I.

INTRODUCTION
Anxiety is a feeling of apprehension, fear, or worry. Some fears and worries are
justified, such as worry about a loved one. Anxiety may occur without a cause, or it may
occur based on a real situation, but may be out of proportion to what would normally be
expected. Severe anxiety can have a serious impact on daily life. Anxiety can be
accompanied by a variety of physical symptoms. Most commonly, these symptoms are
related to the heart, lungs, and nervous system. You may feel as if you are having a heart
attack.
Panic disorders are composed of discrete episodes of panic attacks. Panic attacks are
frightening but fortunately physically harmless episodes. They can occur at random or
after a person is exposed to various events that may "trigger" a panic attack. They peak in
intensity very rapidly and go away with or without medical help. As with most behavioral
illnesses, the causes of panic attacks are many. Certainly there is evidence that the
tendency to have panic attacks can sometimes be inherited. However, there is also
evidence that panic may be a learned response and that the attacks can be initiated in
otherwise healthy people simply given the right set of circumstances. The American
Psychiatric Association’s official Diagnostic and Statistical Manual of Mental Disorders
IV (DSM-IV) defines a panic attack as a discrete period of intense fear or discomfort, in
which 4 (or more) of the following symptoms develop abruptly and reach a peak within
10 minutes:
• Palpitations, pounding heart, or fast heart rate
• Sweating
• Trembling and shaking
• Sensations of shortness of breath or smothering
• Feelings of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, lightheaded, or faint
• Derealization (feelings of unreality) or depersonalization (being detached
from oneself)
• Fear of losing control or going crazy
• Fear of dying
• Paresthesias (numbness or tingling sensations)
• Chills or hot flashes
Some of these symptoms will most likely be present in a panic attack. The attacks can
be so disabling that the person is unable to express to others what is happening to them. A
doctor might also note various signs of panic: The person may appear terrified or shaky
or be hyperventilating (deep, rapid breathing causing dizziness). Recent literature
suggests that men and women may experience different symptoms during an attack.
Women tend to experience a predominance of respiratory symptoms compared to men.

I have chosen this disorder, not only to fulfill the requirements of psychiatric-mental
health nursing, but also to learn about the disorder: that almost 80% of the world
population experiences but don’t know that they are suffering from it and what I have
been diagnosed with and suffering from for the 6 months. I expect that after this case
study I can gain adequate information on distinguishing panic disorders from other
disorders and help those that suffer from it to manage it.

II. OBJECTIVES

A. STUDENT – CENTERED
After 2 weeks of student nurse – client interaction, the student nurse will be able to:
1. establish rapport with the client.
2. assess for client’s needs.
3. prioritize the identified problems.
4. involve in planning the management of his problem.
5. implement the plan of management of the client’s problem.

B. CLIENT – CENTERED
After 2 weeks of student nurse – client interaction, the client will be able to:
1. establish trust with the student nurse.
2. verbalize feelings about his condition and being confined in the hospital.
3. gain insight about his disorder.
4. explain his current stress management techniques.
5. demonstrate new methods of stress management as taught by the student nurse.

III. NURSING ASSESSMENT

1. PERSONAL HISTORY
1.1 PATIENT’S PROFILE
a. Name: Roberto Villasor
b. Age: 56 years old
c. Sex: Male
d. Civil Status: Separated
e. Religion: Roman Catholic
f. Date of Admission: July 28, 2004
g. Room No: XII
h. Complaints: Palpitations, agitation, couldn’t breathe, insomnia, visual and auditory
hallucinations, imagines some harm coming to him.
i. Diagnosis: Panic Disorder

1.2 FAMILY AND INDIVIDUAL INFORMATION, SOCIAL AND HEALTH

HISTORY
The patient comes from a family of 5 children with him being the eldest. He said
that none in his family has ever been admitted to the psychiatric ward nor been diagnosed
with panic disorder. He is from Antique. His educational attainment is only high school
level. He first worked in Manila as a houseboy and after 3 years was transferred to a
government office by his boss as a secretary, but when martial law broke out, he stopped
and got work as a bartender, where he met his future wife, a Boholana (he didn’t want to
mention the name). They got married after a few months of courting and conceived 2
children. After being a bartender for a year, he sought work as a door to door salesman;
he did this for 2 years. He then got work on an international fishing boat. During that
time he was working on the boat, he said that some of his co-workers became his enemies
because he was favored by the captain because he was industrious. During that time, he
said he had a conflict with his wife which lead to their separation. He was first admitted
to the psychiatric ward ten years ago for complaints of palpitations, dyspnea, severe
headaches, and hallucinations and was discharged over a year ago and lived with his
cousin in Liloan, but was admitted again July 28, 2004 for complaints as mentioned
above. He is a diabetic, smoker, and had a below-the-knee amputation in 1996 due to
Buerger’s disease. He said he was given anti-Tuberculosis drugs the second time he was
admitted, but he has stopped taking them now.

