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
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,
Brenes, G.A. (2003). Anxiety and Chronic Obstructive Pulmonary Disease: Prevalence, Impact, and Treatment. Psychosomatic Medicine, 65,  Byer, B. & Myers, L.B. (2000). Psychological correlates of adherence to medication in asthma. Psychology, Health & Medicine, 5,
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,
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,
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,
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,
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, Livermore, N., Sharpe, L. & McKenzie, D. (2010). Prevention of panic attacks and panic disorder in COPD. European Respiratory Journal, 35,
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.

18. Any questions?