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.
Onymnomycin
Got an Rx from a dentist today:
Onymnomycin 300mg
1 qid until finished
#40
0 refills
I love it when prescribers make shit up.
Evolution of thought processes
Phone rings. "Hello, may I help you?"
"Hi, I was wondering if I can take an Aleve for my shoulder ache? I also take lisinopril."
7 years ago:
WTF is lisinopril?
Time: instantaneous
6 years ago:
I know how to spell lisinopril!
Time: ~0.5 seconds
5 years ago:
Lisinopril is for blood pressure!
Time: ~1-2 seconds
4 years ago:
Have I seen this before? Yes… I have because Aleve is naproxen sodium, and I've seen people take Naprosyn with lisinopril.
Time: ~2-3 seconds
3 years ago:
Lisinopril is an ACE inhibitor, and I see this combination every day.
"Sure, that's fine."
Time: ~0.75 seconds
2 years ago:
*Visual, mental review of systems, picturing the RAAS pathway and envisioning how naproxen is metabolized to see where and how the two intersect.*
"Sure, that's fine."
Time: ~0.5 seconds or so
Most recently:
How old is she? What's her creatinine clearance? Might she be better off with diclofenac or celecoxib? Eh, it's probably okay on a short-term basis, and it's not a terrible choice, but it's probably not the best choice, either.
"Sure, that's fine."
Time: ~1-2 seconds
What's the next step, I wonder? Quicker processing? Maybe. Deeper comprehension? Hopefully.
This development of thought processes is the difference between these two residents. The ability to take in a situation in its entirety, process it efficiently, while remaining calm and friendly takes time and exposure, and has very little to do with intelligence or any other innate quality.
* Naproxen is considered an unacceptable agent in geriatric patients even though it is used in the elderly pretty regularly. (My grandmother, for instance.) Probably because most internists, orthopods, and others are often not terribly familiar with geropharmacology, which is why geriatrics is its own specialty both in Medicine and Pharmacy.
On the list of things I expected to hear today, this was not near the top
I'm was a little upset this evening, but I'm getting more comfortable now.
I called my GI doc three days ago to discuss my ongoing issues, and I was able to get an appointment for this afternoon(!). The nurse that did the preliminary vitals and whatnot stuff was unfamiliar to me. She told me that the GI folks were borrowing her for the day from Cardiology downstairs. For some reason she decided to listen to my heart… and she took a really long time doing so. I don't remember anyone listening to my heart before except at my PCP's, and never for so long.
"Hmm," she said.
"'Hmm'? What does 'hmm' mean?" I asked.
"I think you have a heart murmur… has anyone ever told you this before?"
"Uh, no. No one's told me that before."
"I see… let me listen again."
Another long pause while she listens.
"Yep, sounds like you have a murmur. Let me tell [Dr GI] so he can have a listen."
We then go on to have a five minute discussion about drugs, psychopharmacology, clinical pharmacy, and people with entitlement issues. (WTF)
My doc comes in, says hello, we talk about a great many things like we always do (last time we talked about the ins and outs of the laws governing anesthesia and CRNAs in the state of Massachusetts and this time we talked about Thanksgiving, travel, and energy efficiency and how it relates to electrical engineering. I love my GI doc — he's great.)
I was substantially less freaked out at this point, and we both almost forgot the murmur. He listens with me sitting up and lying down. He confirms it, suspects PVCs — something I've suspected I've had for about four years now — and we talk cardiologists. Turns out, one of the guys downstairs is an arrhythmia specialist, and does a lot of work with people my age.
–
I've been having mental battles with myself over the last couple of weeks whether I'm merely a hypochondriac, or if there's a real problem with whatever body part is letting me know it's there. I don't like to diagnose myself; I don't like to be one of those people. But I know that 1) I don't like going to the doctor every other week 2) I don't like taking pills and 3) I do my damnest not to be one of the people who taxes the system. I think that sort of rules out hypochondriasis.
Dropping a diagnosis on someone can be very disconcerting, even something relatively benign (most likely) like arrhythmia. Intellectually, I know that heart arrhythmia aren't a huge deal. I know millions of people have some kind of arrhythmia. I also know that most people have PVCs at some point during their life, and that rare is the person who has never had a skipped or extra beat. I have suspected that I have had some kind of heart trouble since the first time I walked up some stairs and I couldn't get my heart rate to drop for about five minutes.
I thought it was just the amphetamines I was taking at the time for ADHD. I'm certain those didn't help.
Since then, I've had four EKGs, and had my heart listened to by four doctors and countless nurses. They've all told me that I'm fine; there's nothing wrong. I heard it so many times, I believed it. I chalked it up to mere anxiety.
I'd just like to tell the world that I'm fucking tired of people ruling out something *actually* being wrong simply because I'm young. Delve deeper. Refer, if you must. Sitting here in my chair, sipping my decaf Columbian, this revelation explains a few things that I noticed were different about myself since since first grade.
