Nurses can take on the difficult role of identifying and managing panic disorders in COPD
In this article…
- COPD patients’ experiences of comorbid anxiety
- Causes of comorbid anxiety
- Impact of panic disorders on patients’ lives
- How individuals can manage these disorders
Thomas Willgoss is doctoral researcher; Abebaw Yohannes is reader in physiotherapy; Juliet Goldbart is professor of developmental disabilities; Francis Fatoye is senior lecturer in physiotherapy; all at the department of health professions, faculty of health, psychology and social care, Manchester Metropolitan University.
Willgoss T et al (2011) COPD and anxiety: its impact on patients’ lives. Nursing Times; 107: 15/16, early online publication.
Background Anxiety is a common comorbidity in people with chronic obstructive pulmonary disease (COPD) but its identification and management are often insufficient.
Aim To explore the experience of living with and managing comorbid anxiety and COPD from a patient’s perspective.
Method The study followed a qualitative approach. In-depth interviews were carried out with 14 patients who had COPD.
Results Participants believed anxiety had a significant impact on their quality of life. It made them feel isolated and caused them to avoid social occasions and daily activities. Identifying anxiety was a challenge because of the overlap in the symptoms of anxiety and those of COPD, and the side-effects of medication.
Conclusion Nurses can play a vital role in screening and managing anxiety, and educating people in strategies to prevent episodes of panic.
Keywords: COPD, Comorbid anxiety, Panic attacks
- This article has been double blind peer reviewed
5 key points
- Anxiety in patients with COPD can be difficult to identify due to medication side-effects and because the symptoms of both conditions overlap
- Nurses can play a vital role in screening and referring people with suspected anxiety disorders
- Management techniques such as breathing control and distraction can be effective and should be taught to those who may be experiencing anxiety
- People with panic disorders can experience periods of extreme fear and may require significant support and guidance to lead a normal life
- Pulmonary rehabilitation can help to break the downward spiral of deconditioning
Anxiety is a common comorbidity in people with chronic obstructive pulmonary disease (COPD), but its identification and management are often inadequate.
There has been little research exploring the experiences of people with COPD who suffer from anxiety. However, investigating what it is like to have a panic disorder from a patient’s perspective can provide an insight into the causes and impact of comorbid anxiety, which will help health professionals to support and manage this condition.
COPD is a progressive respiratory disorder characterised by airflow obstruction. Recurrent symptoms include a cough, sputum production, breathlessness and impaired exercise tolerance (Currie and Legge, 2006).
The disabling nature of the condition can severely affect patients’ quality of life and mental health (Garrido et al, 2006). Psychiatric comorbidity is common in patients with COPD, more so that in other respiratory diseases, such as pulmonary tuberculosis (Aydin and Ulusahin, 2001).
Anxiety disorders seem to be particularly common among people with COPD, exceeding their prevalence in the general population and in people with many other long-term conditions (Vögele and von Leupoldt, 2008). In a recent review of the prevalence of anxiety, we found as many as 74% of people with COPD may have a clinically significant level of anxiety (Yohannes et al, 2010).
Comorbid anxiety in people with COPD is associated with decreased functional status and decreased quality of life (Di Marco et al, 2006). People with COPD and comorbid anxiety may also use health services more, because they have an increased risk of exacerbations and readmissions (Laurin et al, 2009).
The management of anxiety in people with COPD is often insufficient. One study found only one quarter of people with COPD and moderate-to-severe anxiety were receiving relevant interventions (Kim et al, 2000).
This may be due to a lack of awareness among health professionals, and because it is difficult to identify anxiety in the first instance. One problem is the potential confusion in distinguishing between symptoms of anxiety and those of the respiratory disease (Yohannes et al, 2010). Many scales used to screen for anxiety include somatic measures of anxiety, which can be easily confused with the somatic symptoms of COPD, such as breathlessness and heart palpitations (Fig 1).
Despite the negative impact of anxiety on quality of life and healthcare usage, there has been little research exploring the experience and impact of anxiety among people with COPD. One study examining the experiences of living with the condition highlighted anxiety and panic as particularly distressing symptoms (Barnett, 2005). However, there has been virtually no research exploring the actual experience of living and coping with panic disorders from a patient’s perspective.
We used a qualitative approach to explore patients’ experiences of living and coping with symptoms of anxiety alongside COPD.
We collected data through in-depth interviews. The interviewer – who had no previous contact with participants –explained the purpose of the research and the criteria required to take part in the study to patients at pulmonary rehabilitation and community support groups. To take part in the study, individuals needed to have a primary diagnosis of COPD, have self-reported symptoms of anxiety and to be able to describe their experiences.
