Postural Tachycardia Syndrome (POTS) is a condition characterized by tachycardia without hypotension when transitioning to the upright position. Patients present with orthostatic intolerance, and may display symptoms concerning for somatization including palpitations, light-headedness, weakness, and fatigue. Depression and anxiety are often associated with POTS, and so antidepressants are common treatment approaches. This case report involves a patient with POTS who experienced an adverse reaction to duloxetine.

Duloxetine is an inhibitor of serotonin and norepinephrine reuptake. In addition to treating depression and anxiety, the medication is well-known to have benefit in somatoform disorders. The etiology of this effect is unclear, but is likely related to the segmental and suprasegmental desensitization of neurons that is mediated by norepinephrine. This same neurotransmitter may be involved in dysautonomia. In fact, some studies have demonstrated that excess norepinephrine can exacerbate orthostatic intolerance (Schroeder, 2002). In certain subtypes of POTS, particularly those where norepinephrine is already elevated, noradrenergic medications can produce an excessive central adrenergic response (Attard, 2023). At least one case report suggests that increased synaptic norepinephrine levels can stimulate presynaptic α-2 adrenergic receptors. This, in turn, reduces norepinephrine release from nerve terminals and can lower blood pressure (Alexandrino-Silva, 2008).

This case study is important because it demonstrates that use of SNRIs or TCAs in hyperadrenergic states such as POTS can contribute to paradoxical hypotension. Antidepressants are commonly used to treat psychiatric comorbidities in POTS. Although SNRIs and TCAs can be an effective treatment in chronic pain and somatoform disorders, these medications may exacerbate POTS symptoms.

Dr. Peterson: “Somatoform disorders are a frequent reason for psychiatric consultations—in adults, adolescents, and children. A variety of syndromes— including POTS—may be poorly understood and characterized, but frequently identified in patients, and clearly have a high rate of comorbidity with somatoform disorders. Treatment approaches including cross-specialty coordination of care and psychotherapy are key, but much less is known about the role and efficacy of psychotropic medications. This case provides an interesting reaction to an SNRI in an adolescent diagnosed with POTS, and should provide a useful platform for further discussion and study of how medications may improve—or exacerbate—this condition.”

Can We Be Too Happy? A Variant of Broken Heart Syndrome

Lead presenter: Daniel Fisher, MD.

Happy Heart Syndrome (HHS) is a rare variant of Takotsubo cardiomyopathy (TC) associated with intense positive emotion rather than heartbreak. The presenters present a case and discuss a possible role for psychiatric consultation.

TC has been commonly referred to as the Broken Heart Syndrome. A recent review of an international registry of stress-induced cardiomyopathy cases reported that less than 5% of cases were consistent with HHS (Stiermaier, 2022). Traditionally, the pathophysiology of TC was thought to be due to a catecholamine surge from intense negative emotion (Nayeri, 2018). Now, both positive and negative emotions have been recognized.

There is a strong association between pre-existing anxiety, mood-spectrum disorders, and TC. The case study patient had no recorded history of psychiatric illness at the time of her TC diagnosis. A previous case report proposed propranolol as a preventive therapy for recurrence of traditional TC (Costin, 2011). Although this could be beneficial for both the psychiatric and physiologic components of traditional TC associated with a ‘tragic event’, a ‘happy event’ may not respond in the same way. Suppression of happiness is generally not a desirable long-term treatment. No known study has focused on the treatment of underlying psychiatric conditions in the long-term management of TC.

Patients with TC may benefit from psychiatric consultation regardless of trigger. Increased awareness and data capture for HHS may be accomplished through proactive psychiatric consultation strategies. Further study may provide insight into the pathogenesis of mood-related cardiac pathologies, provide possible preventive steps, and improve treatment outcomes.

