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Doctors' Answers to "Frequently Asked Questions" - Panic


These comments are made for the purpose of discussion and should NOT be used as recommendations for or against therapies or other treatments. An individual patient is always advised to consult their own physician.

[posted 11/7/1999]
Question: I would like to know what is the main diffrence between KLONOPIN and ATIVAN,I have taken ativan in the past for my panic attacks and they really work for me.But know I have a new doctor and he wants me to take Klonopin instead.I also have asthma and I heard Klonopin can cause shortness of breath and increased salivation. So out of the two which one has the worst side effects for someone with asthma, and which one is worse on the liver.

Answer: Mainly duration of action, you shouldn't see too much difference. There will be no effect of Klonopin on the asthma. Both are about the same in all areas. Some patients do better on one or the other, but in a non-predictable manner.

[posted 11/3/1999]
Question: Hello there. I have panic attacks when driving in lanes other than the right lane. I have been taking Rivotril for 6 years, and I have to take 2 0.5mg in the morning and the same in the evening to and from work. Recently my doctor told me that i may have a chemical discrepancy in that my nerve receptors can not retain serotonin for a long period, and he has recommended Paxil 20mg. I took the 20mg Paxil(along with the Rivotril which I am suppoed to decrease once the Paxil starts to take effect0 for 3 days, and going to work everything seemed fine except last Friday I had a severe panic attack at the traffic lights at an intersection where I was not in the right lane. I had a similar experience on Saturday. This only occurs when I am not in the right lane. I have voluntarily reduced the Paxil to 10mg at 10pm at night and 1mg of Rivotril in the morning and evening, but still have that "fear". How long does Paxil take before these fears subside? and should I have taken the 20mg as prescribed? or stay on the 10mg and increase it to 20mg after a couple of weeks? By the way, when I took the 20mg Paxil, I was extremely hyper similar to taking a non-drowsy sinus of cold medication.
Please advise, and keep up the good work, you are doing us "sufferers" a great service.
Best regards

Answer: Paxil takes a couple of weeks to be effective. 20 mg would be a usual starting dosage for most adult patients, but can be increased to 80 mg or so under physician supervision. The agitation you describe is a common side effect and tends not to go away. But, a great drug for panic in most circumstances.

[posted 10/18/1999]
Question: I have been taking alprazolam (xanax) for over ten years now for severe anxiety/panic attacks. Recently I have been hearing a lot about alternatives that are more natural. Can I take 5-HTP, which increases serotonin levels, with alprazolam? Can you suggest other alternatives to alprazolam to help control anxiety, depression, and insomnia? Thank you!

Answer: There should be no problem combining 5-HTP. However, newer treatments for panic/anxiety center on using SRI antidepressants like Prozac, Paxil etc. These by themselves or in combination with Xanax are very effective and generally with less side effects.

[posted 10/15/1999]
Question: I read over the questions submitted about clonazepam, and while some were similar, mine is a bit different. I was diagnosed with panic disorder about 3 months ago. I tried a few drugs, including zoloft. It made me feel so sick that I got off it after only a few days. I then went several weeks without any medication. It was OK, but I still needed something. 2 weeks ago under the doctor's approval I started to take a half a .5mg tablet of clonazepam in the morning, and the other half in the evening. This seems to be doing the trick, but my questions and concerns are the following. 1. If I continue at that amount, will tapering off be a problem or long process? 2. I keep hearing about side effects like seizures and memory loss. I've never had a seizure in my life, but are either of these possible for me on the dose I have? 3. On such a low dose, is missing a dose a big problem?

Answer: Any of these drugs is addictive. The addiction is a function of the dosage and the time taking the medication. This is a small dosage, but will be addictive over time. Seizures and memory loss would not be expected to be a problem at this dosage. Stopping the drug abruptly could potentially cause seizures, although unlikely at this dosage. Missing a dosage here and there should be no problem.

Skin Rash and Panic Attacks [posted 1/13/99]
Question: For about 8 months now I have been suffering through aching joints, muscles, disoriented thoughts, brief headaches and sometimes ringing in my ears. At the beginning of this 8 months I was putting in a lawn and garden in at my Pueblo, Colorado home. At different time periods I was covered in mud and yard materials. Shortly after I was finishing my yard I was getting this weird rash on my arms. Eventually after about 1 month this rash went away. I am only 29 years old and I watch my diet and I exercise. For the past 8 to 9 months I have been having random panic attacks. These panic attacks just come on and out of no-where.

