Dr Nicole Livermore MAPS MCHP MCCLP, Senior Clinical Psychologist, Prince of Wales Hospital, South Eastern Sydney
The respiratory ward and clinic at Prince of Wales Hospital provide treatment for people suffering from chronic respiratory diseases. The bulk of both inpatients and outpatients have chronic obstructive pulmonary disease (COPD), a condition caused primarily by cigarette smoking and one of the major causes of disability and death worldwide. In COPD, panic disorder is up to ten times more prevalent than in the general population, and panic attacks and anxiety symptoms are common (Divo et al., 2012).
There are various challenges to be considered in treating panic spectrum psychopathology in COPD – for example, the problem of “controlled breathing” being a “safety seeking behaviour” in CBT for panic disorder, while COPD’s cardinal symptom – worsening shortness of breath on physical exertion (in the context of an eventually fatal illness) – necessitates attention to managing breathing. Modifications need to be made to standard CBT for panic attacks and panic disorder as a result of the nature of respiratory diseases.
A clear cognitive theme emerging from therapy sessions is of catastrophic interpretations about breathing difficulty, as conceptualised in Clark’s (1986) cognitive model of panic e.g. “It feels like I'm going to run out of air and suffocate on the spot”. As a clinical psychologist working in a respiratory ward, it is necessary to, on the one hand, validate people’s suffering in living with an illness that makes “getting a good breath” a distant memory, while on the other hand encourage them to consider that self-management of their breathing could make a difference – that catastrophic interpretations, and panic attacks, are understandable, but not inevitable.
Psychology’s role with COPD patients at Prince of Wales Hospital
A four session CBT program for the treatment of anxiety and panic attacks in COPD, and the prevention of panic disorder, has been developed and evaluated at Prince of Wales Hospital. The program specifically addresses catastrophic interpretations about breathing difficulty. In a randomised controlled trial including 41 people with moderate to severe COPD, the four, one hour CBT sessions were effective in treating existing panic attacks, and preventing the development of panic attacks and panic disorder over an 18 month follow up period (Livermore, Sharpe & McKenzie, 2010).
The program was also associated with a lower number of hospital admissions between the six and 12 month follow-ups in the CBT group compared with the routine care group, and a significant 17% decrease in ratings of shortness of breath (mediated by a change in catastrophic interpretations) when baseline psychophysiological testing was repeated at six month follow up. The latter results have provided the first evidence that a psychological intervention aimed at helping people with COPD to reduce anxiety and manage their breathing could reduce the intensity of shortness of breath as measured by psychophysiological testing (Livermore et al., 2015).
Jill was a 72 year old woman who had been diagnosed with COPD 12 years previously. Her first panic attack had occurred 17 months before referral to clinical psychology, when she had begun to feel very short of breath and light headed one day when walking: “I felt like my breathing could stop and my heart could stop beating”. Her anxiety symptoms had steadily worsened since then. She was experiencing recurrent unexpected and unpredictable panic attacks, and had been avoiding walking alone, bus travel, and elevators for several months. Treatment goals were to reduce anxiety symptoms and specific agoraphobic avoidance behaviours. Treatment started with the four session CBT Preventative and Treatment Intervention for Panic in COPD. Additional sessions were focused on addressing agoraphobic avoidance with a systematic program of exposure to avoided situations (e.g. physical exercise) and sensations. Jill was well motivated to participate, and by the end of 12 sessions of CBT her panic disorder and agoraphobia had resolved. She continued to be symptom free at 12 month follow up and had joined a weekly walking group for people with COPD: “I’ve got my freedom back again.”
Excerpt from Livermore, Sharpe & McKenzie, 2008, p. 626-627.
Further innovations and developments in psychological treatment keep on coming, with the multidisciplinary hospital environment creating a fertile milieu for such developments.
Components of Four Session CBT Preventative and Treatment Intervention for Panic in COPD:
- The person's experience of managing their shortness of breath.
- The stress response, cycle of panic anxiety, and impact on shortness of breath in COPD.
- The use of "pursed lip breathing".
- Home based practice, including breathing monitoring form.
- The use of activity planning and pacing.
- Cognitive therapy – changing unhelpful thinking.
- Home based practice.
- Further activity planning and pacing – the importance of physical activity.
- Further cognitive therapy.
- Home based practice.
- Development of a CBT Based "Personal Good Management Plan".
- Clark, D.M. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 24, 461-470.
- Divo, M., Cote, C., de Torres, J. P., Casanova, C., Marin, J. M., Pinto-Plata, V., Zulueta, J., Cabrera, C., Zagaceta, J., Hunninghake, G., Celli, B., Group, B. C. (2012). Comorbidities and risk of mortality in patients with chronic obstructive pulmonary disease. American Journal of Respiratory and Critical Care Medicine, 186, 155-161.
- Livermore, N., Sharpe, L., McKenzie, D. (2010). Prevention of panic attacks and panic disorder in COPD. The European Respiratory Journal, 35, 557-563.
- Livermore, N., Dimitri, A., Sharpe, L., McKenzie, D. K., Gandevia, S. C., Butler, J. E., 2015. Cognitive behaviour therapy reduces dyspnoea ratings in patients with chronic obstructive pulmonary disease (COPD). Respiratory Physiology & Neurobiology, 216, 35-42.
- Livermore N, Sharpe L & McKenzie D. (2008). Cognitive behaviour therapy for panic disorder in chronic obstructive pulmonary disease: Two case studies. Behavioural and Cognitive Psychotherapy, 625-630.
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