Respiratory Physiology & Neurobiology 216 (2015) 35–42
Contents lists available at ScienceDirect
Respiratory Physiology & Neurobiology journal homepage: www.elsevier.com/locate/resphysiol
Cognitive behaviour therapy reduces dyspnoea ratings in patients with chronic obstructive pulmonary disease (COPD) Nicole Livermore a,b , Andrew Dimitri c,e , Louise Sharpe b , David K. McKenzie c,e,f , Simon C. Gandevia d,e,f , Jane E. Butler e,f,∗ a
Department of Liaison Psychiatry, Prince of Wales Hospital, Sydney, Australia Department of Psychology, University of Sydney, Sydney, Australia c Department of Respiratory Medicine, Prince of Wales Hospital, Sydney, Australia d Department of Neurology, Prince of Wales Hospital, Sydney, Australia e Neuroscience Research Australia, Sydney, Australia f Faculty of Medicine, University of New South Wales, Sydney, Australia b
a r t i c l e
i n f o
Article history: Received 17 December 2014 Received in revised form 25 May 2015 Accepted 27 May 2015 Available online 3 June 2015 Keywords: Inspiratory resistive loads Chronic obstructive pulmonary disease Dyspnoea Cognitive behaviour therapy
a b s t r a c t There is evidence that psychological factors contribute to the perception of increased difficulty of breathing in patients with chronic obstructive pulmonary disease (COPD), and increase morbidity. We tested the hypothesis that cognitive behaviour therapy (CBT) decreases ratings of perceived dyspnoea in response to resistive loading in patients with COPD. From 31 patients with COPD, 18 were randomised to four sessions of specifically targeted CBT and 13 to routine care. Prior to randomisation, participants were tested with an inspiratory external resistive load protocol (loads between 5 and 45 cmH2 O/L/s). Six months later, we re-measured perceived dyspnoea in response to the same inspiratory resistive loads and compared results to measurements prior to randomisation. There was a significant 17% reduction in dyspnoea ratings across the loads for the CBT group, and no reduction for the routine care group. The decrease in ratings of dyspnoea suggests that CBT to alleviate breathing discomfort may have a role in the routine treatment of people with COPD. © 2015 Elsevier B.V. All rights reserved.
1. Introduction The American Thoracic Society has defined dyspnoea as a “subjective experience of breathing discomfort that derives from interactions among multiple physiological, psychological, social, and environmental factors, which may induce secondary physiological and behavioural responses” (Parshall et al., 2012). The impact of psychological factors on dyspnoea perception in chronic obstructive pulmonary disease (COPD) has become a topic of growing interest as the multidimensional nature of dyspnoea has become more evident (e.g. Giardino et al., 2010; Laviolette et al., 2014; Livermore et al., 2008; Vogele and von Leupoldt, 2008; von Leupoldt and Dahme, 2007). Dyspnoea on exertion is the principal symptom of COPD, and occurs in the context of an increasingly disabling, and commonly fatal, illness. COPD patients with
∗ Corresponding author. Margarete Ainsworth Building, Neuroscience Research Australia, Barker St., Randwick 2031, Australia. Tel.: +61 2 9399 1608. E-mail address: [email protected] (J.E. Butler). http://dx.doi.org/10.1016/j.resp.2015.05.013 1569-9048/© 2015 Elsevier B.V. All rights reserved.
