Are We Missing Anxiety in People with Chronic Obstructive Pulmonary Disease (COPD)?

Introduction

Anxiety is a common emotion experienced by us all. Anxiety can be beneficial and help us identify danger and respond appropriately with ‘flight’or ‘fight’reactions. When we perceive danger, the automatic fear response occurs faster than conscious thought. Surges of adrenaline are leased which subside quickly once the perceived or actual threat has passed [1]. Anxiety is one of the most common mental health problems in the developed economies such as the United Kingdom where it is both prevalent and increasing [1]. The persistence of anxiety can leave apprehension, a chronic sense of worry, tension or dread and can be debilitating [1]. Anxiety can cause real emotional distress which can impact on physical, social and psychological well-being.

There is a growing recognition that people with long term physical health problems have an increased risk of developing symptoms of anxiety. Many illnesses require an acceptance of the primary diagnosis, its prognosis, possible complications and adjustment in lifestyle. Co-morbid anxiety may have direct impacts on the primary disease. Examples of anxiety impacting on physical illnesses include avoidance of activity to reduce symptoms such as breathlessness, inappropriate use of medication and persistence of smoking (as a coping strategy for anxiety management). This can result in further deterioration of the lung and heart disease in those with smoking related cardiac or respiratory disease.

Chronic Obstructive Pulmonary Disease (COPD) is a smoking related lung disease. COPD is an umbrella term used to collectively describe chronic lung diseases such as smoking related ‘chronic bronchitis’ and ‘emphysema’ that cause limitation in lung airflow [2]. Symptoms include breathlessness, cough and intermittent acute worsening of symptoms- so called acute exacerbations of COPD. Exacerbations are common and unpredictable. Infections are frequent and result in progressive deterioration of lung function and physical functioning. Stable COPD is therefore frequently associated with disruption to normal social and employment functioning and with further unpredictable events that may lead to hospitalisation. Therapies for COPD include a major focus on preventing disease progression (through smoking cessation), limiting symptoms and/ or reducing exacerbation frequency through inhaled and other pharmacotherapies and physical training to improve breathlessness and stamina.

Anxiety causes a number of physical responses such as increased respiratory rate and heart rate. In individuals who have normal lung function these symptoms can be alarming. However, for people who have a respiratory disease such as COPD, the fear anxiety causes can be very distressing and debilitating. People commonly report thinking that they cannot breathe and experience catastrophic thoughts such as they are going to die. Patients become anxious about becoming breathless and avoid exertion which may trigger unpleasant symptoms occurring. This leads to physical de-conditioning thereby compounding exertional breathlessness, reducing confidence, which collectively exacerbates the panic cycle [3]. A vicious cycle develops and panic attacks are common [4,5]. Panic disorder is up to ten times more prevalent in patients with COPD than in the general population [5].

It is entirely plausible that some COPD hospitalisations are primarily related to anxiety or panic attacks. Increased reliance on hospitals as a surrogate for support can create a further vicious cycle of lack of confidence and loss of control. Furthermore inappropriate escalation of medical therapies aimed at preventing infective exacerbations of COPD will likely undermine patient confidence as these have very limited scope in preventing panic attack associated admissions.

Patients with anxiety and depression often suffer from low selfconfidence or self-efficacy, which may lead to worse disease related coping [6] and poor self-care behaviours, such as unwillingness to engage in pulmonary rehabilitation, decreased physical activity, failure to quit smoking, poor eating habits, and poor medication adherence [7-9]. Survival is also decreased [10] (Table 1).

  

    
Acute/ Unstable phase 
    
Stable    Phase 
  
  

    

      
Panic associated admissions 
      
Hospitalisation costs 
      
Inappropriate escalation of COPD    pharmacotherapy 
      
Possible failure to accept    hospitalization when needed 
      
Reduced survival 
    
      
 
    

      
Poorer quality of life 
      
Continued smoking 
      
Poor medication compliance 
      
May decline vaccinations 
      
Poor inhaler technique 
      
Avoidance of helpful interventions such as exercise,    physical activity and pulmonary rehabilitation 
      
Disruption of normal social and employment functioning 
    
  

Table 1:  Consequences of anxiety in COPD.