Ten Years of Panic

It’s not funny at all to have panic attacks. Some people say it’s preferable to feel pain. The panic disorder is one of the most violent psychiatric problems and it brings the patient quite fast to the ER and then, if properly managed, to a psychiatrist. The good news is that panic is treatable in most cases and is considered an “easy” psychiatric disorder compared to schizophrenia or the bipolar disorder, for instance. This time I will write about a psychiatric case that was managed in such a way that it made me question many things. It’s an interesting exercise for both the psychiatrists who might read me but also for other psy professionals and, maybe, the general public.

We’re talking about a middle-aged man who is having panic attacks intermittently for 10 years. He tried several treatments but he cannot recall exactly the medication. For the last 2 years he was on 2 drugs: Sertraline 100 mg in the morning and Levomepromazine 25 mg, one half in the morning, one half at noon and one half in the evening. This treatment was started directly at these doses, not gradually. He is feeling fine and asks me to renew his receipt. When questioned about psychotherapy, he says that nobody told him that this is an option to treat panic disorder.

Take a break a bit and think about this situation without reading further. What is right? What is wrong? What is surprising?

Now take an extra moment to perceive what you feel regarding this patient and his situation. Do you feel something related to this case or the situation?

Now… let’s see…

The first surprising thing is that the patient has this disorder for 10 years. It’s a long time. It might be the fact that he has met only incompetent doctors. But it might also be another hidden reason: the panic attacks help him in some way. Always think about symptoms or psy disorders from this perspective: having panic attacks can serve as justification to do or not to do certain things. They can also help someone to hide behind the disorder or avoid some situations or life altogether. People are able to suffer and accept suffering if that helps them. It might be surprising but you cannot exclude this as a hypothesis. Ten years can force pretty much everyone to do the impossible to solve an unpleasant situation. Few people can be passive in such a degree so as to do nothing.

Sertraline (Zoloft) is an antidepressant drug and is efficient on panic attacks. Well tolerated and well known, it is often my choice as well. However, to start directly this drug at such a high dose is dangerous for 2 reasons: first, it causes agitation, and second, it increases both the risk of suicide (increases impulsivity) and the risk of side-effects (I’m thinking here about the serotonin syndrome, potentially life-threatening). It is not enough to know what medication to give; you need also to know when to give it, how, in what dose, etc.

Levomepromazine (Nozinan) is an antipsychotic drug, used often in the treatment of schizophrenia or manic states. It is an old drug, with several side-effects, and is mainly used as a sleeping-pill, for sedation. For this reason, it is given in the evening, for insomnia, or as an adjunctive drug for other antipsychotic drugs (when extra sedation is needed). To give you an idea about the strength of sedation, imagine that a single tablet of Levomepromazine (remember that the patient took one and a half tablet daily) is 2 or 3 times stronger than a tablet of Diazepam (Valium); if taken by someone who is not heavily agitated, it makes that person sleep for almost 24 hours and makes it difficult for her to wake up so as to eat or pee… As a consequence, when used during the day, it causes severe difficulties in coordination and heavy danger for driving (and the patient was a daily car driver). It is not recommended to be used for any anxiety disorder. In fact, Sertraline alone is most of the time enough to manage panic attacks (especially at this dose), and no extra medication is normally needed.

Given these circumstances, would you renew the patient’s receipt? Would you change it? If yes, in what way?

Psychotherapy is the first line of treatment in panic disorder. Medication is the second line. Psychotherapy addresses the cause; medication keeps a decent quality of life while the patient works with his psychotherapist. Not telling to the patient that psychotherapy is an option is a poor choice, as long as this therapy is available in the area (he lives in a city, there are psychotherapists in the city, he is not isolated in a remote village). Also, combining medication with psychotherapy is much more effective than medication alone or psychotherapy alone.

What do you feel regarding the entire story now, after everything has been explained?

What would you like to tell to the previous psychiatrist who managed this case?

What would you like to tell to the patient? What would you like to ask him more?

This was a classical psychiatry case, although extreme in many ways. If you feel you learned something interesting or new from it, please let me know.

10 thoughts on “Ten Years of Panic

  1. Wave

    I am not a psy professional but this question comes to mind: wasn’t it enough to give the patient some pills that he could take only if he felt the onset of the panic attack, and encourage him to journal his experiences so we would have a basis for therapy and understanding what are the triggers. Just saying.

    Liked by 1 person

  2. b.csilla

    As a patient who had experienced panic attacs, I would choose therapy any tine instead of pills. But I do have a couple of years of therapy behind me to see it’s worth.
    I would have some “kind” words to say to his previous doctor about perscribing pills to him for something that can be cured by therapy.
    I saw the value if psichotherapy and I wouldn’t it teade it with nothing.
    It is hard work, and some pretty intense sessions of looking in the mirror but it helped enormosly. No pills can ever do that. Some things you have to feel in order to make a change in your life.

