Panic disorders

Because long-term exposure to high-dose benzodiazepines may place some patients at risk for physical and psychological dependence, we recommend the use of antidepressants for the treatment of panic disorder. For most patients, SSRIs should be considered first-line agents. The choice should be based on the factors discussed in Chapter 2. MAOls are usually reserved for patients whose symptoms have not responded to SSRIs and TCAs. A major caveat is that patients with panic disorder initially may be highly sensitive to the stimulant effect of small doses of antidepressants. For highly anxious patients with panic disorder, treatment may be 

Unfortunately, no guidelines exist for the duration of pharmacotherapy. We recommend attempting to discontinue medication gradually every 6-12 months if the patient has been relatively symptom-free. However, many patients require longer-term pharmacotherapy. 

Miscellaneous. In recent years, other medication classes have been tested in the treatment of specihc anxiety syndromes. For example, atypical antipsychotics have been used as adjunctive treatments for OCD and GAD, and mood stabilizers have been used to treat PTSD. These syndrome-specific regimens will be discussed in the following sections. 

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CCK is found in the digestive tract and the central and peripheral nervous systems. In the brain, CCK coexists with DA. In the peripheral nervous system, the two principal physiological actions of CCK are stimulation of gaU. bladder contraction and pancreatic enzyme secretion. CCK also stimulates glucose and amino acid transport, protein and DNA synthesis, and pancreatic hormone secretion. In the CNS, CCK induces hypothermia, analgesia, hyperglycemia, stimulation of pituitary hormone release, and a decrease in exploratory behavior. The CCK family of neuropeptides has been impHcated in anxiety and panic disorders, psychoses, satiety, and gastric acid and pancreatic enzyme secretions. 

Beginning in the 1960s, ben2odia2epiae anxiolytics and hypnotics rapidly became the standard prescription dmg treatment. In the 1980s, buspkone [36505-84-7] (3), which acts as a partial agonist at the serotonin [50-67-9] (5-hydroxytryptamine, 5-HT) type lA receptor, was approved as treatment for generali2ed anxiety. More recently, selective serotonin reuptake inhibitors (SSRIs) have been approved for therapy of panic disorder and obsessive—compulsive behavior. 

SSRIs are widely used for treatment of depression, as well as, for example, panic disorders and obsessive—compulsive disorder. These dmgs are well recognized as clinically effective antidepressants having an improved side-effect profile as compared to the TCAs and irreversible MAO inhibitors. Indeed, these dmgs lack the anticholinergic, cardiovascular, and sedative effects characteristic of TCAs. Their main adverse effects include nervousness /anxiety, nausea, diarrhea or constipation, insomnia, tremor, dizziness, headache, and sexual dysfunction. The most commonly prescribed SSRIs for depression are fluoxetine (31), fluvoxamine (32), sertraline (52), citalopram (53), and paroxetine (54). SSRIs together represent about one-fifth of total worldwide antidepressant unit sales. 

Antidepressants are small heterocyclic molecules entering the circulation after oral administration and passing the blood-brain barrier to bind at numerous specific sites in the brain. They are used for treatment of depression, panic disorders, generalized anxiety disorder, social phobia, obsessive compulsive disorder, and other psychiatric disorders and nonpsychiatric states. 

Anxiety is a normal reaction. Pathological anxiety interferes with daily-life activities and may be accompanied by autonomic symptoms (chest pain, dyspnoea and palpitations). Severe forms include phobic anxiety and panic disorder. 

OCD, panic disorder, general anxiety disorder, social anxiety disorder, post-traumatic stress syndrome Depression, OCD, panic disorders, post-traumatic stress disorder... 

Cowley DS Alcohol abuse, substance abuse, and panic disorder. Am J Med 92(suppl) 41S 8S, 1992... 

In two studies in which benzodia2epines were gradually tapered, concurrent cognitive-behavioral therapy (CBT) did not increase the proportion of patients who were able to successfully discontinue their use of these agents (Oude Voshaar et al. 2003 Vorma et al. 2003). On the other hand, other studies of patients with panic disorder found that CBT facilitated the discontinuation of benzodiazepine use (Otto et al. 1993). Similarly, CBT may be superior to supportive medical management in preventing the reoccurrence of panic attacks in panic disorder patients in whom alprazolam has been tapered (Bruce etal. 1999). 

Bruce TJ, Spiegel DA, Hegel MT Cognitive-behavioral therapy helps prevent relapse and recurrence of panic disorder following alprazolam discontinuation a longterm follow-up of the Peoria and Dartmouth studies. J Consult Clin Psychol 67 151-156, 1999... 

Nutt DJ, Glue P, Lawson C, et al Flumazenil provocation of panic attacks evidence for altered benzodiazepine receptor sensitivity in panic disorder. Arch Gen Psychiatry 47 917-923, 1990... 

