On panic disorder and benzodiazepine use

I’m taking a class just for fun right now — psychopharmacology — and the discussions that crop up are quite excellent. Many of the students are prescribers in my area, and I fill their scripts on a regular basis. It makes for an interesting, voyeuristic look into their thought processes given some of the case studies. That is, I know who they are, but they don’t know who I am…

This week’s topic is panic disorder and relapse in patients with and without a history of substance abuse. Fun topic, really, and one close to my heart.

Case study:

[You are] working with a 32 year old man who comes to you for an evaluation of panic in August in Lowell. He meets the diagnostic criteria for panic disorder and has been experiencing untriggered episodes for the last 2 months. Name three factors that would guide your selection of medication and then discuss your pharmacologic plan for this unfortunate man.

One of the responses — by a prescriber in my area — was to encourage deep breathing, progressive relaxation, identifying triggers and avoiding the situation, CBT, and starting an SSRI. If panic continues, start a benzo.

This strikes me as fairly typical approach for a primary care provider in dealing with someone who presents during an acute panic attack, but I think that it’s doing the patient a disservice. Perhaps it’s also a typical response for a psychiatrist who is afraid to use benzodiazepines.

I’ll post my response here, verbatim, because I think there’s a deep (and common) misunderstanding of what panic is, and what having a panic attack is like.

It seems like you’re thinking of panic as something that can be gotten out of, as though it’s a normal fight-or-flight type response where removal from a stressful stimulus means no more panic.

This is dangerous thinking, and forgive me if I’ve read you wrong.

It can be harder than perhaps some practitioners think to identify a trigger. While triggers can often be identified, I think it’s important to note that when a patient first presents, and you make a diagnosis of panic disorder, discovering these triggers will be more complex than simply avoiding a stressful situation, or simplifying and eliminating stressors from one’s life. (Which is a very time-consuming process.)

You can’t turn the ship on a dime.

Please don’t fall victim to the idea that because you’ve been scared out of your wits a few times and your heartrate went up and your BP went through the roof that that is a panic attack. It’s not. Panic attacks usually appear in a completely idiopathic manner, particularly the first time they hit. It’s not an “Oh Gee, you scared me,” type of thing, it’s more of a “DEAR GOD I’M DYING, SOMEONE PLEASE DIAL 911” type of thing.* (The caps are appropriate there. ;) )

Panic attacks can, and do hit without any warning in an otherwise comfortable, relaxed setting. Watching a movie in your living room, for example.

It’s not like [situation] -> panic attack a few minutes or an hour later with a clear antagonist. It can come days after the stressors. It can also take a few weeks and lots of practice to build up an arsenal of effective coping mechanisms to return oneself to a calming state in the middle of an active attack.

Re: Deep breathing. This can also be problematic as at the point where one’s lungs are fully inflated one can experience a PVC or PAC, which is VERY disconcerting to someone who’s already acutely aware of what their heart is doing. I can actually trigger PVCs in myself by doing this.

I don’t mean to lecture. I’m not the professor, and perhaps I’ve read too much between the lines of what you’ve written. As someone who didn’t get out of bed for 3 weeks the first time I had a panic attack, I feel very strongly about the issue, and combatting it aggressively rather than taking a more laid back, it’ll-fix-itself approach. Particularly this: “deep breathing, progressive relaxation, identifying triggers and avoiding the situation, CBT, [etc.]”

Those are all great long-term approaches, but the short-term is what someone with panic disorder in an active phase cares about most. Long term stuff can come after, just get me through right now.

And I am keenly aware that my personal experience should never cloud my clinical judgement inasmuch as that is humanly possible.

* I tried to dial 911 my first time, in the middle of a biochemistry lecture, no less. But I couldn’t see well enough to dial the number. In retrospect, knowing what I know now, I’m glad I couldn’t because that would have been a misuse of medical resources. :p

Early in panic, people are usually not capable of accessing the skills to use behavioral coping mechanisms. You usually need to halt the panic quickly and this is where BZDs are needed. Panic is such an uncomfortable and painful experience, the BZD’s are in a way like pain medications in the early stages of treatment.

5 thoughts on “On panic disorder and benzodiazepine use

  1. Some MDs seem scared of benzos. I have restless leg syndrome and painful neuropathy secondary to chemo. After having to stop dopamine agonists due to refraction and rebounding and getting no relief with gabapentin, my primary care doc was reluctant to go to the next recommended step (benzos). She instead sent home to have two weeks of sleplessnes and discomfort while waiting to see a neurologist – who, to my relief, listened to my history then said I would probably need to be on benzos for life.

