Introduction
Panic disorder is a chronic a psychiatric condition that can be treated. This condition is normally found in young adults, and it has been estimated that about sixty percent of patients who suffer from panic disorder also have agoraphobia.
Agoraphobia often coincides with Panic Disorder. Agoraphobia is defined as a fear of having a panic attack in a place from which escape is difficult.
Sufferers of agoraphobia refuse to leave their homes, or set up a fixed route in which they can not deviate. Anxiety disorders are treatable. Most patients of anxiety disorder treated with professional care. Success of treatment varies with the individual. Some people may respond to treatment after a few months, and with some it may takes a year or more.
Panic disorder with agoraphobia results in major functional impairment in the daily routines of the patient; furthermore in young adults this can have an adverse effect in their work, social and family life.
Cognitive behavioural therapy (CBT) was considered to be the only treatment for panic disorder with agoraphobia. Nevertheless, traditional cognitive behavioural therapy takes up a lot of time it does not have an fast effect on the patient, very less patients can have avail this treatment, as there are very few therapists who are qualified enough to use this therapy apart from this the health care system also has many limitations regarding this therapy.
In the last few years researchers have found out a number of pharmacological treatments. The benzodiazepine alprazolam has proved d to be the most useful in the treatment of panic disorder and has a quick start of efficacy.
Nevertheless, it is inappropriate for long-term utilization as of issues regarding dependence, withdrawal, several dose regimes and likely to be misused. The selective serotonin reuptake inhibitor (SSRI) paroxetine has also proven to have a short and the long term efficacy, and has an excellent tolerability profile; paroxetine was the first licensed drug for the treatment for panic disorder.
Case Report
Anna who was a 35-year-old woman sought outpatient treatment after suffering from recurrent panic attacks for 8 years. She experienced her first attack when she was on a flight from the America to Europe. After this incident the patient suffered several panic attacks in many different of settings, theses included narrow rooms, supermarkets and public libraries, due to this she did not want to confront such situations.
Panic attacks took place twice or thrice a week, and were related to somatic as well as psychological symptoms, which take place in a few minutes and end within 30 minutes. In these attacks, the patient had palpitations, increase in heart rate, and ultimately during the attacks she also was afraid that was going crazy, apart from this she also experienced derealization.
Before referral whiles he was driving on the motorway. She developed a hot sweat, shaking, pins and needles, a dry mouth and a lump in the throat. She was hyperventilating, experienced palpitations, and felt terrified that he was going to collapse or even die.
During the attacks, she felt as if she was free of problems, even though she did experience a little anticipatory anxiety which resulted in avoiding particular situations, like not driving into the city because she was afraid of traffic jams. The patient often walked her dogs only on the route which was familiar to her however the trip to the hospital, situated in the centre of Vienna, was difficult for her due tow which she needed her mother to accompany her.
Due to her symptoms she felt scared when she was alone and only went out if a friend or family member accompanied her. She reported that she was experiencing stress since an important relationship ended.
At the time, when panic disorder with agoraphobia was diagnosed, the treatment began by making Anna aware of the nature, cause and course of panic disorder, and by putting emphasis on the fact that this is a common and treatable.
The patient stated that sometime back she underwent CBT for 3 years each session was of two hours, and took place once a week. The psychotherapist recommended the patient not to take any medical treatment, as he thought that the therapy which he was using i.e. CBT was almost complete and pharmacotherapy may be counterproductive. In CBT the psychotherapist gradually exposed the patient, at first with a friend. Nevertheless gradual exposure with a friend or relative then reduced.
Nevertheless, the patient was aware of pharmacotherapy for panic disorder from TV and articles regarding and was interested. And along with CBT Medication was first given with a combination of 0.5 mg alprazolam trice a day along with 10 mg paroxetine once a day and the patient carried on going to her psychotherapist.
0.5 mg alprazolam along with 10 mg paroxetine was used for approximately a week, the patient reported no more symptoms of panic, even though she still experienced a little anticipatory anxiety, and the dosage of paroxetine was increased to 20 mg. After several weeks the dosage was again increased, to 40 mg, which is known to be the minimal dose for a patient suffering from panic disorder.
After 4 months the psychotherapist slowly withdrew the doses of alprazolam. Ever since the patient began pharmacotherapy, she has experienced no further symptoms of panic. She experiences mild anticipatory anxiety and this anxiety does not have an effect on her social functioning. She is able to travel and goes to hospital appointments without her mother. She still takes a dose of 40 mg paroxetine but only once a day for 2 years thus the treatment has greatly helped her.
Family Background
Anna was born in USA. She enjoyed his early childhood and had a good relationship with her parents. During her time at a local secondary school he had many friends and enjoyed sport.
When she was 13 years old his parents divorced, but she did not feel that this had a great effect on him. She continued to live with her mother and saw his father regularly. Anna left school at 16 to take up an apprenticeship. Since the age of 15 years, she had been involved in a relationship with a girl of his own age which he ended.
