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.

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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.

The more you talk, the less I believe you

Something I've noticed for years: the more a patient talks at you, the more likely they are to be lying. They talk and talk and talk, and nothing of substance comes out. It's a smokescreen for something else they want. They tell you their life story, and then ask for an early fill on their Vicodin as though the two are somehow related.

Do they think I'm stupid? I can't count the number of times I've put the phone down with the person still talking at me (without having said more than "May I help you?") done something, and then come back with them still blowing hot air.

The more words someone uses, the greater the chances are that they're full of shit.

This is in contrast to someone with a legitimate issue who will tell you their story in as few words as possible, and then ask what they need to do. Even people who typically blow smoke talk less when they're actually telling the truth and they have, for instance, a police report to back it up.

Every retail pharmacist in the world knows exactly what I'm talking about, and I'm sure most ED types do too. Remarkable that the bottom-feeders on the planet haven't figured out that if they just kept their mouths shut, I'd be 2-3x more likely to believe them. I would have thought such a skill would be accidentally uncovered and remembered. But perhaps idle chatter is the verbal form of a nervous twitch, and many of these folks are halfway decent candidates for the Darwin Awards anyway, so I shouldn't be surprised that they haven't learned from past successes.

In any event, they'd all be shitty poker players.