Healthcare and Medicine Reference
In-Depth Information
controls, 37 and pentagastrin administered during sleep
resulted in abrupt awakenings accompanied by panic
symptoms in patients with panic disorder. 38 These findings
have been upheld as evidence for a physiologic explanation
for nocturnal panic, because during sleep the influence of
cognitive factors is purportedly minimal or absent.
However, several studies suggest that cognitive factors
also play a role. In an investigation employing caffeine
administration during sleep, more fully elaborated panic
attacks were preceded by a period of lighter sleep before
awakening, providing support for a mixture of physiologic
and cognitive influences on sleep panic. 39 In another study,
participants with recurrent nocturnal panic attacks who
were primed to expect intense physiologic changes during
sleep (as indicated by an auditory signal) were less likely to
awaken with panic symptoms than those for whom such a
signal was unexpected, highlighting a role for presleep
attributions. 40
Physiologic differences in those with nocturnal panic
have also been found to normalize with cognitive behavior
therapy (CBT). 41 Based on this evidence, it has been argued
that although physiologic differences exist for those with
nocturnal panic, they should be seen as a function of panic
disorder psychopathology rather than as an explanatory
mechanism. 33
controlled-release paroxetine, which are approved by the
U.S. Food and Drug Administration (FDA) for this
purpose. The SSRIs have been found to be effective in the
treatment of panic disorder (with or without agoraphobia).
High-potency benzodiazepines (alprazolam, extended-
release alprazolam, and clonazepam are approved by the
FDA for this purpose) have also been widely used to treat
panic disorder (with or without agoraphobia). Some medi-
cations (e.g., propranolol, buspirone) used often in the
management of other forms of anxiety have been shown
to be ineffective in the treatment of panic disorder. 42 , 43
Although there has been little pharmacologic research on
the treatment of sleep disturbances associated with panic
disorder, preliminary observations suggest that sleep
panic attacks are responsive to antidepressant antipanic
medications. 44 , 45
Research has shown CBT to be at least as beneficial as
first-line drug treatments. 46 CBT involves challenging
irrational thoughts about panic symptoms and their con-
sequences, the elimination of avoidance behavior, and
gradual exposure to feared interoceptive sensations and
agoraphobic situations. CBT also has the benefit of yield-
ing long-lasting effects. 46 It is unclear whether standard
CBT for panic disorder is beneficial in improving sleep,
although one study suggests that combined pharmacologic
treatment and CBT was insufficient in eliminating objec-
tive and self-reported sleep disturbances. 19 One CBT study
included modifications targeted to nocturnal panic, such
as psychoeducation about normal physiologic changes
during sleep, challenging of catastrophic thoughts about
nocturnal panic, interoceptive exposure to relaxation con-
ditions, and sleep hygiene. 41 Compared to waitlist controls,
participants who received this intervention fared better on
measures of physiologic and self-reported anxiety and
sleep quality, including nocturnal panic specifically. There
is otherwise little information to guide the specific treat-
ment of patients with panic disorder who have nocturnal
panic attacks; this remains an area ripe for further research.
In the absence of empirical data in this regard, it is rec-
ommended that patients with significant sleep disturbance
including nocturnal panic attacks be treated with an anti-
panic agent or with CBT and that they be instructed on
the implementation of good sleep hygiene measures (see
Chapters 79 and 80).
Treatment
The aim of drug treatment is to block panic attacks (waking
and nocturnal panic attacks) and to eliminate secondary
fears and avoidance activities (e.g., sleep phobias). The
removal of exogenous (e.g., caffeine) factors or the correc-
tion of maladaptive behavior (e.g., sleep deprivation) that
often exacerbate panic disorder should also be an integral
part of the drug treatment program. If a thorough medical
assessment has not recently been performed, this should
be conducted (including, routinely, thyroid-stimulating
hormone measurement to rule out most thyroid problems)
before proceeding with antipanic treatments.
Historically, tricyclic antidepressants (e.g., imipramine)
and monoamine oxidase inhibitors (e.g., phenelzine) were
mainstays in the treatment of panic disorder. For reasons
of tolerability and safety, these have been largely sup-
planted by the selective serotonin reuptake inhibitors
(SSRIs), such as fluoxetine, sertraline, paroxetine, and
Case Study: Sleep Panic
Ms. R. is a 28-year-old woman with a 2- to 3-month
history of onset of episodes during sleep where she
awakes abruptly with a feeling of fear and shortness
of breath. She is also aware of tachycardia at the time
of awakening. She otherwise feels intensely alert, with
no sense of confusion and no dream recall on awaken-
ing. She and her significant other deny somnambulism.
After experiencing an episode, she typically gets out of
bed and has great difficulty going back to sleep. She
also reports increasing worries and avoidance about
going to sleep.
The patient reports that she has been experiencing
somewhat similar attacks during the daytime on an
occasional basis since the age of 17 years. She reports
having experienced these episodes—which feature
shortness of breath, tremulousness, tachycardia, and
dizziness—several times weekly from 17 to 20 years of
age; during this period, she sought care in the emer-
gency department and had multiple medical tests to
rule out a seizure disorder or a vestibular disorder.
The attacks eventually waned, although she admits to
experiencing lesser forms of these attacks once or
twice monthly from age 20 years through to the time
of her presentation. She states that she had learned
that these attacks, although bothersome, were not
dangerous, and she was able to function well despite
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