Answer: First, get checked as to the cause of the rash. Either inflammatory, infectious or allergic? Panic attacks do not give aching joints. Get an evaluation that focuses on the rash and joints (a rheumatologist would be a good pick).

Panic attack or Heart attack? [posted 7/24/98]
Question: This past October I was treated for hypothyroidism (lithium-induced) because I had omitted my thyroid medication for some months. I was started at 0.175 Synthroid, with disastrous results: I head three "heart attacks", where 911 was called. These attacks included inability to breathe, sweating at night, inability to stand still, inability to move the body from rigididy, crushing sensation around the chest, great palour with dark under-eye circles, weakness and many others... My doctor, as well as other doctors, except one who thought it may have been electrolyte imbalance, all said it was a panic attack. I was never given a cardiogram (thought the high dose was terminated), but all insisted (including 911) that it was a panic attack. By the way, I still had to take 900 mg Lithium. How do you tell a Panic attack from a Heart Attack? I would be most appreciative of an answer as it was the scariest experience in my life, and I have had panic attacks before.

Answer: Heart attacks are cessation of blood to a part of the heart. Not to be confused with tachycardia when the heart works fine-just beating too fast to be effective. Both can be fatal, but are significantly different. Lastly, your physician probably restarted the dosage too high which caused the problem. Usually, we start at a lower dose and work up to avoid exactly this problem.

Panic Attacks - Imiprimine [posted 7/17/98]
Question: My 7 year old son was just prescribed imipramine for panic attacks and anxiety. The neurologist is starting at 10 mg a day and adding to dosage + 10 mg weekly until we see improvements or until up to 60 mg daily. I want information on possible side effects or what to watch for that could be a concern or contraindication for this medication. Also, how common is this drug used in children? How common are panic attacks in children?

Answer: I'm not a pediatrician so I can't tell you the incidence of panic attacks, but it seems pretty small. In general, panic attacks start in late teens, but I'm sure it can start earlier. Generally, we favor SRI antidepressants to treat panic attacks not a tri-cyclic like imipramine. In general, imipramine is too sedating and has minimal effectiveness in adults-can't testify to children. Side effects would be dry mouth, sedation, irregular heart beats, constipation. It should be pretty risk free if he doesn't have any heart conditions. I would personally try Paxil, Prozac, etc. first.

Drug Treatment for Panic attacks
Question: What is the drug of choice for a 68 year old female with a history of panic attacks for 5 years?

Answer: Either xanax, valium or any of the SRI antidepressants would be a good choice with your problems to treat a panic attack.

Panic attacks and anxiety
Question: I see a psychiatrist but am starting to lose faith. I have been on 15 different drugs for anxiety/panic, and they all make me terribly ill. The only thing I have not tried is an MAOI. Any other suggestions?

Answer: Nausea would normally start with the start of the drug and not after you have been on it for awhile.

Panic Attacks
Question: I am currently taking klonopin for panic attacks, but I don’t like the side effects. Are there other better medications that can be taken for this disorder?

Answer: There are many drugs used in panic attacks. Serotonin Reuptake Inhibitor (SRI) and anti-depressants are sometimes useful. Beta-blockers have also been used.

Panic attack/anxiety
Question: I would like to know what is the recently recommended medication to treat panic attack and anxiety.

Answer: Panic attacks are common and usually start in the late teens or early 20s. They tend to run in families and often occur for several months followed by long spells where they are absent. A large percentage of patients will develop depression at some time during their lives. Several medical conditions will mimic or cause this disorder and need to be screened prior to treatment. Also, different drugs have been known to trigger this disorder. Alcohol, antihistamines, caffeine, cocaine, pseudoephedrine, aspirin, hallucinogens (LSD etc.) are the ones available without a prescription - the rest are prescription drugs. Treatment centers on use of drugs SRI antidepressants, tricyclic antidepressants, MAO antidepressants, beta blockers and benzodiazepines (Valium, klonopin, etc.). in about that order. Combinations of the drugs are also often effective.

