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Panic disorder: An anxiety disorder with effective treatments

Behaviour, Depression, Mental Health | November 21, 2014 | Author: The Super Pharmacist

depression, mental

Panic disorder: An anxiety disorder with effective treatments

Panic disorder is a mental health condition in which the sufferer experiences recurrent panic attacks. Panic attacks may occur occasionally or often and often arise without warning. A panic attack may include feelings of choking, shortness of breath, a racing heart or palpitations, dizziness, feeling faint, chills, hot flashes, or chest pain. A person who is experiencing a panic attack may fear losing control or that they are going crazy or dying. Sufferers may complain that they feel as if they are having an out of body experience or that they are outside of themselves. Commonly, people who are experiencing a panic attack feel an overwhelming sense of dread and impending doom. While everyone will occasionally feel apprehensive or anxious, a panic attack is a fundamentally different experience in that it is much more severe to the point of being overwhelming. While 1 in 4 people will experience a panic attack in their lifetime, about 5% of the population will develop recurrent panic attacks signifying panic disorder.

Drug treatments for panic disorder

Several psychoactive medications have been used to treat panic disorder with varying degrees of success. Drug treatments for panic disorder include:

  • monoamine oxidase inhibitors (MAOIs)
  • tricyclic antidepressants (tricyclics)
  • selective serotonin reuptake inhibitors (SSRIs)
  • serotonin-norepinephrine reuptake inhibitors (SNRIs), and
  • benzodiazepines.

Each of these drug classes has advantages and disadvantages in terms of onset of action, efficacy and side effects. No single drug or drug class will work for every person with panic disorder.

Monoamine oxidase inhibitors

MAOIs are one of the oldest treatments for panic disorder. They are not often used in the treatment of any disorder because of their unfavorable side effect profiles.

If patients can tolerate MAOIs, they can be quite effective. For example, phenelzine successfully reduced panic attacks, anxiety, and various phobias better than those treated with placebo. 

Unfortunately, phenelzine like most MAOIs can cause significant oedema, orthostatic hypotension (low blood pressure upon standing), rash, sexual dysfunction, suicidal ideation, and hypertensive crisis among others. MAOIs are usually not considered a first-line drug treatment for panic disorder because of these side effects.

Tricyclic antidepressants

Like MAOIs, tricyclics are relatively older psychoactive medications and, while effective, they often cause unwanted effects. Over a dozen clinical trials have shown that tricyclic antidepressants (e.g. amitriptyline, imipramine and clomipramine) are superior to placebo in reducing the frequency and number of panic attacks that people experience. In fact, they are as effective as SSRIs. People have difficulty taking tricyclics because these drugs commonly cause orthostatic hypotension, sleep disturbances, weight gain, hypertension, sexual dysfunction, and anti-cholinergic side effects such as constipation and urinary retention, tremor, skin flushing, and rapid heart rate. Because of the side effect profile, people recently diagnosed with panic disorder usually begin with an SSRI rather than a tricyclic antidepressant and use this option when alternatives are not tolerated in ineffective. People who have been treated with tricyclic antidepressants and tolerate the drug can usually be maintained on the tricyclic for long periods.

Selective serotonin reuptake inhibitors (SSRI)

SSRIs are the workhorses of psychiatry. They are effective in a wide variety of psychiatric disorders including panic disorder. At least 12 clinical trials have shown that SSRIs are superior to placebo treatment for panic disorder and are relatively well tolerated by most patients. 

Selective serotonin reuptake inhibitors (SSRI)SSRIs can reduce the frequency of panic attacks, reduce the anxiety that is associated with impending panic attacks, and help patients overcome phobias.

There are numerous SSRIs available and all appear to be equally effective in treating panic disorder. Therefore, the choice of SSRI depends on the side effect profile of the individual drug and patient preference.

SSRIs may cause headaches, nausea, diarrhoea, insomnia, and sexual dysfunction; however, these side effects appear to be less severe and better tolerated than with tricyclic antidepressants or MAOIs.

Serotonin-norepinephrine reuptake inhibitors (SNRI)

SNRIs are the most recent addition to the antidepressant/anti-anxiety drug armament. Although SNRIs are slightly better at treating depression than SSRIs, there is little evidence to suggest that SNRIs are better at treating panic disorder. One SNRI in particular, venlafaxine, reduced the frequency of panic attacks, anxiety, and phobia when compared to placebo in randomised clinical trials. Side effects of venlafaxine include nausea, constipation, daytime sleepiness, and sexual dysfunction.