1.3 LEVELS OF GROWTH AND DEVELOPMENT

Normal Development of Middle adulthood (40-65 years old)

a. Physical and Cognitive Development

Major physiological changes occur between 40-65 years of age. The most visible
changes are graying of the hair, wrinkling of the skin and the thickening of the waist.
Balding commonly begins during the middle years, But may also begin in young adults.
Decreases in hearing and visual acuity, are often noted during this period. According to
national health care statistics 23% of all visits to office-based physicians by adults aged
44-64 are for primary diagnosis of glaucoma. Often based physiological changes have an
impact on self-concept and body image. The most significant physiological changes
during middle age are menopause in women and climacteric in men.

According to Jean Piaget, middle age belongs to the individuals thinking moves to
abstract and theoretical subjects in the formal operations period. Thinking can venture
into such subjects as achieving world peace finding justice and seeking meaning in life.
Adolescence can organize their thoughts in their minds; they have the capacity to reason
with respect to possibilities. New Cognitive powers allow the adolescent to do more far-
reaching problem solving including their futures and that of others; this thinking matures
with experience in the adult years.

Piaget believed that the sequencing of these stages occurs for all children but that
the rate of achievement may vary. He also theorized that this would be true in all cultures.
He acknowledged that biological maturation plays a role in this developmental theory but
believed that rates of development depend upon the intellectual stimulation and challenge
in the environment of the child.

Changes in the cognitive function of middle adults are rare except with illness or
trauma. The middle adult can learn new skills and information. Some middle adults enter
educational or vocational programs to prepare themselves for entering the job market or
changing jobs.
b. Psychosocial Ch44444444444psychosocial changes in the middle adult may involve
expected events, such as children moving away from home, or unexpected events such as
marital separation or the death of a close friend. These changes may result in stress that
can affect the middle adult’s overall level of health. Nurses should assess the major life
changes occurring in the middle adult and the impact that the changes have on that
person’s state of health. Nursing assessment should also include individual
psychosocial factors such as coping mechanisms and sources of social support.

In the middle adult years, as children depart from the household, the family enters
the post parental family stage. Time and financial demands on the parents decreased, and
the couple faces and the task of redefining their own relationship. As grandchildren
arrive, grand parenting styles must be chosen. It is during this period that many middle
age adults begin to take in a healthier lifestyle. Although not advisable to wait until this
stage in life to think about health promotion, “better late than never” those apply.
Assessment of health promotion needs for the middle adult include adequate rest, leisure
activities, regular exercise, good nutrition, reduction or cessation in the use of tobacco or
alcohol, and regular screening examinations. Assessment of the middle adult’s social
environment is also important, including relationship concerns; communication and
relationships with children, grandchildren, and aging parents; and caregiver concerns
with their own aging or disabled parents.

According to Eriksson’s Developmental theory, the primary developmental task of

the middle years is to achieve generativity. Generativity is the willingness to care for and
guide others. Middle adults can achieve generativity with their own children or the
children of close friends or through guidance in social interaction with the next
generation. If middle adults fail to achieve generativity, stagnation occurs. This is shown
by excessive concern with themselves or destructive behavior toward their children and
the community.

c. Sexual Changes
While it has long been recognized that women experience a dramatic physical and
hormonal change in middle adulthood, it has only recently come to light than some men
also experience physical and hormonal changes. From Dr. Michael Zals book, The
Sandwich Generation, (1992) the"current awareness may be due to the fact that more
men now live to reach the period of life from age 40 to 60 when a general slowing of
physical processes may be expected". Many of these changes require men to adjust
psychologically more than physically.
The hormonal change for men happens over a longer and more gradual period of time.
This is why men do not see a sudden, dramatic change. Typically men begin to see
changes in the 40's and continue into the 60's. The male hormone, testosterone, starts to
decrease and the pituitary gonadotropine hormone increases. Due to this hormonal
change some men may experience the following:
• One may experience an increase in time to achieve an erection.
• Erections may not be as complete as in the past.
 • More direct stimulation may be required to achieve an erection.
• The overall decline in sexual potency.

These are all normal changes due to aging. It is crucial that men and their spouses
treat these changes as an opportunity to try new things. Dr. Zal states, "The quality and
enjoyment of sex does not have to change in mid-life." Many couples, for example, can
bring new ideas to improve foreplay, allow their imagination to provide a more romantic
mood with less distractions, and engage in changes that will enhance the intimacy
between them and their spouse.
When a couple works together to understand the changes that all people
experience in life, a smoother transition is made possible. A couple must look at these
changes as positive. This will help to ease the tension of the sexual changes we all will
experience sooner or later.

2. PRESENT PROFILE OF FUNCTIONAL HEALTH PATTERNS

2.1 HEALTH PERCEPTION / HEALTH MANAGEMENT PATTERN

The client describes his health as good and he feels that he is in good condition. In
order to keep himself healthy, he eats his daily recommended diet with a minimal sugar
intake. He used to undergo physical examinations once every year since it was required
by the work he was involved in. He exercises everyday even without any legs. He has had
complete immunizations. He describes the main characteristic of his illness as feeling
nervous caused by stress. He has followed the prescribed instruction given to him
because he is eager to get well even though he doesn’t mind being in the psychiatric ward
since there are people he can talk to. He feels he only has problems in mobility but no
problem with caring for himself because he has gotten used to the fact that he has no legs.