The study was approved by the North West-12 Lancaster NHS Research Ethics Committee and the ethics committee of Manchester Metropolitan University.
Once we had obtained written, informed consent, individual interviews were conducted at participants’ local outpatient clinics (n=5) or their homes (n=9).
Data was collected from a sample of 14 COPD patients. The study participants were recruited from pulmonary rehabilitation groups (n=6) and Breathe Easy community support groups (n=8) in the north west of England. The participants recruited from pulmonary rehabilitation groups were all undergoing an eight-week programme of twice-weekly rehabilitation incorporating exercise and education components. The remaining participants were members of the Breathe Easy support network, a regional network of support groups supported by the British Lung Foundation.
The participants were five men and nine women aged 43-76 years. Four were living alone at the time of the study, nine lived with their spouse and one lived with an older parent. On average, participants had been diagnosed with COPD for six years and had a smoking history of 20 pack years (a pack year equates to smoking 20 cigarettes per day for one year).
We recorded interviews digitally then transcribed them verbatim. Each transcript was read and reduced into manageable chunks using an open-coding scheme, which organised data into categories.
The data was analysed based on a “framework analysis” approach (Kreuger 1994); this uses a thematic approach, and also allows themes to develop both from research questions and narratives of research participants (Rabiee, 2004). Once we had identified organising themes, these were reported back to participants through a process of informal member checking. This involved verifying the researcher’s interpretations of the data with participants to ensure the validity of themes.
Following data analysis, we identified four organising themes: causes; experiences; impact; and management of anxiety.
Causes of anxiety
Participants felt their feelings of anxiety were the result of disease-related worries. They were well informed about their disease and had interacted with others who had more advanced COPD.
Participants expressed their concerns about future disability, particularly on the possibility of needing regular supplementary oxygen. For many, the sudden impact of their COPD and the related deterioration left them feeling anxious about the future. One participant noted: “It has been very sudden and, to be honest with you, it is no good saying I am not worried about it because I am.”
Participants described both general feelings of anxiety and more acute episodes of intense anxiety (panic attacks). For some, these attacks were the result of breathlessness, often due to overexertion. “I don’t know whether it was the exertion of a big meal and getting in and out of the car and walking up the drive but, by the time I got in, I was absolutely gasping. And the more I gasped, the more panicky I got and the worse it got,” said one participant.
For many participants, panic attacks were closely linked with breathing and they described this breathing-anxiety relationship as a vicious cycle. Episodes of panic were often preceded by breathlessness, which was worsened by subsequent feelings of panic. This cycle was often made worse because participants were confused between their symptoms of anxiety, breathlessness and the side-effects of medication.
For others, panic attacks were not related to breathlessness but were idiopathic in nature. These events often occurred without warning, particularly when alone or in bed at night. Participants also described how they became anxious in relation to their medication. For some, being without what they deemed “life-saving medication” was enough to trigger a panic attack. As one participant said: “It is a fear of being without medication that I think causes me panic attacks.”
Experiences of anxiety
Episodes of panic were the focus of participants’ recollections and were described in vivid detail.
They talked of a sensation of losing control during these episodes, which resulted in feelings of helplessness. They felt that panic had taken control of their body, yet they were fully aware of their predicament and powerless to control it. Some experienced particularly unpleasant somatic symptoms during panic attacks, including profuse sweating and incontinence.
Participants found these experiences extremely traumatic. They talked of how they felt intense fear because they felt helpless and were unable to regulate their breathing. One said: “You can’t calm yourself down to get a breath. It is so terrifying that you can’t.”
Sometimes participants treated these experiences as near-death events, believing their inability to breathe was a sign they may suffocate. Some described the experience of a panic attack as a sensation of feeling trapped. These claustrophobic feelings were interpreted with reference to difficulties in breathing. “It is like the walls are closing in and the closer they get the less you can breathe,” said one.
Participants felt these experiences had a long-term impact in that they were frequently revisited in the form of flashbacks. For some, flashbacks to previous panic attacks acted as a trigger for further attacks in a vicious cycle of events.
Impact of anxiety
Participants generally felt that anxiety had a significant impact upon quality of life.
Those who linked their anxiety to breathlessness found that avoiding potential breathlessness had a significant impact on their lives. They said they had become fearful of breathlessness as it was felt to be a precursor to a panic attack. Avoiding exertion was felt to be the only option, and this had an impact on their day-to-day lives.
“Cleaning windows, doing the gardening, exercising the dog, walking a distance or up a hill – it gets eroded bit by bit because of your fear of being breathless and being caught out and there being no one to help,” said one participant.
