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.