Panic Disorder
Question: It has been suggested that I use SSRI drug (Paroxtine) (Aust. Aropax). I haven't experienced full panic for some time but am still experiencing severe anticipatory anxiety which is limiting my life to quite a degree. Should I go ahead with taking this drug? What's against it? I have read the counterindications and potential withdrawal problems. Is this drug construed as being addictive? What are the side effects? Should I battle on without drug assistance?

Answer: There have been several treatment protocols for the syndrome called Panic Attacks. Use of the serotonin reuptake inhibitors(SRI) has been very effective in about 60-70% of patients with this problem. Use of SRI with drugs such as klonopin is also effective. Occasionally, use of beta-blockers is also helpful. Paroxetine(Paxil) is one of the common SRIs used in this disorder. There is no withdrawal problem and the drug can be stopped at any time without tapering, etc. The drug is not addictive, although some patients feel so good on it that they really don't want to stop taking it. I would really try and see how you feel on the drug. The only way to see the difference is to try it. I have had amazing stories from patients who have fought this problem all their life. They really never knew what it felt like to not have the problem, so give it a go.

Panic Attacks and Seratonin
Question: What is the relationship between seratonin and panic attacks?

Answer: Panic attacks are extemely common and unfortunately tend to be very debilitating. They tend to be precipitated by situational clues-closed spaces, heights, etc and also tend to run in families. The individual often feels like they are going to die. Rapid heartbeat, shortness of breath, sweating, choking, chest pain, etc. are the common signs. Some individuals will awake at night with the above symptoms thought to be triggered by different sleep stages. About 1% of all people will experience these-women about twice as commonly as men. Treatment involves making the right diagnosis and ensuring that cardiac conditions, thyroid conditions or other medical causes are not the cause. Tri-cyclic anti-depressants have been the drug of choice until recently. Since the advent of seratonin uptake inhibitor drugs these are usually the drug first tried due to low side effects and effectiveness. Other drugs include fairly potent sedatives like clonazepam and alprazolam and a class of anti-depressants called MAO inhibitors. Generally, one starts with the serotonin uptake inhibitors and proceeds to the other drugs if there is lack of effectiveness. Some psychologists have experimented with desensitization of the triggering situational clue. It does seem that some sort of chemical "imbalance" causes these episodes-whether it is serotonoin or not is not yet clear.

Panic Disorder
Question: I have been taking .75 milligrams of Klonopin for diagnosed panic disorder. I have been on the medication for about 1.75 years and I am afraid that I am addicted and will never be able to stop. I am hesitant to reduce my dosage as I get edgy and suffer from extreme tightness in the chest which I associate with heart problems. I also take Propanol (30 milligrams a day) as I suffer from PVC's and I always think that something is seriously wrong with my heart even though tests have shown otherwise. The chest pain and PVC did not start until about 2 years ago and this is when I went to the emergency room in an ambulance for the first time, thinking I was having a heart attack. I take Pepcid daily and believe that this helps relieve some of the symptoms of chest pain. Most of the time, however, I am still convinced that there is something wrong with my heart. I even experience flashes of heat or hot blood from the left side of my chest into my arm, periodically. I cannot find an answer as to why this happens from any physician or book. I used to be such a different person. I am even afraid to exercise now, as I feel that I may suffer a heart attack. How do I get off of Klonopin and find either a better medicinal solution or just get off of medication altogether. I have been given Paxil to try but have been afraid because I have heard that these SSRI type drugs are better suited for depression and OCD, and may cause more anxiety in panic disorder sufferers. However, as I understand, they can help obsessiveness and compulsiveness. I seem to be obsessed alot about my heart and chest pains. Is it worth trying Paxil? My first "panic attack" occured when I had been on 20 milligrams of Prozac for 2 weeks. This was when I was not taking Klonopin. I also feel slow and not as mentally responsive, which is something I attribute to the Klonopin.

Answer: Panic disorder is a very common and very disabling problem. There is the exact feeling of having a heart attack or not being able to breathe. While we don't exactly know the cause, it does appear to run in families and has some of the same characterists of depression. In general, the SRI anti-depressants(paxil for example) are very helpful, although it may take moderate to high doses to treat the problem. Twenty milligrams is a small dose of paxil. If this is truly your problem you need to work closely with your physician increasing the dose until the symptoms are under control, using Klonopin as necessary during an attack and using paxil to prevent further attacks.


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