As needed medication for Panic Attacks, besides Benzo's and Vistaril?

[shahseh22]

Hi,
I have a patient who is only interested in a Benzo, however, due to his extensive history of substance use, I am trying to avoid anything addicting. He's already on an SSRI but I want something that will be helpful for when he is having the panic attacks. Vistaril was of no benefit in him. I mentioned taking Buspar regularly but he does not want to take anything on a regular basis. I even talked about low dose Propanolol (has asthma).

I was wondering if there is anything else you guys would suggest using? I was thinking of Seroquel PRN.

Thanks

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[uname943]

Hi,
I have a patient who is only interested in a Benzo, however, due to his extensive history of substance use, I am trying to avoid anything addicting. He's already on an SSRI but I want something that will be helpful for when he is having the panic attacks. Vistaril was of no benefit in him. I mentioned taking Buspar regularly but he does not want to take anything on a regular basis. I even talked about low dose Propanolol (has asthma).

I was wondering if there is anything else you guys would suggest using? I was thinking of Seroquel PRN.

Thanks

CBT.

Don't waste your time with quetiapine. Maintain boundaries with no benzos.

 

[splik]

PRN medications are an absolute no no in panic disorder. if someone is having a panic attack it already too late. given that panic peaks over 5-10 minutes, by the time the drug kicks in the panic attack will be over anyway. all you are doing is given the patient another safety behavior that prevents fear extinction and reinforces the idea that the patient is helpless, unable to manage their own emotions, and dependent on drugs to regulate powerful feelings.

ensure that the patient is on an adequate dose of an SSRI (high doses are necessary, often much higher than for depression) and that the patient engages in exposure therapy. the problem with these patients who want benzos, is nothing else will ever work for them because they don't want it to. you need to dispel the notion that you will ever prescribe benzos or that as needed medication is appropriate for panic.

panic disorder is one of the few things we can actually cure in psychiatry.

 

[birchswing]

Flex stomach muscles (stops overly deep breathing). Focus on your thumb's nail. Find the corners of a room. Or just exist (you're going to anyway, so that's an easy one). Etc.

The problem is people use the word panic attack loosely to a variety of situations that are not textbook panic attacks. In that case, the solution varies based on what the actual problem is.

Edit: You mentioned asthma. I actually came across an article a while ago on a specific program for treating co-morbid panic disorder and asthma, as they often go together and exacerbate each other. I don't have the article link at the moment, but maybe something to look into.

Edit 2: Found it:

Psychological treatment of Comorbid Asthma and Panic Disorder: A Pilot Study

 

[hamstergang]

Edit 2: Found it:

Psychological treatment of Comorbid Asthma and Panic Disorder: A Pilot Study

I did some of my training with this guy. I dont know enough to know if there's really something to this, but at least when I was there it seemed that he would oversell his results and the extent of support in the literature for such things.

 

[birchswing]

I did some of my training with this guy. I dont know enough to know if there's really something to this, but at least when I was there it seemed that he would oversell his results and the extent of support in the literature for such things.

It looks like it's basically CBT and asthma education, with attention given on how to distinguish panic and asthma. Given how many people are just given medicine for both anxiety and asthma, it's not implausible that education for each problem would work. It's not a terribly exotic or maybe even a new idea, but I would imagine one that for time constraints doesn't get enacted much outside of trials such as this one (and they found that the shorter the duration the better). I would say it's the same with diabetic education classes (I doubt many diagnosed with Type 2 ever attend), but the nutritional informational often provided is so bad I'd say people are better off without it in that particular case.

 

[erg923]

Hi,
I have a patient who is only interested in a Benzo, however, due to his extensive history of substance use, I am trying to avoid anything addicting. He's already on an SSRI but I want something that will be helpful for when he is having the panic attacks. Vistaril was of no benefit in him. I mentioned taking Buspar regularly but he does not want to take anything on a regular basis. I even talked about low dose Propanolol (has asthma).

I was wondering if there is anything else you guys would suggest using? I was thinking of Seroquel PRN.

Thanks

1. Your patient does not want to take any role in his mental healthcare. Have a conversation about this fact.

2, prn benzo for panic disorder Durant treat panic disorder.

