Too Worried To Breathe

1
Too Worried To Breathe?

• Identifying anxiety and depression in patients
  with COPD and what to do about it

2
Outline

• Why worry about worry
• Prevalence Rates
• Overview of Depression and Anxiety
• Anxiety and COPD
• Anxiety Assessment
• Treatment of Anxiety and Treatment Issues
  Specific to COPD

3
Why worry?

• Presence of anxiety and depression is associated
  with
• More frequent hospital admissions (and GP visits)
• Greater duration of hospitalisation
• Poorer outcomes following emergency treatment
• Increased avoidance of potentially therapeutic
  activities that require exertion
• Inadequate medication use
• Lower reported quality of life irrespective of
  physical symptoms poorer physical and social
  functioning

4
Prevalence

• Symptoms of anxiety and depression are common in
  patients with chronic obstructive pulmonary
  disease (COPD)
• Overlap of symptoms sleep disturbance,
  decreased energy, and shortness of breath
• Anxiety and depression diagnosed in 16-34 of
  patients with COPD, with subclinical symptom
  prevalence as high as 50
• Compared with 10-30 in patients with cancer

5
Depression

• Depressed mood
• Markedly diminished interest or pleasure
• Significant weight loss or weight gain
• Insomnia or hypersomnia
• Psychomotor agitation or retardation
• Fatigue of loss of energy
• Feelings or worthlessness or excessive or
  inappropriate guilt
• Diminished ability to think or concentrate, or
  indecisiveness
• Recurrent thoughts of death (not just fear of
  dying) recurrent suicidal ideation or a suicide
  attempt

6
Anxiety

• Anxiety Disorder due to a General Medical
  Condition
• Generalised Anxiety Disorder (GAD)
• Panic Disorder (with or without agoraphobia)
• Adjustment Disorder

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Anxiety Disorder due to a General Medical
Condition

• Prominent anxiety, panic attacks, or obsessions
  or compulsions.
• Evidence that the disturbance is the direct
  physiological consequence of a general medical
  condition
• Not better accounted for by another mental
  disorder
• The disturbance causes significant distress or
  impairment

8
Generalised Anxiety Disorder (GAD)

• Excessive worry and apprehension, occurring more
  days than not for at least six months.
• This is accompanied by at least three additional
  symptoms in the categories of
• Motor tension e.g. muscle tension, trembling,
  restlessness, fatigue
• Autonomic hyperactivity e.g. shortness of breath,
  rapid heartbeat, dry mouth, cold hands, dizziness
  (but not to the degree of qualifying as panic
  symptoms)
• Vigilance and scanning e.g. feeling keyed up
  all the time, difficulty concentrating, startling
  easily, insomnia or irritability

9
Adjustment Disorder

• Development of emotional and behavioural symptoms
  in response to a significant life change or
  stress.
• Distress exceeds expected levels, given the
  cause, or causes significant impairment in social
  or occupational functioning.
• Usually symptoms resolve within 6 months once
  stressor has ended
• If symptoms do persist (in response to a chronic
  stressor) an alternative diagnoses including
  depression, GAD and panic disorder should be
  considered

10
Panic Attacks

• Discrete period of intense fear or discomfort
  coming on abruptly and peaking within 10 minutes,
  in which four or more of the following symptoms
  are present
• Palpitations, pounding heart or accelerated
  heart-rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or smothering
• Feelings of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, light-headed or faint
• Derealisation (feelings of unreality) or
  depersonalisation (feeling detached from oneself)
• Fear of losing control or going crazy
• Fear of dying
• Numbness or tingling sensations
• Chills or hot flushes

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Panic Disorder

• Recurrent and unexpected panic attacks (for at
  least one month)
• Persistent worry about additional attacks, and
  the implications of attacks or their consequences
  (e.g. losing control, having a heart attack,
  going crazy)
• Significant change in behaviour related to the
  attacks.

12
Agoraphobia

• Anxious about situations from which escape might
  be difficult (or embarrassing), or in which help
  might be unavailable
• Difficult situations often include being at home
  alone, being in a crowd, travelling alone in a
  car
• Avoids any situation in which they might have a
  panic attack, endures it with marked distress, or
  requires a companion to face it.

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Clarks Model of Panic

• Internal/External Perceived Trigger
• Trigger

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Panic in COPD

• Short of breath What if I cant
• Weather breathe?

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AssessmentThe application of traditional anxiety
diagnostic criteria is complicated by respiratory
symptoms

• Physical Symptoms
• unexplained somatic complaints, e.g. heart
  palpitations, headaches, fainting, dizziness
• Hyperventilation
• Muscular tension, especially in shoulders, neck
  and jaw
• Feeling stressed out, keyed up
• Cognitive Symptoms
• Expecting the worst, excessive worry
• Catastrophic thinking, e.g. the world is a dirty
  place, something bad is going to happen
• Behavioural Symptoms
• Avoidance of feared situations
• Easily startled
• Rituals to reduce anxiety

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Assessment (cont.)