2.2 NUTRITIONAL – METABOLIC PATTERN

He takes in three meals a day with mid morning and mid afternoon snacks. He
drinks a lot of water, about 10 to 12 glasses a day, with the occasional alcoholic drink if
there is any available. His appetite is good, he has no indigestion, vomiting, nausea nor a
sore mouth. He is restricted to a diet with minimal sugar and he prefers eating fish and
vegetables. He doesn’t take any vitamins or food supplements. He lost weight in the last 6
months, about 6 kilos as described by the client, probably because he doesn’t move
around so much since he has no legs and because of his sugar - restricted diet. He has no
problems swallowing liquids or solids, chewing and feeding himself.

2.3 ELIMINATION PATTERN

He has no problems or complaints with his pattern of urinating although he says
there comes a time where he urinates a lot. He has no inserted catheters, incontinent
briefs or cystostomies.
He only defecates once a day usually in the morning; stool is colored brown and
solid. He has no ileostomies or colostomies. He doesn’t use any enemas, cathartics,
laxatives or suppositories.
He has warm and brown skin with adequate turgor. He has no pruritus nor edema.
2.4 ACTIVITY – EXERCISE PATTERN
He doesn’t have anymore work. He just likes to sit down and talk, since he can’t
walk or move around unless he’s in his wheelchair. He exercise by moving his arms,
shoulders and neck, which he does when he wakes up and before he goes to sleep. He has
no problem bathing and grooming himself. He doesn’t have any problems in toileting. He
has no complaints of dyspnea or fatigue.

2.5 SLEEP – REST PATTERN

He sleeps between 9 to 10 p.m. He usual sleeping time is about 5 to 6 hours. He
doesn’t have any sleeping aids. He exercises before he goes to sleep to get him to feel
tired. He has a hard time falling and remaining asleep.

2.6 COGNITIVE PERCEPTUAL PATTERN

He used to have glasses but doesn’t use them anymore. He doesn’t have any
complaints of vertigo, insensitivity to superficial pain or cold and heat. He is able to read
and write.

2.7 SELF – PERCEPTION PATTERN

He is most concerned about the status of his children since they are living with his wife in
Bohol. He wishes to get well soon, but on the other hand, he doesn’t mind remaining in
the psychiatric ward. He doesn’t feel anything different about himself just because he is
ill. He still says that he is ill because he is nervous.

2.8 ROLE – RELATIONSHIP PATTERN

He speaks Bisaya, Tagalog and English. His speech is clear. He expresses himself
mostly by talking and sometimes through writing.
He used to live with his cousin in Liloan who he also turns to for help in time of
need. Most of his sibling s reached college. He wishes that he could understand why he
and his wife had a conflict.

2.9 SEXUALITY – SEXUAL FUNCTIONING

He thinks that there is no problem with his sexual functioning but he can’t be sure
because he hasn’t been sexually active for a very long time.

2.10 COPING – STRESS MANAGEMENT PATTERN

He makes decisions by himself. The thing he likes about himself is his being
industrious and truthful no matter what the situation is. The thing that he wants to change
about his life is that he wants that his children be with him, but the thing preventing him
is financial constraints and the fact that he doesn’t know exactly where his children are.
He usually smokes and just relaxes when he is under stress.

2.11 VALUE – BELIEF SYSTEM

He finds strength and meaning in the Lord, that’s why he verbalized that the Lord
is everything. He used to go to church on Sundays, but not anymore since he was
admitted. He doesn’t really desire a religious person or practice during his confinement
because he said that praying and faith is enough.
3. PATHOPHYSIOLOGY AND RATIONALE

3.1 NORMAL ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM

Brain
A portion of the central nervous system contained within the skull. The brain is
the control center for movement, sleep, hunger, thirst, and virtually every other vital
activity necessary to survival. The brain controls all human emotions—including love,
hate, fear, anger, elation, and sadness—. It also receives and interprets the countless
signals that are sent to it from other parts of the body and from the external environment.
The brain makes us conscious, emotional, and intelligent.
The adult human brain is a 1.3-kg (3-lb) mass of pinkish-gray jellylike tissue
made up of approximately 100 billion nerve cells, or neurons; neuralgia (supporting-
tissue) cells; and vascular (blood carrying) and other tissues.
Between the brain and the cranium—the part of the skull that directly covers the brain—
are three protective membranes, or meninges. The outermost membrane, the dura mater,
is the toughest and thickest. Below the dura mater is a middle membrane, called the
arachnoid layer. The innermost membrane, the pia mater, consists mainly of small blood
vessels and follows the contours of the surface of the brain.
A clear liquid, the cerebrospinal fluid, bathes the entire brain and fills a series of
four cavities, called ventricles, near the center of the brain. The cerebrospinal fluid
protects the internal portion of the brain from varying pressures and transports chemical
substances within the nervous system.
From the outside, the brain appears as three distinct but connected parts: the
cerebrum (the Latin word for brain)—two large, almost symmetrical hemispheres; the
cerebellum (“little brain”)—two smaller hemispheres located at the back of the cerebrum;
and the brain stem—a central core that gradually becomes the spinal cord, exiting the
skull through an opening at its base called the foramen magnum. Two other major parts
of the brain, the thalamus and the hypothalamus, lie in the midline above the brain stem
underneath the cerebellum.
The brain and the spinal cord together make up the central nervous system, which
communicates with the rest of the body through the peripheral nervous system. The
peripheral nervous system consists of 12 pairs of cranial nerves extending from the
cerebrum and brain stem; a system of other nerves branching throughout the body from
the spinal cord; and the autonomic nervous system, which regulates vital functions not
under conscious control, such as the activity of the heart muscle, smooth muscle
(involuntary muscle found in the skin, blood vessels, and internal organs), and glands.

