Taylor Hughes

N627
2/27/2014
Case 133: Panic Attacks

G.G. is a 35-year-old male who presents to the ED with complaints of
difficulty breathing, chest pain and tightness, dizziness, palpitations, nausea,
paresthesia, and feelings of impending doom. He is diaphoretic, trembling, and
having trouble thinking clearly. This all started about 40 minutes ago during a work
meeting and has progressively gotten worse. G.G. admits to having 3 similar
episodes in the past 2 weeks, none were as severe or long as this one. G.G. also
informs the staff that he has been under severe stress at work and at home. He is
going through a divorce, he lost his child last summer in a MVA, and his company is
downsizing.
The initial step to take with a patient who presents these symptoms is to
remain calm. As the nurse in this situation it is important to rule out any situations
that could be detrimental, such as a heart attack or pulmonary emboli. The first step
would be to apply oxygen to help the patient breathe easier and hopefully promote
relaxation. This has more of a placebo effect, especially if the patient is not having a
heart attack. The next step would be to get an EKG to rule out a heart attack. If a
heart attack is ruled out, the nurse may get orders for other tests. A chest x-ray may
be ordered to rule out a pulmonary emboli or blood work may be drawn to look at
cardiac enzymes, which will tell if muscle damage has occurred.
Once a full medical work up is completed and everything physical has
checked out to be fine it is important to get to the underlying cause. It was
determined that G.G. was having a panic attack. This was determined by the DMS IV
definition of panic attacks. A discrete period of intense fear or discomfort, starting
abruptly and reaching a peak within 10 minutes. May experience symptoms of
palpitations, sweating, shaking or trembling, chest pain/discomfort, nausea,
abdominal distress, dizziness, faintness, feeling unreal or detached from oneself,
fear or going crazy or losing control, fear of dying, parethesias, chills or hot flashes,
and sensation of shortness of breathing or smothering (Varcarolis, 2011 p. 110).
The admitting doctor ruled out everything physical which lead him to believe that
there was something psychologically wrong. According to the DSM IV a patient
needs four or more symptoms from the above list to receive this diagnosis
(Mathyssek, 2012, p.1). G.G. had seven of the symptoms necessary to diagnose a
person with panic attacks.
One symptom G.G. is particularly concerned with is his difficultly
remembering information. When a person is under severe stress it causes an
increased production of glucocorticoids. If a person remains under stress for a
period of time the glucocorticoids can cause structural damage to the hippocampus,
which is responsible for memory (Peavy, 2009). G.G. had admitted to being under
stress for a while now, which could have lead to some hippocampus damage and
ultimately to why he is having trouble with his memory.
G.G. is curious as to what caused him to have these panic attacks. As a nurse it
is important to explain the different risk factors and triggers that made him more
susceptible to panic attacks. It may also be pertinent to explain the different
neurotransmitters and hormones that could be off balance because it could help him
understand why he will take certain medications.
Aside from losing his child, going through a divorce, and having his job
threatened there are multiple other triggers that could have lead to his panic attack.
For example, a history of childhood abuse, experiencing a traumatic event, financial
difficulties, significant stress from school or work, or taking on an additional role
that was not planned represent possible triggers. There are many more things that
can trigger a panic attack and it is all patient dependent. What effects one person
lightly may effect another person drastically. There are certain risk factors that put a
person at a higher risk for developing panic attacks. For instance, women are at a
higher risk of developing panic attacks than men. Also, people in their late teens to
early adulthood are at greater risk (Mayo Clinic, 2012).
Genetics and brain function can also play a role in the development of panic
attacks. There are many neurotransmitters and hormones that can be off balance,
leading to panic attacks. A few neurotransmitters include GABA, which promotes
relaxation and decreases brain activity, serotonin, which contributes to feelings of
well being and happiness, and norepinephrine, which is responsible for the fight or
flight response. Different hormones can also lead to panic attacks such as adrenaline
or epinephrine, both are responsible for the fight or flight response. It is also
believed that the thyroid, which produces a multitude of hormones, is responsible
for regulating GABA, serotonin, and norepinephrine. If the thyroid is not working
properly it can lead to imbalances of these neurotransmitters. An over active
amygdala can lead to panic attacks as well. The amygdala is responsible for
processing emotions and if it is not working properly the body does not have the
right amount of time to process emotions (Calm Clinic, 2009). With panic attacks
one or more of these issues could be happening simultaneously. Along with the
different risk factors and imbalances, all of these things contribute to the onset of
panic attacks.
