncope patients with clear-cut precipitants for their syncope (such as the sight of blood) were excluded from the psychiatric syncope group. A psychiatric diagnosis for syncope was present in 17 of the 72 patients (24%). The psychiatric diagnoses consisted of panic disorders (9 patients), major depression (6 patients), and major depression with panic attacks (2 patients). Compared with nonpsychiatric syncope patients, psychiatric syncope patients were younger (37 vs 60 years of age, p
The purpose of this article is to review the literature and present new data concerning the relationship between psychiatric disorders and unexplained syncope. Several case series are presented of patients with syncope in whom psychiatric structured interviews were undertaken, tilt-table (physiologic) testing was performed, and health-related quality of life was measured. Patients seen in a syncope specialty clinic underwent structured psychiatric interviews in addition to in-depth medical evaluations. Tilt-table testing was performed on a separate series of patients to determine susceptibility to syncope during the orthostatic challenge of head-up tilt; in some cases, tilt studies included simultaneous electroencephalographic (EEG) monitoring and cerebral blood flow measurements. Formal functional status assessment was carried out using the Sickness Impact Profile, the Symptom Check List 90, and the Medical Outcomes Study Short-Form 36. Psychiatric disorders (in particular, panic disorders and major depression) were a common cause of syncope (24-31% of syncope patients). Tilt table studies showed several physiologic profiles in syncope: (a) a typical vasovagal (hypotension-bradycardia) response, (b) a “psychosomatic” response (fainting with normal vital signs), and (c) a gradual decline in blood pressure (dysautonomic response). EEG and cerebral blood flow measurements in three patients with the psychosomatic response
From the Syncope Evaluation Center, the Division of General Medicine (M.L.) and the Cardiac Arrhythmia Service (N.A.M.E.), Department of Medicine, New England Medical Center, Boston, Massachusetts, the Drvisron of General Internal Medicine (M.P., G.W.D.), the Department of Medicine, Department of Psychiatry (I.V.), and the Drvrsion of Biometry (G.W.D.), Department of Community and Family Medicine, Duke University Medical Center, Durham, North Carolina, and the Arrhythmia Service (B.P.G.), Department of Medicine, Medical College of Ohio, Toledo, Ohlo. This work was presented in part at the Symposium on Somatization Panic Disorders and Anxiety, the University of Washington, Seattle, Washington, May 30, 1991. Requests for reprints should be addressed to Mark Lrnzer, M.D., NEhC Box 1042, New England Medical Center, 750 Washington Street, Boston, Massachusetts 02111.
lA-18s
January 24, 1992
The Amerrcan Journal of Medtcine
to tilt were normal during fainting. Functional status measurements showed serious impairment in two series of syncope patients. Conclusions were as follows: (a) Psychiatric disorders are common in syncope. (b) Tilt-table methodology may elucidate underlying mechanisms of syncope in these subjects. (c) Syncope can seriously disrupt a patient’s life and result in important psychosocial sequelae. (d) There is an intimate relationship between unexplained syncope and psychiatric illness, mandating a combined medical and psychiatric approach to such patients. yncope is a transient loss of consciousness with loss of postural tone. Psychiatric syncope is a syncopal disorder that, in the opinion of a consulting psychiatrist, is likely to have resulted from the psychiatric condition [l]. Alternatively, psychiatric syncope may be viewed as a syncopal disorder occurring in the setting of a psychiatric illness, with no other apparent cause for syncope [Z]. Psychiatric causes of syncope have, in the past, been felt to be uncommon [2,3], occurring in l-7% of patients with syncope. However, recent work from our laboratories [1,5] and from that of Kapoor et al [4, 61 suggests that the prevalence of psychiatric disorders responsible for syncope and presyncope (near loss of consciousness) may be as high as 26%. Furthermore, the psychosocial sequelae of recurrent syncope have not, until recently, been evaluated. Data accumulated in the Syncope Clinic at Duke University between 1988 and 1989 have shown that the psychosocial impairment that results from recurrent syncope is considerable [7], and comparable to the physical and psychosocial impairment seen in several other chronic diseases. These studies suggest that there is an important relationship between psychiatric illness and syncope. This article will (a) introduce the concept of psychiatric syncope, describing the patients, their symptom complex, their treatment, and how they differ from nonpsychiatric syncope patients; (b) discuss the range of psychiatric disorders seen in syncope patients; (c) discuss new diagnostic modalities
S
Volume 92 (suppl 1A)
SYMPOSIUM
(in particular, loop electrocardiogram (ECG) recorders and tilt-table studies), as well as bedside maneuvers (such as hyperventilation) useful in the diagnosis of psychiatric syncope patients; (d) describe the pathophysiology of the three types of tilttable induced syncope, and specifically, the “psyehosomatic” type of syncope; and (e) delineate the physical and psychosocial impairment that results from recurrent syncope. Last, this article will present the “vicious cycle” of psychiatric distress and syncope, and discuss the problems that this cycle poses for clinicians, patients, and researchers.
PSYCHIATRICSYNCOPE: THE ORIGINALCASESERIES In 1990 we published a series of 72 patients seen in the Syncope Clinic at Duke University. These patients underwent a standardized evaluation, with a loo-item intake questionnaire, a thorough history and physical examination, and a series of bedside maneuvers to provoke syncope. A subgroup of these patients, which for the most part consisted of patients whose syncope remained unexplained after a diagnostic workup, were referred to a psychiatrist for evaluation. Psychiatric diagnoses were made by the psychiatrist on the basis of a semistructured clinical interview as well as strict criteria from the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-IIIR). Patients in whom a psychiatric diagnosis was made, but where the psychiatrist did not feel that this diagnosis was responsible for syncope, were excluded from the psychiatric syncope category. Also, vasovagal syncope patients with clear-cut precipitants for their syncope (such as the sight of blood) were excluded from the psychiatric syncope group. A psychiatric diagnosis for syncope was present in 17 of the 72 patients (24%). The psychiatric diagnoses consisted of panic disorders (9 patients), major depression (6 patients), and major depression with panic attacks (2 patients). Compared with nonpsychiatric syncope patients, psychiatric syncope patients were younger (37 vs 60 years of age, p
