Fighting Fear

Confronting phobias and other fears

Panic Disorder and Mitral Valve Prolapse

A possible relationship between an emotional and physical disorder.

Mitral valve prolapse is a condition which is supposed to occur frequently in the presence of panic disorder. Since it is a heart condition, patients told they have this condition have one more thing to worry about. Uncommonly, in the company of heart disease, mitral valve prolapse can, indeed, be serious; but that condition is fundamentally different from the common configuration of the heart that is often diagnosed casually as mitral valve prolapse.

The mitral valve is a valve between the left atrium of the heart and the left ventricle, two chambers of the heart. In 5 to 10 Percent of the population, or even more, the leaflets of the valve billow, or bend, in an exaggerated movement during ventricular contraction. Most of the men and women who are said to have this condition have no symptoms at all, suggesting that MVP (mitral valve prolapse) may in most cases be simply a normal variant, particularly among women, in whom it seems to be more common. The diagnosis is made, sometimes with difficulty, on the basis of auscultory findings determined on examination with a stethoscope and also on the heart’s appearance on echocardiography. This illness, if that is what it is, is of such little apparent significance that it has only been discovered and defined in recent years.

The two most common symptoms of MVP are palpitations and chest pain—both common features of anxiety. The chest pain is usually described as sharp and sudden and may last for hours or longer. Occasionally it occurs with exertion and may suggest angina, the pain of coronary insufficiency. The true origin of the pain is unknown but may relate to certain skeletal abnormalities of the chest wall that often accompany this condition. The palpitations that many persons with MVP complain of may stem from occasional extra beats or a run of fast heats. Sometimes they are due to no more than a heightened awareness of an apparently normal heartbeat.

There are, very rarely, possible complications of MVP, including infection on the mitral valve leaflets. To prevent this some doctors recommend antibiotics before undergoing dental procedures. However, the great majority of people with MVP have none of these complaints or any others throughout their lives. Those who do have chest pain or cardiac arrhythmias are treated readily and successfully with a variety of drugs. What, then, is the relationship between this very common and usually not at all serious cardiac abnormality and that other very common condition, panic disorder and agoraphobia?

People who are anxious or panicky often demonstrate a preoccupation with their health and in particular with their heart since that seems the most vital of the vital organs. “Soldier’s heart” is a syndrome marked by fatigue, hyper-ventilation, dizziness, palpitations, shortness of breath, chest pain, and apprehension; and it is common in civilian life as well.  These symptoms are thought to be of emotional origin, and yet they overlap with those of a variety of organic cardiac diseases, muscular disorders of the chest wall, esophageal diseases, and a number of other illnesses —and certainly mitral valve prolapse. It seems reasonable to wonder, therefore, if some of these people are responding to a subtle but real underlying physical illness such as MVP.

A different hypothesis that has been investigated suggests that both MVP and panic disorder stem from the same basic cause: a dysfunction of the autonomic nervous system. In support of this idea, a number of studies have been reported in which there was a high incidence of MVP in patients who suffered panic attacks and were phobic. As is often the case, when other investigators pursued this new inquiry, these original significant findings began to look less significant. It looks now as if the prevalence of MVP in phobic patients is little if at all above what would be expected in an ordinary population.  Should it turn out, though, on still further investigation that there is indeed such an association, a ready explanation suggests itself: phobics often show a concern about physical health even prior to developing their phobias. It is easy to understand how such a person suddenly experiencing au irregularity of heartbeat or pain in the area of the heart—from whatever cause—might develop a full-blown panic attack and as a result set in motion the process by which he or she develops a phobia. If so, MVP might reasonably be considered a precipitant of a phobia although not really a direct cause, no more than acid indigestion, which also provokes chest pain and is also especially common among phobics, should he regarded as a cause of their condition.

There is no evidence that MVP alters the course of a phobia. Someone so affected has panic attacks that are no more or less distressing than someone without MVP. That person’s illness is not likely to last longer or to be more severe. He or she is no more or less likely to respond to tranquilizers, antidepressants, or exposure therapy.

There is a class of drugs, the beta-blockers, that are effective in treating both the chest pain and the irregular heartbeat of MVP, although, as indicated previously, most of the time no treatment other than reassurance is necessary. These are drugs, incidentally, that had a vogue a number of years ago in the treatment of anxiety since they are supposed to block the physical signs of anxiety such as hyperventilation, palpitation, and trembling. As happened previously, though, with other drugs such as the major tranquilizers and then the minor tranquilizers, an early enthusiasm faded with time and more experience. Phobics taking the beta-blockers complain that the outward signs of anxiety are lessened, but they feel “just as panicky inside.” Mitral valve prolapse in any case should not be a source of concern. It is a benign condition for the most part and readily managed.

In summary, most phobics—even most people in general— will try to make sense out of physical symptoms by attributing them to one or another illness that they may have read or heard about. But they should try not to jump to conclusions. To someone not trained in medicine, it seems like every illness merges into every other. Even professionals are sometimes misled. Someone who has physical symptoms should see a doctor; but the search for an underlying physical cause of agoraphobia should not distract anyone indefinitely from engaging in an exposure therapy.

To show how problematical the diagnosis of MVP is, I mention my own personal experience: those doctors who had listened to my heart when I was younger always heard an extra sound which had always been described to me as “functional,” that is, not suggestive of an underlying cardiac disease. When a number of years ago echo-cardiography was invented, it became possible to actually see the heart functioning; and, therefore, a cardiologist I saw suggested I have this test done to further evaluate my cardiac murmur. When the test came back, he told me I had MVP, but not to pay attention to it since the condition had no clinical significance. I wondered, but did not say, what the purpose of the test was if it had no implications for treatment. Anyway, ten years later, the same cardiologist looking at the same test (not a subsequent test) told me I did not have MVP.

When I pointed out that he had previously told me on the basis of the same test that I did have it, he said,“The criteria have changed.” This is an example of how someone should not take too seriously the result of a single laboratory test.

 (c) Fredric Neuman. Excerpted from "Fightin Fear." Follow Dr. Neuman's blog at fredricneumanmd.com/blog/ or ask advice at fredricneumanmd.com/blog/ask-dr-neuman-advice-column/

Fredric Neuman, M.D. is the Director of the Anxiety and Phobia Center at White Plains Hospital.

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