I was always a pretty strong long-distance runner, but I suspect that's simply because walking was never (mentally) an option. I DID notice (and other parents noticed) that it took me longer to recover than the other kids. Where I might run a mile in 7 minutes or so, it would take me 45 minutes to an hour to get my breathing under control where other kids would be fine in 10 or 15 minutes.
Being in first grade, I thought nothing of it the first time someone said something to me about it. My chronic ear infections and multiple cases of severe poison ivy tended to be more pressing.
In junior high and early high school, I had a paper route, and despite biking 5-10 miles every day loaded down with newspapers, my CV endurance never really got beyond a certain point. When I played lacrosse in high school, my heart felt like it was going to explode pretty regularly. Moreso than the other kids.
More recently, while at the gym, I've hated cardio. There are days where I can run for 45 minutes to an hour and be fine, except for the very long recovery time afterwards. Other days, as soon as I move past a walk, I can feel my heart skipping beats. If I continue on, I get lightheaded and have to sit down. (Otherwise I'll fall down.) The more regular I am with cardio, the worse this problem is. It doesn't get better, it gets worse. Oh, and there's also the fact that about 10% of the time that I take a deep breath, my heart skips. (This is why deep breathing doesn't work for me when it comes to managing panic attacks.)
Of course, there's nothing wrong with me. I'm too young to have anything wrong with me. 19? 21? 25? Fuck it, it's all in your head. Maybe these R tards should read Groopman's book and try to take some of the principles to heart.
So while I was a little upset today at being informed that I have a heart murmur, I am somewhat comforted to know that I'm not mentally defective (at least not in that way 
), and that perhaps I have an answer. At last. Yes, I know murmurs come and go. They're not always present while the provider is listening. But a Holter monitor was never discussed. Maybe I should have been more pushy. But like I said, I didn't want to be one of those people.
–
Back to diagnosis dropping before I close. Knowing something in your mind and reconciling it with the emotional reaction you have to this input are two completely different animals. In fact, logical reconciliation doesn't come until later, if at all.
I have been guilty of being somewhat dismissive when someone tells me something that's obviously bothering them. If I know it's trivial, or a problem that's easily managed, you tend to not think of it as a terribly big deal. Familiarity with and exposure to a disease state causes a recalibration of Normal. Perhaps even indifference.
But nothing is trivial, even if it's not serious or life-threatening. Not to the person receiving the news. Nothing. (Unless they're drugged out of their mind, like I was when they said "Hey dude you have Crohn's." I just didn't give a fuck at that point.)
Oh, and what takes the cake is that when I got home from work tonight, and informed my family of this revelation, my mom laughs and says "Oh yeah, I have a murmur, too." and my grandmother pipes up and tells me she's got one, too. What the fuck, people. TELL ME THESE THINGS so when I'm asked if there's any history of illness in my family I can give the correct answer. I know my grandfather died of a heart attack, but I always thought he was an isolated case and it was because he was a lifelong smoker and alcoholic. :rolleyes: But no, apparently most of my grandmother's brothers and sisters and my own aunts and uncles have murmurs, too.
The mind boggles. Apparently this information is trivial.
Sometimes I need to talk to the doctor, not the nurse
Most of the time, I don't mind dealing with nurses. Not MAs or CNAs. Real nurses. They're pretty great with very, very few exceptions, and with very rare exception they know and acknowledge their limits. In fact, I've had quite a few laughs on the phone with nurses, and I'm usually relieved when the office staff puts me through to a nurse, because I know I'm not going to get smoke blown up my ass. Anyway, one of the limits of your average RN's knowledge is drugs and pharmacology. Yeah, they might take a PCol class, but it's not real pharmacology. And that's perfectly fine.
But this means that sometimes, just sometimes, talking to a nurse isn't enough. This usually happens when I need to speak to the doctor about a combination of problems. Most recently it was a dosage change coupled with non-compliance, a language barrier, and poor instructions on the script thanks to a pharmacokinetic difference between two drugs in the same class that it was clear the doctor wasn't aware of. (Doubling the dose of a statin with a short half life isn't going to matter if it's taken at the wrong time of day.)
It was for a Medicaid patient, who needs an interpreter who isn't always around to explain things to her. Visions of trainwrecks were dancing through my head at this point. How am I going to get this across to the prescriber, who I know for certain will not come to the phone?
So I call the office, and I get a call back from the nurse about 20 minutes later. I explain the issue as clearly as I can, and I can just feel her eyes glazing over. "Oh. Um. Hmm. Okay. I'm going need to have Dr So-and-so call you back tomorrow."
Argh.
It can take days to unravel a problem like this. It would take 30 seconds if I could just speak to the fucking doctor. I have the solution figured out. Now all I need is for him to listen, and then say "OK".
And they wonder why pharmacists don't do more interventions like this: they just don't have the time to chase some telephobic jackass around all day because he can't ever be bothered to come to the phone. This folks, is why the children's game is called "Telephone". Everyone loses.
