Certain medications, particularly anxiolytics and antidepressants, are effective in suppressing panic attacks and creating a sense of well-being. Among these, the benzodiazepine alprazolam had been favored by some psychiatrists, but lorazepam and clonazepam are almost as effective and are considered less likely to cause dependence. They are all effective within hours. In mild cases, the benzodiazepines may be used intermittently rather than several times daily, but they tend to be less useful once a panic attack has become established. Panic attacks tend to recur when the medications are discontinued, even after prolonged (6 to 12 months) administration. Any reduction in the amount of these medications should be gradual.
Tricyclic antidepressants and drugs that raise serotonin concentrations in the nervous system (selective serotonin reuptake inhibitors [SSRIs]) may also be effective in the prevention of panic attacks and agoraphobia, but their onset of action is delayed for weeks. They become useful for symptoms of anxiety that recur or persist for more than several months. The doses are similar to those used to treat depression, and small differences between them do not seem to be clinically important (see Chap. 48). Buspirone, a specific serotonin 5-HT2 agonist, has been promoted as effective in the treatment of anxiety and as a surrogate for benzodiazepines, but to us its benefit has seemed to be slight. It is important to point out that during the initial weeks of administration of antidepressants, the underlying anxiety symptoms may worsen and an anxiolytic is usually required until the antidepressant becomes effective. Propranolol, 10 to 20 mg tid, or a long-acting form of adrenergic blocker, can reduce many of the autonomic accompaniments of anxiety and is useful to many patients. Psychiatric consultation is, of course, invaluable. With regard to psychotherapy, behavioral therapy (progressive exposure of the patient to panic-provoking situations) is said to be beneficial, particularly if agoraphobia is a major symptom. Relaxation activities, including biofeedback and meditation, help many patients, although persistence is required in performing these exercises at least once daily and they are less helpful once a panic attack has begun. Cognitive-behavioral psychotherapy, which is discussed in relation to the treatment of depression in Chap. 48, also appears to be useful in the treatment of panic disorder, according to Andreasen and Black.
A cardiac consultation and some simple tests (electrocardiogram, chest films) are often needed to reinforce to the patient the benign nature of the cardiac and respiratory symptoms and to alleviate fear of heart disease. These and other concepts of the treatment of anxiety were discussed by Goodwin and Guze. Anxiety symptoms arising in relation to a particular threatening event in a nonneurotic individual carry the best prognosis, but the symptoms may be prolonged, a feature of posttraumatic stress disorder.
In this state, patients are overwhelmed by an intense and irrational fear of some animal, object, social situation, or disease. Although acknowledging that there are no grounds for a particular fear (hence it is not a delusion) and that such provocative stimuli are for the most part innocuous, the patient is nonetheless powerless to suppress it. This disorder was known to Hippocrates, who drew a distinction between normal and morbid fears. Westphal, in 1871, was the first to give morbid fears the status of a disease.