Clinical Notes : Mental Health

33. Panic Attack

 

Presentation

A panic attack is the abrupt onset of intense fear or 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

  • Sensations of shortness of breath or smothering

  • Feelings of choking

  • Chest pain or discomfort

  • Nausea or abdominal distress

  • Feeling dizzy, unsteady, light-headed, or faint

  • Chills or heat sensations

  • Paresthesia (numbness or tingling sensations)

  • Derealization (feelings of unreality) or depersonalization (being detached from oneself)

  • Fear of losing control or “going crazy”

  • Fear of dying

Panics can be full blown or milder “near” panics and they usually build to a crescendo in 10 minutes. 

 

Epidemiology

  • Incidence is 7-9% of the population, and twice this amount if milder panics are included. 

  • more common in women with a ratio of 3:2. 

  • most start late in the teens or early 20s but can occur at any age. 

  • often associated with stressful events, life upheavals or traumas either past or present

  • 50% associated with another mental health issue

    • depression

    • health anxiety

    • social anxiety

    • Generalised Anxiety Disorder

    • obsessive-compulsive disorder

    • a phobia 

    • post-traumatic stress disorder

 

Management of acute attack

  • Reassure the patient that their symptoms are neither from a serious medical condition nor from a psychotic disorder, but rather from a chemical imbalance in the fight-or-flight response.

  • Explain effects of hyperventilation and adrenaline

  • Identify the precipitating fear (where possible) and frequently reassure patient this is not happening.

  • Help the patient breathe as per the 5-2-5 method.

    • Inhale using the diaphragm for 5 seconds.

    • Hold breath for 2 seconds.

    • Exhale for 5 more seconds.

    • Repeat 5 times

  • Consider distraction excercise to halt negative thinking

    • Ask patient to repeat 5 random numbers

    • e.g. 15 - 4 - 11 - 8 -- 3

    • or 5 random objects in the room

    • e.g. chair - pen - nose - computer - window

    • Repeat distraction excercise 3 times in succession changing the numbers or objects

  • Breathing into a paper bag is not routinely recommended anymore as first line management.

  • Where the 5-2-5 method and the distraction excercise fail to terminate the attack, administer sublingual benzodiazepine and breathe into paper bag.

  • Observe in OOH service for minimum 30 minutes after attack is aborted

    • Provide safety-netting for the period between OOH visit and GP follow-up appointment

    • Benzodiazepines, sedating antihistamines or antipsychotics should not be prescribed for panic disorders, but, in the absence of previous drug or alcohol abuse, may be considered for a maximun of 3 days until the GP follow-up appointment

 

A+E referral

  • Refer to A+E if acute panic attack is not successfully terminated, or if it recurs within minutes of cessation

  • Refer to A+E for significant co-morbidity and/or concomitant drug/alcohol abuse

  • Refer to psych A+E if suicidal

 

Follow up management

  • Document presentation, clinical findings, management and outcome

  • Refer to GP for review and longer term management which may include one or more of the following :

    • Physical and lab. workup to exclude precipitating co-morbidities

    • SSRI

    • Referral for CBT

    • Psych referral for underlying mental health issue

 
 
 
 
 

Generalised anxiety disorder and panic disorder in adults: management

Clinical guideline CG113 .

January 2011

Access

Evidence-based pharmacological treatment of anxiety disorders, post-traumatic stress disorder and obsessive-compulsive disorder: a revision of the 2005 guidelines

British Association for Psychopharmacology

2014

Access
 

Practice guideline for the treatment of patients with panic disorder, second edition.

American Psychiatric Association.

2009

Access

Barsky AJ, Delamater BA, Orav JE.

Panic disorder patients and their medical care. Psychosomatics. 1999 Jan-Feb;40(1):50-6.

Access

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