Case Report
Stiff person syndrome masquerading as panic attacks PASIEKA/ Science Photo Library
Cyrus S H Ho, Roger C M Ho, Einar P Wilder-Smith
Lancet 2014; 383: 668 Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (C S H Ho MRCPsych, R C M Ho FRCPC), and Division of Neurology, National University Health System, Singapore (Prof E P Wilder-Smith MD) Correspondence to: Dr Cyrus S H Ho, Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074 [email protected]
668
In June, 2012, a 43-year-old Chinese woman came to our clinic with dysphoria, insomnia, and fear of heights. She had no history of mental health problems. The patient had grade 1 L4–L5 spondylolisthesis with lumbar fusion in 2011. Her daughter had died from leukaemia 3 years earlier. The patient was diagnosed with long-term grief, and paroxetine was started. During the next few months she developed panic attacks. When startled by noise, she had painful muscle spasms causing her to momentarily freeze. After titration of antidepressant, her mood improved but panic attacks persisted. In January, 2013, slurred speech, facial asymmetry, and increasing difficulty in writing and walking were noted. She had had eight falls in 2 months and two motor vehicle accidents because she could not press the brake. She subsequently required walking aids because of increasing stiffness and worsening fear of falling. Her gait was stiff on neurological assessment. There was severe lumbar hyperlordosis, axial stiffness, and rigidity. Smooth eye pursuit showed occasional saccadic intrusions in all directions. Arm and leg power was full with normal tone and reflexes. Glabellar tap resulted in elicitation of the sternocleidomastoideus tendon reflex bilaterally. Results were normal for full blood count, electrolytes, thyroid function, fasting glucose, anti-doublestranded DNA antibodies, antibodies to cardiolipin, and extractable nuclear antigens. Antiglutamic acid decarboxylase (GAD) 65 antibodies were 230 U/mL (normal:
Stiff person syndrome masquerading as panic attacks PASIEKA/ Science Photo Library
Cyrus S H Ho, Roger C M Ho, Einar P Wilder-Smith
Lancet 2014; 383: 668 Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore (C S H Ho MRCPsych, R C M Ho FRCPC), and Division of Neurology, National University Health System, Singapore (Prof E P Wilder-Smith MD) Correspondence to: Dr Cyrus S H Ho, Department of Psychological Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 5 Lower Kent Ridge Road, Singapore 119074 [email protected]
668
In June, 2012, a 43-year-old Chinese woman came to our clinic with dysphoria, insomnia, and fear of heights. She had no history of mental health problems. The patient had grade 1 L4–L5 spondylolisthesis with lumbar fusion in 2011. Her daughter had died from leukaemia 3 years earlier. The patient was diagnosed with long-term grief, and paroxetine was started. During the next few months she developed panic attacks. When startled by noise, she had painful muscle spasms causing her to momentarily freeze. After titration of antidepressant, her mood improved but panic attacks persisted. In January, 2013, slurred speech, facial asymmetry, and increasing difficulty in writing and walking were noted. She had had eight falls in 2 months and two motor vehicle accidents because she could not press the brake. She subsequently required walking aids because of increasing stiffness and worsening fear of falling. Her gait was stiff on neurological assessment. There was severe lumbar hyperlordosis, axial stiffness, and rigidity. Smooth eye pursuit showed occasional saccadic intrusions in all directions. Arm and leg power was full with normal tone and reflexes. Glabellar tap resulted in elicitation of the sternocleidomastoideus tendon reflex bilaterally. Results were normal for full blood count, electrolytes, thyroid function, fasting glucose, anti-doublestranded DNA antibodies, antibodies to cardiolipin, and extractable nuclear antigens. Antiglutamic acid decarboxylase (GAD) 65 antibodies were 230 U/mL (normal:
