![]() ![]() Generally contraindicated potential to cause respiratory depression in patients with preexisting respiratory impairmentsĬase reports of triggering decompensation and unmasking previously undiagnosed myasthenia gravis Common medications for treating insomnia and acute anxiety in patients with myasthenia gravis DrugĬase reports of triggering decompensation in myasthenia gravis ![]() This creates a challenge for providers in selecting appropriate treatment modalities, especially when combined with the unique pharmacologic constraints associated with the disease itself. At present, the existing body of literature on pharmacotherapy for psychiatric comorbidities in myasthenia gravis is quite limited ( 7). Interestingly, psychiatric consultation liaison requests for patients with neuroimmunological diseases have been noted to be relatively rare ( 4). ![]() Symptoms of anxiety and depression have been shown to have a significant effect on health-related quality of life in patients with myasthenia gravis ( 3), highlighting the importance of effective diagnosis and treatment. The exact relationship between myasthenia gravis and psychiatric comorbidity remains an area for further study. Case reports in which psychopathologic complaints have remitted with effective treatment of somatic myasthenic symptomatology appear to support this theory ( 6), as do existing data that have demonstrated an association between disease severity and higher scores on depression and anxiety rating scales ( 4). They suggest that higher figures may be better attributed to psychological reactions to more severe courses of myasthenia than to true co-occurring psychiatric disorders ( 5). However, other studies have indicated a prevalence of overall psychiatric comorbidity closer to 30%, which is similar to that of the general population ( 5). In fact, some studies have suggested that the point prevalence may be as high as 45% for anxiety ( 2, 3) and 58% for depression ( 2, 4). Psychiatric comorbidities are quite common in patients with myasthenia gravis, particularly mood and anxiety disorders ( 4). Psychiatric Comorbidities in Myasthenia Gravis She was able to be discharged on this regimen after medical stabilization and reported continued adherence at the time of outpatient follow up per records. The following morning, she reported significant improvement in sleep and mood. Because there was no clear benzodiazepine withdrawal presentation and the patient had a history of positive response to doxazosin, she was started on a trial of prazosin 1 mg at bedtime. She had no tremors, hallucinations, or cognitive dysfunction.įrom the initial assessment, it was difficult to determine whether the patient’s symptoms of anxiety and insomnia were secondary to benzodiazepine withdrawal, a primary anxiety disorder, or PTSD. There was no evidence of psychomotor agitation on exam, and vital signs demonstrated only mild, intermittent elevations in heart rate and blood pressure. Despite this, she described symptoms consistent with prior episodes of withdrawal, including restlessness and heart palpitations. She had been detoxed with lorazepam before transfer to our facility. She reported that she had been taking alprazolam for anxiety for 11 years, and felt that her symptoms were well controlled on this before hospitalization. She otherwise denied any history of sleep problems or sleep medications. She reported that she had briefly taken doxazosin for difficulty sleeping while at an inpatient drug rehab facility in the past this had provided full relief of symptoms at the time. She denied experiencing nightmares or flashbacks. ![]() She reported that while her current mood was “terrible” from lack of sleep, she felt that her depression was well controlled as an outpatient on bupropion 300 mg. She described feeling exhausted, irritable, and extremely anxious as a result. On interview, the patient reported that while she typically slept about 10 hours per night outside of the hospital, she had been unable to sleep at all since admission to the outside hospital one week ago. The psychiatric consultation liaison service was consulted to provide medication recommendations. They had attempted to treat these symptoms with trazodone and zolpidem, without success. Her initial presenting symptoms of weakness, shortness of breath, dysphagia, and muscle spasms had improved significantly with intravenous immunoglobulin and solumedrol however, the primary team was concerned that persistent anxiety and insomnia were preventing a full recovery. The patient is a 31-year-old woman with a history of myasthenia gravis and reported anxiety, depression, attention deficit hyperactivity disorder, posttraumatic stress disorder (PTSD), and polysubstance abuse who presented to the neurology service as a transfer from an outside hospital in myasthenic crisis, likely precipitated by drug use and sleep deprivation. ![]()
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