 

[thoffen]

People can definitely have placebo responses to PRN medication for panic attacks and also can have serious anticipatory anxiety before panic sets in. I still agree that for panic disorder, you don't want to go down that route. I try to get people to prioritize treating the disorder and not the symptom, and the interventions needed are the ones where a person learns to be the center of control for their symptoms and not something external like avoiding an environment or taking a drug.

 

[Armadillos]

I’ve always been tempted to give someone demanding a PRN for panic attacks occurring a couple times a week prn Prozac

 

[nitemagi]

At the core of both the "condition" and response is expectation. Call it placebo or otherwise. Anxiety escalates to manic [usually] because of anticipation that it will get worse and worse or something worse will happen. Similarly the pill gives the expectation of relief, breaking the expectation of worsening. It gives hope. But it doesn't break the cycle itself.

 

[Mass Effect]

PRN medications are an absolute no no in panic disorder.

Totally disagree with this. PRN meds are actually indicated while awaiting response to SSRI in panic disorder. In the case of the OP's patient, I would not use them, but in general population and those with no substance abuse history, prn meds are absolutely helpful.

 

[WingedOx]

Totally disagree with this. PRN meds are actually indicated while awaiting response to SSRI in panic disorder. In the case of the OP's patient, I would not use them, but in general population and those with no substance abuse history, prn meds are absolutely helpful.

no. no. no. no. no. no. no.

Disabuse yourself of this and do the same for anyone else who professes that this should be standard of care. I'm particularly toxic about this because I'm in the midst of a disaster of a case of this method of prescribing gone wrong, but it's always been a bad idea. The problems with PRNs described above in the thread still exist with a patient who's new to tx.

 

[Mass Effect]

no. no. no. no. no. no. no.

Disabuse yourself of this and do the same for anyone else who professes that this should be standard of care. I'm particularly toxic about this because I'm in the midst of a disaster of a case of this method of prescribing gone wrong, but it's always been a bad idea. The problems with PRNs described above in the thread still exist with a patient who's new to tx.

Nope, disagree. I've used benzos used short-term, low-dose and seen them to be beneficial for patients with debilitating panic attacks. I don't use them for every patient and not in every circumstance certainly.

 

[WisNeuro]

As almost everyone in this who knows anything about models of anxiety has intoned, they are a terrible idea for panic attacks. It does nothing for the actual panic attack, and just introduces another safety cue to the patient. And, out of every patient who can somehow just use the meds prn for a short period of time, there are many more who will just find another doc who will prescribe them on maintenance. So much more harm than good, especially in panic disorder.

 

[WingedOx]

As almost everyone in this who knows anything about models of anxiety has intoned, they are a terrible idea for panic attacks. It does nothing for the actual panic attack, and just introduces another safety cue to the patient. And, out of every patient who can somehow just use the meds prn for a short period of time, there are many more who will just find another doc who will prescribe them on maintenance. So much more harm than good, especially in panic disorder.

Yeah, seriously. The benzo is AT BEST a placebo for the patient. It's reckless.

 

[WingedOx]

there’s only so much one can accomplish in one session.

Thing we need to disabuse of ourselves part II: The feeling that we have to provide relief on day 1.

We need to accept that there's a limit to what we can accomplish at the onset of treatment and that the treatment itself is lengthy and often difficult. Primary care docs often struggle with this concept, but there's no excuse for us as trained psychiatrists.

 

[DisorderedDoc417]

Thing we need to disabuse of ourselves part II: The feeling that we have to provide relief on day 1.

We need to accept that there's a limit to what we can accomplish at the onset of treatment and that the treatment itself is lengthy and often difficult. Primary care docs often struggle with this concept, but there's no excuse for us as trained psychiatrists.

Please, please understand that you are making way too much sense right now. Patients will not put up with such realistic and boring sounding expectations — they want to feel amazing right here, right now. Don’t believe me? Take a look at my pager at 3AM from the nurses who are happy to report that the patients anxiety is at an all time high. At that point, I’m feeling anxious. But does the resident ever get some Ativan? Not a chance....

 

[nitemagi]

I generally get a pretty good response through a combination of psychoeducation about anxiety, panic attacks, F-o-F, and then leading them through the experience of turning on anxiety (hyperventilation for example), then turning it off through progressive muscle relaxation and brief self-hypnosis. This give them immense hope, because they feel different in session, which they often don't believe is possible.

