How should panic attacks/disorder be treated in the ED?

[quickfeet]

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Kind of a nuanced question, but one I am curious about as I review my EM Basic notes on "Chest Pain" where it lists a variety of benign conditions in the DDx. "Panic attack/panic disorder" is one of them.

Now I personally have seen some of these patients, both with and without a psychiatric diagnosis of panic disorder (majority who have had extensive cardiac/medical workup as outpatients to r/o other conditions).

Just curious what your thoughts are on how to dispo these patients. Obviously we refer them to psychiatrists, but we would also rather they not come back in within the next 24-48 hours saying they are having another "heart attack."

 

[birchswing]

It's a very difficult position for a patient. Every message you hear says to not doubt yourself when you're having chest pain. And the symptoms of a heart attack and panic attack can overlap quite closely. As someone whose original primary diagnosis was panic disorder, I've never been to an ER for chest pain, even though I've thought I should go at times. I've been talked out of it and waited to see an outpatient doctor.

For a person with panic disorder, if they come in with chest pain, and you have actually ruled out heart attack (done a very sensitive troponin test or whatever is done these days), and you've explained that the problem was a panic attack, I see it being unlikely for them to return, unless there was another problem like hypochondria or somatoform disorder.

My thought is that the best course of action is to provide good medical information as to the cause of the chest pain and rule out heart attack. You also have to remember that things besides panic disorder can trigger chest pain and then cause panic. For example, there can be soreness in the cartilage of the chest or acid reflux, etc. These pains can trigger anxiety, rather than anxiety triggering the pain. It's good to find an actual cause and explain how the anxiety reaction works--that the body may have a hypersensitivity to certain sensations.

But I think the chest pain issue is one that is simply difficult for both patients and doctors with all the messages you see that say in no uncertain terms to not doubt and it's better to be safe than sorry. I've struggled with this myself as I live with my parents and my father is from a Christian Science background and my mother is well . . . not the compassionate type. I actually had a time I had severe chest pain and was concerned it was dissection as I have a dilated aortic root, and my primary care doctor wanted me to go into the ER. My mom was home and wouldn't take me. I told her I was getting a cab. She called my father who was out of state on a business trip, and he called me crying asking me why I was tearing our family apart. I have may have anxiety, but they are nuts when it comes to health. My father practically has a nervous breakdown if I ask him to drive me to any non-scheduled medical appointment, such as Urgent Care. And my mother is just . . . non-involved.

Anyway, my original point was going to be that many ER visits are not what a patient's worst fear is. A case is either life threatening or it's not--and usually it's not. And given that chest pain is something that is supposed to be taken very seriously, I think the worst thing about unnecessary visits to the ER over a panic attack is probably the cost to a patient.

 

[shan564]

I'd probably try to get the patient in to see a PCP while they're waiting to see a psychiatrist. I might start propranolol for autonomic symptoms.

 

[birchswing]

I'd probably try to get the patient in to see a PCP while they're waiting to see a psychiatrist. I might start propranolol for autonomic symptoms.

I've noticed on a number of occasions that propranolol is the go-to beta blocker for psychiatrists. It's not usually a first-line beta blocker due to its high lipid solubility, increasing the risk of CNS side effects, and it's far more likely to cause problems with breathing than many selective BBs. A good doctor would ask if the patient has asthma, but in someone with light asthma who doesn't know they have it, it can still cause quite a heavy, constricted feeling, which will definitely exacerbate anxiety.

I've tried a number of beta blockers and I've found bisoprolol to have the best mix of qualities: it's highly cardioselective, half of it is metabolized by the kidney so it has less risk of interactions, very little of it crosses the brain blood barrier, and it has a decent enough half life that taking it once a day is usually sufficient. Propranolol was the first one I was put on and I got a very heavy feeling in my chest in spite of no asthma diagnosis; metoprolol had a lot of interactions with Paxil but was otherwise fine. But bisoprolol hits the sweet spot for me.

