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08 Feb 2012
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Panic Attacks: Symptoms and Therapy

If you get panic attacks, you’re not alone. Research has found that more than three million Americans will experience panic disorder during their lifetime. According to the American Academy of Child and Adolescent Psychiatry, panic disorder can begin during childhood or before age 25. And  research suggests that panic disorder is more prevalent in women than in men.

While it is not clear what causes the disorder, researchers believe it is inherited and runs in families. At one time, researchers believed panic disorder was caused by psychological problems, but experts now believe genetic factors or changes in body chemistry, combined with stressful circumstances, play a pivotal role. According to the American Psychological Association, even though each panic attack peaks within about 10 minutes, sometimes attacks repeat in clusters for up to an hour after the initial attack, with associated fear over the possibility of another attack. Subsequent attacks may occur days and even weeks later.

This element of fearfulness is called anticipatory anxiety. People fear having another attack while performing the same activity or being in the same situation as when a panic attack occurred before. Anticipatory anxiety can be so extreme that people turn away from the outside world, fearing that contact will brook  new attacks. For example, if an attack occurred while driving on the freeway, a person may be so afraid of driving on the highway that he’ll only drive on secondary roads. Also, if someone experienced a panic attack while walking through the mall, they’ll avoid this activity for fear of another attack. According to the National Institute of Mental Health (NIMH), panic disorder can also occur in conjunction with other disorders, particularly depression and substance abuse. About 30 percent of people with panic disorder abuse alcohol and 17 percent abuse drugs. However, substance abuse can also be an attempt to alleviate the anguish and distress caused by panic attacks. NIMH-funded research has resulted in effective treatments to help people with panic disorder, which includes medication and cognitive-behavioral psychotherapy. This type of therapy can reduce or prevent attacks in 70 to 90 percent of people with panic disorder.

Symptoms of Panic Disorder

While there are more than a dozen physical or emotional sensations a person can experience during a panic attack, not everyone experiences all of them. And even though it is not technically life-threatening, left untreated, panic disorder can interfere with relationships, schoolwork, employment and normal development.

It is not uncommon for a person with panic disorder to experience an anxious feeling even between attacks. People with panic disorder will begin to avoid situations where they fear an attack may occur or situations where help might not be available. The Anxiety Disorders Association of America has formulated questions to help an individual determine whether he’s experiencing panic disorder. These include:

1.  Are you troubled by repeated and unexpected “attacks” of intense fear or discomfort for no apparent reason?

2.  During such attacks, do you experience at least four of the following symptoms?

  • pounding heart
  • sweating
  • trembling or shaking
  • shortness of breath
  • choking
  • chest pain
  • nausea or abdominal discomfort
  • “jelly” legs
  • dizziness
  • a feeling of unreality or being detached from yourself
  • fear of losing control
  • going crazy
  • fear of dying
  • numbness or tingling sensations or chills or hot flashes

3.  Do you have a fear of places or situations where escape or getting help might be difficult, such as a crowded room or traffic jam?

4.  Do you have a fear of being unable to travel without a companion?

5.  For at least one month following an attack, have you felt persistent?

  • Concern about having another attack?
  • Worry about going crazy?
  • Need to change your behavior to accommodate the attack?

While anxiety, worry, and stress are all a part of most people’s life today, anxiety becomes a disorder when the symptoms become chronic and interfere with our daily lives and our ability to function.

 

Source: Psych Central

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08 Feb 2012
Articles • Depression • Individual Therapy • Medication

What You Need to Know About Treatment-Resistant Depression

This article deals mainly with use of medication and other physcian-administered treatments for Depression.  I am concerned with the number of patients I see for intakes/evaluations who have never been referred for psychotherapy/counseling.  ‘Talk therapy’ has been shown to be quite beneficial for many patients with depression.  The key is finding the right combination of treatments to help each patient.  – Molly Allen, PsyD, Licensed Psychologist

What You Need to Know About Treatment-Resistant Depression Depression can be effectively treated with psychotherapy and medication. But it takes time to find the correct medication and dose. Still, for about one million patients with depression, even several trials of medication don’t seem to be enough, and their symptoms linger.

These individuals may have treatment-resistant depression or refractory depression. While there’s some debate over the precise definition, treatment-resistant depression is typically thought of as failing to achieve remission after two treatments or two antidepressants, according to George Papakostas, M.D., director of Treatment-Resistant Depression Studies in the Department of Psychiatry at Massachusetts General Hospital.

Why Some People Have Treatment-Resistant Depression

People develop treatment-resistant depression for many reasons. Some struggle with severe depression, which is difficult to treat. Medical illness and comorbid psychological disorders — such as drug or alcohol abuse or eating disorders — also complicate treatment response, according to Dr. Papakostas and Yvette Sheline, M.D., professor of psychiatry and the director for the Center for Depression Stress & Neuroimaging
 at the Washington University in St. Louis. Severe stress also can impact improvement, Dr. Sheline said.

