This is a really tough one.....in practice.....if the pt is in a full-blown attack w severe hyperventilation/tachy.....
I'd do a quick PE/abcs etc.,,,,make sure they are not in an SVT/WPW, etc. .....then.....
I'd probably give them an IV & 1mg of Ativan....when the attack subsides, they will hopefully be more cooperative.....by the time that happens, their tox screen will have come back and you can ask about use of stimulants like crystal, coke, pseudafed, RedBull-like drinks, diet pills....then get into social stressors that might have precipitated the attack. You'd also need to check bal, tsh, asa/tylenol levels....
Counseling about panic attacks will be an important part of treatment.
kai1111, i don't think that we should do PE and start emergency treatment..i think we should counsel only, take a short history and explain treatment options.
what do you think?
I hope someone with more experience helps us.....but,....it seems inhumane to me to make a person with a fullblown panic attack/anxiety attack get counseling....I try at the onset, but if it is totally futile, then I think you have to treat them medically....now I am talking about a really intense attack.....in this case they are so preoccupied with their sxs that you can't get a history and they are in distress. Aren't we supposed to provide relief from suffering? Perhaps they are having sxs from some stimulant and this is their first experience. If they are tachy and anxious from hyperthyroid or a re-entrant arrhythmia, I think we have to treat them.....I've had patients that are so 'out there' I couldn't possibly start to counsel them till their expisode has subsided, then they are usually more cooperative and motivated...then the counseling and education begins.
For the purposes of this test, however,....I wonder if they want us to counsel and do nothing else? Help needed.
Here are 5 steps that have proven to be helpful to a whole bunch of people who experience panic attacks.
Step 1: R-e-l-a-x...
One step that helps lots of people get a handle on their panic attacks is to learn and practice relaxation strategies. Here are three different types of relaxation strategies you can try:
First, try changing your breathing patterns. Stress often causes us to breathe shallowly. Unfortunately, breathing shallowly can actually prolong stress by depleting your oxygen supply and increasing muscle tension. This can lead to headaches, nervousness and a lowered threshold to panic attacks. To overcome this, practice monitoring your breathing and noticing when it becomes shallow or rapid. When this happens, take a minute to slow down, get comfortable, and breathe deeply. Begin this process by slowly but forcefully blowing all of the air out of your lungs, deep-down into your belly. This allows you to slowly and effortlessly "refill" your lungs with fresh air. Try breathing in through your nose and focusing on filling the bottom of your lungs first before filling the top. As you breathe in, your abdomen should rise slowly; and, as you breathe out, it should fall slowly. Gradually breathe more deeply and more slowly until you reach a comfortable plateau. Sighhh . . . .
A second technique is to scan your entire body, tensing and relaxing all your muscles. Begin by sitting in a chair with your feet flat on the ground. Focus on your feet and notice any muscle tension in your feet or toes. Tense your feet muscles by curling your toes like you're trying to dig into the carpet. Tense the muscles for a five-count, then allow them to go limp and release all the tension. It helps to exhale deeply and think the word "relax" at the moment you release the tension. After relaxing your feet, move up to your calves, tense and release. To your pages
, tense and release, and so on. Try to move through all of the following muscle groups: your feet, calves, pages
, "glutes," abdomen, lower back, chest, upper back, neck and shoulders, and finally, facial muscles. To tense up your facial muscles, squint hard and press your lips together (think Clint Eastwood), then just let your face go slack and expressionless. When you've completely covered your entire body, your muscles should feel warm and relaxed. Ahhhhh....
Finally, try taking a "mental vacation." No, not a trip to the Betty Ford clinic-just an imaginary visualization of a peaceful place. Mental imagery can be a great way of creating peaceful feelings. Start by imagining a peaceful, serene setting. Perhaps this will be someplace you've gone before where you felt totally calm and relaxed. Or maybe it can be a fantasy place with all the ingredients to help you relax and unwind. Once you've imagined this fantasy place, take a "sensory inventory" by asking yourself: "What do I see that's peaceful or beautiful?" "What do I hear that's soothing?" "What do I smell that reminds me of pleasant, peaceful feelings?" "What do I feel on my skin (is it warm, cool, breezy, still?)" and "What do I taste?" For example, someone who loves the beach might think about seeing a beautiful sunset over the water, hearing the waves gently lapping at the shore or the seagulls peacefully calling, smelling the scent of suntan oil, feeling the warmth of the sun and the gentle breeze, and tasting the salty air....Ahhhhh....
Imagining each of these sensations in detail actually helps to create the same peaceful feelings in your body that you'd experience if you were actually at the beach. Plus, no sand in your undies!
By themselves, deep breathing, muscle relaxation, and mental imagery can be very powerful. When you put them all together, you've got a combination that can melt away your physical tension and anxious thoughts and replace them with peace and relaxation.
