EXPANDING MULTIPLE SCLEROSIS EXPERTISE IN LANCASTER

Neha V. Safi, MD, MS

Resources

Ornish D., Schewitz L., Billings, J.H> et al. Intensive lifestyle changes for reversal of coronary heart disease, JAMA 1998: 280(23): 2001-2007.

Hambrecht R., Walter C., Mobius-Winkler S., et al. Percutaneous coronary angioplasty compared with exercise training in patients with stable coronary artery disease: a randomized trial. Circulation. 2004;109(11):1371-1378.

Ornish D., Magbauna M.J.M>, Weidner G., et al. Changes in prostate gene expression in men undergoing an intensive nutrition and lifestyle intervention. Proc NATL Acad Sci USA. 2008;105(24):8369-8374.

www.NEJM.org/doi/full/10.1056/NEJMoa012512 pubmed.mcbi.nim.nih.gov/21102320

Rejeski, JJ, Fanning, J., B.J. et al Six-month changes in ghrelin and GLP-1 with weight loss. International Journal of Obesity. 45,888-894 (2021)

You T. Ogawa E. Effects of meditation and mind body exercise on brain-derived neurotrophic factor. Sports Medicine and Health Science Vol2, Issue 1, March 202, 7-9.

Knaeppen K. Goekint, M., Heyman, EM et al. Neuroplasticity – Exercise-Induced Response of Peripheral Brain-Derived Neurotrophic Factor. Sports Med 40, 765-801(2010)

We are proud to welcome neurologist Neha V. Safi, MD, MS to our Neuroscience Institute team. Dr. Safi specializes in multiple sclerosis (MS) treatment.

Training:

• Fellowship: Multiple Sclerosis, Corinne Goldsmith Dickinson Center for Multiple Sclerosis at Mount Sinai

Areas of Expertise:

• Multiple Sclerosis (MS)

• Myelin Oligodendrocyte Glycoprotein AntibodyAssociated Disease (MOGAD)

• Neuromyelitis Optica Spectrum Disorder (NMO or NMOSD)

• Residency: Neurology, NewYork-Presbyterian/ Weill Cornell Medical Center

• Abnormal Reflexes

• Arm or Leg Weakness

• Optic Neuritis

• Sensory Impairment

• Transverse Myelitis

• Trigeminal Neuralgia

• Unsteady Gait

Dr. Safi is part of LG Health Physicians Neurology and sees patients in Lancaster. To refer a patient, please call 717-396-9167.

Neuroscience Institute

EMMA BATCHELDER, MD Resident, Penn State Health Milton S. Hershey Medical Center

Picture this…you’re driving around town on your typical route during your day off. Overall, you’re feeling pretty good. Suddenly, out of nowhere, your heart starts pounding and you break into a sweat. You can’t breathe and your head is spinning. You feel dizzy and nauseous. You wonder, “Is this a heart attack? Am I dying?” It almost feels like you aren’t even present in your own body. Maybe you pull over and take some deep breaths until the feeling passes and you can safely drive home. Maybe you head to the emergency department, where medical evaluation, including blood work and cardiorespiratory workup, is largely unrevealing. You are told that you had a panic attack, and a short while later, perhaps after being treated with a benzodiazepine, you feel back to baseline. Does this story sound familiar? If it does, you’re not alone. Panic disorder is a common psychiatric illness affecting up to 5 percent of people at some point during their lifetime [1] and contributes significantly to health care cost and burden of disease [2] while greatly impacting a patient’s quality of life.

A panic attack, as defined by the Diagnostic and Statistical Manual of Mental Disorders, is an “abrupt surge of intense fear or intense discomfort that reaches a peak within minutes” and includes at least four of the following symptoms:

• Palpitations, pounding heart, or accelerated heart rate

• Sweating, trembling, or shaking

• Shortness of breath or the sensation of smothering

• The sensation of choking

• Chest pain

• Nausea or abdominal distress

• Feeling dizzy, lightheaded, unsteady, or faint

• Chills or feeling overheated

• Paresthesia

• Derealization or depersonalization

• Fear of losing control

• Fear of dying [3]

Patients often describe feeling a “sense of doom.” Some patients feel as if they are going to die and may present to the emergency department for evaluation of symptoms that may be concerning for a heart attack or other life-threatening medical event. Panic disorder is characterized by recurrent, unexpected panic attacks with at least one panic attack followed by at least one month of consistent worry or concern about additional panic attacks or their consequences and/or significant maladaptive changes in behavior related to the panic attacks [3]. Not all panic attacks are suggestive of panic disorder. Panic attacks can also occur in the context of other anxiety, mood, psychotic, substance use, and trauma-related disorders. Similar symptoms can also occur in patients with specific or social phobias when exposed to a feared stimulus; however, in patients with panic disorder, the symptoms are unprovoked and come on suddenly [1].

