Acta Psychiatr Scand 1998: 98: 254-255 Printed in UK - all rights reserved

Strohle A, Muller M, Rupprecht R. Marijuana precipitation of panic disorder with agoraphobia. Acta Psychiatr Scand 1998: 98: 254-255. 0 Munksgaard 1998.

We report the case of a 16-year-old adolescent with the onset of a panic disorder with agoraphobia after a first panic attack during marijuana intoxication. There was a good response to standard cognitive behavioural

Copyright 0 Munksgaard 1998 ACTA PSYCHlATRlCA

A. Strohle, M. Mullet, R. Rupprecht Max Planck Institute of Psychiatry, Munich, Germany

Key words panic disorder,

Andreas Strohle. Max Planck Institute o f Psychiatry, Kraepellnstr 2-10.80804 Munich- Germany

SCANDINAVICA ISSN 0001-690X

Case report

Marijuana precipitation with agoraphobia

.-m . of panic disorder

1 therapy for panic disorder.

Introduction

It has been reported that marijuana abuse may provoke panic attacks (1). A significant association between agoraphobia and the consumption of marijuana has been described (2), as well as an increased risk of anxiety reactions in patients with panic disorder who smoke marijuana (3). We report the case of an adolescent with the onset of a panic disorder with agoraphobia after a single panic attack during marijuana intoxication.

Case report

A 16-year-old trainee joiner sought help in our out- patient anxiety disorder unit. He described a severe avoidance behaviour after experiencing several unexpected panic attacks and fear of myocardial infarction during the attacks. The patient reported having smoked his first marijuana cigarette 2 years ago. He remembered slight feelings of nausea for a couple of minutes, but no feelings of anxiety. Four months ago he smoked marijuana again, and a few minutes after the third cigarette he experienced his first panic attack, which lasted about 45 min. There was no further marijuana consumption thereafter. However, 3 days after this single intoxication a spontaneous panic attack again occurred unexpect- edly while the patient was in the underground. During the following weeks about 10 panic attacks occurred without prior marijuana consumption, and the patient developed a severe agoraphobia. He was no longer able to go to school or to pursue his leisure activities. There were no symptoms of major depression or signs of a psychotic disorder.

I Accepted for publication March 31. 1998

After the exclusion of specific somatic disorders the patient was informed about the nature and treatment of his panic disorder with agoraphobia, and cognitive behavioural therapy (4) was started. The patient was highly motivated and engaged in therapy, and after a few weeks of treatment the agoraphobic avoidance behaviour disappeared, despite the sporadic occurrence of spontanous and incomplete panic attacks.

Discussion

Although Weil et al. (1) assumed panic reactions to be the most frequent adverse reactions to mari- juana this is, to our knowledge, the first case without further psychiatric comorbidity in which the onset of a panic disorder with agoraphobia is associated with a first panic attack caused by marijuana consumption. Because of the prominent fear of a heart attack in our patient, and the overlap with the so-called irritable heart syndrome (5), we consider that the symptomatology of our patient differs from that of a previously described case series (6). The good response to cognitive behav- ioural therapy is also in contrast to the reported difficulties in treating depersonalization and agora- phobia associated with marijuana use (6).

The temporal course, the putative dose- response effect of marijuana and the psycho- pathology in our patient argue against a random association, and suggest that a substantial pharma- cological role was played by marijuana intoxi- cation. However, if marijuana intoxication is a

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Marijuana precipitation of panic disorder

common trigger for the development of a panic disorder with agoraphobia, we would have expected it to have been reported earlier. Recently, Langs et al. (7) reported on three patients with comorbid depression and recurrent panic attacks after marijuana consumption. However, it seems possible that the diagnosis of panic disorder is sometimes missed because depersonalization may be the most prominent feature of marijuana- precipitated psychopathology (6).

Although there was no family history of panic disorder for our patient, both parents had been abstinent alcoholics for more than 10 years. It seems possible that subjects with a probably gene- tically linked increased risk for panic disorder, as is the case for most patients who experience deper- sonalization during marijuana intoxication (6), may be at greater risk of adverse subjective experiences during intoxication. Furthermore, there may be a greater risk that the psychoactive substance trig- gers an underlying panic disorder. Marijuana use

should therefore not only be considered in the clinical evaluation of panic attacks, but also in the evaluation of panic disorder.

References

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WEIL AT. Adverse reactions to marijuana. N Engl J Med

DEGONDA M, ANGST J. The Zurich Study. XX. Social phobia and agoraphobia. Eur Arch Psychiatry Clin Neurosci 1993:

SZUSTER RR, PONTIUS EB, CAMPOS PE. Marijuana sen- sitivity and panic anxiety. J Clin Psychiatry 1988: 49: 427-429. MARGRAF J, SCHNEIDER S. Panik. Angstanfalle und Ihre Behandlung. Berlin: Springer-Verlag, 1990. DA COSTA JM. Irritable heart: the clinical study of the form of functional cardiac disorder and its consequences. Am J Med Sci 1871: 71: 17-52. MORAN C. Depersonalization and agoraphobia associated with marijuana use. Br J Med Psycho1 1986: 59: 187-196. LANGS G, FABISCH H, FABISCH K, ZAPOTOCZKY HG. Can cannabis trigger recurrent panic attacks in susceptible patients? Eur Psychiatry 1997: 12: 415-419.

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