TREATMENT OF NEGATIVE CRISES (PANIC ATTACKS)
G. M. Dyukova, I. P. Shepeleva, and O. V. Vorob'eva
UDC 616.839-039.31+616.891.6039.31]-085.214.32-036.8
Vegetative crises (VC) have traditionally been regarded as the most dramatic manifestation of the psychovegetative syndrom. In the English-language literature identical states which have been designated as "panic attacks" have been described clinically. In the past decade our notions of the clinical-pathogenetic and therapeutic problems of the VC have undergone substantial changes. Klein, et al. [6] found for the first time in 1962 that the tricyclic antidepressants (TA) possess a specific therapeutic activity in relation to the VC, and, moreover, independent of whether or not they are combined with depression. The effects of various types of antidepressants, the tricyclic (inipramine, desimipramine, clomipramine, amitryptiline, etc.) and MAO inhibitors (phenelzine) have been studied subsequently. The results of treatment with antidepressants have been compared with the results of the use of placebos (the double blind method) and other psychotropic and vegetotropic agents. It has been demonstrated in many studies [2, 5, 12] that the antidepressants surpass both placebos and other psycho- and vegetotropic preparations in effectiveness. It has been found that the doses of antidepressants used for the treatment of VC are lower than those which are used for treatment of depression, and range from 10-300 rag, 150 mg on the average. At the same time, the effectiveness of the use of TA for VC has ranged from 70 to 90%, while the effectiveness of placebo has ranged from 9 to 43%. Treatment with TA has arrested not only spontaneous VC, but also experimental VC induced by the administration of lactate. The principal predictable patterns of the treatment of VC patients with TA have been identified. Thus it has been demonstrated that the crises become more frequent and the symptoms of anxiety increase eight to ten days after the prescription of the preparation; as a rule the latter regress two weeks after the beginning of treatment. The predictability of the appearance of this phenomenon has permitted some investigators [8] to consider it to be a biological marker which makes it possible to predict the future effectiveness of a preparation. In order to ease this critical period, it is recommended that the patient always be warned of the possibility of a worsening of the condition; benzodiazepines can sometimes be added to the treatment during this period, or the dose of TA can be reduced. Most investigators [1, 7, 10] define the third to fourth weeks as the period of the manifestation of the effectiveness of a preparation; the VC are arrested first, and the agoraphobic symptoms and other phobic disturbances are arrested substantially more slowly. In the opinion of many authors [9, 10], therapy should be prolonged from several months up to a year or several years, with the useof maintenance doses after three to four months of a crisis-free course. In the process, the reduction in the dose of the preparation should be very slow (by 25 mg over the course of two to three months). Chlorimipramine (anafranil) is recognized as the most effective of the TA. The effectiveness of small doses (10-50 mg per day) is an advantage of this preparation. It is recommended that therapy be begun with preparations having the least pronounced cholinergic properties (imipramine), and, assuming the absence of an effect, switching to amitryptiline. Despite the considerable experience with the use of TA in VC, imipramine has proven to be the most intensely studied; the characteristics of treatment with amitryptiline have been studied to a substantially lesser extent. An atypical benzodiazepine, clonazepam, was used for the first time in 1983 [4] to arrest VC. Its high affinity for the benzodiazepine receptors (exceeding that of the typical benzodiazepines by a factor of 3) is a specific feature of this preparation. It has been convincingly demonstrated [11] that VC are arrested with the use of clonazepam in 78% of cases. The prolonged half-life (the medication does not have to be taken frequently and there are no rebound phenomena), the clear effect achievable at small doses (1.9 mg per day on the average), and the rapidly commencing therapeutic effect (it becomes clear over the course of the first week whether it makes sense to continue treatment with this preparation) have proven to be advantages of this preparation. Some authors [2, 3], taking account of the rapidly commencing effect with the use of clonazepam, recommend beginning the therapy of VC with clonazepam, and switching to the TA if this ineffective. The duration of Department of the Pathology of the Vegetative Nervous System, TsNIO NICh, I. M. Sechenov Moscow Medical Academy. Translated from Zhurnal Nevropatologii i Psikhiatrii imeni S. S. Korsakova, Vol. 91, No. 5, pp. 3-5, May, 1991. Original article submitted December 10, 1990. 0097-0549/92/2204-0343512.50 e1992 Plenum Publishing Corporation
343
TABLE. 1. Results of the Treatment of VC Patients
Clonazepam (2 rag)
Amitryptiline (75 mg) Treatment method!