Benzodiazepines

Benzodiazepines are the prototypical anti-anxiety drug class. Alprazolam, diazepam clonazepam, and lorazepam are all effective in reducing panic attack frequency, anxiety, and phobia in people with panic disorder. In fact, benzodiazepines are essentially equivalent to SSRIs and tricyclic antidepressants for the treatment of panic disorder. Of note, only alprazolam and clonazepam are approved by the FDA for the treatment of panic disorder. The major advantage of benzodiazepines in the treatment of panic disorder is that they are effective within the first week of treatment. Other antidepressants listed above take two to four weeks for full effect. This can be helpful in people who are experiencing frequent, severe panic attacks and need urgent help. Unfortunately, people who take benzodiazepines are at risk of developing a chronic dependence on the drug similar to, but not always precisely like, addiction. People who develop a dependence on benzodiazepines usually must be weaned off the drug and started on a different treatment option.

Psychotherapeutic treatments

Cognitive behavioral therapy

Psychotherapeutic treatmentsCognitive behavioral therapy is a set of psychotherapeutic techniques that is based on the concept that our thoughts are the source of our feelings and lead to our behaviors.

Cognitive behavioral therapy or CBT is delivered in a finite number of structured sessions (usually 12 to 24) in which the patient examines their thoughts and the therapist encourages the patient to view these thoughts in different, healthier ways. 

According to CBT, if patients can change their thoughts, they can change their feelings and behaviors.

CBT may include specific therapeutic approaches such as patient education with or without cognitive restructuring, self-monitoring in which the patient keeps a diary of panic attacks and possible triggers, applied relaxation, and exposure (especially for phobias). CBT is particularly effective for the treatment of panic disorder. In fact, controlled clinical trials have shown that antidepressant medications and CBT are equally effective in treating panic disorder. Moreover, when drug treatment is combined with cognitive behavioral therapy the combination may be slightly more effective than either treatment approach individually.

Psychodynamic therapy

Psychodynamic therapy is focused on examining a person's past life events as they relate to the current experience or behaviors. Psychodynamic therapists help patients identify unresolved conflicts and dysfunctional or abusive relationships that exist currently or in the past. The basis of psychodynamic therapy is that past experiences shape our current experience and by a correcting or supplementing abnormal or missing experiences, the patient can improve their current circumstances. Psychodynamic therapy may last two years or more. There has been surprisingly little work done to examine the efficacy of psychodynamic therapy in panic disorder. Most clinical trials have been small or lacked sufficient randomisation or controlled groups. One carefully designed study showed that psychodynamic therapy was superior to applied relaxation, but more work is needed in this area.

Interpersonal psychotherapy

Interpersonal psychotherapy postulates that a person's strained or unfulfilling relationships or lack of relationships leads to psychological problems, such as panic disorder. Thus, improving interpersonal relationships may reduce psychological symptoms. Trials of interpersonal psychotherapy show that this approach is inferior to cognitive behavioral therapy in the treatment of panic disorder.

“Acceptance” psychotherapy

In acceptance-based psychotherapy, the patient is encouraged to accept circumstances as they are rather then to attempt to change their thoughts or feelings. This approach draws on the concepts of Zen Buddhism, but is unrelated to religious practices. The approach includes “mindful” observation of all experiences, i.e. living in the moment.

Acceptance-based psychotherapy is relatively new and has not been adequately tested as a treatment for panic disorder. However, small trials have shown early promise.

Long-term prognosis

Sadly, most people with panic disorder experience a recurrent, chronic disease that lasts for many years. Long-term studies (between 1 to 5 years after treatment initiation) have revealed that most patients will experience fewer symptoms with treatment. Unfortunately, very few patients experience a complete remission or cure of panic disorder. 

Certain groups of patients are more likely to enjoy long-term remission. These include women, people with few life stressors, those who have relatively infrequent attacks, and those with subthreshold panic, which is a milder form of panic disorder. Conversely, people with panic disorder who also have major depression, agoraphobia, or personality disorders generally have poorer outcomes. Somewhat surprisingly, individuals who have infrequent panic attacks actually access emergency medical care more frequently than others with panic disorder because they often go undiagnosed and fear that their symptoms may have a cardiovascular or neurological cause.

As a rule, those who are properly diagnosed with panic disorder, diagnosed relatively early in the course of their illness, and competently treated by psychological/psychiatric providers fare better than those who are not.

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