 

[quickfeet]

I'd probably try to get the patient in to see a PCP while they're waiting to see a psychiatrist. I might start propranolol for autonomic symptoms.

I would think that would be a little outside what an EM physician would prescribe. Maybe a 3 day supply of clonazepam or something and hope they see someone in that time period?

Also raises the question of how health anxiety/"hypochondriasis" should be treated in the E.D. setting. So far as I have learned from a psychiatrist attending, the repeated ordering of EKGs and simple blood work is actually quite harmful for these patients (reinforces the idea that something might be wrong and needs investigation rather than forcing themselves to live with the uncertainty which is apparently what the goal of treatment is), even though they are automatic for certain ED presentations.

 

[birchswing]

I would think that would be a little outside what an EM physician would prescribe. Maybe a 3 day supply of clonazepam or something and hope they see someone in that time period?

This might be the right answer, but in my years of observing the medical system, I see that doctors sometimes take a non-resistant path with the known. I could imagine this patient seeing an outpatient doctor follow up and the doctor asking, "So did the Klonopin help? Great. Well no reason to fix what isn't broken. Here's a refill." I'm not against the judicious use of benzodiazepines; I just am not convinced that in the way things actually work that there is much chance for judiciousness. To me it seems like you're playing roulette sending the patient on their way with benzos and hoping they get a doctor who will find a better long-term solution.

I don't disagree that prescribing benzos in an ER is unlikely or uncommon or unreasonable, though. I'm already on benzodiazepines and I've been offered additional benzodiazepines I've turned down on two occasions in the ER--once for severe vertigo, and once for what turned out to be a thyroid issue that was causing me to be very anxious and shake all over. And it wasn't an unreasonable idea that in each case the benzos would have been palliative, which I guess is probably the ER's biggest charge besides saving lives. Benzodiazepines are quite safe excepting their physical dependency and they do work, so I can see why they are used in ERs. For me though, I just knew it would be a bigger problem for me to deal with later on so I declined. And I wonder if it could be for others, as well.

The other issue with responding to panic attacks with benzodiazepines immediately is that you create a connection between relieving what feel like life-threatening symptoms with a particular medication.

I was very young when I started benzodiazepines, and I very seriously believed that when I felt like I couldn't breathe due to anxiety that taking Ativan was akin to taking an asthma inhaler for someone else. It starts to feel like oxygen.

Ideally in that situation in the ER you could reinforce that the patient *did* have a panic attack and had done very well having one--they survived and endured it. And you can try to say something positive about some aspect of the way they handled it. Whereas when you give a benzodiazepine, for me at least, the message I took in was: You do have an actual disease. You're not safe. This is like oxygen.

Granted I was young and things were not well explained to me, but I think there's something there that might be universal.

 

[Shikima]

I would think that would be a little outside what an EM physician would prescribe. Maybe a 3 day supply of clonazepam or something and hope they see someone in that time period?

Also raises the question of how health anxiety/"hypochondriasis" should be treated in the E.D. setting. So far as I have learned from a psychiatrist attending, the repeated ordering of EKGs and simple blood work is actually quite harmful for these patients (reinforces the idea that something might be wrong and needs investigation rather than forcing themselves to live with the uncertainty which is apparently what the goal of treatment is), even though they are automatic for certain ED presentations.

So, a beta blocker is "outside" of what you'd prescribe but a benzo is ok? le sigh.

There must be a reason why benzos are controlled substances.....


From a scientific standpoint, how are you going to cross cover them when dealing with the half-life of said benzodiazepines and then causing rebound anxiety symptoms? I guess you're stuck prescribing Paxil 10mg at bedtime until they can follow-up with their PCP and then maybe get into psychiatry. Or you can utilize social workers and create a listing local therapists, where arrangements have been made in advance, that they can see for an emergent and initial intake and start that process.

 

[milesed]

We have such a high rate of substance abuse in my area, I'd strongly prefer the ER not to give a Rx for benzos. If a one time dose is needed while in ER- fine.

I think referring out to pcp or psychiatry is best as they will be managing it.