• Inquiry into the development of these symptoms
  should cover
• Nature, frequency and intensity
• Rate of onset
• Duration of symptoms
• Recent stressful life events
• Social supports
• Situations
• Anticipation
• Autonomic arousal level

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• Avoidance and ritualised behaviour
• Involvement of others
• History of anxiety disorders
• Family history of anxiety disorders
• Concurrent substance abuse or withdrawal from
  substances
• Duration and intensity of symptoms is usually
  important in distinguishing between normal
  anxiety in the face of a threat, and clinically
  significant anxiety.

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Assessing Severity

• No standardised scales rating severity of anxiety
  symptoms have been validated in the primary care
  setting.
• Self-monitoring scales can indicate the persons
  subjective distress which can be very useful
• SUDs (subjective units of discomfort)
• Level of functional disruption is another
  dimension to consider.

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SUDs

• Use an anxiety thermometer.
• 0 no anxiety, complete calm and relaxation
• 100 very severe anxiety or panic, the worst you
  have ever felt.
• Write down how you feel physically, what thoughts
  and feelings you have at three or four points
  along the scale to give reference points

• 100 ____________
• 90 ______________
• 80 ______________
• 70 ______________
• 60 ______________
• 50 ______________
• 40 ______________
• 30 ______________
• 20 ______________
• 10 ______________
• 0 ______________

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Too Much Worry

• I have trouble getting to sleep because I am
  worrying
• I can be sitting quietly and suddenly become
  short of breath
• I almost always have a nagging worry about when
  Im going to have an episode of difficult
  breathing
• I seem to be getting more and more frightened to
  leave the house
• Id rather stay home so I can avoid being exposed
  to the dangers out there e.g. peoples germs
• Im frightened of getting on elevators,
  airplanes, or bridges and will go out of my way
  to avoid them
• I walk around feeling as if something bad is
  going to happen

21
Too Little Worry

• I frequently overextend myself and pay for it
  with worse symptoms the next day or two
• I try to use as little medication as possible,
  and as little oxygen as possible, even when my
  doctor wants me to use more
• Sometimes I pretend I dont have COPD, even in
  situations when I know it might be important to
  let others know
• When Im feeling hassled by my COPD, I drink
  more alcohol than I should because it lets me
  forget about the COPD

22
Worry Just Right

• There is an ideal level of worry
• Understand you have a chronic and challenging
  illness
• Things you can do that will help or exacerbate
• Fluctuations are normal

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Why Treat Anxiety?
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Treatment Outcome
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Treatment Issues with COPD

• Treatment of choice for panic disorder with
  agoraphobia is CBT
• Traditional techniques include cognitive
  restructuring, interoceptive exposure and
  repeated confrontations of avoided situations
• Need to balance appropriate monitoring with
  hypervigilance
• Focus on improving mobility and targeting phobic
  avoidance
• Anxiety can often co-occur with depression, and
  treatment depression can dramatically improve
  anxiety.

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Treatment of Anxiety in Patients with COPD

• Coping skills
• Education/awareness (self management plans)
• Self help material. Good examples are
• The Anxiety and Phobia Workbook by Edmund Bourne
  (New Harbinger Publications, 1990)
• Living with Fear. Understanding and Coping with
  Anxiety by Isaac Marks (McGraw-Hill, new York,
  1978)
• Relaxation and breathing
• Activity hierarchy aiming to increase activity
• Sleep management skills (SLEEP)
• Monitor progress
• Cognitive behaviour therapy

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SLEEP

• S set a regular bedtime
• L limit use of bed
• E exit bed if not asleep in 15-20 minutes
• E eliminate naps (alternative activity)
• P put your feet on floor same time every
  morning (/- 30 mins)
• Increased activity helps improve regulation of
  sleep

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Pharmacological Treatments

• Antidepressants SSRIs, tricyclic antidpressants
  and low dose benzodiapines can be effective in
  treating anxiety and depression
• Caution with regard to toxicity and effect on
  respiratory function

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Referral

• There is a serious risk of suicide
• Depression is likely
• There are psychotic symptoms
• The diagnosis is unclear and needs further
  evaluation
• The person has limited access to social support
• There is significant co-occurrence of other
  disorders or complex problems
• There are contributing social factors
• The primary health professional feels their
  skills are not appropriate
• The patient requests it
• Symptoms fail to remit

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Feel the Fear and Do it Anyway!