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"FEAR EAT SOUL ON" -
MEDICINES AGAINST ANY EMERGENCY AND PANIC ATTACKS

Fear can be understood as an inappropriate emotional response that is inappropriate to the threat. Every state of anxiety is associated with expressive phenomena of facial expressions and gestures as well as with adrenergic symptoms. Often there is a vicious circle between the vegetative disorders and fear. Fear should differ from fear in that it is object-related and adapted to the size of the threatening danger, so that those affected can counter the threat through sensible action. Subjectively, however, fear is felt in a similar way to fear.

Our lives are often shaped by fear. Real fear, the feeling of an indefinite or meaningless threat, can be experienced by everyone in external stressful situations or serious illnesses. This "normal fear" only needs treatment if it is felt to be unbearable or if it lasts for a disproportionately long time. Every year in the USA 5% of the population (= 12 million people) experience fear as so unbearable that they seek treatment.1 Practical advice for managing anxiety and emotional distress1-4 we gave ten years ago (cf. a-t 12 [1980], 96).

For short-term damping of Anxiety Benzodiazepines are still the drug of choice. Diazepam (VALIUM and others), chlordiazepoxide (LIBRIUM and others), chlorazepate (TRANXILIUM and others), lorazepam (TAVOR and others) and oxazepam (ADUMBRAN and others) have proven themselves. The sedatives mentioned have the same clinical effect in principle, even if there are differences in the pharmacokinetics (cf. a-t 11 [1984], 87; 10 [1988], 87). Older people should receive shorter-acting substances with no cumulative active metabolites, such as oxazepam or lorazepam.

Buspirone (BESPAR) has been available since 1985 as an anti-anxiety agent that does not come from the benzodiazepine series (cf. a-t 5 [1985], 35). It is not sedating. Because of the lack of addiction potential, it is recommended for the treatment of chronic anxiety, especially in elderly patients. However, it does not appear to have such pronounced anti-anxiety effects. In terms of action, it is more like neuroleptics. As a disguised neuroleptic, disorders of dopamine-dependent neurological functions are possible - for example akathisia or dystonia (cf. a-t 2 [1988], 22). The desired effect sets in after one to two weeks. Patients treated with a benzodiazepine derivative may respond less well to buspirone. When changing to this drug, the benzodiazepine dose should be slowly withdrawn beforehand. Overall, the therapeutic benefit of buspirone appears questionable.7

Arousal states associated with physical discomfort, especially on the part of the autonomic nervous system, can turn into sudden extreme feelings of fear. In the state of such Panic attacks the patient sees himself in a hopeless situation up to the point of fear of death. Physical abnormal sensations such as oppression, shortness of breath, heart sensations, sweating or chills, tremors, the feeling of soft knees, drop in blood pressure, the urge to urinate or other physical symptoms determine the clinical picture. At least four of these symptoms are required to diagnose a panic attack. Those affected are at great risk of suicide. Panic episodes can recur. They are unpredictable.5

Tricyclic antidepressants such as imipramine (TOFRANIL) or monoamine oxidase inhibitors such as phenelzine (NARDIL [Great Britain; not commercially available in this country]) are recommended for the prophylaxis of such panic attacks (cf. a-t 3 [1989], 30). Low initial doses of 10-25 mg imipramine are slowly increased. Many patients need 150-300 mg daily. The effect starts after two weeks at the earliest. The full effect takes up to six weeks. Although phenelzine (45-90 mg / day) is best studied, other MAOIs, such as tranylcypromine (PARNATE), also appear to be of benefit. Because of the risk of a sometimes dangerous rise in blood pressure, foods rich in tyramine such as red wine, beer, fermented sausages or cheeses or soy products should be avoided (cf. a-t 3 [1989], 30).

Alprazolam (TAFIL) in higher doses is the only drug that has been approved by the American FDA to prevent such excitement. Panic attacks respond to 2 - 3 mg alprazolam / day within a week. If you are claustrophobic, up to 6 mg per day may be required. The daily dose is to be divided into several individual doses. In order to avoid seizures upon abrupt discontinuation, the benzodiazepine should be tapered by 0.25 mg daily.1

That other benzodiazepines are also effective in treating panic attacks is plausible, but not adequately researched. Like all benzodiazepines, alprazolam leads to physical dependence. However, panic patients often need long-term treatment. The British Committee on Safety of Medicines advises avoiding benzodiazepines for the treatment of depression or phobias. Behavioral therapies have shown success in panic attacks and phobias that can last years after treatment is complete.

If you don't feel comfortable in company, then social phobias developed, e.g. if he has to give a lecture or take part in public events that involve eating and drinking, can do this more easily in individual cases if he takes a benzodiazepine or a monoamine oxidase inhibitor beforehand. The routine medication is dangerous and should be refused.

With the term "Stage Fright" describe other sensations that are also associated with physical symptoms of anxiety such as tremor. Propranolol (DOCITON et al.) And other beta-blockers can be taken in low doses to alleviate such symptoms (cf. a-t 1 [1977], 90). However, they only have a minor influence on the more emotional complaints.

Of course, the prescription of psychotropic drugs for such exceptional conditions must be one Risk-benefit assessment precede. Sedation that is too intense with benzodiazepines can be particularly difficult for older people - for example, through impaired coordination. Anterograde amnesia - it is no longer possible to remember what happened after taking the drug (so-called film breakage) - is a not uncommon complication of benzodiazepine consumption and a frequent complication with alcohol consumption. Paradoxical reactions such as aggressive behavior or depression also occur. After reports of non-personality acts under the influence of benzodiazepines, e.g. robbery after flunitrazepam (ROHYPNOL) became known in both the Netherlands and Germany (NETZWERK case 4850, see page 71), Hoffmann-La Roche wants information for all age groups in the Include the instruction leaflet.6

While benzodiazepines used to be considered harmless with regard to permanent consequences even in overdoses, it is now recognized that benzodiazepine overdoses can have life-threatening consequences, especially if they are taken together with alcohol, barbiturates, opiates and other centrally active drugs. Patients with disorders of the respiratory function generally have to forego agents that dampen the central nervous system.

It should be noted that benzodiazepines can lead to dependency and abuse if they are used indiscriminately over a long period of time. Sudden withdrawal from such agents can cause insomnia, nausea, vomiting, convulsions, sweating, increased irritability, paresthesia, and other physical disorders. Withdrawal is easier with long-acting benzodiazepines than with short-acting derivatives such as Lorazepam (TAVOR). We have reported several times (most recently in Issue 2 [1989], 24).

CONCLUSION: In the treatment of anxiety and tension states, the therapist is often under situation pressure, so that the acute dampening of arousal with benzodiazepines or antidepressants is in the foreground. Only then can behavioral and psychotherapeutic influencing as well as the search for the "fear focus" be tackled. The patient can learn behavioral techniques to ward off and reduce anxiety. If psychotropic drugs are used too early or without criticism, the patient is deprived of psychotherapeutic options that have a more specific effect and can offer longer-lasting success.

In urgent cases and emergencies, the short-term administration of medication is indispensable and justified, whereas long-term treatment with dependency-inducing substances requires an intensive risk-benefit analysis.