Behau.Res.Thu. Vol.30,No. I,pp.75-77,1992

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Respiratory

function,

Copyright 0

cognitions,

and panic in chronic obstructive patients

JAMESPORZELIUS,‘* MARIANNE VESTS and

1991 Pergamon Press plc

pulmonary

MICHAEL NOCHOMOVITZ~

’ University of Rochester,

School of Medicine and Dentistry, Pain Treatment Center, 300 Crittenden Boulevard, Rochester NY 14642 and ‘Pulmonary Treatment Center, Department of Medicine, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, Ohio, U.S.A. (Received 29 January 1991)

Summary-The present study investigated the relationship between respiratory function, catastrophic thoughts about anxiety, and panic in 48 Chronic Obstructive Pulmonary Disease (COPD) patients. During a routine office visit which included respiratory function tests (Forced Vital Capacity, FVC; Forced Expiratory Volume-first second, FEV,) patients completed a battery of questionnaires which assessed history of panic, days with shortness of breath, general activity level, agoraphobic cognitions, perception of bodily sensations, anxiety and depression. Thirty-seven percent of the sample reported experiencing a panic attack. Subjects showed a significant impairment in respiratory functioning. Patients with a history of panic did not differ from those who had not experienced panic on demographic, physiologic, or activity variables. Patients who experienced panic reported significantly more agoraphobic cognitions and greater concern with bodily sensations than did patients who did not experience panic. INTRODUCTION

Biopsychosocial models of panic which propose that panic results from a cognitive reaction to specific physical sensations (Clark, 1986; Beck, 1987) have spurred a great deal of recent research. A number of innovative studies have provided support for this theoretical formulation in samples of panic patients and healthy individuals (Salkovskis & Clark, 1990; Holt & Andrews, 1989; Rapee, Mattick & Murrell, 1986). COPD patients represent a population whose physical condition presents them with chronic or chronic-episodic exposure to those physiological sensations associated with the onset of panic (e.g. shortness of breath, palpitations, sweating, faintness, dizziness, lightheadedness, numbness or tingling sensations, flushes, trembling or shaking). Thus, they would be expected to have greater opportunity to pair these sensations with cognitive reactions that could lead to severe anxiety or panic. As a result, these patients may exhibit a higher incidence of panic attack than would be expected in the general population. There have been few systematic, empirical reports of the incidence of panic and anxiety in patients suffering with COPD. The few reports that have evaluated psychological problems in this population have provided some evidence that this is a population at risk. Agle and Baum (1977) reported that, of 23 patients selected for a pulmonary rehabilitation program, 22 were determined by psychiatric assessment to display symptoms of anxiety sufficient to interfere with their performance in the program. In another study, psychiatric interview was used to diagnose panic and other anxiety disorders in 34% of 50 consecutive patients with chronic airflow obstruction admitted to a respiratory unit (Yellowlees, Alpers, Bowden & Ruffin, 1987). These studies provide evidence that anxiety and panic may be significant problems in a substantial portion of COPD patients. The present study attempts to extend these findings by applying an objective measure of panic, and provides further investigation into, and assessment of, those factors which may be responsible for a high incidence of anxiety in this patient population. The cognitive theories mentioned above would suggest that patients who experience catastrophic cognitions in addition to the physiological sensations associated with COPD will be more susceptible to panic. This postulation has been supported by studies which have demonstrated that information expected to alter catastrophic cognitions can produce positive or negative changes in affect in Ss’ response to hyperventilation (Salkovskis & Clark, 1990) and can reduce the frequency of panic in claustrophobic patients exposed to a feared stimulus (Rachman, Levitt & Lopatka, 1988). While a number of studies have tested these theories in patients presenting with panic attack, COPD patients present the opportunity to investigate the relationship of catastrophic cognitions, physical symptoms, and panic in a population whose presenting problem is respiratory dysfunction (physical symptoms) rather than panic. This opportunity may enhance our knowledge about the relationships of cognitions, physical symptoms, and panic, and may provide us with this information in a patient population which presents a significant challenge for treatment efforts. The present study investigates the hypothesis that COPD patients with a history of panic, experience a greater number of catastrophic thoughts regarding the results of physical symptoms and anxiety than do COPD patients who do not experience panic. Further, we investigate whether respiratory function differs for those patients who panic and those who do not, anticipating that the degree of impairment in respiratory function is not related to panic while catastrophic cognitions are. Finally, the present study examines the perception of bodily sensations hypothesizing that panickers will report more attention to bodily sensations regardless of their objective physiological status. METHOD

