Pulmonary Embolism and Deep Vein Thrombosis Presenting as Anxiety, Akathisia, and Aggression in a Bipolar Patient: A Case Report From Iran

Abstract

Objectives: Mortality from cardiovascular causes, including pulmonary embolism (PE), is the second most common cause of mortality in psychiatric patients. Signs and symptoms that are specific to PE include tachycardia and dyspnea. It rarely manifests as acute psychosis and other unspecific signs and symptoms. Many common treatment modalities for psychiatric disorders increase the risk of coagulopathies and conditions, such as catatonia are associated with an increased incidence of venous thromboembolism (VTE). PE is a preventable cause of death for psychiatric patients. Therefore, we present this case to emphasize the importance of VTE complications in psychiatric patients.Case Presentation: A 56-year-old woman was hospitalized a week before admission due to aggression, restlessness, and disturbance. She was hospitalized more than 6 times with the diagnosis of "bipolar spectrum". Based on available information, a diagnosis of "unspecified and related bipolar disorder" with akathisia (possibly doxepin and selective serotonin reuptake inhibitor [SSRI] induced) was considered. Doxepin, citalopram, and olanzapine were tapered. Also, sodium valproate tablet 200 mg/qid and propranolol tablet 20 mg/bid were added to her drugs. After two weeks, with no progress in relieving symptoms, tachycardia was detected. Therefore, consultation with an internal medicine specialist and more evaluation was requested. With a high level of D-dimer, and low saturation, we considered thromboembolism, the patient was sent to a general hospital, and then the diagnosis of VTE was confirmed.Discussion: One of the vital causes of death in psychiatric wards is VTE. It is difficult to diagnose VTE in a psychiatric patient; therefore, it can increase the risk of mortality. Therefore, psychiatrists must perform essential assessments for patients with clinical suspicion. We publish this case to raise awareness of thromboembolic complications in psychiatric patients, especially hospitalized patients.