 

[smalltownpsych]

I generally get a pretty good response through a combination of psychoeducation about anxiety, panic attacks, F-o-F, and then leading them through the experience of turning on anxiety (hyperventilation for example), then turning it off through progressive muscle relaxation and brief self-hypnosis. This give them immense hope, because they feel different in session, which they often don't believe is possible.

That just sounds like an awful lot of work. Which points to the much bigger problem in our healthcare system and culture. I just went on a diet because my PA told me I was getting too fat and old and my numbers were starting to reflect it. He said to either lose some weight or I would have to start taking medications. To try and soften the blow, I guess, he also said that he hopes that he is in as good a shape as me in fifteen years . Ten pounds later (about ten more to go) and I am feeling amazing. Heart rate and blood pressure have both dropped. I am eating like a European now and loving it. I just came back from a trip there and saw how healthy they are. Unfortunately, I am the exception rather than the rule because I know that medications to treat symptoms will do nothing to eliminate the underlying cause. Anyway, now that I am getting back to my fighting weight, I'm going to kick some millenial PA butt!

 

[OldPsychDoc]

... Anyway, now that I am getting back to my fighting weight, I'm going to kick some millenial PA butt!

 

[LadyHalcyon]

Hi,
I have a patient who is only interested in a Benzo, however, due to his extensive history of substance use, I am trying to avoid anything addicting. He's already on an SSRI but I want something that will be helpful for when he is having the panic attacks. Vistaril was of no benefit in him. I mentioned taking Buspar regularly but he does not want to take anything on a regular basis. I even talked about low dose Propanolol (has asthma).

I was wondering if there is anything else you guys would suggest using? I was thinking of Seroquel PRN.

Thanks

What about a beta blocker?

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[birchswing]

What about a beta blocker?

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That's what the above referenced propanolol is. It can cause bronchospasm in asthmatics, which OP's patient apparently is. There are highly cardio-selective beta blockers less likely to exacerbate asthma in low doses, but they don't cross the blood-brain barrier and aren't known for psychoactive properties like propanolol. However, they could still mediate the flight-or-fight phenomenon. But if it is a frank panic attack (the way they are described in textbooks--which is different from the way people commonly use the term), the parasympathetic nervous system activates not long after the panic subsides and the beta blockade of a beta blocker may be unnecessary or even unnerving.

 

[LadyHalcyon]

That's what the above referenced propanolol is. It can cause bronchospasm in asthmatics, which OP's patient apparently is. There are highly cardio-selective beta blockers less likely to exacerbate asthma in low doses, but they don't cross the blood-brain barrier and aren't known for psychoactive properties like propanolol. However, they could still mediate the flight-or-fight phenomenon. But if it is a frank panic attack (the way they are described in textbooks--which is different from the way people commonly use the term), the parasympathetic nervous system activates not long after the panic subsides and the beta blockade of a beta blocker may be unnecessary or even unnerving.

Oh shoot I skimmed the post and didn't see propanol mentioned.. Just seroquel. But yeah I'm honestly not too familiar with them but I have seen them prescribed for panic attacks and for situation specific anxiety triggers (like before a presentation if someone has severe stage fright).

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[michaelrack]

There are selective beta 1 blockers that do cross the blood brain barrier

Metoprolol is considered moderately lipophilic

 

[erg923]

Totally disagree with this. PRN meds are actually indicated while awaiting response to SSRI in panic disorder. In the case of the OP's patient, I would not use them, but in general population and those with no substance abuse history, prn meds are absolutely helpful.

Is this based on clinical psychological science and currently accepted explanatory models of anxiety pathology/disorder and fear extinction...or your limited and subjective clinical experience?

Are you reinforcing/enabling "escape conditioning" via this method? If so, is this "helpful"? And to whom?

 

[michaelrack]

One must distinguish between a short term scheduled regime of benzos and prn benzos for panic disorder

 

[michaelrack]

I am against prn benzos for panic disorder

 

[WingedOx]

Oh shoot I skimmed the post and didn't see propanol mentioned.. Just seroquel.

Oh Seroquel... is there indication left that we haven't thrown to the wall to see what sticks?

 

[WisNeuro]

Oh Seroquel... is there indication left that we haven't thrown to the wall to see what sticks?

