PSYCHOGENIC HYPERVENTILATION SYNDROME

 60 YEAR OLD FEMALE WITH PSYCHOGENIC HYPERVENTILATION & RIGHT RENAL CYST :

** This is an ongoing case. I am in the process of updating and editing this E LOG as and when required.

Note: This is an online E Log book recorded to discuss and comprehend our patient's de-identified health data shared, AFTER taking his/her/guardian's signed informed consent.

Here, in this series of blogs, we discuss our various patients' problems through series of inputs from available global online community of experts with an aim to solve those patients' clinical problems, with collective current best evidence based inputs.

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I have been given the following case to solve, in an attempt to understand the concept of "Patient clinical analysis data" to develop my own competence in reading and comprehending clinical data, including Clinical history, Clinical findings, Investigations and come up with the most compatible diagnosis and treatment plan tailored exclusively for the patient in question.

CASE :

CHIEF COMPLAINT: 

PAIN IN THE RIGHT LOIN REGION SINCE 1 MONTH

DECREASED APPETITE SINCE 1 MONTH

HISTORY OF PRESENT ILLNESS:

PATIENT WAS APPARENTLY ASYMPTOMATIC 1 MONTH BACK , AFTER WHICH SHE

STARTED DEVELOPING PAIN IN THE RIGHT LOIN REGION,INSIDIOUS IN ONSET AND

GRADUALLY PROGRESSIVE , ASSOCIATED WITH NAUSEA.

H/O BREATHLESSNESS SINCE 1 MONTH GRADE II-III

H/O BURNING MICTURITION WITH PAIN ABDOMEN SINCE 4 DAYS

H/O CONSTIPATION PRESENT

NO H/O FEVER ,VOMITINGS, LOOSE STOOLS

(Patient reports she has episodes of shortness of breath.

The episodes are not precipitated by any stressful event/ stressors

Patient has shortness of breath in the night while she is asleep and hence gets up & has fearfulness.)

PAST HISTORY:

H/O SURGERY FOR RIGHT RENAL CALCULI 10-15 YEARS BACK

N/K/C/O DM,HTN,THYROID DISORDER

GENERAL EXAMINATION: 

NO PALLOR NO ICTERUS, CYANOSIS, CLUBBING, LYMPHADENOPATHY

VITALS: 

TEMP : 99 F    PR: 100BPM     RR: 30 CPM.        BP: 160/90 mmHg

GRBS: 138MG/DL

CVS :S1,S2 HEARD , NO THRILLS, NO MURMURS 

RS : BAE +

PER ABDOMEN: SOFT ,NON TENDER

CNS: PATIENT IS CONCIOUS, COHERENT AND COOPERATIVE, NO FOCAL NEUROLOGICAL DEFICIT

PSYCHIATRY REFERAL WAS DONE:

ADVICED - TAB CLONAZEPAM MD 0.25 mg ( if anxious)

                Relaxation and diversion techniques explained .

                Patient psycho educated

INVESTIGATIONS:

SEROLOGY :NEGATIVE

LFT :

TB : 2.08

DB : O.44

SGOT : 16

SGPT : 19

ALP : 156

TP : 7.2

ALB : 4.48

CUE

PUS CELLS 2-3

EPITHELIAL CELLS 2-3

ALBUMIN NIL

SUGAR, BILE SALTS AND BILE PIGMENTS : NIL

ABG :

PH :7.74

PCO2 : 11.8

PO2 : 120

HCO3 : 16.8

HEMOGRAM:

HB : 12.5 

TLC : 8800

PLT :3.06

RBC : 3

RFT ON 02/7/24

UREA : 21

CREAT : 1

NA : 141

POTASSIUM : 4.2

CHLORIDE : 102

USG : B/L GRADE II RPD CHANGES

-RIGHT RENAL CYST

ECG:

2D ECHO:

NO RWMA MILD

TRIVIAL TR+ ,AR+MR+

NO RWMA,NO AS/MS,SCLEROTIC AV

EF= 68

GOOD IV SYSTOLIC FUNCTION

Grade I DIASTOLIC DYSFUNCTION;NO PAH

MINIMAL PE+

IVC SIZE (O.8 CMS) COLLAPSING

PROVISIONAL DIAGNOSIS:

?HYPER VENTILATION ( PSYCHOGENIC)

TREATMENT GIVEN:

IV FLUIDS NS @ 75 ML/HR WITH 1 AMPULE OPTI NEURON

TAB PAN 40 MG PO/OD

TAB PCM 650MG PO/SOS

TAB MVT PO/OD

SYP CREMAFFIN 15 ML PO/HS AT 9 PM

RELATED ABSTRACT : https://journals.lww.com/mjdy/fulltext/2013/06010/psychogenic_dyspnea.4.aspx

Dyspnea is a very common presenting complaint of a patient. Though commonly due to an organic disease, dyspnea can be a manifestation of underlying anxiety disorder. 