 

[OldPsychDoc]

There is nothing (except time and effort) preventing you from doing an "Intro to CBT for Panic Disorder" intervention in the ED.

 

[WingedOx]

We have such a high rate of substance abuse in my area, I'd strongly prefer the ER not to give a Rx for benzos. If a one time dose is needed while in ER- fine.

I think referring out to pcp or psychiatry is best as they will be managing it.

First followup after ER visit:

"yeah doc, they gave me this xanax medication and told me to take it four times per day. It works perfectly! I don't really have time for therapy or anything, can you just give me more of that med?"

 

[thoffen]

Hmm...In pondering this question I realized that it is not something I've ever actually done. Treating panic attacks in ED setting has never been anything I've been asked to assist with. I have had the experience of "I only want Xanax, and they gave it to me in ED so why can't you?" many times.

I think the key limiting repeated presentations is to validate the patient without performing workup that isn't indicated. That said, I totally get ED docs for covering their ass when it comes to chest pain.

RE: beta blockers in this setting, I'm just not up to speed on the literature for/against it. I would like to point out that psychiatrists do need to learn more about beta blockers in general, for the reasons that birschwing points out. We look down upon med/surg teams mismanagement of behavioral dysregulation, especially in delirium, but imagine them looking at our rx habits when it comes to propranolol and clonidine.

 

[MacDonaldTriad]

This whole discussion is grating on my need to teach pharmacology. Psychiatrists have no interest in polar, non-lipophilic medications because if they cannot get through the blood brain barrier, they are not of much use to us. We are counting on CNS effects, not trying to avoid them.

If you really feel that the ER patient does have a panic disorder and not just a panic attack, you would be much better off starting an SSRI (assuming you are not going to do the CBT thing as OPD suggests). Sure it will not help for a few weeks, and you shouldn’t give more than a very low dose as it paradoxically can make them worse before it helps, but at least you have moved towards the direction the psychiatrist will be going while they are waiting to be seen.

The only thing worse than giving them a benzo is to give them a “PRN” benzo like Xanax. If you had an condition that involved sporadic and irrational fear, you really wouldn’t want to be thinking about your need for a sedative multiple times a day. “Let’s see, do I think I may have a panic attack in the next couple of hours? I hope not, I’m going to try not to take this. What if I do?…. Where is that bottle?” Talk about getting into someone’s kitchen where they are most vulnerable. This is just down right mean.

 

[AcronymAllergy]

This whole discussion is grating on my need to teach pharmacology. Psychiatrists have no interest in polar, non-lipophilic medications because if they cannot get through the blood brain barrier, they are not of much use to us. We are counting on CNS effects, not trying to avoid them.

If you really feel that the ER patient does have a panic disorder and not just a panic attack, you would be much better off starting an SSRI (assuming you are not going to do the CBT thing as OPD suggests). Sure it will not help for a few weeks, and you shouldn’t give more than a very low dose as it paradoxically can make them worse before it helps, but at least you have moved towards the direction the psychiatrist will be going while they are waiting to be seen.

The only thing worse than giving them a benzo is to give them a “PRN” benzo like Xanax. If you had an condition that involved sporadic and irrational fear, you really wouldn’t want to be thinking about your need for a sedative multiple times a day. “Let’s see, do I think I may have a panic attack in the next couple of hours? I hope not, I’m going to try not to take this. What if I do?…. Where is that bottle?” Talk about getting into someone’s kitchen where they are most vulnerable. This is just down right mean.

And you'd also basically be implementing an intermittent reinforcement schedule, which are the toughest to extinguish, particularly with panic or benzos (let alone both).

 

[MLT2MT2DO]

I've noticed on a number of occasions that propranolol is the go-to beta blocker for psychiatrists. It's not usually a first-line beta blocker due to its high lipid solubility, increasing the risk of CNS side effects, and it's far more likely to cause problems with breathing than many selective BBs. A good doctor would ask if the patient has asthma, but in someone with light asthma who doesn't know they have it, it can still cause quite a heavy, constricted feeling, which will definitely exacerbate anxiety.