Cerebrum
Most high-level brain functions take place in the cerebrum. Its two large
hemispheres make up approximately 85 percent of the brain's weight. The exterior
surface of the cerebrum, the cerebral cortex, is a convoluted, or folded, grayish layer of
cell bodies known as the gray matter. The gray matter covers an underlying mass of fibers
called the white matter. The convolutions are made up of ridgelike bulges, known as gyri,
separated by small grooves called sulci and larger grooves called fissures. Approximately
two-thirds of the cortical surface is hidden in the folds of the sulci. The extensive
convolutions enable a very large surface area of brain cortex—about 1.5 m2 (16 ft2) in an
adult—to fit within the cranium. The pattern of these convolutions is similar, although
not identical, in all humans.
The two cerebral hemispheres are partially separated from each other by a deep
fold known as the longitudinal fissure. Communication between the two hemispheres is
through several concentrated bundles of axons, called commissures, the largest of which
is the corpus callosum.
Several major sulci divide the cortex into distinguishable regions. The central
sulcus, or Rolandic fissure, runs from the middle of the top of each hemisphere
downward, forward, and toward another major sulcus, the lateral (“side”), or Sylvian,
sulcus. These and other sulci and gyri divide the cerebrum into five lobes: the frontal,
parietal, temporal, and occipital lobes and the insula.
The frontal lobe is the largest of the five and consists of the entire cortex in front
of the central sulcus. Broca's area, a part of the cortex related to speech, is located in the
frontal lobe. The parietal lobe consists of the cortex behind the central sulcus to a sulcus
near the back of the cerebrum known as the parieto-occipital sulcus. The parieto-occipital
sulcus, in turn, forms the front border of the occipital lobe, which is the rearmost part of
the cerebrum. The temporal lobe is to the side of and below the lateral sulcus. Wernicke's
area, a part of the cortex related to the understanding of language, is located in the
temporal lobe. The insula lies deep within the folds of the lateral sulcus.
The cerebrum receives information from all the sense organs and sends motor
commands (signals that result in activity in the muscles or glands) to other parts of the
brain and the rest of the body. Motor commands are transmitted by the motor cortex, a
strip of cerebral cortex extending from side to side across the top of the cerebrum just in
front of the central sulcus. The sensory cortex, a parallel strip of cerebral cortex just in
back of the central sulcus, receives input from the sense organs.
Many other areas of the cerebral cortex have also been mapped according to their
specific functions, such as vision, hearing, speech, emotions, language, and other aspects
of perceiving, thinking, and remembering. Cortical regions known as associative cortex
are responsible for integrating multiple inputs, processing the information, and carrying
out complex responses.

Cerebellum
The cerebellum coordinates body movements. Located at the lower back of the
brain beneath the occipital lobes, the cerebellum is divided into two lateral (side-by-side)
lobes connected by a fingerlike bundle of white fibers called the vermis. The outer layer,
or cortex, of the cerebellum consists of fine folds called folia. As in the cerebrum, the
outer layer of cortical gray matter surrounds a deeper layer of white matter and nuclei
(groups of nerve cells). Three fiber bundles called cerebellar peduncles connect the
cerebellum to the three parts of the brain stem—the midbrain, the pons, and the medulla
oblongata.
The cerebellum coordinates voluntary movements by fine-tuning commands from
the motor cortex in the cerebrum. The cerebellum also maintains posture and balance by
controlling muscle tone and sensing the position of the limbs. All motor activity, from
hitting a baseball to fingering a violin, depends on the cerebellum.
Thalamus and Hypothalamus
The thalamus and the hypothalamus lie underneath the cerebrum and connect it to
the brain stem. The thalamus consists of two rounded masses of gray tissue lying within
the middle of the brain, between the two cerebral hemispheres. The thalamus is the main
relay station for incoming sensory signals to the cerebral cortex and for outgoing motor
signals from it. All sensory input to the brain, except that of the sense of smell, connects
to individual nuclei of the thalamus.
The hypothalamus lies beneath the thalamus on the midline at the base of the
brain. It regulates or is involved directly in the control of many of the body's vital drives
and activities, such as eating, drinking, temperature regulation, sleep, emotional behavior,
and sexual activity. It also controls the function of internal body organs by means of the
autonomic nervous system, interacts closely with the pituitary gland, and helps
coordinate activities of the brain stem.

