Review Question - QID 217738

This patient presenting with recurrent episodes of intense discomfort accompanied by palpitations, diaphoresis, chest discomfort, and dyspnea with multiple prior normal ECGs most likely has panic disorder. In a patient with no substance abuse history and with an occupation where sedation may cause safety concerns, a short-acting benzodiazepine is preferred for treating panic disorder.

Panic disorder is characterized by recurrent panic attacks, characterized by episodes of intense fear or discomfort with palpitations, diaphoresis, trembling, chest pain, nausea, dizziness, and/or derealization. Benzodiazepines can be used in the short-term to alleviate symptoms of panic disorder. Benzodiazepines can be broadly classified as short- or long-acting in nature. Short-acting benzodiazepines include alprazolam, oxazepam, and midazolam. Long-acting benzodiazepines include chlordiazepoxide, lorazepam, and diazepam. In patients with occupations where sedation causes a serious safety concern (e.g., truck drivers, heavy machinery operators, construction workers), short-acting benzodiazepines should be used. Long-acting benzodiazepines are commonly used in the treatment of alcohol withdrawal.

Nardi et al. review the use of benzodiazepines for the treatment of panic disorder. They found that benzodiazepines were effective and well-tolerated for this disorder. They recommended that benzodiazepines be considered first-line pharmacotherapy, along with selective serotonin reuptake inhibitors.

Incorrect Answers:
Answer 2: Bupropion is an anti-depressant medication that is used in the treatment of major depression. It is preferred in patients with depression who wish to avoid sexual dysfunction or want to quit tobacco use concurrently. Patients with depression present with depressed mood or anhedonia and at least 4 of the following for at least 2 weeks: sleep disturbances, feelings of guilt or worthlessness, low energy, impaired concentration, appetite changes, psychomotor retardation, or suicidality.

Answer 3: Buspirone is used in the treatment of generalized anxiety disorder as an adjunctive therapy along with selective serotonin reuptake inhibitors. Generalized anxiety disorder presents with excessive worry or anxiety over multiple domains of life on more days than not for at least 6 months and causes functional impairment. Episodic panic attacks are more characteristic of panic disorder.

Answers 4 & 5: Chlordiazepoxide and lorazepam are long-acting benzodiazepines that are also used in the treatment of panic disorder. However, long-acting benzodiazepines are not preferred in patients with occupations in which sedation causes serious safety concerns.

Bullet Summary:
Short-acting benzodiazepines include alprazolam, oxazepam, and midazolam.