Self-help for breathlessness and anxiety

1. Self-help for breathlessness and anxiety Dr Jane Hutton Consultant Clinical Psychologist SLaM and King’s College Hospital

2. Overview • COPD, breathlessness and anxiety • Aims and development of self-help material • Content and current applications • Next steps

3. COPD • Broad term • Narrowing of airways • Breathlessness, cough, phlegm • ~.9m diagnosed, ~2.8m not • Smoking most common cause • Progressive, irreversible, shortens life • …but much can be done to manage

4. Management • Stop smoking • Keep fit and active • Pulmonary rehabilitation • Energy conservation • Breathing and posture training • Diet, hydration, weight management • Avoid irritants and infections

5. Anxiety and its impact • Under-diagnosed and under-treated • GAD and panic disorder much more common than in general population • Anxiety symptoms even more common • 37% had panic attack in last 3 weeks • Anxiety associated with poorer functioning and hospitalisation • Best predictor of quality of life • Anxiety triggered by symptoms predicts catastrophic cognitions and avoidance

6. Anxiety and its impact • Misinterpretations of danger, heightened attention • Experience of panic attacks associated with better knowledge but lower adherence for severe exacerbation • Predicts engagement in rehabilitation • Treatment of anxiety leads to improved QoL and probably improved functioning • Brenes, 2003; Prigatono et al, 1983; Gurney-Smith et al, 2002;Dowson et al, 2004; Hynninen et al, 2005

7. Breathlessness is not dangerous • Common, understandable misconception • Avoidance of exertion leading to maintenance of fears, reduced fitness and low mood • Can be challenged by behavioural experiments and pulmonary rehabilitation • Not desirable to avoid breathlessness altogether • Keeping active and confident will entail some degree of breathlessness

8. Role of CBT • CBT-based interventions can be very beneficial, even in severe COPD • Significantly improved depression and health status and depression and reduced A&E attendance (Howard et al, 2010) • Some other studies show significant benefits in anxiety (e.g. Livermore et al (2010)

9. Aims of self-help booklet • To help clients understand their breathlessness • To manage it better and be less distressed and restricted by it • To reduce the degree to which breathlessness is exacerbated by anxiety • Can stand alone or be guided by health professional

10. Development • Input from service leads in respiratory nursing and physiotherapy • Pilotting with respiratory nurses and physiotherapists, and patients in a pulmonary rehabilitation class

12. Part 1: Understanding • Acknowledge fear is understandable • Give hope and information resources • Explore integrated mind/body model with client’s own examples • Symptom check-list • Check understanding of anxiety, how it can make breathlessness worse, and how it changes over time • Identify key triggers for breathlessness and use problem-solving to address one

13. Part 2: Thoughts and Awareness • Explore frightening and inaccurate thoughts • Discuss how thoughts can lead to distress and avoidance • Discuss thought suppression, distraction and worry time • Introduce strategies for grounding and reducing heightened awareness • Breathing for relaxation • Monitoring anxiety

14. Part 3: Self-care and Confidence • Explore ways of reducing stress levels and increasing activity • Explore ways of explaining condition and enlisting appropriate help from family and friends • Build confidence and strategies for appointments with health professionals

15. Current applications • Low Intensity intervention • Integrated within Lambeth/Southwark pulmonary rehabilitation programme • General feedback: patients responding very well to it and able to take what they need, contents understandable and valuable • Southwark (Talk Health) and other IAPT services

16. Next steps • Freely available on IMPARTS website • Feedback welcome • Evaluation by trainee health psychologist of acceptability, impact on anxiety, cognitions and self-efficacy • Self-efficacy mediates association between lung function and QoL and predicts physical functioning (Kohler et al, 2002; Arnold et al, 2005)

17. References http://www.kcl.ac.uk/iop/depts/pm/research/imparts/K-quick-links/Breathlessness-and-anxiety.pdf Arnold, R., Ranchor, A.V., DeJongste, M.J.L., Koeter, G.H., Hacken, N.H.T.T., Aalbers, R. & Sanderman, R. (2005). The relationship between self-efficacy and self-reported physical functioning in chronic obstructive pulmonary disease and chronic heart failure. Behavioral Medicine, 31, 107-114. Brenes, G.A. (2003). Anxiety and Chronic Obstructive Pulmonary Disease: Prevalence, Impact, and Treatment. Psychosomatic Medicine, 65, 963-970. Byer, B. & Myers, L.B. (2000). Psychological correlates of adherence to medication in asthma. Psychology, Health & Medicine, 5, 389-393. Dowson, C.A., Town, G.I.., Frampton, C. & Mulder, R.T. (2004). Psychopathology and illness beliefs influence COPD self-management. Journal of Psychosomatic Research, 56, 333-340. Gurney-Smith, B., Cooper, M.J. & Wallace, L.M. (2002), Anxiety and panic in chronic obstructive pulmonary disease: The role of catastrophic thoughts. Cognitive Therapy and Research, 26, 143-155. Howard, C., Dupont, S., Haselden, B., Lynch, J. & Wills, P. (2010). The effectiveness of a group cognitive-behavioural intervention on health status, mood and hospital admissions in elderly patients with chronic obstructive pulmonary disease. Psychology, Health & Medicine, 15, 371-385. Hynninen, K.M.J., Breitve, M.H., Wiborg, A.B., Pallesen, S. & Nordhus, I.H. (2005).Psychological characteristics of patients with chronic obstructive pulmonary disease: A review. Journal of Psychosomatic Research, 59, 429-443. Kohler, C.L. Fish, L. & Greene, P.G. (2002). The relationship of perceived self-efficacy to quality of life in chronic obstructive pulmonary disease. Health Psychology, 21, 610-614. Livermore, N., Sharpe, L. & McKenzie, D. (2010). Prevention of panic attacks and panic disorder in COPD. European Respiratory Journal, 35, 557-63. Porzelius, J. Vest, M. &Nochomovitz, M. (1992). Respiratory function, cognitions, and panic in chronic obstructive pulmonary patients, Behavioural Research Therapy30, 75–77. Prigatano, G.P., Wright, E.C. & Levin, D. (1984). Quality of life and its predictors in patients with mild hypoxemia and chronic obstructive pulmonary disease, Archives Internal Medicine,144, 1613–1619.

18. Any questions?