Brain Stem
The brain stem is evolutionarily the most primitive part of the brain and is
responsible for sustaining the basic functions of life, such as breathing and blood
pressure. It includes three main structures lying between and below the two cerebral
hemispheres—the midbrain, pons, and medulla oblongata.
Midbrain
The topmost structure of the brain stem is the midbrain. It contains major relay
stations for neurons transmitting signals to the cerebral cortex, as well as many reflex
centers—pathways carrying sensory (input) information and motor (output) commands.
Relay and reflex centers for visual and auditory (hearing) functions are located in the top
portion of the midbrain. A pair of nuclei called the superior colliculus control reflex
actions of the eye, such as blinking, opening and closing the pupil, and focusing the lens.
A second pair of nuclei called the inferior colliculus, control auditory reflexes, such as
adjusting the ear to the volume of sound. At the bottom of the midbrain are reflex and
relay centers relating to pain, temperature, and touch, as well as several regions
associated with the control of movement, such as the red nucleus and the substantia nigra.

Pons
Continuous with and below the midbrain and directly in front of the cerebellum is
a prominent bulge in the brain stem called the pons. The pons consists of large bundles of
nerve fibers that connect the two halves of the cerebellum and also connect each side of
the cerebellum with the opposite-side cerebral hemisphere. The pons serves mainly as a
relay station linking the cerebral cortex and the medulla oblongata.

Medulla Oblongata
The long, stalklike lowermost portion of the brain stem is called the medulla
oblongata. At the top, it is continuous with the pons and the midbrain; at the bottom, it
makes a gradual transition into the spinal cord at the foramen magnum. Sensory and
motor nerve fibers connecting the brain and the rest of the body cross over to the opposite
side as they pass through the medulla. Thus, the left half of the brain communicates with
the right half of the body and the right half of the brain with the left half of the body.
Reticular Formation
Running up the brain stem from the medulla oblongata through the pons and the
midbrain is a netlike formation of nuclei known as the reticular formation. The reticular
formation controls respiration, cardiovascular function, digestion, levels of alertness, and
patterns of sleep. It also determines which parts of the constant flow of sensory
information into the body are received by the cerebrum.

Brain Cells
There are two main types of brain cells: neurons and neuroglia. Neurons are
responsible for the transmission and analysis of all electrochemical communication
within the brain and other parts of the nervous system. Each neuron is composed of a cell
body called a soma, a major fiber called an axon, and a system of branches called
dendrites. Axons also called nerve fibers, convey electrical signals away from the soma
and can be up to 1 m (3.3 ft) in length. Most axons are covered with a protective sheath
of myelin, a substance made of fats and protein, which insulates the axon. Myelinated
axons conduct neuronal signals faster than do unmyelinated axons. Dendrites convey
electrical signals toward the soma, are shorter than axons, and are usually multiple and
branching.
Neuroglial cells are twice as numerous as neurons and account for half of the
brain's weight. Neuroglia (from glia, Greek for “glue”) provide structural support to the
neurons. Neuroglial cells also form myelin, guide developing neurons, take up chemicals
involved in cell-to-cell communication, and contribute to the maintenance of the
environment around neurons.

Cranial Nerves
Twelve pairs of cranial nerves arise symmetrically from the base of the brain and
are numbered, from front to back, in the order in which they arise. They connect mainly
with structures of the head and neck, such as the eyes, ears, nose, mouth, tongue, and
throat. Some are motor nerves, controlling muscle movement; some are sensory nerves,
conveying information from the sense organs; and others contain fibers for both sensory
and motor impulses. The first and second pairs of cranial nerves—the olfactory (smell)
nerve and the optic (vision) nerve—carry sensory information from the nose and eyes,
respectively, to the undersurface of the cerebral hemispheres. The other ten pairs of
cranial nerves originate in or end in the brain stem.