    Liked by 2 people

  3. Wave

    From what you are saying, arriving in front of a psychiatrist in a disturbed state leads to a long-term drugs prescription and not necessarily any advice regarding psy therapy.
    I think that the lack of modern procedures and accountability is at the root of this problem, a requirement could be set for any long term medication plan to be approved only after a psychotherapist saw the patient as well, and in some countries there is a requirement that 2 doctors should approve the treatment plan in certain cases.
    Most likely the patient you saw did not take the prescribed daily doses(or he would not be able to function). My concern is that if someone would take the medicine as prescribed, the side effects might soon cause more problems than the problem he had when he came there. Therefore someone’s life might be permanently damaged by the very people that were supposed to help him.

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    1. Not necessarily.
      Not all psy disorders require long-term treatments and most panic attacks need around 6 months of medical treatment or psychotherapy.
      At the root of the problem there is a lack of common sense. The patient should have searched for a different doctor after the heavy sedation (or should have demanded a reduction of doses). The doctor should have been competent.
      I don’t think there is lack of modern procedures; even in the past this treatment would have been considered barbaric.
      A psychotherapist is not required to plan a treatment or to make recommendations for the simple reason that a psychotherapist is not a doctor (doesn’t have a medical school degree).
      Requiring 2 doctors to decide is more likely a bureaucratic reflex; one doctor is enough if (s)he is competent. A doctor verifying the work of another is absurd and makes me remember East Europe where people spy each other and responsibility is shared so as to diminish guilt. One doctor is perfectly capable of deciding in a simple case of panic disorder.
      It is likely that the patient actually took the medication as prescribed. He struggled with sedation but he didn’t question the competence of his physician because of the (again) East European belief that “the doc knows best” and “suffering is necessary to heal”. He probably functioned badly with a lot of coffee during the day until his body learned to live with the drug. He surely had problems but shall I write about the degree of masochism in my country?
      No, his life was not damaged. It could have been damaged in case of a car accident due to excessive sedation but fortunately everything went fine. His treatment remains in my memory an example of excessive medication, something like trying to kill a mosquito with a cannon.

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      1. An university degree. It depends on country and school of psychotherapy. The most frequent degree in Romania is the one of psychology, but I have seen psychiatrists (I’m one of them), social workers, family doctors, nurses (especially psychiatric nurses), philosophers and even theologians. I guess the degrees should be somehow related to the human psyche, but I remember that the requirement was simply to have a university degree (so as to be able to understand what is being talked about).

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  4. Wave

    I have a degree in economics, does this mean I can register as psychoterapist?
    And by the way I would still enforce a procedure where a second opinion is necessary, and also an audit every now and then (but at least yearly) from someone in Bucharest, that the local physicians don’t know. If nobody is ever questioned or made accountable for their actions, cases arise like the ones you described.

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    1. You can register to begin training for psychotherapy. It takes some years to become a therapist… the minimum I saw was 3 years.
      A second opinion can always be asked by the patient (he was free to do it, I don’t know why he didn’t). Nobody enforces second opinions in medicine because it would be a monumental task… doctors verifying each other would double the amount of work for everyone.
      So as to do an audit you need to know how to do it. We doctors don’t know this. Other professionals can’t do it either because they lack clinical training. It’s like me coming to your economical job and verifying you; I have no idea what economics is all about and what an audit is all about! Plus, I wouldn’t know what to verify! Same is for medicine. Even a doctor in a different speciality can’t verify me and I can’t verify him in his area. So the only ones who can verify are the academics, the professors of psychiatry teaching at the university. Now… who would have the enormous amount of time and the gigantic ability to sustain effort so as to verify… yearly… the practice of each psychiatrist??? No way.
      As for this idea to name someone from the capital city… in a corrupted country you can’t do that because that person will be paid/bribed and you will do nothing. This is not a practical way to solve the situation because you can’t heal a dysfunctional system from the inside (many people tried and all of them failed).
      Situations like this arise because certain persons are tolerated in their respective positions, using the argument that “better someone than nobody”. You can clean the system efficiently if you bring a team of experts from abroad and re-test everyone, re-examine each doctor, and remove permanently from medicine those who can’t pass the revalidation. You make the entire system collapse and then you rebuild it with young doctors who are presently emigrating for lack of jobs in the country. This can be done but will not be done for reasons that are linked to politics and leadership. And this is an area I won’t venture into.

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