Three typical patterns of psychogenic dyspnea, viz. panic attack, psychogenic hyperventilation, and compulsive sighing

Psychogenic hyperventilation syndrome:

This is a very characteristic and typical syndrome. Once witnessed, it is easy for a clinician to recognize this pattern in future. A classical case can be described as follows.

A young lady presents to the clinician with complaints of severe breathlessness. The onset is sudden and starts with dyspnea. It is accompanied by giddiness, ringing in ears, severe fatigue, and finger spasms. On examination, the muscles are flaccid, making the lady even difficult to sit or stand properly, fingers show typical tetanic type carpopedal spasms, and the respiration is deep, rapid, and forceful. The cyanosis is typically absent, oxygen saturation is normal and there is only mild or no tachycardia. Respiratory and cardiovascular system examination is usually normal.

The pathophysiology behind this syndrome is very interesting. The syndrome, triggered usually by an acute emotional stress, is an attention-seeking behavior. Strange inputs from subconscious mind stimulate the respiratory center. This leads to excess hyperventilation by the person. 

Hyperventilation results in excess washout of carbon dioxide (CO2) from the blood, thus inducing acute respiratory alkalosis. This is responsible for all the neurological manifestations of the syndrome. Alkalosis pushes the calcium from blood into the cells, thus inducing acute hypocalcemia resulting in carpopedal spasms of the fingers.

It is important to remember that acute hyperventilation due to any cause can trigger the same metabolic cascade. Hence, it is important to rule out other causes of acute hyperventilation such as brain stem stroke, pulmonary embolism, acute myocardial infarction, foreign body aspiration, tension pneumothorax, carbon monoxide poisoning, etc.. 

In these patients, lactate levels are frequently elevated. The exact mechanism is not known because high lactates are usually associated with acidosis and not alkalosis. This therefore should not be regarded as an adverse sign or as a pointer toward diagnosis other than psychogenic hyperventilation.

 It is important to note that the patient of psychogenic hyperventilation syndrome is never hypoxic, and therefore presence of cyanosis or significant tachycardia always points to an organic disease. Sometimes, the typical symptomatology can also be misdiagnosed as a conversion reaction

DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders: 4th Text revision) classifies psychogenic hyperventilation syndrome under somatoform disorders. A somatoform disorder is a mental disorder characterized by physical symptoms that suggest physical illness or injury, but symptoms cannot be explained fully by a general medical condition, direct effect of a substance, or are attributable to another mental disorder. In somatoform disorder, medical test results are either normal or do not explain the person’s symptoms. 

Patients with this disorder often become worried about their health because the doctors are unable to find a cause for their health problems. This causes severe stress, due to preoccupations with the disorder that portrays an exaggerated belief about the severity of the disorder. DSM-IV-TR also requires that the symptoms are not intentionally produced and are not malingered.

Criteria for diagnosing psychogenic hyperventilation:

1. Patient should be hyperventilating 

2. Somatic causes of hyperventilation should be ruled out

3. Patient should have multiple complaints related to hypocapnea 

4. Cyanosis should be absent

5. PCO2 should be low and PO2 should be normal 

6. Carpopedal spasm or other signs of hypocalcemia should be present.

Once the diagnosis is made, the treatment can give a dramatic response. It is called as “paper bag breathing.” The patient is firmly instructed to get up in bed. It is important to send the relatives out of the sight of the patient. This is because the phenomenon is usually an attention-seeking one and by sending away the relatives, an important motive for the hyperventilation syndrome is removed. The patient is then made to breathe in a paper bag. This leads to re-inhalation of the exhaled CO2. This increases the CO2 levels in the blood again and reverses the whole cascade within minutes. Some physicians have also advocated administering calcium gluconate injection to relieve the carpopedal spasms. However, this may not be necessary as the patient usually does not have calcium deficiency but has only intracellular shift of calcium

Thorough counseling of the patient and relatives is essential and improvement in social and family environment is advised. Cognitive behavioral therapy (CBT) is the best established treatment for a variety of somatoform disorders including psychogenic dyspnea. Many personality traits and morbid conditions have been linked with this syndrome.