How the Brain Works

The brain functions by complex neuronal, or nerve cell, circuits. Communication
between neurons is both electrical and chemical and always travels from the dendrites of
a neuron, through its soma, and out its axon to the dendrites of another neuron.
Dendrites of one neuron receive signals from the axons of other neurons through
chemicals known as neurotransmitters. The neurotransmitters set off electrical charges in
the dendrites, which then carry the signals electrochemically to the soma. The soma
integrates the information, which is then transmitted electrochemically down the axon to
its tip.
At the tip of the axon, small, bubblelike structures called vesicles release
neurotransmitters that carry the signal across the synapse, or gap, between two neurons.
There are many types of neurotransmitters, including norepinephrine, dopamine, and
serotonin. Neurotransmitters can be excitatory (that is, they excite an electrochemical
response in the dendrite receptors) or inhibitory (they block the response of the dendrite
receptors).
One neuron may communicate with thousands of other neurons, and many
thousands of neurons are involved with even the simplest behavior. It is believed that
these connections and their efficiency can be modified, or altered, by experience.
Scientists have used two primary approaches to studying how the brain works.
One approach is to study brain function after parts of the brain have been damaged.
Functions that disappear or that are no longer normal after injury to specific regions of
the brain can often be associated with the damaged areas. The second approach is to
study the response of the brain to direct stimulation or to stimulation of various sense
organs.
Neurons are grouped by function into collections of cells called nuclei. These
nuclei are connected to form sensory, motor, and other systems. Scientists can study the
function of somatosensory (pain and touch), motor, olfactory, visual, auditory, language,
and other systems by measuring the physiological (physical and chemical) changes that
occur in the brain when these senses are activated. For example, electroencephalography
(EEG) measures the electrical activity of specific groups of neurons through electrodes
attached to the surface of the skull. Electrodes inserted directly into the brain can give
readings of individual neurons. Changes in blood flow, glucose (sugar), or oxygen
consumption in groups of active cells can also be mapped.
Although the brain appears symmetrical, how it functions is not. Each hemisphere
is specialized and dominates the other in certain functions. Research has shown that
hemispheric dominance is related to whether a person is predominantly right-handed or
left-handed. In most right-handed people, the left hemisphere processes arithmetic,
language, and speech. The right hemisphere interprets music, complex imagery, and
spatial relationships and recognizes and expresses emotion. In left-handed people, the
pattern of brain organization is more variable.
Hemispheric specialization has traditionally been studied in people who have
sustained damage to the connections between the two hemispheres, as may occur with
stroke, an interruption of blood flow to an area of the brain that causes the death of nerve
cells in that area. The division of functions between the two hemispheres has also been
studied in people who have had to have the connection between the two hemispheres
surgically cut in order to control severe epilepsy, a neurological disease characterized by
convulsions and loss of consciousness.

Vision
The visual system of humans is one of the most advanced sensory systems in the
body. More information is conveyed visually than by any other means. In addition to the
structures of the eye itself, several cortical regions—collectively called primary visual
and visual associative cortex—as well as the midbrain are involved in the visual system.
Conscious processing of visual input occurs in the primary visual cortex, but reflexive—
that is, immediate and unconscious—responses occur at the superior colliculus in the
midbrain. Associative cortical regions—specialized regions that can associate, or
integrate, multiple inputs—in the parietal and frontal lobes along with parts of the
temporal lobe are also involved in the processing of visual information and the
establishment of visual memories.

Language
Language involves specialized cortical regions in a complex interaction that
allows the brain to comprehend and communicate abstract ideas. The motor cortex
initiates impulses that travel through the brain stem to produce audible sounds.
Neighboring regions of motor cortex, called the supplemental motor cortex, are
involved in sequencing and coordinating sounds. Broca's area of the frontal lobe is
responsible for the sequencing of language elements for output. The comprehension of
language is dependent upon Wernicke's area of the temporal lobe. Other cortical circuits
connect these areas.

Memory
Memory is usually considered a diffusely stored associative process—that is, it
puts together information from many different sources. Although research has failed to
identify specific sites in the brain as locations of individual memories, certain brain areas
are critical for memory to function. Immediate recall—the ability to repeat short series of
words or numbers immediately after hearing them—is thought to be located in the
auditory associative cortex. Short-term memory—the ability to retain a limited amount of
information for up to an hour—is located in the deep temporal lobe. Long-term memory
probably involves exchanges between the medial temporal lobe, various cortical regions,
and the midbrain.

The Autonomic Nervous System

The autonomic nervous system regulates the life support systems of the body reflexively
—that is, without conscious direction. It automatically controls the muscles of the heart,
digestive system, and lungs; certain glands; and homeostasis—that is, the equilibrium of
the internal environment of the body. The autonomic nervous system itself is controlled
by nerve centers in the spinal cord and brain stem and is fine-tuned by regions higher in
the brain, such as the midbrain and cortex. Reactions such as blushing indicate that
cognitive, or thinking, centers of the brain are also involved in autonomic responses.

B. SCHEMATIC DIAGRAM OF PSYCHOPATHOLOGY

PREDISPOSING FACTORS

Psychoanalytic Interpersonal Behavioral Family Biological

 PRECIPITATING STRESSORS

Physical Integrity Self-system

APPRAISAL OF STRESSOR

COPING RESOURCES

COPING MECHANISMS

Task oriented Ego oriented

Constructive Destructive

CONTINUUM OF ANXIETY RESPONSES

ADAPTIVE RESPONSES MALADAPTIVE RESPONSES

Anticipation Mild Moderate Severe Panic

3.3 DISEASE PROCESS AND ITS EFFECTS ON DIFFERENT ORGANS/

SYSTEMS

3.3.1 BIOLOGIC THEORIES

3.3.1.1 GENETIC THEORIES
Anxiety may have an inherited component, because first degree relatives of
clients with increased anxiety have higher rates of developing anxiety.