panic attacks or panic disorder rate their intensity of dyspnoea in response to inspiratory resistive loads significantly higher than COPD patients without panic and healthy age-matched controls (Giardino et al., 2010; Livermore et al., 2008). This finding is important because anxious and depressive symptoms and disorders are common in COPD, and they increase suffering, morbidity, utilisation of health services, and even mortality (Abrams et al., 2011; Celli and MacNee, 2004; Divo et al., 2012; Kunik et al., 2005; Ng et al., 2007). Once distressed psychological states develop, they may increase ventilation and worsen perceived dyspnoea to a degree that is disproportionate to impairment in lung function, so creating a vicious cycle of increasing disability (Chida et al., 2008; de Voogd et al., 2011; Parshall et al., 2012; Smoller et al., 1996). Cognitive behaviour therapy (CBT) is an effective treatment for anxious and depressive symptoms and disorders in the physically healthy, and there is evidence of its usefulness in patients with COPD (Baraniak and Sheffield, 2011; Butler et al., 2006; de Godoy and de Godoy, 2003; Eiser et al., 1997; Hynninen et al., 2010; Lamers et al., 2010; Livermore et al., 2010a,b). Whether interventions to reduce psychological distress in people with COPD can also influ-
36
N. Livermore et al. / Respiratory Physiology & Neurobiology 216 (2015) 35–42
ence the perception of dyspnoea intensity has not previously been investigated in a psychophysiological study. In a randomised controlled trial of 41 subjects with moderate to severe COPD, Livermore and colleagues (2010) showed that an individually administered brief CBT intervention (4 sessions) effectively treated panic attacks and prevented the long-term development of panic attacks and panic disorder. In the same sample, testing of the perceived size of inspiratory resistive loads was conducted at baseline and at the 6-month follow-up assessment for 31 of the subjects. Initial assessments of the other 10 subjects had to be conducted in another area of the facility, where resistive load testing equipment was not available. We now report whether changes in the perception of inspiratory resistive loads accompanied the CBT intervention. Our hypothesis was that 4 sessions of CBT for the treatment of panic attacks, and prevention of panic attacks and panic disorder, would decrease ratings of dyspnoea magnitude produced by inspiratory resistive loads. 2. Methods 2.1. Participants Of the 41 subjects with COPD who participated in an already reported randomised controlled trial of CBT versus routine care, 31 were recruited to rate their “breathing difficulty” when breathing through inspiratory resistive loads (Livermore et al., 2008). The full sample in the current study comprises those 31 subjects. The ratings provided a measure of their level of perceived dyspnoea before and after CBT intervention. Their mean age was 72 ± 6 years. We collected physiological data during the loaded breaths for which ratings of “perceived effort to breathe” were made. Data collected included inspiratory time, flow, volume, and mouth pressure. Due to equipment failure, some data for 7 patients were lost so that full physiological data were available from a subset of 24 subjects. However, dyspnoea ratings were available for all 31 patients. Subjects were recruited from the outpatient clinics or inpatient ward in the Department of Respiratory and Sleep Medicine at Prince of Wales Hospital, Sydney, Australia (Livermore et al., 2010b). In brief, all subjects were receiving ongoing outpatient treatment, all were being treated with a combination of long-acting 2 agonist/inhaled corticosteroid and a long-acting anticholinergic, and all had lung function that corresponded to the Global Initiative for Chronic Obstructive Lung Disease stages II or III (Pauwels et al., 2001) with forced expiratory volume in 1 s (FEV1 ) post-bronchodilator
Contents lists available at ScienceDirect
Respiratory Physiology & Neurobiology journal homepage: www.elsevier.com/locate/resphysiol
Cognitive behaviour therapy reduces dyspnoea ratings in patients with chronic obstructive pulmonary disease (COPD) Nicole Livermore a,b , Andrew Dimitri c,e , Louise Sharpe b , David K. McKenzie c,e,f , Simon C. Gandevia d,e,f , Jane E. Butler e,f,∗ a
Department of Liaison Psychiatry, Prince of Wales Hospital, Sydney, Australia Department of Psychology, University of Sydney, Sydney, Australia c Department of Respiratory Medicine, Prince of Wales Hospital, Sydney, Australia d Department of Neurology, Prince of Wales Hospital, Sydney, Australia e Neuroscience Research Australia, Sydney, Australia f Faculty of Medicine, University of New South Wales, Sydney, Australia b
a r t i c l e
i n f o
Article history: Received 17 December 2014 Received in revised form 25 May 2015 Accepted 27 May 2015 Available online 3 June 2015 Keywords: Inspiratory resistive loads Chronic obstructive pulmonary disease Dyspnoea Cognitive behaviour therapy
a b s t r a c t There is evidence that psychological factors contribute to the perception of increased difficulty of breathing in patients with chronic obstructive pulmonary disease (COPD), and increase morbidity. We tested the hypothesis that cognitive behaviour therapy (CBT) decreases ratings of perceived dyspnoea in response to resistive loading in patients with COPD. From 31 patients with COPD, 18 were randomised to four sessions of specifically targeted CBT and 13 to routine care. Prior to randomisation, participants were tested with an inspiratory external resistive load protocol (loads between 5 and 45 cmH2 O/L/s). Six months later, we re-measured perceived dyspnoea in response to the same inspiratory resistive loads and compared results to measurements prior to randomisation. There was a significant 17% reduction in dyspnoea ratings across the loads for the CBT group, and no reduction for the routine care group. The decrease in ratings of dyspnoea suggests that CBT to alleviate breathing discomfort may have a role in the routine treatment of people with COPD. © 2015 Elsevier B.V. All rights reserved.