G.G. wants to know what the difference is between panic attacks and panic
disorder. According to the DSM IV panic attacks are when a person has intense
fear/discomfort for a period of time and exhibits four or more of the symptoms
listed earlier in the paper such as palpitations, sweating, dizziness, or chest pain
(Mathyssek, 2012, p.1). This differs from panic disorder because with panic disorder
there are reoccurring episodes of panic attacks. Also at least one of the attacks has
to be followed by a months worth of persistent concern of having another attacks or
worrying about certain consequences such as going crazy. Sometimes with panic
disorder a person can develop agoraphobia, the fear of being in an open or public
place (Varcarolis, 2011 p. 111). This can be very crippling for a person and does not
allow this person to live a good quality life. They are afraid to leave their own
homes, which can lead to noncompliance with treatment.
Panic disorder, with or without agoraphobia, can develop in a person who
does not seek treatment for reoccurring panic attacks. It has been shown that the
prevalence of panic attacks in the United States is 28.3% and of those people 3.7%
of them develop panic disorder. Only 1.1% of these people end up developing panic
disorder with agoraphobia (Kessler, 2006). As a nurse working with the public this
is important to know because there is a good chance that patients will exist with a
new onset or history of panic attacks. It is vital for a nurse to know what to look for
and how to handle the situation should a panic attack happen. Nurses need to help
the person get through the panic attack by being supportive and nonjudgmental.
This will help the patient while they try to alleviate the panic. Lastly, the nurse
should try to find out what specifically works for the patient to help them through
this time of crisis.
G.G. is getting ready to leave the hospital but before discharge the doctor
gives him a weeks worth of Xanax to help him with the panic attacks until he can see
his primary care provider. G.G. is curious as to why the doctor only gave him a
weeks worth of medication. As the nurse taking care of this patient, it is important
to do patient teaching on the recommended clinical guidelines for people with panic
attacks. One of the main reasons for only giving a weeks worth of medication is due
to the fact that as a health care team it is important for everyone to be involved in
the plan of care in order to stay on a track of succession (HHR, 2009, p.4). If the
doctor had given G.G. a years worth of medication than G.G. may have never gone to
his PCP and blown off the underlying cause of his panic attacks.
According to the U.S Department of Health and Human resources (2009)
there are specific clinical guideline recommendations that help a person with panic
attacks have a good quality of life. It is important for the patient and the health care
team to establish a therapeutic relationship. The treatment plan needs to be
adjusted to fit the specific patients needs. For instance, G.G. could have terrible side
effects to Xanax, which would be a reason for a change in the medication regimen.
By making an appointment with his PCP G.G. gets his health care team involved and
allows everyone to make sure that he is on the right track and progressing. The
guideline also suggests that the patient should establish goals. The health care team
should monitor the patients progress and educate the patient and family on the
different resources and avenues available to help the patient cope (p. 4-5).
G.G. makes an appointment with his PCP and also goes to see a counselor to
talk about the different ways to cope with stress. His PCP and counselor agree to
start him on a low dose SSRI. There are certain treatments and medications that are
also recommended in the clinical guidelines. A few medications that are
recommended include selective serotonin reuptake inhibitors and benzodiazepines
(HHR, 2009, p. 5). An SSRI, such as Celexa, helps increase the levels of serotonin in
the brain. This ultimately increases the feeling of well-being and controls the feeling
of panic. A benzodiazepines, such as Xanax, increase the levels of GABA. This will
help promote relaxation and decrease brain activity so the persons brain is not
going a million miles a minute.
Patient teaching with these medications is important. They have some pretty
nasty side effects that can cause the person to be non-compliant. This is another
reason that having the whole health care team involved is crucial. It is important to
inform patients of these side effects and help find ways to manage them. Some side
effects for these medications include dry mouth, nausea, somnolence, and
depression. Furthermore, it is the nurses responsibility to inform the patient about
not abruptly stopping these medications. It can cause the illness to worsen and
other side effects that are dangerous (Medscape, 2014).
G.G. informs his counselor that he does not know how to cope with the stress
of work. According to the U.S Department of Health and Human resources (2009)
there are several types of therapy that have been shown to effectively help patients
cope with stress and reduce panic. They include cognitive behavioral therapy,
exposure therapy, and panic-focused psychodynamic psychotherapy (p. 6). There
are also ways to help deal with coping that are not as therapy driven such as
exercise or meditation. Someone like G.G. who has caught this illness early on may
try a less hands on approach, such as meditation to see if it can alleviate the panic
before trying a therapy based program.
