Introduction
Infection with the spirochete that causes Lyme disease — Borrelia burgdorferi — is primarily transmitted by tick bites. Although the early classic symptom, erythema migrans, is well known, late complications, such as neurological complications, can present a complex clinical picture: neuropathy, meningitis, radiculoneuropathy, and various neuropsychiatric symptoms. Psychiatric symptoms include depression, cognitive impairment, mood disorders, and panic-like manifestations.
Clinical observations
Early literature contains several case studies suggesting a link between panic-like symptoms and borreliosis. Fallon et al. (1993) described in detail patients who experienced panic attacks and other psychiatric symptoms during or after Borrelia infection. The authors emphasised that mental symptoms can occur in borreliosis and require recognition.
Sherr (2000) reported on three patients whose panic attack-like episodes ultimately led to the recognition of a tick-borne infection. These observations suggest that panic disorder is rarely the first sign of infection, but rather occurs as a late complication.
In a 2015 case study, new-onset (but severe) panic attacks and depression occurred in a patient with a history of Lyme infection. The authors reported that in some cases, psychiatric symptoms may change in response to antibiotic treatment.
These individual cases do not prove a causal relationship at the population level, but they do provide an important warning: when investigating new or unusual psychiatric symptoms, the examining physician should consider the possibility of infection.
Possible pathomechanisms
The explanation for the link between panic attacks and Lyme disease is not uniform; possible mechanisms include:
- Direct central nervous system involvement (neuroborreliosis): Borrelia can enter the central nervous system, where it can cause inflammation and neurotransmitter imbalance — this may be the cause of panic attacks in some patients.
- Immune-mediated and inflammatory processes: systemic and local inflammation may affect the cytokine environment in the brain and anxiety mechanisms (e.g. HPA axis, serotonergic and GABAergic systems), thus contributing secondarily to the development of panic-like symptoms.
- Secondary psychological reactions: Chronic pain, exhaustion, uncertainty about diagnosis/treatment, and health-related anxiety can also trigger or exacerbate panic attacks. In addition, isolation and deterioration in quality of life associated with the disease can also cause psychological symptoms.
- Pharmacological and therapeutic factors: Cases of mood and anxiety changes observed after certain antibiotic treatments suggest that therapy may also have psychological side effects, and that long, uncertain treatment itself can be psychologically stressful for the patient.
Overall, multifactorial mechanisms are likely to be at work: in some patients, direct neural involvement may be dominant, while in others, inflammation or psychosocial factors may be more prominent.
Diagnostic challenges and clinical recommendations
Detecting a possible Lyme infection underlying panic attacks is difficult because:
- Panic disorder is a common and distinct psychiatric entity; infectious causes are rarely among the first considerations in the differential diagnosis.
- The interpretation of serological tests is often unclear, and direct diagnostic methods are not always available.
- Early detection and targeted antibiotic treatment are important for the prevention of neurological complications. Therefore, in cases of panic symptoms, if there is a history of tick exposure, EM (erythema migrans), neurocognitive symptoms or neurological abnormalities, it is worth considering Lyme-specific testing.
In clinical practice, it is important to take a thorough medical history (tick exposure, skin symptoms, temporal relationship), and to perform a physical and neurological examination. Where justified, serology (ELISA + Western blot) and, if available, direct diagnostic methods should be used. Concurrent treatment of psychiatric and neurological symptoms may be necessary: psychotherapy and (in cases of severe panic attacks) short-term anxiolytic intervention are recommended, along with targeted antibiotic treatment in cases of infection.
Treatment and therapeutic considerations
If Lyme infection (especially neurological complications) is confirmed, antibiotic treatment is the first choice. In addition to antibiotics, symptomatic treatment of psychiatric symptoms (e.g. SSRIs, short-term benzodiazepines, cognitive behavioural therapy) may be warranted to maintain patient well-being, but a multidisciplinary approach is essential. Some case studies describe the alleviation of psychiatric symptoms as a result of antibiotic treatment, but as there are few cases that can be definitively linked to Lyme disease, conclusions must be drawn with caution. This is probably because in many cases the possibility of Lyme disease is not even considered, or if it is, reliable, direct diagnostic methods are not used and false negative results are obtained.
Summary
- Clinicians should be aware that Lyme infection can also present with neuropsychiatric symptoms — panic attacks are less common but possible manifestations.
- In cases of known tick exposure, an infectious aetiology should be considered when investigating new, unusual or therapy-resistant panic symptoms.
- Due to the heterogeneity of the evidence, a personalised, multidisciplinary approach is recommended: collaboration between a Lyme specialist, neurologist and psychiatrist is recommended for accurate diagnosis and targeted therapy.
Sources:
https://pubmed.ncbi.nlm.nih.gov/8335653/
https://www.mdpi.com/2227-9032/10/7/1178
https://onlinelibrary.wiley.com/doi/10.1155/2015/457947
https://pubmed.ncbi.nlm.nih.gov/15990495/
https://www.mdpi.com/2076-3425/11/6/789
https://pubmed.ncbi.nlm.nih.gov/7726196/
https://www.cureus.com/articles/276245-lyme-neuroborreliosis-in-the-context-of-dementia-syndromes#!/
(C) Lyme Borreliosis Foundation