Physicians in my healthcare system seem to love to use it for sleep. Much more so than I've seen in other places. One of my recent geriatric patients was prescribed Seroquel 200mg tid, mirtazapine, 50mg diphenhydramine, and amitriptyline for her sleep problems. Sometimes she sleeps too well.

 

[WingedOx]

Physicians in my healthcare system seem to love to use it for sleep. Much more so than I've seen in other places. One of my recent geriatric patients was prescribed Seroquel 200mg tid, mirtazapine, 50mg diphenhydramine, and amitriptyline for her sleep problems. Sometimes she sleeps too well.

Ah yes, the "Fistfull of Benadryl" prescribing pattern.

 

[WisNeuro]

Ah yes, the "Fistfull of Benadryl" prescribing pattern.

Yeah, during my evaluation, she reported that she mixes up her meds a lot, and sometimes she accidentally takes those in the morning instead of bedtime and just passes out and wakes up at like 10PM. She's borderline intellectual functioning and needs some help. Her med list of 22 different Rxs wasn't helping. She has since been referred to another provider for a medication review after I raised some significant concerns about the current script list and her level of functioning being risk factors for death in the near future.

 

[LadyHalcyon]

Physicians in my healthcare system seem to love to use it for sleep. Much more so than I've seen in other places. One of my recent geriatric patients was prescribed Seroquel 200mg tid, mirtazapine, 50mg diphenhydramine, and amitriptyline for her sleep problems. Sometimes she sleeps too well.

Yes. They prescribe it here as well for sleep, in addition to trazodone. Lots and lots of trazodone.

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[WingedOx]

Yes. They prescribe it here as well for sleep, in addition to trazodone. Lots and lots of trazodone.

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I'm unfortunately too liberal with the trazodone myself, I'll admit, but unfortunately, counseling sleep hygiene has a high NNT.

 

[LadyHalcyon]

I'm unfortunately too liberal with the trazodone myself, I'll admit, but unfortunately, counseling sleep hygiene has a high NNT.

I think it's probably better than the hypnotics.. So at least there is that!

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[WingedOx]

I think it's probably better than the hypnotics.. So at least there is that!

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Yeah, if we're playing the "least harmful" game, it's usually my go-to, particularly if a patient has already been taking another quick-onset sleep aid (so he'll likely psych himself out of getting melatonin to work).

Though I'm on my hospital's pharmacy committee and one of the pharmacy residents did a QI of our department to see how well we're doing the full cover your ass monitoring QT-prolonging drugs, and the answer is: not well at all.

 

[WisNeuro]

I'm unfortunately too liberal with the trazodone myself, I'll admit, but unfortunately, counseling sleep hygiene has a high NNT.

To be fair, it's mostly because people just won't do it. Been a while since I've done formal sleep hygiene in a therapy context, but almost everyone who would actually do the work, got significantly better. It's just that 50%+ would start it out, try one thing, quit, and then go ask for sleep meds, claiming that that they tried sleep hygiene and it doesn't work.

 

[Shikima]

Best is for proactive management with education. Explaining it like Splik has would lend to a lot of insight development once the hurt feelings are resolved.

 

[Blitz2006]

Yes. They prescribe it here as well for sleep, in addition to trazodone. Lots and lots of trazodone.

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We prescribe a lot of trazodone as well.

Not to hijack, but is priapism risk dose dependent?

Also, do you discuss these risks with all patients you prescribe trazodone to? I feel this is under discussed in a clinical setting, but perhaps that's just my ignorant observation.

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[WisNeuro]

We prescribe a lot of trazodone as well.

Not to hijack, but is priapism risk dose dependent?

I thought it was just the low-dose, and usually happened shortly starting, but I haven't looked into it in quite a while.

 

[WingedOx]

To be fair, it's mostly because people just won't do it.

[thatsthejoke.jpg]

 

[WisNeuro]

[thatsthejoke.jpg]

I'm spectrumy. You have to put /sarcasm or something at the end

 

[LadyHalcyon]

I'm spectrumy. You have to put /sarcasm or something at the end

Ahhhhh.. That may explain the extreme cognitive rigidity #sarcasm #kinda

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[nitemagi]

I'm unfortunately too liberal with the trazodone myself, I'll admit, but unfortunately, counseling sleep hygiene has a high NNT.

I think I weigh that against the low NNH with many hypnotics, especially z-hypnotics. Admittedly I prescribe a lot of trazodone myself.