Step 2: Change Habits
Sometimes it helps to make some changes in your daily routine, like adding exercise and reducing or eliminating stimulants like caffeine, nicotine and sugar. Exercise helps to burn off excess tension that might otherwise come out as anxiety or panic. Eliminating stimulants, like caffeine, helps prevent your cup from "running over" with anxiety.
If you tend to bottle up your feelings and worry a lot by yourself, it may be helpful to pay more attention to your emotions and become more willing to express them to others.
Step 3: Discover The Power of Positive Thinking
Another way of tackling panic attacks is to look at the way you talk to yourself, especially during times of stress and pressure. Panic attacks often begin or escalate when you tell yourself scary things, like "I feel light-headed . . . I'm about to faint!" or "I'm trapped in this traffic jam and something terrible is gonna happen!" or "If I go outside, I'll freak out." These are called "negative predictions" and they have a strong influence on the way your body feels. If you're mentally predicting a disaster, your body's alarm response goes off and the "fight-flight response" kicks in.
To combat this, try to focus on calming, positive thoughts, like "I'm learning to deal with panicky feelings and I know that people overcome panic all the time" or "This will pass quickly, and I can help myself by concentrating on my breathing and imagining a relaxing place" or "These feelings are uncomfortable, but they won't last forever."
Sometimes it's helpful to remind yourself of these FACTS about panic attacks:
* A panic attack cannot cause heart failure or a heart attack.
* A panic attack cannot cause you to stop breathing.
* A panic attack cannot cause you to faint.
* A panic attack cannot cause you to "go crazy."
* A panic attack cannot cause you to lose control of yourself.
If it's too hard for you to think calming thoughts or to concentrate on relaxation strategies when you're having a panic attack, find ways to distract yourself from the negative thoughts and feelings. Some people do this by talking to other people when they feel the panic coming on. Others prefer to exercise or work on a detailed project (such as gardening, deep cleaning your bathroom, sheep shearing, or reenacting historic naval battles with scale models constructed entirely from paper clips and Junior Mints). Changing scenery can sometimes be helpful, too, but it's important not to get into a pattern of avoiding necessary daily tasks. If you notice that you're regularly avoiding things like driving, going shopping, going to class, or taking buses, it's probably time to get some professional help.
Step 4: Getting Help
You might find that dealing with panic attacks will be easier if you have a person who can act as a coach as you learn how to cope with the attacks. Meeting with someone who has experience working with panic attacks and anxiety can help you find the right mixture of strategies that will work for you. This might be a therapist, psychiatrist or family doctor. Here at UT, you can come to the Counseling & Mental Health Center and talk to a counselor about different ways of overcoming panic attacks. In individual counseling, group counseling, or a combination of the two, you'll probably be able to learn the skills and develop the self-understanding you need to overcome your panic. If you'd prefer to remain anonymous or to talk to a counselor from the comfort of your own room, call the UT Telephone Counseling Service at 471-CALL.
In addition to counseling, sometimes it can be helpful to talk to a psychiatrist or other physician about taking medication to help you cope with panic attacks. This has been a helpful tool for many people, though lots of people also recover from panic problems without medicine. Taking medicine for panic problems is usually temporary. It can provide relief of some symptoms while you focus on learning strategies for managing anxiety in the future.
Step 5: Keep the Faith!
Above all, have faith that you CAN learn how to handle panic attacks. If you practice the techniques you've learned about here, or seek out more information through counseling or the self-help resources below, the chances are EXCELLENT that you'll be able to overcome the panic problems in your life!
Anxiety & Panic Workbooks
Hi, Sorry I didn't read the forum for a while.
So, in panic attack - I don't know how was the QE2 station with the patient who didn't want to give hx( if you tell me a little more, maybe I can help). But if the patient is in full attack you cannot counsel, you have to treat first, and then to counsel. If the station is about counseling then the patient already experienced simptoms and now is fine, just very worried.
In my understanding, in OSCE
's, if the patient doesn't want to tell you something that means you didn't ask the right question and/or you are not on the right track.
When you don't know what the station is about, then ask about feelings, thoughts and ideas, concerns and expectations, what he/she wants to accomplish today. Then you know where to go.
About tx - in acute attack yes, you give benzos first and then SSRI's, but you need to rule out any organic causes, especially arrhithmias, drugs and neurologic diseases. Relaxation techniques help but don't forget CBT( the self talk is part of the CBT). In my oppinion in OSCE
, you don't have time to describe in detail relaxation techniques, just to mention and to say, either we can set up a new meeting and I'll tell you more, or to referr to someone else.
As I said, if you tell me a little more about the station, I'll try to help.
mdc
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