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Re: Best thing for panic attacks/extreme anxiety Rakken

Posted by Elizabeth on October 28, 2001, at 17:37:43

In reply to Best thing for panic attacks/extreme anxiety, posted by Rakken on October 28, 2001, at 12:44:21

Hi there. This is going to be pretty long, partly because there were some things in your post that confused me a lot. I hope I can be of help, but there are some things that didn't make much sense to me. I'm hoping you can clear up my confusion.

> What works well for panic attacks and anxiety? I have heard that xanax works well but is short acting. Klonopin lasts longer and seems more of a therapeutic choice. Any other things (like a list - pos/neg)?

Any benzodiazepine would probably work; Xanax, Klonopin, and Ativan (the "high-potency" benzos, in decreasing order of potency) are the ones most commonly used. Lower-potency ones may work at equivalent doses, but they'd probably be very sedating at such high doses (like, 60 mg/day of Valium).

The other major treatment for panic disorder is antidepressants. SSRIs, MAOIs, and some tricyclics are effective, but it may take several weeks at an effective dose before they start to help. Antidepressants, especially SSRIs, often make the anxiety worse at the beginning, so it's a good idea to start at a very low dose and increase it gradually, as tolerated. You should also be able to take a benzodiazepine as-needed until you've reached an effective dose of the AD. Xanax is probably best for as-needed use, since it's fast-acting. (You can also make Ativan work faster by dissolving it under your tongue; you can probably take Xanax this way too, but it tastes very bitter.) The tricyclic imipramine was the first drug used in the treatment of panic disorder, but not all tricyclics are effective. Maprotiline and protriptyline are not effective, and I would not expect amoxapine to be very effective either although I'm not sure about that one. My experience has been that desipramine (even at very high levels) does not work as well as the MAOIs and other antidepressants do. Amitriptyline and doxepin would probably work, but they are both often very sedating and often have other unpleasant side effects. I'm not sure about trimipramine. I think the best tricyclics for panic disorder are probably imipramine, clomipramine, and nortriptyline. (These are just the ones that are used in the USA. There are others that may be preferable if you're in a country where they're available.) All the irreversible MAOIs work very well for panic and most other anxiety disorders. I think Nardil is particularly effective.

The "atypical antidepressants" Wellbutrin and trazodone are known not to work. I don't think that Serzone and Remeron have been studied much, and Effexor probably has the same advantages and disadvantages as the SSRIs. (Some people need to go up to very high doses of Effexor for depression, and they sometimes get a lot of side effects. If your problem is strictly anxiety, a lower dose would probably be fine for you.) BuSpar, an antidepressant which is approved for generalized anxiety is *not* effective for panic disorder but may help in combination with an antidepressant or a benzodiazepine.

Some anticonvulsants, such as Depakote and Neurontin, may work also, but these usually aren't used except when other treatments have failed or if you have bipolar disorder too.

Now, the above treatments are for panic disorder (spontaneous panic attacks). You said you have panic attacks and anxiety, but you didn't say what sort of anxiety, or what (if anything) triggers the panic attacks. That can make a lot of difference. Do you know what you have been diagnosed with?

> And what would work well combined with Adderall?

Benzodiazepines, and most antidepressants and anticonvulsants, are fine to take in combination with Adderall. You might want to monitor tricyclic serum levels if you're taking one of those. Combining MAOIs with stimulants should only be done with a great deal of caution.

> Adderall isn't very effective for me at under 30 mg and wears off early in the afternoon so I have to take 10 mg dextrostat.

I'm confused, I guess. What is the amphetamine supposed to be helping with? Adderall seems like an odd choice for anxiety -- it sounds like there is something more going on for you, and this can affect the choice of treatment for your anxiety. (For example, some anti-anxiety drugs can worsen the symptoms of other disorders.)

> I'm worried about my pdoc wanting to try ssri's and tricyclics on me for the anxiety. I've been on ssri's and they haven't been effective.

Which SSRIs have you taken, and what happened exactly (how long did you take them, etc.)? Have you tried other antidepressants? ADs do usually work, but you have to have patience.

> Neither has risperdal. And I hear zyprexa doesn't help very well in combination with adderall.

Again, this is sounding weird. Why would your doctor prescribe Risperdal for anxiety? It's just not effective (and is also liable to cancel out whatever benefit you might be getting from the Adderall). Antipsychotic drugs are a totally inappropriate treatment choice for panic disorder and most other types of anxiety. Is there some other condition that the Risperdal was supposed to treat? What kind of anxiety do you have, other than panic attacks?

> And I am worried that my pdoc will rule out some treatments since I have overdosed on lorazepam and smoked marijuana in the past. A year ago for the lorazepam.

How old are you, and do you still use marijuana? Was the Ativan overdose a suicide attempt (and if not, what was it?), and did you do it more than once? How much Ativan did you take (approximately)? Was the Ativan prescribed to you, and if so how did it work in the prescribed dose? I think the answers to these questions should affect the doctor's choice of medication.





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