To the Editor: We present case vignettes of three patients with panic disorder (per DSM-IV) who underwent neuroendocrine testing of hypothalamic-pituitary-adrenocortical axis activity with the 11β steroid hydroxylase inhibitor metyrapone (3 g given orally at midnight, i.e., 27.3–31.3 mg/kg of body weight). They were the first three patients in our hospital to participate in this single-blind, placebo-controlled study, and they unexpectedly developed transient dissociative symptoms after metyrapone administration but not after placebo ingestion. All patients had been free from psychotropic medication for at least 1 week and had negative urinary screens for illegal drugs.
Mr. A was a 30-year-old man who had suffered from panic disorder (without other lifetime axis I disorders) for 1.5 years. Thirty minutes after metyrapone ingestion, he felt dreamy and disconnected from his body and his surroundings, similar to how he felt right before losing consciousness during administration of general anesthesia. However, he did not feel panicky and did not experience the somatic symptoms of a panic attack.
Mr. B was a 57-year-old man who had suffered from panic disorder with agoraphobia for 28 years; he also had lifetime diagnoses of benzodiazepine abuse and major depression (both in remission for 1 year). Forty minutes after metyrapone ingestion, he felt unreal, developed tunnel vision, perceived objects as "swinging back and forth," and concurrently had a typical panic attack.
Mr. C was a 20-year-old man who had suffered from panic disorder with agoraphobia for 4 years and had comorbid secondary alcoholism; the latter had been in remission for 3 months. One hour after metyrapone ingestion, he developed tunnel vision, felt unreal and detached from his surroundings, and perceived objects as diminished in size. No other symptoms of a panic attack emerged.