3.3.1.2 NEUROCHEMICAL THEORIES

Gamma-amino butyric acid (GABA) is the amino acid neurotransmitter believed
Be dysfunctional. GABA, an inhibitory neurotransmitter, functions as the body’s natural
anti-anxiety agent by reducing cell excitability, thus decreasing the rate of neuronal
firing. It is available in one-third of the nerve synapses especially those in the limbic
system and the locus ceruleus the area where the nerurotransmitter norepinephrine that
excites cellular function is produced. Because GABA reduces anxiety and norepinephrine
increases it, researchers believe that a problem with the regulation of these
neurotransmitters occurs.
Serotonin (5-HT), the indolamine neurotransmitter has many subtypes. 5-HT1a
plays a role in anxiety as well as in affecting aggression and mood.

3.3.2 PSYCHODYNAMIC THEORIES

3.3.2.1 PSYCHOANALYTIC THEORIES

Freud saw a person’s innate anxiety as the stimulus for behavior. He described
defense mechanisms as the human’s attempt to control awareness of and to reduce
anxiety. Defense mechanisms are cognitive distortions that a person uses unconsciously
to maintain a sense of being in control of a situation, to lessen discomfort, and to deal
with stress. Because defense mechanisms arise from the unconscious, the person is
unaware of using them. Some people overuse defense mechanisms, which stops them
from learning a variety of appropriate methods to resolve anxiety-producing situations.
The dependence on one or two defense mechanisms also can inhibit emotional growth,
lead to poor problem-solving skills, and create difficulty with relationships.

3.3.2.2 INTERPERSONAL THEORY

Harry Stack Sullivan viewed anxiety as being generated from problems in
interpersonal relationships. Caregivers communicate anxiety to infants or children
through inadequate nurturing, agitation when holding or handling the child and distorted
messages. Such communicated anxiety can result in dysfunction such as failure to
achieve age-appropriate developmental tasks. In adults, anxiety arises from the person’s
need to conform to the norms of his cultural group. The higher the level of anxiety, the
lower the ability to communicate and to solve problems and the greater chance for panic
disorder to develop.
Hildegard Peplau understood that humans existed in interpersonal and physiologic
eralms; thus, the nurse can better help the client to achieve health by attending to both
areas. She identified the four levels of anxiety and developed nursing interventions and
interpersonal communication techniques based on Sullivan’s interpersonal view of
anxiety.

3.3.2.3 BEHAVIORAL THEORY

Behavioral theorists view anxiety as being learned through experiences.
 Conversely, people can change or “unlearn” behaviors through new experiences.
Behaviorists believe that people can modify maladaptive behaviors without gaining
insight into the causes for them. They contend that disturbing behaviors that develop and
interfere with a person’s life can be extinguished or unlearned by repeated experiences
guided by a trained therapist.

3.4 COMPARATIVE CHART

Classical Symptom Clinical Symptom Rationale

*Palpitations, pounding heart, Manifested This is manifested due to the effects of

or tachycardia
*Sweating
*Trembling and shaking
*Sensations of shortness of
breath or smothering
*Feelings of choking
*Chest pain or discomfort
*Nausea or abdominal
distress
*Derealization
*Depersonalization
*Fear of losing control
*Fear of dying
hyperventilation wherein the client has to
compensate for the oxygen lost.
Manifested This is manifested because there is
increased heat production in the body due
to the increase in heart rate.
Manifested This is manifested because the client has
a sense of nervousness.
Manifested This is manifested by the client because
of the nervousness and the chest pain that
occurs, the client reacts by holding his
breath.
Manifested This is manifested by the client because
the airway narrows as a result of the client
straining because of his nervousness.
Manifested This is manifested by the client because
of the decreased tissue perfusion, pain
is elicited.
Not manifested This is manifested by the client because
of the decreased tissue perfusion.
Manifested This is manifested by the client because
he feels that something is wrong with him
or
that someone is after him.
Not manifested This is manifested by the client because
he thinks of something that isn't really
happening or is going to happen.
Manifested This is manifested by the client because
he feels that something is wrong with him
and it is something that he can't control or
manage.
Manifested This is manifested by the client because
 of the symptoms of the panic attacks
which
to him could possibly signify a heart
attack.

4. NURSING INTERVENTION

4.1. CARE GUIDE OF PATIENT WITH DISEASE CONDITION

Taking care of panic attacks at home is possible, but be careful not to mistake another
serious illness (such as a heart attack) for a panic attack. In fact, this is the dilemma that
doctors face when people experiencing panic are brought to a hospital's emergency
department or the clinic.

If a person has been diagnosed with panic attacks in the past and is familiar with the
signs and symptoms, the following techniques may help the person stop the attack.

