“Treating anxiety without SSRIs” was interesting and informative. At our resident clinic, we treat many patients with generalized anxiety disorder (GAD), and their management can be very challenging—particularly for patients with numerous medical and psychiatric comorbidities.
The differential diagnosis presented in the article, however, states that mitral valve prolapse (MVP) should be considered in a patient who presents with symptoms suggestive of GAD. Although it was believed in the past that MVP could lead to GAD, the studies that postulated such a relationship turned out to be flawed; they were inconsistent in their definition and diagnostic criteria for both GAD and MVP, and control groups were not appropriately matched.1 The present state of the so-called MVP syndrome, as currently taught, is that the relationship between GAD and MVP is likely to be coincidental.
The latest editions of 2 of the most widely used medical textbooks (Cecil’s Medicine, 23rd ed, and Harrison’s Principles of Internal Medicine, 17th ed) do not mention either panic disorder or GAD as part of the possible presenting clinical symptomatology of MVP. In addition, a well-respected cardiology textbook states that the neuropsychiatric symptoms previously attributed to MVP have not been confirmed in carefully controlled studies and that the relationship between GAD and MVP is not clear.2 Finally, even family medicine board review texts are shattering the longstanding belief that there is a relationship between GAD and MVP. One such text states that patients with MVP do not have GAD or panic disorder at higher rates than the general population.3
I hope the day comes when we can put to rest the alleged link between GAD and MVP. Until then, I will continue to tell my patients that the typical course of MVP is benign and that their panic disorder or GAD is probably not related to their cardiac condition.
Luis Liu Pérez, DO
Firelands Regional Medical Center
Sandusky, Ohio