The etiology of panic disorder has been described in several different models. Models point toward abnormalities in neurotransmitters including gamma-aminobutyric acid (GABA), cortisol, and serotonin, as well as differences in neural circuity, and genetic, epigenetic, and environmental factors [5]. Adverse childhood experiences have been found to contribute to the development of panic disorder. A recent study has shown that patients with panic disorder may have hypermethylation of the IL-4 gene, and in patients with panic disorder, childhood trauma is associated with higher IL-4 methylation [4].

The course of panic disorder may be unpredictable, with patients experiencing fluctuating symptoms over time. The two mainstays in the treatment of panic attacks and panic disorder are psychotherapeutic and psychopharmacological interventions. In panic disorder, psychotherapy-based intervention often consists of cognitive behavioral therapy (CBT) or other therapy modalities, as well as mindfulness-based strategies. Many patients find benefit in relaxation techniques and breathing retraining. Panic disorder can also be treated pharmacologically with antidepressants, particularly selective serotonin reuptake inhibitors (SSRIs), which are first-line treatments, and benzodiazepines. Benzodiazepines may be used when symptoms are severe or if patients require symptomatic relief while waiting for antidepressant medications to take effect; however, given the side effect profile, addictive potential, and dangerous withdrawal syndrome associated with these medications, caution should be exercised when initiating and tapering benzodiazepines. The goal of pharmacologic treatment is to prevent panic attacks; lessen or eliminate associated anticipatory anxiety, avoidance, or other maladaptive behaviors; and to treat symptoms of comorbid conditions, such as other anxiety disorders, mood disorders, substance use disorders, or trauma-related disorders [1,5].

Overall, prognosis is individualized and can be unpredictable, with approximately 60 percent of patients experiencing remission of symptoms within six months. Pharmacotherapy and CBT are effective in approximately 80 percent of patients; however, relapses are common. Often, medication non-adherence can present challenges in terms of symptomatic control and lead to symptom recurrence. Various psychosocial stressors may also contribute to relapse of symptoms. There are several factors that may be associated with poor outcomes, including having a chronic illness; low socioeconomic status; living alone; single marital status; and some personality traits, such as high interpersonal sensitivity and neuroticism. Panic disorder is also associated with development of cardiac disease; patients with panic disorder are at a higher risk of developing coronary artery disease and have an elevated risk of sudden death compared to the general population. Furthermore, patients with panic disorder are at a higher risk of experiencing suicidal ideation [5].

Panic disorder can greatly impact a patient’s health, quality of life, and overall functioning. As such, it is of high importance to identify panic disorder early in the illness course, educate patients on treatment options (both psychotherapy and pharmacologic interventions), encourage medication adherence, and conduct frequent screenings for suicidal ideation.

Resources

1. Roy-Byrne, P. P., Craske, M. G., & Stein, M. B. (2006). Panic disorder. Lancet (London, England), 368(9540), 1023–1032. https://doi-org.ezaccess.libraries.psu.edu/10.1016/S0140-6736(06)69418-X

2. Deacon, B., Lickel, J., & Abramowitz, J. S. (2008). Medical utilization across the anxiety disorders. Journal of anxiety disorders, 22(2), 344–350. https://doi-org.ezaccess.libraries.psu.edu/10.1016/j. janxdis.2007.03.004

3. Association, A. P. (2022). DSM-5-TR(tm) Classification. American Psychiatric Publishing

4. Zou, Z., Huang, Y., Wang, J., Min, W., & Zhou, B. (2020). DNA methylation of IL-4 gene and the association with childhood trauma in panic disorder. Psychiatry research, 293, 113385. https://doi. org/10.1016/j.psychres.2020.113385

5 .Cackovic, C., Nazir, S., & Marwaha, R. (2022). Panic Disorder. In StatPearls. StatPearls Publishing.