• First, relax your shoulders and become conscious of any tension that you may be
feeling in your muscles.
• Then, with gentle reassurance, progressively tense and relax all the large muscle
groups. Tighten your left leg with a deep breath in, for example, hold it, then
release the leg muscles and the breath. Move on to the other leg. Move up the
body, one muscle group at a time.
• Slow down your breathing. This may best be done blowing out every breath
through pursed lips as if blowing out a candle. Also, place your hands on your
stomach to feel the rapidity of your breathing. This may allow you to further
control your symptoms.
• Tell yourself (or someone else if you are trying this technique with someone) that
you are not "going crazy." If you are concerned about not being able to breathe,
remember that if you are able to talk, you are able to breathe.
• If a person is diagnosed with any medical illness, especially heart disease, home
treatment is not appropriate. Even if the person has a history of panic attacks,
home care is not appropriate if there is any new or worrisome symptom.

Medical Treatment

Generally, panic attacks are treated with reassurance and relaxation techniques. By
definition, panic attacks last less than an hour, so many times a person already feels much
better by the time he or she makes it to the doctor's office. Nevertheless, because the
diagnosis is made by excluding more dangerous causes, people may be given medications
during their attack.

• If the doctor is suspicious of a cardiac (heart) cause, then the person may be given
aspirin and various blood pressure medicines. An IV line may be started and
fluids given. Some doctors will prescribe various antianxiety medicines such as
diazepam (Valium) or lorazepam (Ativan) during the evaluation.

• Once the diagnosis of panic attack is made, however, the person may be surprised
that no medicines are prescribed. Before medications are started, the person
requires further evaluation by a mental health professional to check for the
presence of other disorders. These may include anxiety disorders, depression, or
panic disorder (a different diagnosis than panic attack).

• If medications are prescribed, several options are available. Selective serotonin

reuptake inhibitors (SSRIs) such as sertraline (Zoloft), fluoxetine (Prozac),
paroxetine (Paxil), and fluvoxamine (Luvox) are often the first choice. Clinical
trials have shown SSRIs reduce the frequency of panic attack up to 75-85%.
SSRIs must be taken 3-6 weeks before they are effective in reducing panic attacks
and are taken once daily.

• Other choices of drug treatment include benzodiazepines such as alprazolam

(Xanax), clonazepam (Klonopin), lorazepam (Ativan), or diazepam (Valium).
They effectively decrease panic attacks by up to 70-75% almost immediately;
however, they must be up to 4 times per day. Additional drawbacks include
sedation, memory loss, and after several weeks, tolerance to their effects and
withdrawal symptoms may occur.

• Tricyclic antidepressants such as imipramine (Tofranil) and MAO inhibitors such

as phenelzine (Nardil) have also been used, but many individuals experience side
effects that are difficult to tolerate.

V. EVALUATION AND RECOMMENDATION

The disorder may be long-standing and difficult to treat. Although some people
with this disorder may not be cured with treatment, most can expect rapid improvement
 with drug and behavioral therapy. The prognosis of the client is good because he is
learning to adapt to his state and learning to manage it.

I strongly recommend that the client undergoes further demonstration and

utilization of stress management techniques. I also recommend that he has to undergo
therapy wherein he can learn to be open about his problems, emotions and feelings
towards others or things.

VI. EVALUATION AND IMPLICATION OF THIS CASE STUDY TO:

A. NURSING PRACTICE
This case study will enable nurses especially those assigned in the psychiatric
ward to fully understand how to manage and provide holistic caring care to a client
suffering from panic disorders.

B. NURSING EDUCATION
This case study will be able to fulfill the future student nurses’ hunger to learn
about panic disorders which is very rampant in the world today especially among the
youth. This will help them be aware of the essence of the panic disorder to the person
affected.

C. NURSING RESEARCH
This case study suggests that further research should be done to further
understand the causes, both physiological and psychological, and to understand the
therapies that each person should undergo, since different people with panic disorders
respond to different kinds of therapies.

VII. REFERRAL AND FOLLOW-UP

The conductor of the case study would like to recommend a follow-up on the
client on the new ways he is using in managing anxiety and a follow-up if the client has
learned to be open in expressing his problems, emotions and concerns.

VIII. BIBLIOGRAPHY
A. Keltner, Norman L. et. Al. Psychiatric Nursing. 4th edition. Missouri: Mosby Inc.
2003

B. Videbeck, Sheila L. Psychiatric Mental Helath Nursing. 2nd edition. USA

Lippincott, Williams, Wilkens. 2004

C. Townsend, Mary C. Essentials of Psychiatric Mental Health Nursing. 2nd edition.

F.A. Davis Company. 2005

D. Stuart, Gail W. and Laraia, Michele T. Principles and Practice of Psychiatric

Nursing. 8th edition. Missouri: Mosby Inc. 2005

E. Shives, Louise Rebraca and Isaacs, Ann. Basic Concepts of Psychiatric – Mental
Health Nursing. 5th edition. USA Lippincott, Williams, Wilkens. 2002

CEBU DOCTORS’ UNIVERISTY

College of Nursing
Cebu City
 A PSYCHIATRIC CASE STUDY
ON
PANIC DISORDER

Submitted by: Submitted to:

Erik-Kristian Venancio Y. Husted Miss Ruby Jean Go
BSN III – A Clinical Instructor