A Real Doctor — Like House MD

People who have panic disorder go to doctors to take care of it.  I have had maybe hundreds of patients, more than I can count over my years of practice, who have come to me with this.  Most of them do well. Usually the panic disorder runs its course.

That is not to say that panic disorder is not terrifying.  Often people believe that their first panic attack is a heart attack.  Often they have come to me already addicted to benzodiazepines by emergency room physicians who (understandably) worry a lot more about the immediate comfort of the patient than about the long term situation. Here is the official government take on panic disorder. Yes, find a psychiatrist you can trust. Yes, they recommend family and support groups.  Good stuff, but free and easy to recommend. Yes, there is some exciting new research but as long as insurance companies and HMOs determine how people get treated, it is unlikely that research will be quickly translated into treatment.

Most people who go with the mainstream treatment do pretty well. Here is another description of mainstream treatment, a little more complete.

I live in a different and special place. I am often the physician who “bats cleanup.”  For people whose panic attacks are long gone and who are still using the benzodiazepines routinely, I work on getting people off these drugs, with multiple strategies. Benzodiazepines can keep people depressed and slow reaction time, and in general, addiction to anything is not a really good idea.  As far as I am concerned, the most serious resource on line is the one belonging to Professor Heather Ashton. What is more fascinating to me is the person who falls through the cracks.  The person who is treated, appropriately, for panic disorder. The panic does not get better. I am a great believer in old fashioned clinical medicine.  Asking the patient a lot of questions. Sometimes a panic attack has other symptoms.  Like rage or anger or raised blood pressure.  But these are not clear differentiators between what is a panic attack and what is not.

I am the one who finds the rare diseases nobody else thinks of.  I started long ago, when I was a fellow in a university. A young man, who wanted to play football, had panic and rage and the regular stuff did not work. He was in college, second year, majoring in history, and he was paralyzed by his attacks. His once excellent grades were plummeting. He would run from his lecture halls from shame.  He had angry attacks that had alienated his friends, so this once gregarious young man had become a loner.  On top of this, he had some native American blood in him, not unusual in the part of the country where I was.  Nobody in his family had ever gotten as far as him in his formal education.  There was a lot of family pride riding on him, and there would be a lot of disappointment if he failed. There is a rare tumor, called a pheochromocytoma.  It is essentially benign, but don’t get too comfortable with that designation because it is possible to get sick or even die from the side effects of a benign tumor.  It secretes, episodically, adrenaline and related molecules. This causes symptoms that sound an awful lot like panic attacks, but with more “vasomotor” signs; high blood pressure and flushing and such.  Since nobody seems to be around who can observe these things, history is not reliable for diagnosis, and we can do better.

There is a simple screen for this admittedly rare condition.  I have done many times what I did then.  Ordered a urine screen for mandelic acid and vanilla mandelic acid, breakdown products of adrenaline and noradrenaline.

He had a very high amount of these compounds in his urine.  It was not too hard to find his pheochromocytoma, which was in the most common location for such things to occur, the area of the appendix. The young man who wanted to play football  was heading back to his college team. Last time I saw him he was post-operative and free of attacks.

Since then, I have ordered this urine test many times and not found another pheochromocytoma.  I have taken care of plenty of people who did not respond to regular treatment for panic attacks.  I have found a variety of conditions, ranging from an overactive nodule (cellular unit) in the thyroid to an excessive use of coffee.

This is my fascination; the patient who does not respond to the common, mainstream treatment. This is why some colleagues say I am like “House” on TV but without the addiction and the personality disorder. House is important.  Important enough that the National Cancer Institute records every time that he discusses any form of tumor on his show, episode number and clinically relevant details. There is a real social need for medical shows. People want to know things, maybe to think that they know what doctors know.  Maybe this is simply the most effective way to circulate knowledge about rare illnesses.

The important thing to me is that overworked doctors pressed for time will go for the mainstream and common diagnosis and treatment.  They may not have the time or resources, let alone the creativity, to go for the solution for the patient who does not respond. This,  is my passion.