number of subjects
action effective abs. ]
Utilization of prepara- 13 tion 19 Placebo method p
10 8
G. M. Dyukova, I. P. Shepeleva, and O. V. Vorob'eva
UDC 616.839-039.31+616.891.6039.31]-085.214.32-036.8
Vegetative crises (VC) have traditionally been regarded as the most dramatic manifestation of the psychovegetative syndrom. In the English-language literature identical states which have been designated as "panic attacks" have been described clinically. In the past decade our notions of the clinical-pathogenetic and therapeutic problems of the VC have undergone substantial changes. Klein, et al. [6] found for the first time in 1962 that the tricyclic antidepressants (TA) possess a specific therapeutic activity in relation to the VC, and, moreover, independent of whether or not they are combined with depression. The effects of various types of antidepressants, the tricyclic (inipramine, desimipramine, clomipramine, amitryptiline, etc.) and MAO inhibitors (phenelzine) have been studied subsequently. The results of treatment with antidepressants have been compared with the results of the use of placebos (the double blind method) and other psychotropic and vegetotropic agents. It has been demonstrated in many studies [2, 5, 12] that the antidepressants surpass both placebos and other psycho- and vegetotropic preparations in effectiveness. It has been found that the doses of antidepressants used for the treatment of VC are lower than those which are used for treatment of depression, and range from 10-300 rag, 150 mg on the average. At the same time, the effectiveness of the use of TA for VC has ranged from 70 to 90%, while the effectiveness of placebo has ranged from 9 to 43%. Treatment with TA has arrested not only spontaneous VC, but also experimental VC induced by the administration of lactate. The principal predictable patterns of the treatment of VC patients with TA have been identified. Thus it has been demonstrated that the crises become more frequent and the symptoms of anxiety increase eight to ten days after the prescription of the preparation; as a rule the latter regress two weeks after the beginning of treatment. The predictability of the appearance of this phenomenon has permitted some investigators [8] to consider it to be a biological marker which makes it possible to predict the future effectiveness of a preparation. In order to ease this critical period, it is recommended that the patient always be warned of the possibility of a worsening of the condition; benzodiazepines can sometimes be added to the treatment during this period, or the dose of TA can be reduced. Most investigators [1, 7, 10] define the third to fourth weeks as the period of the manifestation of the effectiveness of a preparation; the VC are arrested first, and the agoraphobic symptoms and other phobic disturbances are arrested substantially more slowly. In the opinion of many authors [9, 10], therapy should be prolonged from several months up to a year or several years, with the useof maintenance doses after three to four months of a crisis-free course. In the process, the reduction in the dose of the preparation should be very slow (by 25 mg over the course of two to three months). Chlorimipramine (anafranil) is recognized as the most effective of the TA. The effectiveness of small doses (10-50 mg per day) is an advantage of this preparation. It is recommended that therapy be begun with preparations having the least pronounced cholinergic properties (imipramine), and, assuming the absence of an effect, switching to amitryptiline. Despite the considerable experience with the use of TA in VC, imipramine has proven to be the most intensely studied; the characteristics of treatment with amitryptiline have been studied to a substantially lesser extent. An atypical benzodiazepine, clonazepam, was used for the first time in 1983 [4] to arrest VC. Its high affinity for the benzodiazepine receptors (exceeding that of the typical benzodiazepines by a factor of 3) is a specific feature of this preparation. It has been convincingly demonstrated [11] that VC are arrested with the use of clonazepam in 78% of cases. The prolonged half-life (the medication does not have to be taken frequently and there are no rebound phenomena), the clear effect achievable at small doses (1.9 mg per day on the average), and the rapidly commencing therapeutic effect (it becomes clear over the course of the first week whether it makes sense to continue treatment with this preparation) have proven to be advantages of this preparation. Some authors [2, 3], taking account of the rapidly commencing effect with the use of clonazepam, recommend beginning the therapy of VC with clonazepam, and switching to the TA if this ineffective. The duration of Department of the Pathology of the Vegetative Nervous System, TsNIO NICh, I. M. Sechenov Moscow Medical Academy. Translated from Zhurnal Nevropatologii i Psikhiatrii imeni S. S. Korsakova, Vol. 91, No. 5, pp. 3-5, May, 1991. Original article submitted December 10, 1990. 0097-0549/92/2204-0343512.50 e1992 Plenum Publishing Corporation
343
TABLE. 1. Results of the Treatment of VC Patients
Clonazepam (2 rag)
Amitryptiline (75 mg) Treatment method!
number of subjects
action effective abs. ]
Utilization of prepara- 13 tion 19 Placebo method p
10 8
