Role of CBT in COPD management Simon Dupont Hillingdon Hospital

What is stress? Resources STRESS Demands Resources 1. Physical health 2. Skills and experience 3. Emotional make-up 4. Social support 5. Ability to relax Demands Demands of everyday life: daily hassles Life changes (e.g. giving up work, bereavement) Social factors (problems in relationships, loneliness) Health issues (exacerbations of illness) Personal factors (feelings of low self-esteem) Resources STRESS Demands

Physical effects of stress or anxiety

Emotional effects of stress or anxiety

Recognising signs of an exacerbation “Is it my lungs?” “Is it anxiety?” “Am I breathless because there is something wrong with my COPD or is it because I feel tense and anxious?”

CBT cycle

Rationale for CBT It is not events themselves that cause distress but what they mean to us Meaning is influenced by past experiences, past learning, our individual rules and the beliefs that we have developed The way in which we interpret events can be biased and cause undue distress

CBT Model of Depression EVENT (getting dressed) Shortness of Breath THOUGHTS - NATS ‘There is no point in trying’ ‘I can’t even cook a meal’ ‘I can’t even walk to the shop’ BEHAVIOURS Inactivity, increase in maladaptive behaviours e.g. smoking, social withdrawal FEELINGS Discouraged, inadequate, guilty, depressed PHYSIOLOGICAL SENSATIONS Fatigue, sleeplessness, lethargy

Bob’s example… Bob has COPD. That morning he was in a hurry, worrying about being late for an appt. Breathing got worse, increased anxiety “I can’t get my breath back”…further anxiety… Heart pounding, gasping for breath, sick, sweaty, dizzy, out of control “I’m dying”, “It’s getting worse” = PANIC ATTACK Family also frightened, feel helpless – call an ambulance

Negative Automatic Thoughts Just pop into your head Are involuntary Do not always fit the facts Affect how you feel Affect what you do

Unhelpful thinking Catastrophising Generalisation Thoughts about worst possible outcome. “I’m out of breath, my lungs are being damaged, I’m about to die”. Generalisation “ Because I’m short of breath in this shop, I’ll also be short of breath in all shops”. All or nothing thinking “Because I cannot do it as before I will not do it at all”. People give up activities that have become harder Mind reading People think they know what other people are thinking and assume that it is negative without checking it out.

Practical tips- help patient to ID and challenge NATS Identify NATS/images What went through your mind before you started feeling that way? Challenge the thoughts What’s the evidence for and against the thought? Are there any thinking errors? What would happen if the thought remains unchallenged? Is there another way of thinking about this?

Whittington psychology pilot Psychology-led sessions: anxiety and breathlessness living with a breathing problem / managing low mood goal setting managing flare-ups relaxation sleep

Psychology pilot 2 sessions a week for one year Modifying the education sessions to be more interactive with a focus on supporting self-management and building self-efficacy Switch from rolling programme to stop-start Psychologist attended assessments and the PR group once a week Psychologist offered individual therapy to any patients showing high levels of distress or other potential barriers to completion

Conclusions of Whittington Addressing psychological barriers to attendance at PR may improve completion rates Improving completion is important in reducing future hospital resource usage Targeting self-efficacy (mastery) in the context of PR may be a primary factor in improving self-management skill and completion of PR

Combining PR & CBT Complete PR Issues with attendance at PR/ freq A&E attenders/would benefit from additional input for anxiety or depression Offer psychology input. Complete alongside PR or rejoin PR Accept and start PR Invite to PR If anxious or depressed, frequent A&E attenders, offer psychology input Complete PR Complete psychology sessions then offer PR

How to assess - starter for ten Do you think anxiety has contributed to any of your hospital admissions?

Assessment - anxiety

Assessment - depression

Open Style of Consultation BATHE technique - Lieberman & Stuart 1993 Background – what’s going on in your life? Affect – how do you feel about this? Trouble – what troubles you about that? Handling – how are you handling that? Empathy – that must be difficult for you

The COPD manual - what is it? ‘Guided self-help’: Client works through programme in their own time at home – guided by facilitator Focuses on psychological issues in COPD and self-management behaviours (CBT) Management of SOB/panic and prevention of A&E attendance 5 weeks: home visit to start programme, T/C wk 3 & 6 The COPD Breathlessness Manual Breathe better, feel better with this five week manual designed to help you manage chronic obstructive pulmonary disease (COPD) and help you feel more in control of breathlessness

Total number of A&E attendances 12 months pre and 12 months post Number Time 43% reduction in A&E attendances in the COPD manual group vs a 10% increase in the BLF booklets group.

Total number of hospital admissions 12 months pre and 12 months post 63% reduction in hospital admissions in the COPD manual Hospital bed days reduced from an average of 1.6 days 12 months pre, to an average of 0.5 days 12 months post.

Changes in Anxiety and Depression over time Anxiety changes over time Depression changes over time HAD scores HAD scores Time Time

Websites By Chris Williams: www.livinglifetothefull.com (for users) www.fiveareas.com (for practitioners) From NHS Choices website: www.fearfighter.com

Books on Prescription http://readingagency.org.uk/about/BoP%20core%20booklist%20with%20copyright.pdf