Having to constantly plan daily activities to avoid breathlessness was a source of frustration. Most participants felt they planned too much and that this limited their ability to participate in social and leisure activities. Planning was seen as a way of ensuring control over their lives, but they felt they worried needlessly about trivial things. In an attempt to avoid panic attacks by planning ahead, they experienced underlying worry about what may go wrong.
Participants also believed their anxiety affected family and friends. They felt it made them irritable and awkward to be around, and they also believed their panic attacks were distressing for their families to witness.
There was a general consensus that anxiety caused isolation. Some felt other people did not understand the impact that anxiety had upon them, while somatic symptoms, such as incontinence and sweating, made them feel embarrassed and made them avoid social situations. Some participants rarely left their homes and were effectively housebound.
Management of anxiety
Participants felt that failure to identify anxiety, particularly panic, was the most important barrier to effective management. Some said they had lived for years with anxiety but had not been aware of it. Sometimes they had confused their panic attacks with acute exacerbations of COPD, resulting in needless hospital admissions. They agreed that identifying episodes of anxiety was a challenge because of the overlap in the symptoms of anxiety and COPD, and the side-effects of medication.
Some participants said they had learnt to recognise the difference between anxiety and an exacerbation through self-management and close monitoring of their symptoms. Although they felt it took a period of adjustment to learn to recognise their anxiety, they agreed that health professionals played an important role in this. Nurses, community psychologists, GPs and physiotherapists were seen as playing a valuable role in helping participants to identify whether they were experiencing anxiety and, if so, how to manage their symptoms. In particular, community nurses had recognised that several participants may be experiencing anxiety and had changed their lives by providing support and education, and referring them for further help.
Rehabilitation was felt to be an important management strategy. Thirteen participants had done or were doing pulmonary rehabilitation and believed increasing their exercise tolerance had enabled them to tolerate increased levels of breathlessness and learn the difference between activity-induced breathing and anxiety-related breathing.
Participants described anxiety management strategies that they felt had enabled them to control their anxiety and to prevent episodes of panic. Breathing exercises were seen as particularly useful for panic, especially taking deep, slow breaths and regulating the rate of breathing.
Others found focusing was a successful strategy for managing panic. This appeared to be particularly useful in those whose panic was idiopathic and not caused by breathlessness from overexertion.
Participants found they could control their panic by focusing on an object in the room or by counting.
This study gives an insight in to the challenges of living with COPD and comorbid anxiety. Participants recounted that anxiety, particularly in the form of panic, was an extremely unpleasant and potentially life-changing experience.
The causes of anxiety in people with COPD were closely linked to their respiratory disease. Alongside the expected disease-related worries, participants highlighted the link that exists between breathing and anxiety.
Through the narratives of people with late-stage COPD, Bailey (2005) found anxiety may be a sign of acute breathlessness rather than a result of it. These interviews indicate that, for some people with COPD, anxiety – particularly panic attacks – may be regarded as a sign of breathlessness, as Bailey proposed.
There also appears to be a group of people with COPD who experience panic attacks that begin spontaneously and are not necessarily triggered by breathlessness. These individuals appear to fit the more traditional view of panic, which has a sudden onset, with rapid breathing as a symptom (Bourne, 2005).
Nurses can play a vital role in identifying those who may be suffering anxiety. There is evidence to suggest that over time, people with respiratory disease can accurately identify the severity of an exacerbation based on their anxiety level (Janson-Bjerklie et al, 1992). For these individuals, nurses may include anxiety as an indicator of illness severity to determine the support and care that may be required.
The vicious cycle of breathlessness and anxiety described by participants in this study fits with the conceptualised “dyspnoea-anxiety-dyspnoea cycle” relationship outlined by Bailey (2005), which suggests patients’ emotional response to breathlessness exacerbates their perception of breathlessness. This cycle can be illustrated by the cognitive-behavioural model of dyspnoea, hyperventilation and anxiety (Fig 2) (Smoller et al, 1996). This positive feedback cycle states that individuals may misinterpret physical sensations such as dyspnoea, leading to anxiety, further autonomic arousal and increased dyspnoea.
Evidence from this study suggests anxiety has a significant impact on daily living in the form of incessant planning, avoidance of activities and isolation. This may help to explain why those with anxiety perform so poorly on measures of quality of life and functional status (Di Marco et al, 2006). Participants described how they avoided breathlessness, which was seen to be a trigger for panic attacks. It is likely these individuals will experience the downward spiral of deconditioning associated with avoidance of exertion, leading to further decreases in tolerance to exercise and breathlessness (Fig 3).
In such cases, pulmonary rehabilitation should be recommended. By repeatedly exposing the person to breathing discomfort under safe, monitored conditions, patients may be desensitised to the fear associated with sensations of dyspnoea (Carrieri-Kohlman et al, 1996). Participants in this study highlighted how prompt referral to rehabilitation or specialist services can be an important step towards breaking this deconditioning cycle.
