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Comorbid Panic Disorder and Chiari I Malformation:
A Case Report
Murat Kulo¤lu*, Ali Çayköylü*, Okan Ekinci**, Yakup Albayrak**,
Orhan Deniz ***
*
Assoc. Prof., Atatürk Education and Research Hospital, Department of Psychiatry, Ankara, Turkey
**
M.D, Atatürk Education and Research Hospital, Department of Psychiatry, Ankara, Turkey
***
Prof., Atatürk Education and Research Hospital, Department of Neurology, Ankara, Turkey
Corresponding Author a. Atatürk E¤itim ve Ara?t›rma Hastanesi Psikiyatri Klini¤i 06520 Bilkent/Ankara, Turkey
Tel.:+90 312 2912525
Fax: +90 312 2912705
E-mail address: kuloglum@yahoo.com
ABSTRACT
Chiari I malformation is a congenital hindbrain anomaly characterized by downward displacement
of the cerebellar tonsils through the foramen magnum, commonly presents in patients with he-
adache or symptoms of dysfunction of the cerebellum, brainstem, and cervical spinal cord. To our
knowledge, there is a limited literature about any anxiety disorder in association with this ano-
maly. We describe a patient who firstly presented with panic symptoms and who later proved to
have Chiari I malformation. The patient had no surgical intervention for this malformation and
had a relative clinical improvement of her anxiety symptoms after psychotropic medication. This
case highlights the importance of searching for a lesion that might otherwise go undetected in
light of normal physical and neurological examinations and laboratory findings. Also, it demonst-
rates a rare comorbidity of Chiari I malformation and panic disorder.
Keywords: Chiari malformation, panic disorder, comorbidity, brainstem
ÖZET
Panik Bozukluk ve Chiari I Malformasyonu Birlikteli¤i: Bir Vak’a Sunumu
Chiari I malformasyonu s›kl›kla ba? a¤r›s› veya serebellum, beyin sap› ve medulla spinalisin servikal
bölümünün disfonksiyonuna ili?kin semptomlar ile tan›nan ve serebellar tonsillerin foramen mag-
numdan a?a¤›ya do¤ru yer de¤i?tirmesi ile karakterize bir konjenital beyin anomalisidir. Bildi¤imiz
kadar›yla bu anomali ile bir anksiyete bozuklu¤u aras›ndaki ili?kiyi târif eden s›n›rl› literatür bilgi-
si mevcuttur. Biz, ilk safhada panik semptomlar› ile ba?vuran daha sonra Chiari I malformasyonu
oldu¤u tespit edilen bir hasta rapor ediyoruz. Vak’aya malformasyonu için cerrahi tedavi uygula-
namam›?t›r. Psikotrop tedavi sonras› anksiyete semptomlar›nda izafî klinik düzelme görülmü?tür.
Bu vak’a fizik ve nörolojik muayene ile laboratuar bulgular›n›n normal olmas›ndan dolay› gözden
kaçm›? bir lezyonu ara?t›rman›n önemine vurgu yapmaktad›r. Ayr›ca panik bozuklu¤u ile Chiari I
malformasyonu aras›nda s›k olmayan bir komorbiditeyi göstermektedir.
Anahtar Kelimeler: Chiari malformasyonu, panik bozuklu¤u, komorbidite, beyinsap›
INTRODUCTION
re (Susman et al. 1989, Nash et al. 2002).
Chiari malformation is a disorder of embryologic
To date, there are three cases have been reported of
development. Chiari I is a congenital malformation
an anxiety disorder in association with this anomaly
characterized by herniation of cerebellar tonsils thro-
(Chisholm et al. 1993, Iwabuchi et al. 1985, Caykoylu
ugh the foramen magnum. Chiari II malformation
et al. 2008). We report a case of female patient with pa-
consists of herniation of not only the tonsils, but also
nic disorder who later proved to have Chiari I malfor-
all of the contents of the posterior fossa into the fora-
mation and had relative clinical improvement after
men magnum. Chiari III and IV malformations are ra-
antidepressant treatment without surgery.