Otto MW, Pollack MH, Sachs GS, et al Alcohol dependence in panic disorder patients. J Psychiatr Res 26 29-38, 1992... 

Schweizer E, Patterson W, Rickels K, et al Double-blind, placebo-controlled study of a once-a-day, sustained-release preparation of alprazolam for the treatment of panic disorder. Am J Psychiatry 150 1210-1215, 1993 Seivewright N Benzodiazepine misuse by illicit drug misusers. Addiction 96 333—334, 2001... 

Rates of smoking among patients with bipolar disorders and anxiety disorders (e.g., posttraumatic stress disorder, panic disorder) are also higher than those in the general population (Lasser et al. 2000), but there has been htde smdy of the factors associated with motivation to quit smoking or of smoking cessation interventions in these patient groups. 

F40.0 Agoraphobia. 00 Without panic disorder. 01 With panic disorder... 

Shah and Jenkins (2000) in a review of mental health economic studies from around the world identified 40 cost-of-illness studies, of which five covered all disorders, one neuroses, two panic disorders and one anxiety. All were from developed countries. There were numerous cost-effectiveness studies but none involving the anxiety disorders specifically. One study in the UK examined the cost-benefit analysis of a controlled trial of nurse therapy for neurosis in primary care (Ginsberg et al, 1984). 

Data from the ECA were used in an analysis of the social costs of anxiety disorders (Leon et al, 1995). Financial dependence was high among anxious individuals, particularly those with panic disorders (unemployment among men was 60%). Chronic... 

Treating a condition is usually cheaper than not treating it (the offset effect). A Spanish study of panic disorder patients reported an offset effect of 14% following 12 months of drug treatment (Salvador-Carulla et al, 1995). Thus, the total direct costs of health-care use during the previous year and the year following diagnosis were US 29 000 and US 46 000 respectively, but the estimated... 

The lifetime prevalence rate for panic disorder is about 1.7%, divided into 2.4% in women,... 

An Australian study compared medical utilization and costs in patients with panic disorder, those with social anxiety disorder, and a control group (Rees et al, 1998). Almost half of the panic disorder patients had seen a primary-care physician more than seven times over a 6-month period, compared with 7% of the social phobic patients and none of the control group. The mean costs were A 150, A 60 and A 20 respectively. The patients with panic disorder were treated with antidepressants (39%), benzodiazepines (15%), relaxants (12%), beta-blockers (7%) and other medication (7%). Twenty per cent received no medication. Patients with panic... 

Unlike most anxiety disorders, panic disorder leads to a high utilization of general medical services, reflecting the frequency, severity and alarming nature of physical symptoms such as palpitations, gastrointestinal distress, respiratory problems and headaches (Zaubler and Katon, 1998). This can result in extensive investigations and sometimes inappropriate but expensive medications. 

An earlier study yielded data at variance with these findings (Edlund and Swann, 1987). In a small group of patients with panic disorder, disability was marked most reported a decreased quality of work and two-thirds claimed to have lost jobs or income. Half could not drive further than 5 kilometres and a third had increased their alcohol use. However, direct costs for treatment were not high, mainly because most had not sought treatment. Note that this study took place before panic disorder became generally recognized and publicized. 

The anxiety disorders are common and surprisingly disabling conditions. Studies on the health economics of generalized anxiety disorder, panic disorder, social anxiety disorders and obsessive compulsive disorder document the cost to the individual and to society. Attention has focused on the major psychiatric disorders such as depression, schizophrenia and the dementias. Studies suggest that many anxiety disorders are of early onset and too often chronic they are quite common and impose a heavy burden on society. More studies will be needed to discern the fine grain in the survey material and to identify more precisely the location and type of societal costs. These factors will vary from country to country, from district to district, between men and women and between various age groups. 

Edlund MJ, Swann AC (1987). The economic and social costs of panic disorder. Hosp Community Psychiatry 5, 1277—9. 

Katon W (1996). Panic disorder relationship to high medical utilization, unexplained physical symptoms, and medical costs. J Clin Psychiatry 57 (suppl. 10), 11-18. 

Rees CS, Richards JC, Smith LM (1998). Medical utilisation and costs in panic disorder a comparison with social phobia. J Anxiety Disordl2A2 -55. 

Salvador-Carulla L, Segui J, Fernandez-Cano P, et al (1995). Costs and offset effect in panic disorders. Br J Psychiatry 166 (suppl. 27), 23-8. 

ZaublerTS, Karon K (1998). Panic disorder in the general medical setting. / Psychosom Res4A, 5 2. 

Gould RA, Otto MW, Pollack MH (1995). A meta analysis of treatment outcome for panic disorder. Clin Psychol Rev 15, 819-44. 

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