Subjects

Data were collected from 48 COPD patients (27 male, 21 female, mean age = 66.7) who were in treatment at the University Pulmonary Treatment Center, University Hospitals of Cleveland. Ss all carried current diagnoses of COPD *Author for correspondence. 75

CASE HBTORIESAh13 SHORTER~~U~ICATIO~

16

Table I. Respiratory function and panic

Panic Measure

X

SW

EVC

87.44

FEV

58.72

18.08 25.55

No panic ____~ X SW 84.70 50.33

19.56 22.17

Table 2. Shortness of breath. activitv level and Dank

Panic Comparison

Measure

F(2.42)= 0.714 P = 0.495

SOB MP13

X

No panic

SW

X

SD

4.667 2.765 4.539 2.832 2.723 0.888 2.379 0.901

Comparison

t(42) = -0.15, NS t(41) = - 1.22,NS

(chronic bronchitis n = 4, asthma n = I, emphysema n = 8, or combinations of these diagnoses n = 29). Patients were currently in treatment and attended regular follow-up visits in the clinic every 4-6 weeks. Measures and procedure

During a routine office visit, Ss completed a battery of questionnaires prior to receiving scheduled medical tests and treatments. Questionnaires included measures of psychological distress, catastrophic cognitions, ccmcern with perception of body sensations, and physical functioning, Ss were grouped as ‘panic’ and ‘no panic’ based upon response to the frequency measure of the Mobility Inventory for Agoraphobia (Chambless, Caputo, Jasin, Gracely & Williams, 1985). This consists of a precise, four-stage definition of panic (high anxiety, body reactions, temporary cognitive impairment, and a desire to escape or flee the situation) followed by self-report of frequency of panic. This measure was modified to obtain history of experience of panic attack, “Have you ever experienced a panic attack?” and frequency within the past 3 weeks, rather than obtaining frequency in the past 7 days. Centerfor Epidemiologic Studies-Depression scale (CES-D). This is a 20-&m scale which assesses frequency of symptoms on a 4”point Likert scale (Radloff, 1977). State-Trait Anxiety Znvenfory, sfate subscale (STAZ-S). This is a self-report measure of anxiety developed by Spieiberger, Gorsuch and Lushene (1970) which has been well validated. Agoraphobic Cognitions Questionnaire (ACQ) and Body Sensations Questionnaire (BSQ). Questionnaires developed by Chambless, Caputo, Bright and Gallagher (1984). to assess fear of fear among agoraphobics. Scale scores are averages of items rated 1-5. ~ait~dimens~onal Pain inventory, general activity subscale (‘PZ-3). The MPI is an assessment tool constructed by Kerns, Turk and Rudy (1985) for assessment of functioning in chronic pain patients. Scale 3 contains 19 items describing typical daily activities. Ss indicate frequency of participation in these activities from &-never, to bvery often. Forced Vital Capacity (FVC) and Forced Expiratory Volume-j%st second (RW,}. Measures of respiratory function were assessed by an exercise physiologist and a pulmonary physician using spirometry. Arterial blood gas analysis. Blood gas measures were recorded from a subset of the patient sample who received this test as part of their scheduled medical evaluation. Analysis included assessment of pH, pCO,, ~0, and HCO,. Additionally, demographic data were obtained from Ss on a self-report questionnaire which included an assessment of patients’ experience of shortness of breath “In the past week, how often have you experienced shortness of breath? -.

number of days (O-7)“.