Charlson Comorbidity Index and Length of Hospitalization in Catatonia Subtypes

Lead presenter: Liliana Patarroyo Rodriguez, MD, MS

The influence of medical comorbidities on catatonia outcomes remains uncertain. The presenters aimed to elucidate disparities in medical comorbidities, assessed by the Charlson Comorbidity Index (CCI), between catatonia subtypes: catatonia associated with psychiatric diagnoses (C-APD) versus catatonia due to another medical condition (C-AMC). Additionally, they investigated how these medical comorbidities impact the length of hospitalization (LOH) among catatonia subtypes.

The cohort included adults hospitalized between May 1, 2001, and May 1, 2021, diagnosed with catatonia upon admission or during hospitalization. Among the 250 patients, 245 CCI scores were accessible. Mean age was 48.3 years, 86% of the patients were white, and 55.4% were female. Of these 187 (76.3%) were diagnosed with C-APD, while 58 (23.7%) were diagnosed with C-AMC. Bush-Francis Scale mean scores were 5.4 for screening items and 11.8 for severity. The mean CCI scores were similar between patients with C-APD (2.5) and C-AMC (2.9) (p=0.34). However, patients with C-AMC had higher prevalence of previous cerebrovascular accident (p=.003) compared to those with C-APD. No significant differences were observed in other medical comorbidities. LOH was longer for patients with C-AMC compared to those with C-APD (35.6 days vs 25.6 days, p=0.002). Mean LOH did not differ (p=0.96) based on the CCI categories (mild, moderate, severe). However, when analyzing the interaction between CCI categories and catatonia subtypes, significantly longer LOH was observed among C-AMC compared to C-APD in the mild CCI category only (38.8 vs 25.4 days, p=0.049). After adjusting for the baseline CCI category, C-AMC was associated with a 1.39 times longer LOH (95% CI 1.10 to 1.77) compared to those with C-APD (p=0.006). 

Data suggests that the etiology of catatonia and its comorbidity profile may influence the LOH, particularly in those with C-AMC. While C-APD was predominant, C-AMC showed a tendency towards higher comorbidities, experienced longer LOH, and had higher prevalences of stroke. Insights provided by the CCI about patient’s health status could inform clinical outcomes, emphasizing the need for evaluation and treatment of comorbid conditions, even in patients with a psychiatric etiology of catatonia.

Assistance with management of agitation is a common psychiatric consultation. A 2012 expert consensus, Project BETA, established a validated treatment algorithm for the management of agitation (Roppolo, 2020). Inappropriate management, including excessive use of physical restraints, can result in significant negative health outcomes. Further, the etiology of agitation is often not treated pharmacologically. Studies have shown that educational interventions can safely decrease restraint use in nursing facilities (Huizing, 2006). The presenters’ project aims to improve justification/documentation of physical restraint initiation and selection of appropriate pharmacologic treatment of agitation through educational intervention.

Eighty-five resident and attending physicians participated in didactic presentations. Participants included internal medicine hospitalist attendings and internal medicine/psychiatry/neurology residents. Knowledge scores increased, on average, by 19% after the didactic presentation. On preliminary evaluation, a total of 7, 22, and 32 charts were reviewed during pre-, mid-, and post-didactic intervention periods, respectively. Correct documentation/justification of restraint initiation occurred in 57%, 55%, and 56% of charts reviewed, and percentage of appropriate treatment of agitation with medication occurred in 43%, 68%, and 72% of charts reviewed during the pre-, mid-, and post-didactic intervention periods, respectively.

This project exemplifies the importance of the C-L psychiatrist’s role as a liaison. While the rate of appropriate documentation/justification for initiation of restraint orders did not change throughout intervention, there was an increase in appropriate pharmacologic management of agitation. Educating primary teams about appropriate management of agitation is essential to maintaining patient safety.

Dr. Meyer Karre: “With physical assaults on the rise in hospitals, the ability to safely manage agitation has become a focus for many psychiatrists in emergency and inpatient settings—with pharmacologic management preferred over physical restraint. The authors of this project aimed to improve rationale for physical restraint and increase appropriate pharmacologic management through targeted education for resident and attending physicians. It is worthwhile to note that knowledge scores and use of pharmacologic management increased with educational intervention, highlighting the importance of education on agitation management to ensure the safety of both patients and staff.”