  2. I have a question for you – that has been bothering me and been causing ME to have breakdowns for the last week. My boyfriend just moved and is experiencing anxiety. His mom took him to the doctor, and his doctor gave him 60 valium and 30 clonazepam with 6 months of refills. He has a 5 year history of drug abuse, and his dad died of a vicodin overdose about 8 years ago. What can I do? I don’t trust this doctor at all, that seems WAY excessive for one visit. he doesn’t even have attacks. He just has “anxiety”. I fear he was just looking for pills. I counted them, the clonazepam was picked up on tuesday and is already gone. The valium had 12 missing after the first 12 hours. Do I call the pharmacy and tell them to REALLY watch for early fills? ( he has no insurance). Do I call the doctor and tell him to get his shit together? Im so lost and scared. Don’t know where I can go or who I can talk to. Boyfriend is in denial, and whenever I bring it up we get in a fight and it ends up worse than it was. Please email me back if you get a chance

  3. Lordy, I just re-read my comment. I can tell I wrote it after I’d just had two weeks of no sleep. I usually have few typos and spelling/syntax errors.

  4. Panic attacks alas!! Yes, those out of the blue are startling. Only quick fix I’ve found and used for 10-12 years of having them about twice a week, was a quick Valsalva maneuver, then a few normal breaths. In about 10-15 sec it resolves them, I guess by letting heart rate pause, it fills up better and restarts slower. If it doesn’t work, do it again but better(only push 2 sec firmly!!)It’s free. Long term: better anxiety/stress management; AND 4-6 grams of fish oil capsules a day. When I run out of my supply, in 2 weeks a panic attack may come back along with my osteo arthritis and sinus allergies and snoring. Hmm–never tried benzos.

  5. The Benzo Replacement?

    Current Depression Medications: Do The Benefits Outweigh the Harm?

    Presently, for the treatment of depression and other what some claim are mental disorders, some of which are questionable, selective serotonin reuptake inhibitors are the drugs of choice by most prescribers. Such meds, meds that affect the mind, are called psychotropic medications. SSRIs also include a few meds in this class with the addition of a norepinephrine uptake inhibitor added to the SSRI, and these are referred to SNRI medications. Examples of SNRIs are Cymbalta and Effexor. Some consider these classes of meds a next generation after benzodiazepines, as there are similarities regarding their intake by others, yet the mechanisms of action are clearly different, but not their continued use and popularity by others.

    Some Definitions:

    Serotonin is a neurotransmitter thought to be associated with mood. The hypothesis was first suggested in the mid 1960s that this neurotransmitter may play a role in moods and emotions in humans. Yet to this day, the serotonin correlation with such behavioral and mental conditions is only theoretical. In fact, the psychiatrist’s bible, which is the DSM, states that the definite etiology of depression remains a mystery and is unknown. So a chemical imbalance in the brain is not proven to be the cause of mood disorders, it is only suspected with limited scientific evidence. In fact, diagnosing diseases such as depression is based on subjective assessment only, as interpreted by the prescriber, so one could question the accuracy of such diagnoses.

    Norepinephrine is a stress hormone, which many believe help those who have such mood disorders as depression. Basically, with the theory that by adding this hormone, the SSRI will be more efficacious for a patient prescribed such a med.

    And depression is only one of those mood disorders that may exist, yet possibly the most devastating one. An accurate diagnosis of these mood conditions lack complete accuracy as they can only be defined conceptually, so the diagnosis is dependent on subjective criteria, such as questionnaires. There is no objective diagnostic testing for depression. Yet the diagnosis of depression in patients has increased quite a bit over the decades. Also, few would argue that depression does not exist in other people. Yet, one may contemplate, actually how many other people are really depressed?

    Several decades ago, less than 1 percent of the U.S. populations were thought to have depression. Today, it is believed that about 15 percent of the populations have depression at some time in their lives. Why this great increase in the growth of this condition remains unknown and is subject to speculation. What is known is that the psychiatry specialty is the one specialty most paid to by certain pharmaceutical companies for support of their psychotropic meds, as this industry clearly desires market growth of these products, as this objective is part of their nature.

