Treatment of vegetative crises

Treatment of panic disorders

Before proceeding to pharmacotherapy, it is necessary to evaluate the potential reserves of non-drug treatment of a patient with panic disorders. At the first contact with the patient the doctor estimates:

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

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

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

Pharmacotherapy of patients with panic disorders involves several therapeutic strategies:

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

In determining the strategy for treating patients with pharmacological drugs, first of all, the benefits of treatment are associated with the risk in its conduct.

As a risk factor in pharmacotherapy, side effects, complications in the therapy process, the possibility of painless withdrawal of the drug. As a benefit from the treatment - the restoration of health, social functioning of the patient and the possibility of preventing relapses.

Cessation of panic attacks

His own experience of arresting an attack usually appears in the patient after several panic attacks. If the patient resorts to the help of a doctor (called an ambulance) to stop the first, as a rule the most severe, paroxysms, then in subsequent attacks, making sure that the 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 views on the nature of the disease and the first experience of communicating with medicine. If a panic attack is regarded as a "heart attack" or "hypertensive crisis," the stopping drugs are valocordin, corvalol, hypotensive drugs or beta-blockers (anaprilin, obzidan); if the disease is regarded as a "nervous disorder", the patient prefers to use sedatives, usually benzodiazepine drugs or, as they are called, "typical benzodiazepines" (seduxen, relanium, tazepam, rudothel, etc.).

Often already at the first appointment to the doctor the patient comes, having in his pocket "saving" pills. Indeed, the use of typical benzodiazepines is the most effective way of arresting a panic attack, as, indeed, of other paroxysmal conditions (for example, epileptic seizures). However, with this symptomatic treatment, the dose of the drug has to be increased over time, and the occasional use of benzodiazepines and the associated recoil phenomenon may contribute to the increase in panic attacks.

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

Prevention of repeated occurrence of panic attacks

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

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

1. tripeptic antidepressants - imipramine (melipramine), amitriptyline (triptyzole), nortriptyline, clomipramine (anafranil, gidifen);
2. four-cycle 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 the antipanic action of antidepressants remain a debate. Initial views on the effect of antidepressants primarily on noradrenergic systems (inhibition of the reuptake of norepinephrine in the synaptic cleft) are not confirmed today by most authors. It has been shown that drugs acting exclusively on noradrenergic systems (desipramine and maprotiline) are not effective in preventing panic attacks. At present, a theory that relates the antipanic efficacy of antidepressants with a predominant effect on serotonergic systems is more likely. Probably, future studies will allow to differentiate among patients with panic disorders the clinical subgroups that effectively respond to antidepressants with different mechanisms of action.

Atypical benzodiazepines include clonazepam (antelepsin, rivotril) and alprazolam (xanax, cassadan).

Benzodiazepines (both typical and atypical) enhance the effect of GABA (y-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. The peculiarity of DBA is their high affinity for benzodiazepine receptors (3 times higher than that of typical benzodiazepines).

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

It is known that with the use of antidepressants, especially tricyclics, in the first decade of treatment there may be an exacerbation of symptoms - anxiety, anxiety, agitation, and sometimes more frequent panic attacks. Adverse reactions to dipeptic antidepressants are largely associated with cholinolytic effects and can manifest as severe tachycardia, extrasystole, dry mouth, dizziness, tremor, constipation, weight gain. The above symptoms can lead at the beginning to involuntary 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, the side effects manifest themselves primarily as a sedation, which usually regresses in 3-4 days as the treatment continues. The phenomenon of recoil, especially expressed in alprazolam, necessitates frequent administration of the drug; Finally, a pronounced drug dependence, especially when there is a substance abuse, limits the use of this group of drugs.

And in this and in another case, a sharp cessation of drug treatment leads to withdrawal syndrome, i.e. A sharp exacerbation of the symptoms of the disease.

As positive points, it should be noted that in the treatment of panic disorders of the therapeutic effect, it is possible to achieve at low doses of antidepressants or atypical benzodiazepines. So, 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 alitrazolam.

In determining the tactics of therapy, two basic questions need to be addressed: drug selection and dose determination.

The choice of the drug is determined mainly by the clinical picture of the disease and the characteristics of the drug. Essential is the question of the nature of paroxysm; 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 showed, the effect of drug therapy does not exceed the efficacy of placebo, therefore it is expedient to immediately raise the question of alternative methods of treatment, perhaps psychotherapy. In the case of the qualification of paroxysm as a panic attack, it is necessary to evaluate the duration of the disease and the symptomatology of the interictal period. If panic attacks have appeared recently or the debut of a panic attack is associated with an alcoholic excess and there is no agoraphobic syndrome, then it is advisable to start therapy with an ABD.

If panic attacks are combined with agoraphobia or other secondary psycho-vegetative syndromes (phobic syndrome, depression, hypochondria), then antidepressants should be used. In the case of severe agoraphobic syndrome, clomipramine can be recommended; with a combination of panic attacks with social phobias, MAO inhibitors, in particular moclobemide, are effective. When choosing a drug, antidepressants with minimal cholinolytic effects, for example, pyrazidol, mianserin, fluoxetine, tianeptine, should be used first.

In some cases, the combined use of antidepressants and DBAs is required, since DBA, firstly, provide an early appearance of the clinical effect (almost the first week of treatment), and second, help to stop the panic attack before the antidepressant starts.

When determining the dose of the drug, the following rules can be helpful:

1. To begin therapy it is necessary from small doses (1 / 4-1 / 2 planned dose) with gradual (within 2-3 days) their escalating.
2. Criterion for the dose limit may be the severity of side effects that do not disappear within 3-4 days.
3. Recommended daily distribution of the drug, depending on the hypnogenic effect. So, with pronounced sleepiness, it is recommended to shift the medication intake in the evening.
4. If it is not possible 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 can be beta-blockers.

Before prescribing a course of drug therapy, the doctor should explain 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 provisions:

1. The course of treatment should be long, sometimes can last up to a year.
2. The essence of the treatment is that it is aimed at preventing recurrence of seizures and social adaptation of the patient.
3. There may be difficulties in the period of adaptation to treatment, since in the first stage of action, both antidepressants and DBA, side effects may appear which eventually go either independently or under the influence of corrective therapy. Sometimes it is advisable to release the patient from work for the period of adaptation to treatment.
4. In the period of adaptation to the treatment of panic attacks may be repeated, and this is not evidence of ineffective therapy. To stop the attack, you can recommend the usual means for the patient - a typical benzodiazepines or an additional administration of ABD (clonazepam, alprozalam).
5. A delay in the effect of therapy is possible, since in most cases the antidepressant effect manifests itself with a latent period of 14 to 21 days after the beginning of their application.
6. Abrupt withdrawal of drugs at any stage of treatment can lead to an exacerbation of the disease, so at the end of treatment, the drug is canceled very slowly.

Kupirovanie secondary psycho-vegetative 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 can affect secondary psycho-vegetative syndromes. As mentioned above, it can be astheno-depressive, hypochondriacal, obsessive-phobic and hysterical syndromes. In these situations, it is advisable to add drugs from the group of neuroleptics: melleril (sonapax), teralene, frenolone, neuleptil, eglonil, chlorprotixen, etaperazine.

Individual selection of pharmacological preparations, use of small doses, combination with cognitive-behavioral psychotherapy and social adaptation allow today to successfully cope with such widespread and socially maladaptive suffering as panic disorders.