Treatment of autonomic crises

Treatment of panic disorders

Before starting pharmacotherapy, it is necessary to assess the potential reserves of non-drug treatment of a patient with panic disorders. During the first contact with the patient, the doctor assesses:

• duration of illness,
• severity of anxiety symptoms,
• the patient's awareness of the nature of his disease,
• the presence or absence of a preliminary somatic and, if necessary, neurological examination,
• previous experience of treatment with pharmaco- or psychotherapy.

In the event that the paroxysms have appeared recently, and secondary psycho-vegetative syndromes have not yet developed and the patient has undergone an adequate somatic examination, then sometimes an explanatory conversation with the doctor about the nature of the disease is sufficient, possibly in combination with placebo therapy.

Special studies conducted by the author together with O. V. Vorobyeva and I. P. Shepeleva at the Center for Pathology of the Autonomic Nervous System showed that 35-42% of patients suffering from panic attacks achieved significant clinical and psychophysiological improvement only with the help of placebo therapy.

Pharmacotherapy of patients with panic disorders involves several therapeutic strategies:

1. stopping the attack itself;
2. prevention of recurrence of paroxysms;
3. relief of secondary psycho-vegetative syndromes.

In determining the strategy for treating patients with pharmacological drugs, the benefits of treatment are primarily related to the risks involved in its implementation.

Risk factors in pharmacotherapy include side effects, complications during therapy, and the possibility of painless drug withdrawal. Benefits of treatment include restoration of health, social functioning of the patient, and the possibility of preventing relapses.

Stopping panic attacks

The patient usually gains personal experience in stopping an attack after several panic attacks. If the patient resorts to the help of a doctor (calling an ambulance) to stop the first, usually the most severe, paroxysms, then in subsequent attacks, having made sure that a catastrophe does not occur, the patient finds his own ways to stop the attack. Usually this is the use of several groups of drugs, the choice of which largely depends on the patient's ideas about the nature of the disease and the first experience of communicating with medicine. If a panic attack is assessed as a "heart attack" or "hypertensive crisis", then the stopping drugs will be valocordin, corvalol, hypotensive drugs or beta-blockers (anaprilin, obzidan); If the disease is assessed as a “nervous disorder”, then the patient prefers to use sedatives, usually benzodiazepine drugs or, as they are called, “typical benzodiazepines” (seduxen, relanium, tazepam, rudotel, etc.).

Often, the patient comes to the first appointment with the doctor with "rescue" pills in his pocket. Indeed, taking typical benzodiazepines is the most effective way to stop a panic attack, as well as other paroxysmal conditions (for example, epileptic seizures). However, with such a symptomatic method of treatment, the dose of the drug must be increased over time, and irregular use of benzodiazepines and the associated rebound phenomenon can contribute to an increase in the frequency of panic attacks.

Thus, it can be concluded that the relief of individual panic attacks with benzodiazepines not only does not lead to a cure for the patient, but also contributes to the progression and chronicity of the disease.

Preventing the recurrence of panic attacks

Numerous studies conducted using double-blind placebo control have convincingly shown that the most effective in preventing panic attacks are two groups of drugs: antidepressants and atypical benzodiazepines (ABDs).

Today, the range of antidepressants effective against panic disorders has expanded significantly and includes:

1. triplicate antidepressants - imipramine (melipramine), amitriptyline (tryptisol), nortriptyline, clomipramine (anafranil, gidifen);
2. tetracyclic antidepressants - pyrazidol, mianserin (miansan, lerivon);
3. MAO inhibitors - phenelzine, moclobemide (aurorix);
4. antidepressants of other chemical groups - fluoxetine (Prozac), fluvoxamine (Avoxin), tianeptine (Coaxil, Stablon), sertraline (Zoloft).

The mechanisms of antipanic action of antidepressants remain controversial. The initial ideas about the effect of antidepressants mainly on noradrenergic systems (inhibition of reuptake of noradrenaline in the synaptic cleft) are not confirmed by most authors today. It has been shown that drugs that act exclusively on noradrenergic systems (desipramine and maprotiline) are not effective in preventing panic attacks. Currently, a theory that links the antipanic effectiveness of antidepressants with a predominant effect on serotonergic systems is considered more likely. Probably, future studies will allow differentiating clinical subgroups among patients with panic disorders that effectively respond to antidepressants with different mechanisms of action.

Atypical benzodiazepines include clonazepam (Antelepsin, Rivotril) and alprazolam (Xanax, Cassadane).

Benzodiazepines (both typical and atypical) enhance the action of GABA (γ-aminobutyric acid), which is the main inhibitory mediator in the central nervous system. The point of application of this group of drugs is the GABA-benzodiazepine receptor complex. A characteristic feature of ABD is their high affinity for benzodiazepine receptors (3 times higher than that of typical benzodiazepines).

Clinical experience shows that the use of drugs from both groups has its positive and negative sides.