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02-Comorbid Panic Disorder -3 27/7/09 10:21 Page 121
ed by rapid breathing, palpitations, and sweating,
trembling, fear of dying, hot flashes and feeling of im-
minent death. The attacks occurred in intervals of seve-
ral days at different times of the day. None of the at-
tacks, which lasted from 5 to 20 minutes, was accompa-
nied by loss of consciousness, motor phenomena, am-
nesia, or any other epileptic symptoms. The patient was
extremely concerned about having these attacks and sa-
id that it caused major changes in her behavior and da-
ily life. There was no personal history of substance mi-
suse or previous psychiatric disorders, and no family
history of mental illness. She was diagnosed with panic
disorder with agoraphobia based on the diagnostic cri-
teria of the Diagnostic and Statistical Manual of Mental
Disorders, Fourth edition - Text Revision [DSM-IV-TR]
Figure 1: MRI of patient shows cerebellar tonsil [white
(American Psychiatric Association, 2000).
arrow] displaced 9 mm below foramen magnum [black
The patient’s physical, neurological and laboratory
arrow] and displacement of brainstem.
examinations showed normal findings and an electro-
encephalograph [EEG] revealed no abnormality. Also,
she has been suffered from vertigo and headache. Sub-
sequently, brain magnetic resonance imaging [MRI]
was performed and revealed the presence of triventri-
cular hydrocephaly, displacement of brainstem and
that the cerebellar tonsils herniated 9 mm into the fora-
men magnum [as seen in Figs. 1 and 2]. After consulta-
tion with the Department of Neurosurgery, a diagnosis
of Chiari I malformation was established, and the ne-
urosurgery department planned a surgery intervention
include decompression and shunt procedure. However,
the patient did not approve surgical intervention after
she was informed about surgery procedure and risks
by the neurosurgery department. They subsequently
proposed an outpatient follow-up without surgery.
In the past one year, although she had been treated
sequentially with various anxiolytic and antidepres-
sant drugs, she had only relative clinical improve-
ment. When the patient was admitted to our outpati-
ent clinic, he had been off of medication for about
Figure 2: Cranial MRI image in a horizontal plane, show-
three months. During this period, she had been appli-
ing hydrocephalus with dilated lateral ventricles [ar-
ed to emergency medical department for palpitation
rows].
and chest pain, where she was often given anxiolytic
drugs and then discharged. At admission, sertraline
was started po at a dose of 25 mg/day and gradually
CASE REPORT
increased to 50 mg/day. The severity of her panic
Mrs. H was 49-year-old, admitted to our outpatient
symptoms was assessed by using the Panic Disorder
clinic. Upon examination, she was found to suffer from
Severity Scale [PDSS] (Shear et al. 1997). Initially her
recurrent unexpected panic attacks and agoraphobia.
PDSS score was 24. Total scores on the PDSS in the se-
She has also worried about having a heart attack and
cond, fourth and sixth weeks were 23, 16 and 14 res-
going crazy. At the age of 48, she developed spontane-
pectively. There was a relative clinical improvement of
ous panic attacks, which were characterized by the acu-
her panic symptoms at the end of sixth week after
te onset of unprovoked and intense anxiety accompani-
sertraline was increased to 50 mg/day. Subsequently
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02-Comorbid Panic Disorder -3 27/7/09 10:21 Page 122
we planned follow-up outpatient care, including both
is possible that in this case an alteration in CSF circu-
psychiatric and neurosurgical appointments.
lation had functionally damaged the cortical subcorti-
cal circuits. This may be another factor that contribu-
DISCUSSION
tes to emergence panic attacks and also probably ca-
Panic disorder is characterized by the presence of
use difficulty to treatment.
recurrent, unexpected panic attacks followed by at le-
ast one month of persistent concern about having
CONCLUSION
another attack. Panic attacks generally occur during
With this report we want to emphasize that selec-
daily activities, suddenly and without any apparent
ting the appropriate treatment for such patients can be
reason. They are a common feature of panic disorder
confounded by factors such as comorbid disorders
and can also be induced by different cerebral diseases
both psychiatric and medical. The clinicians must as-
(Wiest et al. 2006, Thompson et al. 2000).
sess these factors before an optimal therapeutic stra-
It is known that Chiari malformation can lead to
tegy can be designed.
compression of the lower brainstem (Nash et al. 2002).
Moreover, the malformation may result in neuronal
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