I've tried a number of beta blockers and I've found bisoprolol to have the best mix of qualities: it's highly cardioselective, half of it is metabolized by the kidney so it has less risk of interactions, very little of it crosses the brain blood barrier, and it has a decent enough half life that taking it once a day is usually sufficient. Propranolol was the first one I was put on and I got a very heavy feeling in my chest in spite of no asthma diagnosis; metoprolol had a lot of interactions with Paxil but was otherwise fine. But bisoprolol hits the sweet spot for me.

It's CNS side effects and high lipid solubility is why psychiatrists use it.
If you want a beta blocker for a POST-STEMI go to your cardiologist.

 

[Dharma]

You mean more than the typically $#!+ talking that goes down back at the computers about the patient "wasting" their time? Seems to be very little patience for just about anything psych related in the ED... Unless it's an OD and they get to run a code, intubate, bust out the IO gun, etc...

 

[b-real]

You mean more than the typically $#!+ talking that goes down back at the computers about the patient "wasting" their time? Seems to be very little patience for just about anything psych related in the ED... Unless it's an OD and they get to run a code, intubate, bust out the IO gun, etc...

Easy there, cowboy. As an ED physician, I have seen my fair share of anxiety attacks. While I do my best not to be impatient, and I treat anxiety as a diagnosis of exclusion, I do get annoyed when they have a known diagnosis, but refuse to actually see a specialist (i.e. you guys) for long term management. Add to that the usual request for a month's worth of Xanax, and we have a problem. That goes for any non-emergent condition where the patient refuses to take responsibility for their health.

 

[Dharma]

Easy there, cowboy. As an ED physician, I have seen my fair share of anxiety attacks. While I do my best not to be impatient, and I treat anxiety as a diagnosis of exclusion, I do get annoyed when they have a known diagnosis, but refuse to actually see a specialist (i.e. you guys) for long term management. Add to that the usual request for a month's worth of Xanax, and we have a problem. That goes for any non-emergent condition where the patient refuses to take responsibility for their health.

I hear ya! Just came off an ED rotation with a few super DBish residents. The issues you describe are most definitely a challenge to one's patience though, no doubt.

 

[Bartelby]

Depending on the presentation I think that a short course of benzodiazepines from the ER can actually be a compassionate choice. First work in some psychoeducation about panic attacks (it can be less than five minutes if you're in a rush), if at all possible give a printed handout about it as well (you can google and print the first reasonable looking result). Explain that their condition is quite likely to be helped a great deal by cognitive behavioral therapy +/- an SSRI and that the benzodiazepine is a short term measure until they are matched with someone who can provide the above in the outpatient setting. Explain the use of the benzodiazepine: they are taking it early in a panic attack which is intended to limit the attack's duration. They are not taking it "just because I might panic today" or anything similar. Provide a very limited quantity (let's say five tablets) and ideally make the referral to an outpatient treater to land as soon as possible. In my opinion don't start a medication that requires long-term followup (like an SSRI) if you don't plan to follow it up. Obviously SSRIs are a better long term choice for panic than benzodiazepines, but in my opinion the treating psychiatrist can explain this and make the transition.

This assumes several things: this is a real panic case (not malingering, personality disorder, substance abuse, etc etc). You check the prescription monitoring program (or whatever is available) and don't see evidence of drug seeking. The person seems to be seeking help in good faith. I am also presuming that the patient's panic attacks are very distressing despite the psychoeducation and that they want a backup plan if the panic occurs before seeing their psychiatrist that isn't just "come back to the ER if your symptoms worsen."

I agree with my colleagues above that popping a benzo to escape panic is reinforcing in a bad way, but I think (for a genuine panic sufferer) being sent back into the world with nothing can be even more distressing. Assuming they land in treatment a good provider can undo the damage of having used ativan a couple of times (they've used lots of other escape behaviors too, none of them are easy to give up). I have seen several panic cases bounce back because they were sent out with nothing, and sending them out with a couple of tabs of benzos might avoid this (which was the next step taken and which appeared to work). In short, don't feel like a drug dealer if you send someone out with a couple tabs of ativan. I think it can really be the right choice in some circumstances.