It is known that when using antidepressants, especially tricyclics, in the first decade of treatment there may be an exacerbation of symptoms - anxiety, restlessness, agitation, sometimes an increase in panic attacks. Side effects of tricyclic antidepressants are largely associated with cholinolytic effects and may manifest as pronounced tachycardia, extrasystole, dry mouth, dizziness, tremor, constipation, weight gain. The above symptoms may lead at first to a forced refusal of treatment, especially since the clinical antipanic effect is usually delayed for 2-3 weeks from the start of therapy.

In the case of ABD, side effects manifest themselves primarily as sedation, which usually regresses after 3-4 days as treatment continues. The rebound phenomenon, especially pronounced with alprazolam, necessitates frequent administration of the drug; finally, severe drug dependence, especially in the presence of a history of toxicomania, limits the use of this group of drugs.

In both cases, abrupt cessation of drug treatment leads to withdrawal syndrome, i.e. a sharp exacerbation of the symptoms of the disease.

As a positive aspect, it should be noted that in the treatment of panic disorders, the therapeutic effect can be achieved with small doses of antidepressants or atypical benzodiazepines. Thus, a positive effect can be achieved using the following daily doses of drugs: 75 mg of amitriptyline, 25-50 mg of clomipramine, 30-60 mg of mianserin, 20 mg of fluoxetine, 2 mg of clonazepam, 2-3 mg of alytrazolam.

When determining the tactics of therapy, it is necessary to resolve two main issues: the choice of drug and the determination of the dose.

The choice of the drug is determined mainly by the clinical picture of the disease and the characteristics of the drug's action. The question of the nature of the paroxysm is essential; first of all, it is necessary to clarify whether the attack is a panic attack or a demonstrative seizure. In the latter case, as our studies have shown, the effect of drug therapy does not exceed the effectiveness of placebo, so it is advisable to immediately raise the question of alternative methods of treatment, possibly psychotherapy. In the case of qualifying the paroxysm as a panic attack, it is necessary to assess the duration of the disease and the symptoms of the interictal period. If panic attacks have appeared recently or the onset of a panic attack is associated with alcohol excess and there is no agoraphobic syndrome, then it is advisable to begin therapy with ABD.

If panic attacks are combined with agoraphobia or other secondary psychovegetative syndromes (phobic syndrome, depression, hypochondria), then it is necessary to use antidepressants. In case of pronounced agoraphobic syndrome, clomipramine can be recommended; when panic attacks are combined with social phobias, MAO inhibitors are effective, in particular moclobemide. When choosing a drug, it is recommended to use antidepressants with minimal anticholinergic effects, such as pyrazidol, mianserin, fluoxetine, tianeptine.

In some cases, the combined use of antidepressants and antidepressants is required, since antidepressants, firstly, provide an early clinical effect (almost already in the first week of treatment), and secondly, help to stop a panic attack before the antidepressants begin to work.

The following rules may be useful when determining the dosage of a drug:

1. It is necessary to start therapy with small doses (1/4-1/2 of the planned dose) with a gradual (over 2-3 days) increase.
2. The criterion for the maximum dose may be the severity of side effects that do not disappear within 3-4 days.
3. It is recommended to distribute the drug over a day depending on the hypnogenic effect. Thus, in case of severe drowsiness, it is recommended to shift the drug intake to the evening.
4. If it is impossible to achieve an adequate dose due to side effects, a combination of drugs from different groups is possible.
5. To achieve an adequate dose of the drug, it is possible to use correctors, which may be beta-blockers.

Before prescribing a course of drug therapy, the doctor should explain to the patient the basic principles of treatment and warn about possible difficulties in the treatment process. In this conversation, it is necessary to emphasize the following points:

1. The course of treatment should be long, sometimes it can last up to a year.
2. The essence of the treatment is that it is aimed at preventing the recurrence of attacks and the social adaptation of the patient.
3. Difficulties may arise during the period of adaptation to treatment, since at the first stage of action, both antidepressants and ABD may cause side effects, which eventually disappear either on their own or under the influence of corrective therapy. Sometimes it is advisable to release the patient from work during the period of adaptation to treatment.
4. During the adaptation period to treatment, panic attacks may recur, and this is not evidence of the ineffectiveness of the therapy. To stop the attack, the patient's usual means can be recommended - typical benzodiazepines or additional intake of ABD (clonazepam, alprozalam).
5. The effect of therapy may be delayed, since in most cases the antidepressant effect manifests itself with a latent period of 14 to 21 days after the start of their use.
6. Abrupt discontinuation of medications at any stage of treatment can lead to an exacerbation of the disease, therefore, at the end of treatment, the drug is discontinued very gradually.

Relief of secondary psychovegetative syndrome In the treatment of patients with panic disorders, it is often necessary to combine basic drugs aimed at preventing repeated panic attacks with drugs that allow influencing secondary psychovegetative syndromes. As mentioned above, these can be asthenodepressive, hypochondriacal, obsessive-phobic and hysterical syndromes. In these situations, it is advisable to add drugs from the neuroleptic group: melleril (sonapax), teralen, frenolon, neuleptil, eglonil, chlorprothixene, etaperazine.

Individual selection of pharmacological drugs, the use of small doses, and a combination with cognitive-behavioral psychotherapy and social adaptation make it possible today to successfully cope with such a widespread and socially maladaptive suffering as panic disorders.