1. Introduction The American Thoracic Society has defined dyspnoea as a “subjective experience of breathing discomfort that derives from interactions among multiple physiological, psychological, social, and environmental factors, which may induce secondary physiological and behavioural responses” (Parshall et al., 2012). The impact of psychological factors on dyspnoea perception in chronic obstructive pulmonary disease (COPD) has become a topic of growing interest as the multidimensional nature of dyspnoea has become more evident (e.g. Giardino et al., 2010; Laviolette et al., 2014; Livermore et al., 2008; Vogele and von Leupoldt, 2008; von Leupoldt and Dahme, 2007). Dyspnoea on exertion is the principal symptom of COPD, and occurs in the context of an increasingly disabling, and commonly fatal, illness. COPD patients with
∗ Corresponding author. Margarete Ainsworth Building, Neuroscience Research Australia, Barker St., Randwick 2031, Australia. Tel.: +61 2 9399 1608. E-mail address: [email protected] (J.E. Butler). http://dx.doi.org/10.1016/j.resp.2015.05.013 1569-9048/© 2015 Elsevier B.V. All rights reserved.
panic attacks or panic disorder rate their intensity of dyspnoea in response to inspiratory resistive loads significantly higher than COPD patients without panic and healthy age-matched controls (Giardino et al., 2010; Livermore et al., 2008). This finding is important because anxious and depressive symptoms and disorders are common in COPD, and they increase suffering, morbidity, utilisation of health services, and even mortality (Abrams et al., 2011; Celli and MacNee, 2004; Divo et al., 2012; Kunik et al., 2005; Ng et al., 2007). Once distressed psychological states develop, they may increase ventilation and worsen perceived dyspnoea to a degree that is disproportionate to impairment in lung function, so creating a vicious cycle of increasing disability (Chida et al., 2008; de Voogd et al., 2011; Parshall et al., 2012; Smoller et al., 1996). Cognitive behaviour therapy (CBT) is an effective treatment for anxious and depressive symptoms and disorders in the physically healthy, and there is evidence of its usefulness in patients with COPD (Baraniak and Sheffield, 2011; Butler et al., 2006; de Godoy and de Godoy, 2003; Eiser et al., 1997; Hynninen et al., 2010; Lamers et al., 2010; Livermore et al., 2010a,b). Whether interventions to reduce psychological distress in people with COPD can also influ-
36
N. Livermore et al. / Respiratory Physiology & Neurobiology 216 (2015) 35–42
ence the perception of dyspnoea intensity has not previously been investigated in a psychophysiological study. In a randomised controlled trial of 41 subjects with moderate to severe COPD, Livermore and colleagues (2010) showed that an individually administered brief CBT intervention (4 sessions) effectively treated panic attacks and prevented the long-term development of panic attacks and panic disorder. In the same sample, testing of the perceived size of inspiratory resistive loads was conducted at baseline and at the 6-month follow-up assessment for 31 of the subjects. Initial assessments of the other 10 subjects had to be conducted in another area of the facility, where resistive load testing equipment was not available. We now report whether changes in the perception of inspiratory resistive loads accompanied the CBT intervention. Our hypothesis was that 4 sessions of CBT for the treatment of panic attacks, and prevention of panic attacks and panic disorder, would decrease ratings of dyspnoea magnitude produced by inspiratory resistive loads. 2. Methods 2.1. Participants Of the 41 subjects with COPD who participated in an already reported randomised controlled trial of CBT versus routine care, 31 were recruited to rate their “breathing difficulty” when breathing through inspiratory resistive loads (Livermore et al., 2008). The full sample in the current study comprises those 31 subjects. The ratings provided a measure of their level of perceived dyspnoea before and after CBT intervention. Their mean age was 72 ± 6 years. We collected physiological data during the loaded breaths for which ratings of “perceived effort to breathe” were made. Data collected included inspiratory time, flow, volume, and mouth pressure. Due to equipment failure, some data for 7 patients were lost so that full physiological data were available from a subset of 24 subjects. However, dyspnoea ratings were available for all 31 patients. Subjects were recruited from the outpatient clinics or inpatient ward in the Department of Respiratory and Sleep Medicine at Prince of Wales Hospital, Sydney, Australia (Livermore et al., 2010b). In brief, all subjects were receiving ongoing outpatient treatment, all were being treated with a combination of long-acting 2 agonist/inhaled corticosteroid and a long-acting anticholinergic, and all had lung function that corresponded to the Global Initiative for Chronic Obstructive Lung Disease stages II or III (Pauwels et al., 2001) with forced expiratory volume in 1 s (FEV1 ) post-bronchodilator