Microsoft's HealthVault: a bad idea in its current form
There is some talk among physicians about using this service to "consolidate" health records for people. This is a phenomenally BAD idea, and I suspect these docs haven't thought it through. The reason for this is because giving patients write access to their "official" healthcare records gives them license to remove or alter things that they don't like, or want to tweak. Yes, I know this isn't an official electronic repository for healthcare records right now, but as soon as a doctor treats it as such, how Microsoft bills the service becomes irrelevant.
When and if Microsoft is able to hide information and tier access to health records, I'll withdraw my criticism of using this service in any official way:
It is better for a layperson to run their changes through someone with specialized knowledge than to attempt to amend their own records. Yes, there are smart people out there who know quite a lot about their medical issues and problems, but they are the minority. Better to have the pharmacist alter information about drug allergies; better to let your doctor alter the details of your colonoscopy findings.
Along the same lines, your pharmacist shouldn't be able to edit the information about your colonoscopy findings, and the doctor's secretary shouldn't be able to note that you are "allergic" to Flagyl because it upset your stomach. Those are the differences between potential medical emergencies (allergies) and superficial issues (upset stomach).
The average layperson is unable (and often unwilling) to distinguish between the two. Ultimately, there is no reason they should have to, either.
Not ten minutes ago, my grandmother asked me to spell "Pergosent" so she can let her doctor know that she is allergic to it. She means Percocet, of course, but even knowing Percocet is imperfect. I asked her if she could take Tylenol ("Yes") and wrote down "oxycodone" instead. That's more accurate. But this is the type of (mis-)information that providers are going to receive if patients have the ability to modify their healthcare records.
This is why write access to any sort of unified healthcare record system (official or otherwise) should be tiered and protected. Patients should have write access only to leave notes to a provider who may then go in an alter the official record. Hiding data from patients is a good idea because it allows a doc, for instance, to leave thoughts about suspected psychiatric issues hidden from the patient while they are browsing their record. I have had instances of people becoming upset because they read something that they didn't like in their record.
This information should be able to be flagged as hidden for anyone below a certain level of access, because a doctor shouldn't worry about offending a patient. And in this particular case, the person DID have psych issues, as it turns out. But she was offended nonetheless.
This isn't healthcare elitism. It's just good medicine. If doctors use HealthVault in its current incarnation as an official and reliable repository for healthcare records, people are going to get hurt.
Yeah, the technology angle is fun, but from a patient safety and accuracy point of view, using HealthVault as a semi-official repository of medical records has many flaws. It's also an invitation to be sued to kingdom come for any doctor that actually does this and something bad happens. There are other potential problems, too, like patients saying that they take 1mg of lorazepam twice daily when they really take 0.5mg at bedtime.
These are the reasons the official record should always be write protected. I'm sure my readers can come up with many other examples, too.
In the final analysis, I think services like this are absolutely fantastic. It's about time the healthcare industry started thinking this way, but there are still some gaping holes that need to be addressed. Kudos to Microsoft for going out on a limb anyway. It's about time someone did.
If you enjoyed this story, please digg it.
[tags]Microsoft, HealthVault, healthcare[/tags]
"He gets so excited he throws up"
"My son is 7 years old, and whenever something exciting happens, he throws up. We're supposed to go to the amusement park today if the weather clears up, and he's afraid — and so am I — that if we go, he'll throw up while we're there.
"I don't know what to do anymore. On the first day of school, he throws up. On the last day of school, he throws up. Waiting in line for a roller coaster, he throws up. If he gets really happy for any reason, he throws up. And he throws up because he throws up and worries that he's going to throw up again.
"Is there anything I can give him so he stops throwing up?"
Straight Face held firmly in place — with superhuman effort — I stopped to think about the problem.*
And lest you think me an insensitive clod, I can assure you that I did (and still do) feel awful for this kid. I wonder what his home life is like. I wonder if he's chemically imbalanced. I wonder if it's a phase he'll grow out of. I wonder how to help him in the short term, today, hopefully without robbing him entirely of the excitement that an amusement park brings. I wonder about abuse, too. I wonder if this behavior is conditioned in some way, and if it might be self-reinforcing, not unlike that destructive positive feedback loop that plagues those with panic disorder. I wonder if he'll grow up with anxiety problems. I wonder if he'll end up a well-adjusted adult, hopefully without the need to be on long-term psych meds.
Most of all, right now, I hope mom has a talk with the pediatrician about it.
Given that my options are severely limited by a lack of prescribing powers, the best solution OTC would be Benadryl to blunt the edge, with the side effect of probably making him very sleepy. Not optimal, for sure, but better than puking before you get on the ride, no? Some would think Emetrol, maybe, but that's a poor solution because that's not going after the actual problem. If the child is overexcited, better to take that down a notch than merely cover the side effects of being in that condition in the first place.
What do you guys think? What would you have done?
* When I was in junior high, my friends and I used to talk about the worst, most absurd "super power" to have. We decided it would be the superhuman ability to crap your pants every time you got excited. "Haha! Yay!… ohhhh…." This is where I coined the phrase "My bowels are aquiver with excitement."
I'd say this child's difficulty ranks right up there…