    Regardless, SSRIs and SRNIs are the preferred treatment methods if depression or other mood disorders that may be suspected by a doctor. Yet these meds discussed clearly are not the only treatments, medicinally or otherwise, for depression treatment.
    Over 30 million scripts of these types of meds are written annually, and the franchise is around 20 billion dollars a year, with some of the meds costing over 3 dollars per tablet. There are about ten different SSRI/SRNI meds available, many of which are now generic, yet essentially, they appear to be similar in regards to their efficacy and adverse events. The newest one, a SNRI called Pristiq, was approved in 2008, and is being promoted for treatment for menopause. The first one of these SSRI meds was Prozac, which was available in 1988, and the drug was greatly praised for its ability to transform the lives of those who consumed this medication in the years that followed. Some termed Prozac, ‘the happy pill’. In addition, as the years went by and more drugs in this class became available, Prozac was the one of preference for many doctors for children. A favorable book was published specifically regarding this medication soon after it became so popular with others.

    Furthermore, these meds have received additional indications besides depression for some really questionable conditions, such as social phobia and premenstrual syndrome. With the latter, I find it hard to believe that a natural female experience can be considered a treatable disease. Social phobia is a personality trait, in my opinion, which has been called shyness or perhaps a term coined by Dr. Carl Jung, which is introversion, so this probably should not be labeled a treatable disease as well. There are other indications for certain behavioral manifestations as well with the different SSRIs or SRNIs. So the market continues to grow with these meds. Yet, it is believed that these meds are effective in only about half of those who take them, so they are not going to be beneficial for those suspected of having certain medical illnesses treated by such meds. The makers of such meds seemed to have created such conditions besides depression for additional utilization of these types of medications, and are active and have been active in forming symbiotic relationships with related disease specific groups, such as providing financial support for screenings for the indicated conditions of their meds- screening of children and adolescents in particular, I understand, and consider dangerous and inappropriate for several reasons.

    Danger and concern primarily involves the adverse effects associated with these types of meds, which include suicidal thoughts and actions, violence, including acts of homicide, and aggression, among others, and the makers of such drugs are suspected to have known about these effects and did not share them with the public in a timely and critical manner. While most SSRIs and SNRIs are approved for use in adults only, prescribing these meds to children and adolescents has drawn the most attention and debate with others, such as those in the medical profession as well as citizen watchdog groups. The reasons for this attention are due to the potential off-label use of these meds in this population, yet what may be most shocking is the fact that some of the makers of these meds did not release clinical study information about the risks of suicide as well as the other adverse events related to such populations, including the decreased efficacy of SSRIs in general, which is believed to be less than 10 percent more effective than a placebo. Paxil caught the attention of the government regarding this issue of data suppression some time ago, this hiding such important information.

    And there are very serious questions about the use of SSRIs in children and adolescents regarding the effects of these meds on them. For example, do the SSRIs correct or create brain states considered not within normal limits, which in effect could cause harm rather than benefit? Are adolescents really depressed, or just experiencing what was once considered normal teenage angst? Do SSRIs have an effect on the brain development and their identity of such young people? Do adolescents in particular become dangerous or bizarre due to SSRIs interfering with the myelination occurring in their still developing brains? No one seems to know the correct answer to such questions, yet the danger associated with the use of SSRIs does in fact exist. It is observed in some who take such meds, but not all who take these meds. Yet health care providers possibly should be much more aware of these possibilities
    Finally, if SSRIs are discontinued, immediately in particular instead of a gradual discontinuation, withdrawals are believed to be quite brutal, and may be a catalyst for suicide in itself, as not only are these meds habit forming, but discontinuing these meds, I understand, leaves the brain in a state of neurochemical instability, as the neurons are recalibrating upon discontinuation of the SSRI that altered the brain of the consumer of this type of med. This occurs to some degree with any psychotropic med, yet the withdrawals can reach a state of danger for the victim in some classes of meds such as SSRIs, it is believed.

    SSRIs and SRNIs have been claimed by doctors and patients to be extremely beneficial for the patient’s well -being regarding the patient’s mental issues where these types of meds are used, yet the risk factors associated with this class of medications may outweigh any perceived benefit for the patient taking such a drug. Considering the lack of efficacy that has been demonstrated objectively, along with the deadly adverse events with these meds only recently brought to the attention of others, other treatment options should probably be considered, but that is up to the discretion of the prescriber, who needs to be informed of what this person prescribes completely.

    “I use to care, but now I take a pill for that.” — Author unknown

    Dan Abshear

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