Caring for the High Anxiety Pulmonary Patient

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Caring for the High Anxiety Pulmonary Patient

• Judy Clementson, Ph.D.
• Neuropsychology Department
• Madonna Rehabilitation Hospital

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Overview

• Anxiety and panic
• description and etiology
• Pulmonary patient anxiety
• Risk factors
• Triggers
• Anxiety approaches and interventions
• Management of panic attacks

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What is anxiety?

• A response to anticipated danger

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Components of Anxiety
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Panic Attack vs. Anxiety

• PANIC
• Sudden onset
• Episodic
• More intense experienced as genuinely
  life-threatening

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Development of Panic Attack

• Often, no triggering event is present
• Catastrophic Interpretations Im suffocating,
  Im dying (may be no obvious triggering event)
• Hypervigilance excessive focus on any internal
  feeling or sensation
• Physiological Arousal actual increased RR, HR,
  etc.

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Panic Attacks Consequences

• Safety Behaviors Reliance on other people or
  behaviors that the patient thinks will decrease
  danger, e.g., using the call light constantly,
  calling out, not wanting to be alone, requesting
  suctioning or anxiety medication frequently
• Magical safety thoughts (or superstitious
  thinking) My safety behaviors protect me they
  alone keep me safe.
• Physical arousal increased dyspnea and
  respiration rate, rapid heart rate, weakness,
  nausea due to respiratory status, medical
  factors, or psychological factors

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Mechanism for Anxiety DevelopmentClassical
Conditioning

• Physiologically-based
• Association is formed between dangerous event and
  other factors present at the time of danger
• These factors then trigger anxiety even when
  danger is not present
• Develops easily and is VERY hard to extinguish

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Development Of Behavioral Responses to Anxiety
Operant Conditioning

• Consequences of actions influence the probability
  of repeating the actions
• Behaviors that ? desired consequences (feeling
  safer) increase, e.g., call light use, staying in
  bed actions? anxiety are avoided
• Need to help person feel safe via use of
  approaches described below rather than
  non-adaptive behaviors

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What about anxiety/panic in pulmonary patients?

• Similar to general anxiety
• Physiological symptoms
• Thoughts/emotions
• Response to treatment
• Significantly Different
• Initially triggered by a biological survival
  response that goes awry
• For many, resolves entirely as respiratory status
  improves

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Pulmonary Patient AnxietyExplanatory Models

• Hyperventilation model
• Carbon dioxide hypersensitivity model
• Cognitive behavioral model

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Factors Increasing Anxiety Risk in Pulmonary
Patients

• Genetic predisposition?anxious/timid temperment
• Early learning history
• Substance abuse history
• Recent history of medical and/or other trauma
• CO2 hypersensitivity
• Confusion/dementia

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Epidemiology of Pulmonary Anxiety

• 3x higher in COPD patients than in the general
  population
• Rates are even higher in patients with
  co-morbidities, e.g. heart failure, cancer
• Panic attacks reported by more than 1/3 of COPD
  patients
• Lifetime prevalence of respiratory disease higher
  in people with panic disorder (47) than in other
  psych dx

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Impact of Anxiety on Pulmonary Patients

• Decreased functional status
• Decreased quality of life
• Disease characteristics of COPD
• ?FVC, ?chest symptoms, ?dyspnea
• Frequency of hospital admission for acute
  exacerbations
• Duration of hospital stay twice as long

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Treatment Goals

• Reduction in anxiety intensity and in frequency
  of panic attacks, via
• More adaptive beliefs about safety and
  self-efficacy
• Decreased physiological arousal
• New responses/behaviors to anxiety triggers
• Improved respiratory status

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Approaches/Interventions

• Based on Cognitive/Behavioral and Medical Models
• Core principle
• To decrease anxiety, we must help the patient to
  feel safe, emotionally and physiologically
• This usually requires a relationship of trust,
  built up over time, in addition to specific RT,
  medical and psychological interventions

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Medical Interventions to Decrease Physiological
Symptoms

• Respiratory treatments, vent setting changes, O2
  increase, etc.
• Medications Buspar, antidepressants, limited use
  of benzodiazepams, very limited use of
  neuroleptic medications

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Behavioral Interventions

• Graduated exposure and desensitization
• weaning, exercise
• Pursed lip breathing
• Progressive muscle relaxation
• Imagery
• Music

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Cognitive Interventions Education

• Medical status and safety
• Understand and trust external monitors
• O2, RR
• Anxiety
• worst before the feared event
• Will decrease with breathing, exercise, exposure
  to feared stimulus such as weaning or walking

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Learning Pyramid
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Cognitive Interventions Changing Thoughts/Beliefs

• Cognitive Therapy
• Situation
• Feelings
• Automatic thought
• Cognitive Distortion
• Rational/realistic thought
• Feelings resulting from realistic thought

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Increasing Coping Ability

• Problem-oriented coping vs.
• emotion-focused coping
• Focus on strengths, positives

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Psychological Interventions

• Nurturing attitude
• Low key, calm, reassuring style
• Help patient to stop fighting anxiety
• Respond to all patient questions ask if patient
  has questions

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Panic Attack Approaches

• Learn to identify early warning signs
• Dont fight panic ride the wave
• Learn to talk yourself through it
• Use coping statements during and after
• This is anxiety, not a medical crisis
• I can do this
• This will end. Ill be tired but OK

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Interventions for Cognitively Impaired Patients

• Family education and support
• Emotional support from family and staff
• Distraction
• Deep breathing, if previously learned
• Medications with immediate anxiolytic effects

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Evidence of Treatment Effectiveness

• One 2-hour session of Group CBT with 6 weekly
  follow-up calls
• Pulmonary rehab programs
• Progressive muscle relaxation
• Pursed lip breathing
• Anti-depressants and Buspar
• Benzodiazepams for immediate relieflimit use as
  much as possible

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Summary

• High anxiety pulmonary patients present many
  challenges
• Excellent, effective care is possible when
  knowledgeable, caring RTs work with the patient
• Thank you!