A variety of genetic, neuroimaging and electrophysiological studies have investigated the underlying causes of treatment-resistant depression. And researchers know one thing for sure: Refractory depression is not the result of one brain region or neurotransmitter system.

Preliminary research suggests that individuals with depression may have abnormalities in the frontal and temporal regions in the brain and dysfunction in serotonin modulation. Also, the subgenual cingulate (Cg25), which is located under the cortex along the midline of the brain, may play a role. Cg25 is activated when an individual experiences sadness. It also connects to other regions involved in mood, motivation and sleep. When antidepressants are effective, this area is less active. Some researchers have hypothesized that in refractory depression, Cg25 doesn’t turn off. In general, according to Papakostas, there isn’t enough evidence to show a consistent or unifying theory.

Other individuals may not have refractory depression after all. For instance, according to Sheline, a thyroid problem may mimic depression. Individuals may have bipolar disorder — though there’s recent evidence that bipolar disorder may be overdiagnosed in patients who appear to have treatment-resistant depression — or a long-term low-grade depression called dysthymia. If a treatment isn’t working, it’s critical that your physician re-evaluate your diagnosis.

Treatment Options for Refractory Depression

According to Sheline, there’s disagreement about the number of medication trials a person needs to try before moving onto more invasive interventions. While physicians determine this on an individual basis, it’s important for patients to have an adequate dose of medication for an adequate amount of time, Sheline said. “Each antidepressant has different therapeutic dose ranges, and these also vary according to individual factors, such as age,” she said.  An adequate duration of treatment is usually six weeks. If there’s partial improvement, doctors may recommend patients stay on the medication for six to 12 weeks, Papakostas said.

This is why it’s especially important to take medication as prescribed. Many patients stop taking their medication after a week if they don’t get better, Sheline said. But this isn’t enough time to see improvement. Skipping or forgetting a dose can decrease a medication’s efficacy and make it look like it’s not the right medication for you. Also critical is practicing healthy habits, such as engaging in physical activities and getting enough sleep, and managing stress. Exercise boosts mood, while stress and lack of sleep exacerbate depression.

If one antidepressant truly doesn’t work, physicians will typically prescribe an antidepressant from a different drug class. Or they’ll prescribe an augmenting agent, such as lithium or an atypical antipsychotic medication to boost the effectiveness of the antidepressant.

If medication and psychotherapy are unsuccessful, these are other options:

Electroconvulsive therapy (ECT). ECT involves placing electrodes on a patient’s scalp, which sends a specific current that induces a short seizure in the brain. In the 1950s, ECT developed a bad reputation because it was administered without anesthesia and with a high voltage, Sheline said. But today, it’s a completely different treatment, she said.

ECT is administered with general anesthesia and the voltage is carefully controlled. In fact, Sheline noted that there is ongoing work to decrease the pulses to minimize side effects. There’s also been concern that ECT is involuntary, Papakostas said. He clarified that ECT is voluntary and requires a patient’s informed consent.

ECT does have various bothersome side effects, including memory loss and headaches. It’s understandable why patients would hesitate to try it, Papakostas said. However, both Papakostas and Sheline agree that a large body of research substantiates ECT’s efficacy. When compared with medication and psychotherapy, ECT appears to work faster and has a higher chance of success, according to Papakostas. It also has the most efficacy data of all the more invasive interventions.

Transcranial magnetic stimulation (rTMS). According to Papakostas, this treatment is second to ECT in quality of data. Transcranial magnetic stimulation doesn’t require anesthesia or induce a seizure like ECT. Instead it creates a magnetic field that produces an electric current in a specific area of the brain. It’s typically used for mild to moderate depression. The Food and Drug Administration has approved one device called the NeuroStar TMS to treat depression, which may be used after one antidepressant has failed.

Vagus nerve stimulation (VNS). In 2005, the FDA approved vagus nerve stimulation for treating treatment-resistant depression. The device is surgically implanted onto the vagus nerve on the left side of the neck and delivers mild electrical impulses. Think of it as a cardiac pacemaker. According to the University of Maryland Medical Center, it sends 30-second impulses to the vagus nerve every five minutes.

For over a decade, VNS has been used to treat patients with epilepsy. Researchers began studying VNS for refractory depression when they noticed that some patients’ moods improved. Whether VNS is an effective treatment for refractory depression is unclear. It appears to help some people tremendously but not others. To date, “the data [on VNS] just isn’t on par with ECT or rTMS,” Papakostas said.

Not finding a treatment that lifts your depression can be utterly frustrating and make you feel hopeless. But while it may take more time and effort, together with your physician, you can find a treatment that works for you. Remaining optimistic is important. “Being able to maintain a positive, hopeful attitude is as critical as [getting the right treatment], Papakostas said.

Margarita Tartakovsky, M.S. is an Associate Editor at Psych Central and blogs regularly about eating and self-image issues on her own blog, Weightless.
APA Reference Tartakovsky, M.  (2012). What You Need to Know About Treatment-Resistant Depression. Psych Central.  Retrieved on February 8, 2012, from http://psychcentral.com/lib/2012/what-you-need-to-know-about-treatment-resistant-depression/