RESULTS Ss demonstrated significant impairment in pulmonary function. Mean Forced Vital Capacity (FVC) was 85.7% of predicted, mean Forced Expiratory Volume, first second (FEV,) was 53.8% of predicted. Ss reported experiencing shortness of breath an average of 4.6 days per week with 47% of the sample reporting daily experience of shortness of breath. Thirty-seven percent of the sample reported having experienced a panic attack. Multivariate analysis of variance was used to identify differences in respiratory functioning (FVC, FEV, ) between the panic and no panic groups. The results of this analysis (Table 1) reveal that the groups did not differ on these measures of physical status. ~nde~ndent r-tests showed no differences between panic and no panic groups on self-report of days with shortness of breath, or in general daily activity (Table 2). Multivariate analysis of variance was also used to investigate group differences on emotional distress. No differences were observed on measures of anxiety and depression (Table 3). Finally, multivariate analysis of variance revealed s~gni~cant differences between the groups on measures of catastrophic cognitions (ACQ) and perceptions of bodily sensations (BSQ) (Table 4). Several correlational analyses were performed to explore the relationships between perception of bodily sensations as measured by the BSQ and frequency of shortness of breath and respiratory function (Table 5). These analyses revealed no correlations between SSQ scores and FEV, , WC, and frequency of shortness of breath. Additio~l~y, fourteen of the Ss received arterial bfood gas analyses as a part of their scheduled medical evaluations. Analyses revealed no s~gn~~~nt correlations between the BSQ and blood gas levels for pH, pC02, pC$,,or HCO,, suggesting that BSQ score reflects acognitive interpretation rather than a direct reflection of physiological, respiratory status. DISCUSSION These data reveal that COPD patients, who experience impaired respiratory functioning and shortness of breath, were very likely to experience panic. However, this incidence of panic may not be greater than that in the general population. Norton, Harrison, Hauch and Rhodes (1985), and Norton, Donvard and Cox (1986) have presented data from non-clinical, student populations who report 35 and 36% incidence of panic within the past year. Table 4. Cog&ions and panic

Table 3. Psychological distress and panic Panic

No panic

Measure

2

SD

R

SD

CES-W

16.4

10.04

12.46

9.11

STAI-S

43.6

9.79

39.18

il.27

Panic Comparison F(2,34) = 0.82 P = 0.449

Measure ACQ

r 1.584

SD 0.530

BSO

1.910

0.745

No panic

x 1.182

1.048

SD 0.294 0,616

Comparison F(2,36) = 8.31 P = 0.001

Table 5. Body sensations Correlations MeWIre

BSQ

and respiratory

function

FEV,

FVC

SOB

0.0636 (39) NS

-0.1013 (39) NS

0.0931

Table 6. Body sensations Correlations Measure

BSQ

(40) NS

and blood gasses

PH

PC%

PO,

HCO,

0.0781 (14) NS

0.1791 (14) NS

-0.1375 (14) NS

0.2691 (13) NS

The present results also suggest that the transition from physical sensations to panic is associated with agoraphobic cognitions, and not with degree of respiratory impairment, or with level of general anxiety or depression. These results provide further evidence for the role of cognitive factors in the occurrence of panic. While all Ss experienced the physiological sensations associated with panic, only 37% experienced panic attacks and these Ss indicated significantly higher frequency of fear-provoking thoughts (higher ACQ and BSQ scores). While panic patients reported more concern with bodily sensations, they did not report feeling more shortness of breath, and scores on the BSQ were not correlated with objective measures of physical status (FEV,,FVC, blood gas levels). This is consistent with findings in non-clinical Ss which suggest that they experience the same physical symptoms as panic patients but do not respond to these symptoms with increased anxiety (Rapee, Antis & Barlow, 1988). These are particularly important findings for COPD patients who must continue to be subjected to the physiological symptoms associated with this disorder. Since these patients suffer from chronic compromised respiratory function, the cognitive factors have a uniquely significant role. The physiological sensations associated with COPD are generally chronic, often progressive, and may trigger more severe problems. Catastrophic interpretations of body sensations cannot necessarily be termed ‘misinterpretations’, since the hyperventilation and panic which can result from these cognitions can indeed produce the health risk suggested by the catastrophic thoughts. Since the physiological sensations are not likely to be eliminated, cognitive modification is an important treatment option for these patients. This treatment modality faces some unique challenges in this patient population since treatment cannot consist of selective exposure to the bodily sensations which are chronic, or to hyperventilation which may be hazardous. Data from the present study suggest only that catastrophic cognitions are temporally associated with panic in COPD patients. There is now some evidence that high levels of fear of anxiety is present in some Ss who have never experienced panic (Donnell & McNally, 1990). Such evidence suggests that the presence of catastrophic cognitions regarding the adverse consequences of anxiety is not simply a result of personal experience with panic. Future research applying cognitive-behavioral treatment programs to assist these patients in participating fully in treatment programs and in managing their physical impairment without the emotional suffering of the panic experience, may provide us with a better understanding of the causal relationships of these variables. REFERENCES

