Management of a Panic Attack

Panic attacks are considered a psychiatric emergency that necessitates swift intervention and a coordinated team approach.

Goals of Management

The primary objectives in managing panic attacks and panic disorder are:

• (a) Reduce Attack Frequency and Intensity: To lessen how often panic attacks occur and how severe they are when they do happen.

• (b) Alleviate Anticipatory Anxiety and Agoraphobic Avoidance: To diminish the constant worry about future attacks and reduce the avoidance of situations or places due to fear of panic.

• (c) Treat Co-occurring Psychiatric Conditions: Address any other mental health disorders that may be present alongside panic disorder, as these often complicate the condition and treatment.

• (d) Achieve Full Symptomatic Remission: To aim for the complete resolution of panic attack symptoms, allowing the individual to function without the burden of panic.

Practical Management Strategies

1. Tailored Approach: Treatment strategies should be individualized and depend on the underlying causes and specific presentation of panic attacks in each patient.

2. Symptom Monitoring: Regularly track the patient’s symptomatic status at each session. This can be achieved through:

   • Rating Scales: Utilizing standardized scales to quantify the severity of panic symptoms.

   • Patient Self-Monitoring: Encouraging patients to maintain a daily diary to record and track their panic symptoms, providing valuable insights into patterns and triggers.

3. Hospital Admission Criteria: For individuals with uncomplicated panic disorder, hospitalization is generally not required unless specific risk factors are present, such as:

   • Evidence of Dangerous Behavior: Actions indicating harm to self or others.

   • Drug Withdrawal Symptoms: Complications arising from withdrawal from substances.

   • Suicidal or Homicidal Ideation: Thoughts or plans of self-harm or harming others, which can occur in the context of severe anxiety or fear.

4. Suicide Risk Assessment: It is crucial to assess the risk of suicide in all patients presenting with panic disorder, as anxiety disorders can sometimes be associated with suicidal thoughts.

5. Immediate Symptom Management: For patients presenting with acute symptoms like chest pain, shortness of breath, palpitations, or near fainting (syncope):

   • Oxygen Administration: Provide supplemental oxygen to address potential hypoxia.

   • Positioning: Position the patient in a supine (lying flat) or Fowler’s position (semi-seated) to aid breathing and circulation.

6. Physiological Monitoring: Closely monitor the patient’s physiological parameters using:

   • Pulse Oximetry: To continuously monitor oxygen saturation levels.

   • Electrocardiography (ECG): To assess heart rhythm and rule out cardiac causes of chest pain or palpitations.

7. Patient Education: Educate the patient to understand the nature of their symptoms. Clearly explain that their symptoms:

   • Are not indicative of a serious medical condition.

   • Are not due to a psychotic disorder.

   • Stem from a chemical imbalance related to the body’s “fight or flight” stress response system.

8. Reassurance and Explanation: Provide frequent reassurance and clear, simple explanations about panic attacks and their management to alleviate fear and misunderstanding.

9. Social Services Intervention: Involve social services to:

   • Facilitate supportive discussions with the patient.

   • Explore resources available for ongoing outpatient care and support in the community.

10. Cognitive Behavioral Therapy (CBT): Employ CBT techniques, which are highly effective for panic disorder. CBT helps patients:

    • Understand Automatic Thoughts: Identify and understand how automatic negative thoughts contribute to anxiety.

    • Challenge False Beliefs/Distortions: Recognize and challenge unhelpful or distorted beliefs that exacerbate emotional responses like anxiety.

    • Early Intervention: CBT is often more effective when initiated early in the course of panic disorder.

11. Behavioral Therapy: Implement behavioral therapy strategies:

    • Gradual Exposure: Involve a structured approach of sequentially exposing the patient to anxiety-provoking stimuli in a controlled manner.

    • Desensitization: Over time, through repeated exposure, the patient becomes desensitized to the anxiety-triggering stimuli, reducing their panic response.

    • Relaxation Techniques: Teach and practice relaxation techniques, such as deep breathing or progressive muscle relaxation, to help patients manage and control anxiety levels.

12. Respiratory Training: Educate patients on respiratory training techniques. These techniques:

    • Control Hyperventilation: Help patients gain conscious control over their breathing patterns to prevent or manage hyperventilation, a common symptom during panic attacks.

    • Anxiety Control: Controlled breathing exercises serve as a tool to self-regulate and reduce overall anxiety levels.

13. Medication Information: When medication is part of the treatment plan, it is essential to:

    • Inform about Adverse Reactions: Clearly explain the potential adverse effects or side effects of specific medications being prescribed.

    • Realistic Expectations: Provide a realistic timeframe for when the patient can expect to see noticeable therapeutic results from medication.

