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Re: Cam, I would really appreciate your insight » grapebubblegum

Posted by Cam W. on May 26, 2001, at 10:45:26

In reply to Cam, I would really appreciate your insight, posted by grapebubblegum on May 26, 2001, at 8:29:04

GBG - Love the name, but like your doctor even more. I have given a couple lectures on the subject of concordance (patient and doctor working together, incorporating each of their belief systems into an integrated whole). Throughout the history of medicine this approach has shown to work than most of the current therapies of the time. The Brits seem to have a lot of writing about this, starting about 25 years ago. The advent of HMOs (U.S.) and Medicentres (Canada), and the lure of the almighty dollar, seem to have really screwed up any chance of this becoming a commonplace reality in North America. My new doc, like yours, gives me some leeway in therapy and treatment, but has to rein me in every now and then (LOL). Keep this lady under your hat, or you may never be able to book appointments.

Panic disorder is thought to be a screw-up of the serotonergic neurons from the raphe nuclei (major source of serotonergic projections in the brain) to a structure enclosed under the hippocampus (can't remember which one - notes are at work and they won't let me have them while I'm on stress leave < shrug >). It seems that there is a lack serotonergic transmission in this pathway. It seems that this lack of serotonin is what panic disorder has in common with depression, OCD, PTSD, etc.; all involve a lack of serotonin in more or less different, but specific, serotonin pathways.

This is why SSRIs are used in panic disorder, as well as depression (and the other conditions). Doses for panic disorder are normally higher by 50% than are used in depression (eg. Paxil™ - paroxetine - doses of 30mg are normally used for panic disorder). Paxil is commonly used in panic disorder because of the antimuscarinic and anxiolytic actions of the drug. One unfortunate problem with the SSRIs being used in panic disorder is that the drugs make the panic worse for the first couple of weeks taking it.

What is going on in your case seems to be a little different than classic panic disorder. As stated above, because panic disorder involves the serotonergic system, it occurs quite frequently (comorbidly) with depression and OCD. I am going to take a guess at what is going on in your body, but remember, it is only a guess. Instead of being deficient in the amount of serotonin your body produces, you may a faulty subset of serotonin receptors (ie. only a partially functional 5-HT1A or 5-HT1B receptor) due to a genetic miscoding in your DNA. So, adding serotonin to your system doesn't really do anything to to these receptors but add side effects through your normally functioning subsets of serotonin serotonin receptors. This could be why SSRIs are ineffective for you and why they seem to making your situation worse.

As for benzodiazepines like Klonopin™ (clonazepam - Rivotril™ in Canada), it has been my experience that people who use them for a real reason (not to forget life &/or stay "high" - or is it low?) do not seem to overuse or abuse them. If anything, some people with bipolar disorder do not seem to use them enough. Seldom have I seen someone with bipolar disorder abuse benzodiazepines; it seems that they like the manic high over the artificial low of benzodiazepines. As for panic disorder, there is a little more concern for the overuse of these drugs. These people can panic at the thought of a panic attack and some will drug themselves into a semi-stupor to avoid an attack. If you are diligent about self-monitoring your use, use the lowest effective dose (hopefully .125mg - 3x daily and not the 12.5mg you wrote - LOL), and restrict increases to breakthrough panic attacks, there should really be no harm in long-term Klonopin use. If need be, keep a journal of your Klonopin use, so that you will be able to show your doc that you are not overusing it.

If you truly do have a defective gene for a subset of serotonin receptors, the only drugs that would be effective for you would be the benzodiazepines (perhaps a beta-blocker as well). Ask your doc about my theory and see what she has to say.

I hope that this is of some help. - Cam




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