Agle, D. P. & Baum, G. L. (1977). Psychological aspects of chronic obstructive pulmonary disease. Medical Clinics of North America, 61, 749-758.

Beck, A. (1987). Cognitive approaches to panic disorder. In Rachman, S. & Maser, J. (Eds), Panic: Psychological perspectives. Hillsdale, N.J.: Erlbaum. Chambless, D. L., Caputo, G. C., Bright, P. & Gallagher, R. (1984). Assessment of fear of fear in agoraphobics: The body sensations questionnaire and the agoraphobic cognitions questionnaire. Journal of Consulting and Clinical Psychology, 52, 1090-1097.

Chambless, D. L., Caputo, G. C., Jasin, S. E., Gracely, E. J. & Williams, C. (1985). The mobility inventory for agoraphobia. Behaviour Research and Therapy, 23, 3544.

Clark, D. (1986). A cognitive approach to panic. Behaviour Research and Therapy, 14, 461470. Donnell, C. D. & McNally. R. J. (1990). Anxiety sensitivity_ and _ panic attacks in a nonclinical _ nopulation. Behauiour _ Research and Therapy, 28, 83-85.

Holt,

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Behaviour Research and Therapy, 27, 253-261.

Kerns, R. D., Turk, D. C. & Rudy, T. E. (1985). The West Haven-Yale multidimensional pain inventory (WHYMPI). Pain, 23, 345-356.

Norton, G. R., Dorward, J. & Cox, B. J. (1986). Factors associated with panic attacks in nonclinical subjects. Behavior Therapy, 19, 239-252.

Norton, G. R., Harrison, B., Hauch, J. & Rhodes, L. (1985). Characteristics of people with infrequent panic attacks. Journal of Abnormal Psychology, 94, 216-221.

Rachman, S., Levitt, K. & Lopatka, C. (1988). Experimental analyses of panic--III.

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Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement,

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Rapee, R. M., Antis, J. R. & Barlow, D. H. (1988). Emotional reactions to physiological sensations: Panic disorder patients and non-clinical Ss. Behaviour Research and Therapy, 26, 265-269. Rapee, R. M., Mattick, R. & Murrell, E. (1986). Cognitive medication in the affective component of spontaneous panic -attacks. Journal of Behavioural Therapy and. Experimental Psychiatry, 17, 245-253. _ Salkovskis, P. M. & Clark, D. M. (1990). Affective responses to hyperventilation: A test of the cognitive model of panic. -_ Behaviour Research and Therapy, 28,’ 51-61.

_

Spielberger, C., Gorsuch, A. & Lushene, R. (1970). The State-Trait Anxiety Inventory. Palo Alto, Calif.: Consulting Psychologists Press. Yellowlees, P. M., Alpers, J. H., Bowden, J. J. & Ruffin, R. E. (1987). Psychiatric morbidity in patients with chronic airflow obstruction. Medical Journal of Australia, 146, 305-307.

Respiratory function, cognitions, and panic in chronic obstructive pulmonary patients.

The present study investigated the relationship between respiratory function, catastrophic thoughts about anxiety, and panic in 48 Chronic Obstructive...
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