G.G. continued with counseling and his SSRI medication. Within a couple
months there was a drastic decrease in the amount of panic compared to what he
had previously been experiencing. Between the different therapy treatments
available and the current medications that help reduce the symptoms of panic
attacks, people with this illness are able to have a much better quality of life. Also,
having a team approach, where everyone is on the same page for the treatment plan,
allows these patients to have a much easier time following the treatment plan and
having a normal day-to-day life.
Review of Literature
A review of the literature was completed before writing this paper and a few
aspects of panic attacks were unclear. This led me to believe that more research
should be conducted in these areas. One area in particular that was unclear was the
cause and pathophysiology of panic attacks. Most of the research that was found
was either on anxiety or panic disorder; there was hardy any research that was
specific to panic attacks. Another area that was interesting was how the diagnosis of
panic attacks correlated with future diagnosis of other mental illnesses or substance
abuse.
A few articles talked about talked about how it is believed that people with
panic disorders are much more inclined to abuse alcohol and substances in order to
self medicate. According to Wayne (2013), patients believe that the alcohol and
sedatives suppress the symptoms associated with panic attacks, however this
solution in only temporary. In actuality these behaviors ultimately worsen the side
effects of panic attacks (p. 5). A different article by Kinley (2011) said that there was
no real significance between the prevalence of substance abuse and panic attacks.
The studies included two groups of people, one group included patients with panic
attacks and the other group included patients without panic attacks (p. 416). Along
with these two opposing articles there were several other articles that supported
both arguments. This leaves questions of whether or not there is or isnt a
connection between the two. More research on this topic could potentially help
patients and their care team figure out different ways to cope with this situation and
find more therapeutic strategies to deal with panic attacks.
The article by Kinley (2011) talked about the correlation between panic
attacks and future mental illnesses. This study had two groups of people; one with
patients who experienced panic attacks and the other had patients without panic
attacks. According to the study, individuals with panic attacks had a higher chance
of developing GAD, panic disorders, social phobias, depression, and/or mania. It also
mentioned that the individuals in the panic attack group were at higher risk for
developing personality disorders (p. 415). Another article by Mathyssek (2012) also
mentions that panic attacks put people at a much greater risk for developing anxiety
and mood disorders (p. 1). There were a few other articles that had similar findings
leading me to believe that this diagnosis of panic attacks does have a correlation
with future diagnosis of mental illnesses.
Most of the research that was looked at had similar risk factors that caused
the onset of panic attacks; however, there were a few discrepancies in the exact ages
in which panic attacks start. The Mayo Clinic (2012) states that the onset of panic
attacks happens in the late teens and early adulthood. According to Mathyssek
(2012) though, the mean onset of panic attacks is age 16 (p. 4). Knowing precisely
when the onset of panic attacks starts could lead to better research on what to look
for in these patients and how to catch this illness earlier. As with any illness, earlier
detection leads to better treatment and outcomes.
The article by Mathyssek (2012) also looked at the different risk factors that
make a person more susceptible to developing panic attacks. A lot of what was
mentioned in this article matched what other resources said, such as the Mayo Clinic
(2012) and the article by Kesslers (2006). Gender is one of the better predictors of
panic attacks. According to Mathyssek (2012) females were more likely to have at
least one panic attack between the ages of 10-20 than males were (p. 4). Kessler
(2006) also states that females are at much higher risk for developing panic attacks
than males (p.5). Socio economic status is a risk factor that is debatable though.
Mathyssek (2012) mentions that individuals with lower socio economic status are
much more likely to develop panic attacks than those with higher socio economic
status (p. 4). However, Kessler (2006) states that there is no statistical significance
between socio economic status and the prevalence of panic attacks (p. 5). If more
research was done that showed people of lower socio economic statuses having
higher risks of getting panic attacks then more research and funds could be used to
help these people.
After examining all of these similarities and discrepancies between the
different research articles published, I believe that there is a lot of good research out
there but there is need for further research in certain areas. Panic attacks occur in
almost 28% of the population and with more research it could allow for earlier
detection and different ways to deal with panic attacks. This illness can be very
detrimental to individuals and with better information on what causes the illness
there could be potentially better treatments. Knowing more about this illness could
help future suffers become well quicker.










References
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Kessler, R., Chiu, W., Jin, R, Walter, E., Ruscio, A., Shear, C. (2006). The epidemiology
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Kinley, D. J., Walker, J. R., Enns, M. W., & Sareen, J. (2011). Panic attacks as a risk for
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