 

[hamstergang]

It's CNS side effects and high lipid solubility is why psychiatrists use it.

I will eventually look this up on my own, but want to ask here anyway for now. My conceptualization of why beta-blockers work is that anxiety brings about sympathetic activation, which leads to physical sensations that lead the patient to become more anxious, which just furthers this cycle. By blunting the sympathetic stimulation peripherally, beta-blockers blunt those physical sensations and break the cycle.

Are there CNS effects of beta-blockers that help with panic? Are more lipophillic beta-blockers more effective with panic?

 

[AcronymAllergy]

Easy there, cowboy. As an ED physician, I have seen my fair share of anxiety attacks. While I do my best not to be impatient, and I treat anxiety as a diagnosis of exclusion, I do get annoyed when they have a known diagnosis, but refuse to actually see a specialist (i.e. you guys) for long term management. Add to that the usual request for a month's worth of Xanax, and we have a problem. That goes for any non-emergent condition where the patient refuses to take responsibility for their health.

Agreed that it could/would be frustrating. Although one thing to keep in mind is that folks with anxiety disorders can be particularly difficult to get into treatment because of the disorder. Especially if they have any idea what to expect in terms of psychotherapy for panic (similar to how the thought of starting prolonged exposure can be very anxiety-provoking for folks with PTSD). Thus, the resistance/reluctance to entering treatment many times is another symptom of the condition.

And this can all of course be amplified if the person has the perception/fear that anytime they go to the ED for anything after having presented in the past for panic, they're going to be dismissed and told it's, "all in their head."

 

[MacDonaldTriad]

“After oral administration > 90% of diazepam (the one with the fastest absorption) is absorbed and the average time to achieve peak plasma concentrations is 1 – 1.5 hours with a range of 0.25 to 2.5 hours. Absorption is delayed and decreased when administered with a moderate fat meal.”

Since by definition panic attacks peak within ten minutes, I’m not buying the use of benzo’s to abort attacks. Even IM, the fastest relief takes more than half an hour. PRN benzo use is very common, but that doesn't mean it should be.

 

[hamstergang]

“After oral administration > 90% of diazepam (the one with the fastest absorption) is absorbed and the average time to achieve peak plasma concentrations is 1 – 1.5 hours with a range of 0.25 to 2.5 hours. Absorption is delayed and decreased when administered with a moderate fat meal.”

Since by definition panic attacks peak within ten minutes, I’m not buying the use of benzo’s to abort attacks. Even IM, the fastest relief takes more than half an hour. PRN benzo use is very common, but that doesn't mean it should be.

I don't think that looking at time to peak plasma level is optimal. When you take a dose of a benzo, how much of it do you need to get into the CNS in order to abort the panic attack? So long as that answer is less than the peak amount, then benzos could still make sense for this purpose.

 

[MacDonaldTriad]

You are right, you don't have to peak to work, but panic attacks seem like hours, but are minutes long.

 

[birchswing]

I just rewatched all 8 seasons of House (well rewatched the beginning, hadn't seen the last two seasons before). Every time someone had a seizure on the show, the gave the patient either Ativan or Valium. I wonder if that was accurate, given that seizures usually only last a few minutes. It was curious to watch whether they'd give Ativan or Valium. That changed from episode to episode, as did the dose. In one episode in the 7th season, the character Chase said, "Push 10 mg benzodiazepine." That really got me out of the story line, and it was odd because they had gotten it right (by actually naming a specific benzodiazepine) the previous 7 seasons.

 

[michaelrack]

•Propanolol is non-selective and highly lipophilic. Atenolol is B1-selective and has low lipophilicity. Metoprolol is B1-selective and has high lipophilicity.