Anna has no past psychiatric history of note. At the age of 9 years, he suffered from meningitis and was in hospital for 1 week. Although she has episodes of migraine, she has not experienced any severe headaches for the last 6 month.
Discussion
Panic disorder is a chronic a psychological condition that can be dealt with, and before pharmacotherapy this patient was functionally limited because of her avoidance behaviour. Her treatment consisted of an extensive programme of insight-orientated psychotherapy. However, after 3 years she was still having panic attacks as well as experiencing anticipatory anxiety. Psychotherapy needs immense commitment from both the parties’ i.e. Patient and therapist and in this case the benefit was limited. The patient had been fully aware the treatment of mental disorders, from which she was quite aware of the treatment of panic disorder in particular, due to which the patient tried to look for a different therapy. A fast alleviation of symptoms occurred as soon as her pharmacotherapy started.
Alprazolam tends result in dependence, and thus this treatment was slowly withdrawn after the fourth month; by the time the patient had reached the sixth month of therapy she was only receiving paroxetine. Current publications have illustrated the fact that paroxetine is useful in long-term treatment and also helps to prevent a relapse. The patient at present has been taking medicine for 2 years due to which there is no relapse in panic symptoms and no negative effects.
This case is an example of the extensive scientific uncertainty regarding the effectiveness of CBT combined with alprazolam and paroxetine in panic disorder, as there are limited studies which help in proving that this treatment is effective.
Nevertheless, at the start of the therapy it was not known if CBT, which has already proven to be effective in this disorder, nor if a combination of CBT and paroxetine would have been beneficial for the patient. Furthermore, this case also emphasizes on the doubtful relationship among psychotherapy and pharmacotherapy.
Nonetheless, recent development has been made regarding these issues. For instance, paroxetine treatment in panic disorder has proven to yield considerably improved results from the 10th week to onwards with brief CBT.
This result showed that by using non-pharmacological response, like in psychotherapy, it has to be kept in mind that a non-pharmacological response is not essentially result in improvement in the quality of life.
Present guidelines suggest a cognitive-behavioral therapy (CBT) along with paroxetine for first-line treatment of panic disorder with agoraphobia. Nevertheless, there are more chances of relapse occurring after antidepressant treatment than after a monotherapy of CBT.
It is highly recommended that combining alprazolam and paroxetine with CBT may also lessen long-term treatment efficacy, for instance, medication result in a state dependent learning context or since it acts as a safety signal that interrupts with the success of exposure to feared stimuli.
Several concerns regarding combining alprazolam and paroxetine with CBT have been found in researches in which CBT in patients that received or didn’t receive medications in the beginning of the therapy.
With a combination of alprazolam and paroxetine treatment whilst receiving CBT, the patient in question showed considerable improvements in panic attacks and in related and symptoms. After CBT, she retained her full remission, mostly in her avoidance and behaviours. In follow-up, she preferred not to stop her medication, as he felt that the symptoms had the most awful long-term effect on her life.
Concluding Remarks
Anna has a difficulty with panic disorder. It is unclear how much agoraphobia she has, but apparently she is only going out when accompanied by a friend or relative. I would ask him to read about panic disorder and agoraphobia and treat her with medication, possibly a reuptake inhibitor, till there were a number of particular reasons for taking another antidepressant. The psychotherapist began the treatment with CBT along with combining low doses of alprazolam and paroxetine and then increasing her to suitable doses over a number of weeks.
Treatment duration is another important consideration. In general, an adequate dosage of an antipanic agent for at least 8 weeks should be considered a minimum before considering a patient “resistant. Situational panic attacks often take longer to subside than unexpected attacks.” If the persistent anxiety attacks are primarily situational, specific cognitive-behavioral treatment/exposure should be considered. Also, if the severity of panic attacks has clearly diminished but the frequency of attacks has not, it may be that further improvement could occur over time.
A review of the quality of the panic attacks (e.g., unexpected vs. situational, intensity, and frequency) with the patient may help in the decision process. At that point, the clinician can consider using a different pharmacological agent, or combining different agents, such as antidepressants and BZs.
In the CBT From the beginning the psychotherapist made it clear that she would also need to learn’ to go out to all activities, ultimately by herself.
Key Points
Patients nowadays are gain awareness from the media regarding diagnosis and treatment of mental illness. CBT along with are a combination of alprazolam and paroxetine is a wise preference for treatment of panic disorder with agoraphobia as it is effective both in the short and the long term. Non-pharmacological response in panic disorder does not guarantee an improvement in the quality of life.
Establishment of clinical efficacy is usually accomplished by using single agents or treatments in patients with relatively “pure” panic disorder, and the literature on treatment is unfortunately not always reflective of clinical reality. Optimal treatment of panic disorder patients often requires more than one pharmacological agent and more than one type of treatment.
The above analysis it can be concluded that Generally medications and CBT work about equally well in the short term as well long term, although some people may respond better to one approach or the other.
References
Guide to Treatment (2009).
Martin M. Antony (2002); Panic Disorder with and without Agoraphobia. Web.
Panic Attacks – Don’t Let Them Rule Your Life (2004).