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

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

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

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

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

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

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

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)

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

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

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

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

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

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

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)

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 Therapy 30, 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.

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