From a lecture I am working on on anxiety disorders. Propanolol has the most evidence behind it, for tx of anxiety in predictable conditions (such as performance anxiety). For pts with asthma/copd, metoprolol could be tried instead (with Caution). If one believes that betal blockers act via peripheral sympathetic effects (and that central CNS effects aren't important); atenolol could be tried.

 

[WisNeuro]

You are right, you don't have to peak to work, but panic attacks seem like hours, but are minutes long.

I'm with you, physiologically, the body can't maintain a state of panic for all that long before going into exhaustion. The benzo just takes the edge of some of the post-panic anxiety. In the meantime, the patient feels like it stopped the panic attack, although the panic attack was almost certainly on the downswing by the time the benzo started to kick in. And the pattern of psychological and physical addiction begins. As time goes on, the data about how terrible benzos are for anxiety just continues to pile up. Simply little to no reason to use these on a maintenance schedule.

 

[shan564]

I will eventually look this up on my own, but want to ask here anyway for now. My conceptualization of why beta-blockers work is that anxiety brings about sympathetic activation, which leads to physical sensations that lead the patient to become more anxious, which just furthers this cycle. By blunting the sympathetic stimulation peripherally, beta-blockers blunt those physical sensations and break the cycle.

Are there CNS effects of beta-blockers that help with panic? Are more lipophillic beta-blockers more effective with panic?

The theory is that they blunt the adrenergic response that leads to panic. IIRC, there are beta-1 and beta-2 receptors in the prefrontal cortex and the hypothalamus. I always assumed that this was the reason why there's better evidence for propranolol than for non-lipophilic and/or beta-1 selective drugs.

I just rewatched all 8 seasons of House (well rewatched the beginning, hadn't seen the last two seasons before). Every time someone had a seizure on the show, the gave the patient either Ativan or Valium. I wonder if that was accurate, given that seizures usually only last a few minutes. It was curious to watch whether they'd give Ativan or Valium. That changed from episode to episode, as did the dose. In one episode in the 7th season, the character Chase said, "Push 10 mg benzodiazepine." That really got me out of the story line, and it was odd because they had gotten it right (by actually naming a specific benzodiazepine) the previous 7 seasons.

IV/IM administration works faster than oral administration. It is correct that IV/IM benzodiazepines will quickly abort seizures.

But yeah, I remember that episode when they said "10mg benzodiazepine" - I almost had a panic attack myself.

 

[Ceke2002]

I think psychoeducation and a referral for appropriate treatment is important for patient's presenting to the ER with panic attacks - especially for preventing patient's rebounding. Even if you only have a few minutes in which to do it, it's far preferable (imho at least) than just tossing the patient out with a benzo on board and telling them they're just having a panic attack.

 

[birchswing]

•Propanolol is non-selective and highly lipophilic. Atenolol is B1-selective and has low lipophilicity. Metoprolol is B1-selective and has high lipophilicity.

From a lecture I am working on on anxiety disorders. Propanolol has the most evidence behind it, for tx of anxiety in predictable conditions (such as performance anxiety). For pts with asthma/copd, metoprolol could be tried instead (with Caution). If one believes that betal blockers act via peripheral sympathetic effects (and that central CNS effects aren't important); atenolol could be tried.

You probably already know this, but if you didn't for your lecture, metoprolol succinate has a much better half life (once daily dosing) than metoprolol tartrate. I only know because I was on it briefly but went off of it because Paxil potentiated the metoprolol too much, even at the lowest dose of metoprolol.

 

[birchswing]

The theory is that they blunt the adrenergic response that leads to panic. IIRC, there are beta-1 and beta-2 receptors in the prefrontal cortex and the hypothalamus. I always assumed that this was the reason why there's better evidence for propranolol than for non-lipophilic and/or beta-1 selective drugs.



IV/IM administration works faster than oral administration. It is correct that IV/IM benzodiazepines will quickly abort seizures.

But yeah, I remember that episode when they said "10mg benzodiazepine" - I almost had a panic attack myself.

