Panic attacks triggered by rapid position change

[dandk1997RN, MSN, RN]

So I'm going out on a limb here since I think this is maybe an oddity, but I'm curious if any of you psych nurses have any input on a situation I encountered last night. I'm a cardiac nurse, so this isn't my forte- my only experience with panic attacks is my personal history of them.

I had a patient last night who was admitted to the hospital last week with SOB, diagnosed with CHF/pulmo HTN, possible SIADH...among other things. Pt has a psych history of SI with two attempts, depression, anxiety, and former sedative addiction, had been refusing psych consults. The pt was on several psych meds (for depression) prior to admission, which were all d/c'd within the last few days- I'm not really sure why. The only thing still ordered was PRN benzo for anxiety.

The pt had two panic attacks during my shift. The pt was very anxious at baseline, has been since admission, and got the benzo after the first attack. The second was about 5 hours later, too soon for a second dose. Both times it occurred when the pt had just sat up from a lying position, and the pt stated to me that things were fine until the rapid position change. No history of vertigo, no dizziness/light-headedness, VS stable...and the patient says this happens every single day. I was able to calm the pt down by coaching through breathing exercises, and showing the pt how to use the button to raise the head of the bed to assist with slowing the pace of the position changes.

Thankfully, the pt has agreed to a psychiatry consult. I won't be back till later this week, at which point the pt will unlikely be on my cardiac unit. Has anybody ever heard of this? It seems bizarre to me that panic attacks might be related to position changes, unless the pt has vertigo or maybe platypnea (or, I guess, orthopnea in cases other than this.)

Any thoughts at all? I would love any and all input. The pt has a lot of strictly medical stuff going on...I'm just wondering if they might be causing this odd (to me, anyway) psych manifestation.

[dandk1997RN, MSN, RN]

Disappointed to see nobody has any thoughts on this. Guess it will remain a mystery to me.

[nurse lala, BSN, RN]

I have never encountered a positionally triggered emotional response. That does not mean it doesn't happen, but I am skeptical. What comes to mind is, the need for collaterol data to confirm the person has positional triggered panic attacks out of the hospital. What stands out to me is refusal to see MH in the recent past, the lack of vital sign changes during the episode, and "former sedative addict". This sure has the flavor of a person not actively working on his issues seeking a drug of abuse.

[Mandychelle79, ASN, RN]

Orthostatic Hypotension? The feelings could be similar to what the patient experiences when having a panic attack ( dizzy, heart pounding, SOB).

[Meriwhen, ASN, BSN, MSN, RN]

My impression is that her emotional state may be partly due to changes in oxygenation and not a psych issue. She's got a whole host of conditions already compromising her gas exchange as it is.

[RNcashy89]

If this is the individual's genuine presentation, it would almost certainly be due to ortho hypo - if anything related to actual position change. +1 for Mandychelle. I feel grossly uneducated to comment on the gas exchange factor :) - but the above comment seems viable also.

[Meriwhen, ASN, BSN, MSN, RN]

If this is the individual's genuine presentation, it would almost certainly be due to ortho hypo - if anything related to actual position change. +1 for Mandychelle. I feel grossly uneducated to comment on the gas exchange factor :) - but the above comment seems viable also.

It comes down to the patient's ability to get oxygen. Some s/sx of low oxygenation include altered LOC, anxiety and (my personal favorite) a sense of impending doom. Seriously. Think about when you can't breathe properly for whatever reason, and you feel like you're struggling to get air, gasping and gulping, but each breath isn't good enough. Are you calm and chill as you do this? I'd bet you aren't. :)

Now consider that the patient has a few processes that can prevent her from getting enough O2: CHF, pulmonary HTN and SOB. There's probably some pulmonary edema in there as well. All of those conditions compromise respirations and thus gas exchange (O2 coming in while CO2 gets exhaled out). Then, as two other posters have pointed out, when the position is changed, orthostatic hypotension is likely involved and low BP also messes with oxygenation. That's a lot of factors standing between a patient and a pulse ox of 95%.

[Meriwhen, ASN, BSN, MSN, RN]

Oh yes, OP: that's not to say that your patient's problem isn't psychiatric in any way--it may very well be. But the physiological conditions should be ruled out--or at least figure out what role(s) they may be playing--before slapping the "it must be a psych issue" label on the problem.

Hope this helps.

[softrbreeze]

I have a pt right now that has the same response to position change. Mine has COPD and an undiagnosed lung mass as well as a h/o CVA, MI, and open-heart surgery so I'm guessing it is related to changing O2 sats with position change. He also has vascular-related dementia. He denies dizziness and pain but he does get frantic and clutches his chest even when slowly lowered to the bed (or lifted). His family thinks it is related to a h/o multiple falls and pt states it feels like he is falling. Xanax helps but I'm curious as to what is actually causing it myself.

[RescueNinjaKy]

Have you done Neuro checks on the patients. Perhaps the position change is affecting her bp which in turns affects icp and her cerebral blood perfusion. It's a bit far fetched but that could cause the sense of impending doom and anxiety/dizziness.

[Whispera, MSN, RN]

I think if I wasn't able to get enough oxygen, I might panic.

I haven't seen this is psych patients, but saw it in hospice patients. When they were getting closer to death, and couldn't grab enough air, they sometimes had terrible anxiety...