    • Treatment Duration: Discuss the likely duration of the medication treatment course.

Psychotherapy Approaches

1. Psychoeducation: Explain to both the patient and their family members that the symptoms are:

   • Not due to a physical disease: Reassure them that panic attacks are not caused by an underlying medical illness.

   • Due to a manageable psychological problem: Frame panic disorder as a psychological condition that is effectively treatable.

2. Reassurance: Reassure the patient that:

   • Common Condition: Panic disorder is a recognized and relatively common condition, and many individuals experience similar problems.

   • Time-Limited Episodes: Panic attacks are typically short-lived and episodic, not continuous or permanent states.

3. Supportive Approach: Be supportive and empathetic towards:

   • The Patient: Offer understanding, validation, and encouragement.

   • Family Members: Provide support and education to family members to help them understand and support the patient effectively.

4. Lifestyle Advice: It is important to advise the patient to reduce or eliminate consumption of:

   • Alcohol: Alcohol can exacerbate anxiety symptoms and interfere with treatment.

   • Smoking: Nicotine is a stimulant and can worsen anxiety.

   • Caffeine: Caffeine, found in coffee, tea, and energy drinks, is a known anxiety-producing agent and should be minimized or avoided.

Nursing Care Strategies

1. Promote Independence: Nurses should be mindful to avoid fostering patient dependence on nursing staff. Excessive dependence can:

   • Hinder Therapeutic Progress: Interfere with the development of a healthy therapeutic relationship that promotes patient autonomy and self-management.

2. Prioritize Comfort and Safety: The nurse’s primary nursing priorities are:

   • Patient Comfort: Alleviating distress and promoting physical and emotional comfort.

   • Patient Safety: Ensuring a safe environment and preventing harm to the patient.

3. Approach to Anxious Patients: When dealing with patients exhibiting heightened anxiety symptoms such as tension, trembling, or sweating:

   • Calm and Quiet Environment: Approach the patient in a calm and quiet manner and in a setting that minimizes stimulation.

   • Gentle Handling: Use a gentle and non-threatening approach to de-escalate anxiety.

4. Reality Acceptance: The nurse should guide and educate the patient to accept the reality of their condition and the need for treatment.

5. Exposure Therapy Support: Support and facilitate exposure therapy by:

   • Encouragement: Encourage the patient to return to or remain in situations or places that trigger anxiety, as part of the gradual desensitization process.

Drug Treatment Options

1. Anxiolytic Medications: Medications to reduce anxiety are a core component of treatment.

2. Long-Term Management Education: Educate the patient about the importance of long-term management, emphasizing:

   • Selective Serotonin Reuptake Inhibitors (SSRIs): As first-line medications for long-term panic disorder management.

   • Psychotherapeutic Techniques: The role and benefits of ongoing psychotherapy, particularly CBT, in conjunction with medication.

3. Benzodiazepines: These medications offer rapid relief from anxiety symptoms but have specific considerations:

   • Not for Long-Term Monotherapy: Benzodiazepines are not recommended for long-term, stand-alone treatment of panic disorder due to dependence potential.

   • Reserved for Refractory Cases: They are typically reserved for patients with severe or refractory panic disorder who have not responded adequately to other treatments.

   • Short-Term Use and Combination Therapy: Can be used for short-term symptom control or in combination with SSRIs during the initial phase of SSRI treatment (as SSRIs take several weeks to become fully effective).

   • Clonazepam Preference: Clonazepam is often preferred over alprazolam due to its longer half-life, which reduces the risk of rebound anxiety and withdrawal symptoms compared to shorter-acting alprazolam, which has a higher abuse and dependence liability.

   • Examples of Benzodiazepines and Dosages:

     • Lorazepam: 1-2 mg every 4 hours as needed for acute anxiety.

     • Diazepam: 10-20 mg intravenously for acute, severe panic (though less commonly used for panic disorder long-term).

     • Clonazepam: 0.5-2mg once daily, often used for longer-term management when benzodiazepines are indicated.

4. Antidepressant Medications: Certain antidepressants are effective in treating panic disorder.

   • Tricyclic Antidepressants (TCAs): e.g.,

     • Amitriptyline: Starting dose of 25mg at night (nocte), gradually increasing to 50mg once daily.

     • Imipramine: Starting dose of 25mg at night (nocte).

   • Selective Serotonin Reuptake Inhibitors (SSRIs): Considered first-line antidepressants for panic disorder due to better side effect profiles than TCAs. e.g.,

     • Fluoxetine: Initial dose of 10 mg once daily (stat), with a maintenance dose of up to 60 mg daily.

     • Sertraline: Starting dose of 50mg once daily, with a maintenance dose up to 200mg once daily.