This study also confirms that confusion is experienced in differentiating between symptoms of anxiety and those of COPD. Participants’ experiences showed how unnecessary hospital admissions can occur as a result of misinterpreted symptoms. This may help to explain the increased risk of readmission associated with comorbid anxiety (Gudmundsson et al, 2005).
The importance of identifying anxiety promptly cannot be overestimated and nurses can play an important role in screening those who may be suffering from comorbid anxiety. For this group, screening should focus on the non-somatic elements of anxiety, such as fear, rather than somatic symptoms such as breathlessness, which can be confused with the symptoms of COPD (Fig 1). In the absence of a validated respiratory-disease specific screening tool, scales such as the Hospital Anxiety and Depression scale or the Geriatric Anxiety Inventory may prove most appropriate.
The study also revealed simple yet effective management strategies employed by participants. Breathing control and focusing are learnt techniques that can help to manage episodes of acute anxiety. These techniques are regularly taught as part of rehabilitation, but few people are enrolled on such programmes as a part of their management. Nurses can play an important role in the educating and demonstrating these management strategies.
One limitation of this study was its small sample size. But we believe the participants are representative of a typical outpatient population in terms of age, sex, years since diagnosis and household situation. We also feel this study captured a fair representation of patient experiences, as interviews continued until no new themes emerged.
Anxiety is a common and distressing comorbidity among people with COPD. Panic attacks are particularly traumatic experiences that can have a long-term detrimental impact upon the quality of life of COPD patients and their families.
Nurses can help patients by screening for and managing anxiety, and educating them in simple, effective strategies to control and prevent panic episodes. NT
Aydin IO, Ulusahin A (2001) Depression, anxiety co-morbidity, and disability in tuberculosis and chronic obstructive pulmonary disease patients: applicability of the GHQ-12. General Hospital Psychiatry; 23: 2, 77-83.
Bailey PH (2005) The Dyspnea-Anxiety-Dyspnea Cycle – COPD patients’ stories of breathlessness: “It’s scary/when you can’t breathe”. Qualitative Health Research; 14: 6, 760-778.
Barnett M (2005) Chronic obstructive pulmonary disease: a phenomenological study of patients’ experiences. Journal of Clinical Nursing; 14: 7, 805-812.
Bourne E (2005) The Anxiety and Phobia Workbook. Oakland, CA: New. Harbinger Publications.
Carrieri-Kohlman V et al (1996) Exercise training decreases dyspnea and distress and anxiety associated with it. Chest; 110: 6, 1526-1535.
Currie GP, Legge JS (2006) ABC of chronic obstructive pulmonary disease: diagnosis. BMJ; 332: 1261-1263.
Di Marco F et al (2006) Anxiety and depression in COPD patients: the roles of gender and disease severity. Respiratory Medicine; 100: 1767-1774.
Garrido PC et al (2006) Negative impact of chronic obstructive pulmonary disease on the health-related quality of life of patients: results of the EPIDEPOC study. Health and Quality of Life Outcomes; 4: 31-39.
Gudmundsson G et al (2005) Risk factors for rehospitalisation in COPD: role of health status, anxiety and depression. European Respiratory Journal; 26: 414-419.
Janson-Bjerklie S et al (1992) Clinical markers of asthma severity and risk: the importance of subjective as well as objective factors. Heart and Lung; 21, 265-272.
Kim HF et al (2000) Functional impairment in COPD patients: the impact of anxiety and depression. Psychosomatics; 41:6, 465-71
Krueger RA (1994) Focus Groups: a Practical Guide for Applied Research. Thousand Oaks, CA: Sage Publications.
Laurin C et al (2009) Chronic obstructive pulmonary disease patients with psychiatric disorders are at greater risk of exacerbations. Psychosomatic Medicine; 71: 6, 667-674.
Rabiee F (2004) Focus-group interview and data analysis. Proceedings of the Nutrition Society; 63: 4, 655-660.
Smoller JW et al (1996) Panic anxiety, dyspnea, and respiratory disease. Theoretical and clinical considerations. American Journal of Respiratory and Critical Care Medicine; 154: 1, 6-17.
Vögele C, von Leupoldt A (2008) Mental disorders in chronic obstructive pulmonary disease (COPD). Respiratory Medicine; 102: 5, 764–773.
Yohannes AM et al (2010) Depression and anxiety in patients with chronic heart failure and chronic obstructive pulmonary disease: prevalence, relevance, clinical implications and management principles. International Journal of Geriatric Psychiatry; 25: 12, 1209-1221.