I see it in news articles sometimes, sadly often with OD cases, where the news report will say something like, "The man had a drug called benzodiazepine in his system."

It's also used in an awkward way in the Jason Isbell song "Different Days."

Best song with a benzodiazepine reference is "Give Me Some Love" by James Blunt.

Although I don't think anyone will ever wax quite as poetically about benzodiazepines as Lou Reed did about heroin.

 

[TraumaBlonde]

Don't forget anxiety is a tell-tale sign for hypoxia Among other things-so it's all about finding the root and then addressing it

 

[MacDonaldTriad]

Birchswing is right, IV does work to abort seizures. I would support this as a way to abort a panic attack, but you would have to get the IV in very fast before you miss your chance to help.

 

[Shikima]

Birchswing is right, IV does work to abort seizures. I would support this as a way to abort a panic attack, but you would have to get the IV in very fast before you miss your chance to help.

Could go IO?

 

[MacDonaldTriad]

That would be better than PR in the context of a panic attack. 🙄

 

[smalltownpsych]

When I was clinical director of a long-term residential facility, we didn't have any prn medications as our only medical staff was an RN. Occasionally we did have kids that would have panic attacks. Our RN would treat them by having patient come to her office, turn down lights, warm or cool compress, soothing voice, and sometimes a little shoulder massage. Remarkably effective treatment and once patient's breathing and heart rate had returned to normal then myself or another therapist would process it with the patient in a psychotherapy room. I don't see why an ER couldn't do the same thing. Although I have observed that many staff don't believe in treating panic attacks palliatively. Probably because of their own dynamics with anxiety and need for perceived control.

 

[cbrons]

Birchswing is right, IV does work to abort seizures. I would support this as a way to abort a panic attack, but you would have to get the IV in very fast before you miss your chance to help.

Seizures are dangerous. Panic attacks are not. Trying to emergently give someone IV lorazepam for panic is reinforcing the myth that they are dangerous and is about the absolute worst thing you could do for someone with panic disorder.

 

[MacDonaldTriad]

Clearly sarcasm doesn't communicate well in a forum.

 

[birchswing]

To be clear, I wasn't suggesting IV benzodiazepines for panic attacks. In fact, I only raised the question of IV benzodiazepines used for seizures because I didn't know if that was a real thing or not—I have seen it in House frequently and wasn't sure if that was something people actually do or not (since it is a fictional TV show--and I had heard that seizures don't always need treatment if they're less than five minutes).

 

[MLT2MT2DO]

I will eventually look this up on my own, but want to ask here anyway for now. My conceptualization of why beta-blockers work is that anxiety brings about sympathetic activation, which leads to physical sensations that lead the patient to become more anxious, which just furthers this cycle. By blunting the sympathetic stimulation peripherally, beta-blockers blunt those physical sensations and break the cycle.

Are there CNS effects of beta-blockers that help with panic? Are more lipophillic beta-blockers more effective with panic?

It is widely known and is excepted that beta blockers work first and foremost on the peripheral receptors. There are however a multitude of beta1 and 2 receptors in the CNS as well, there are some decent papers that also talk about the activity of these not only in anxiety but in other mood disorders as well. As far as more lipophilic, it is basic physiology that more lipophilic agents cross the blood brain barrier easier.

But yeah, any PDR will tell you it works because of its actions on the periphery. All you need to do is Think of the classic board question where a patient gets depression from propranolol to know it does more.

 

[michaelrack]

You probably already know this, but if you didn't for your lecture, metoprolol succinate has a much better half life (once daily dosing) than metoprolol tartrate. I only know because I was on it briefly but went off of it because Paxil potentiated the metoprolol too much, even at the lowest dose of metoprolol.

good to know, as an internist I only knew them as metoprolol immediate release, and metoprolol extended release (toprol XL), but now I know that they are 2 slightly different chemicals

 

[cbrons]

So far as I understand it, beta blockers could work in anxiety disorders by dampening physiologic signals of the FoF response. Along the line of the James–Lange theory of emotion.