Emotional Aspects of COPD

Summarized by Robert W. Griffith, MD
February 13, 2006

Introduction

Chronic obstructive pulmonary disease (COPD) is the 4th leading cause of death in the USA today. It is an extremely distressing complaint, inducing depression, anxiety, and panic disorder in as many as 42%, 50%, and 32% of its victims, respectively. It's therefore incumbent on the treating physician to be aware of these emotional components, and to treat them accordingly. Unfortunately, it's been found that less than a third of healthcare providers identify anxiety and depression in their patients. In a disease like COPD primary care physicians are in a position to improve the quality of life of their patients, provided they recognize and treat the emotional disorders that are so common.

The reason for emotional problems

The symptoms of depression, anxiety, and COPD may overlap, to a certain extent - rapid and difficult breathing, sweating, palpitations. The lung disease may have a relatively poor long-term outlook, leading understandably to feelings of frustration, hopelessness, and helplessness. Depressed mood lowers the energy level still further, making the symptoms even less tolerable.

Anxiety is created by the unpredictable nature and fear-arousing symptoms of respiratory distress. This distress is closely allied to panic; the patient may interpret COPD-related breathing difficulty as life-threatening suffocation, or harmless chest pains as a heart attack.

Diagnosing the problem

The symptoms of depression in association with COPD are the same as those for other patients - depressed mood, loss of interest or pleasure, sleep disturbances, weight changes, fatigue, poor concentration, and even thoughts of death.
Anxiety is shown by restlessness, muscle tension, loss of concentration, and irritability. If physical symptoms predominate - shortness of breath, chest pains, tingling sensations, trembling, feelings of faintness and choking - it's labeled panic disorder.
It can be hard to distinguish anxiety symptoms from those of COPD itself. However, anxiety should be suspected when the symptoms seem excessive for the actual stage of COPD.

Assessing the patient

If the symptoms suggest a diagnosis of depression, anxiety, or panic, the patient can be screened by a number of suitable tests. There's one screen called PRIME-MD that contains two depression and three anxiety screening questions that have been validated for use in COPD:

1. In the past month, have you been bothered a lot by:
   - little interest or pleasure in doing things
   - feeling down, depressed, or hopeless?
2. In the past month, have you been bothered a lot by:
   - "nerves", or feeling anxious or on edge:
   - worrying about a lot of different things?
3. During the past month:
   - have you had an anxiety attack (suddenly feeling fear or panic)?

Treatment choices

Both drug and non-drug treatments are suitable for the emotional problems encountered in COPD patients. It's advisable to explain these to the patient, and find out which approach they would prefer.
The non-drug treatment options include exercise therapy, short-term psychotherapy, and cognitive behavioral therapy ¹. Although primary care physicians or staff can provide some of the simple forms of CBT, expert assistance will be necessary in many cases. A suitably trained psychotherapist can help explain the links between the symptoms of COPD itself and the emotional overlaying condition.
Some patients may prefer to begin with drug treatment - antidepressants have a definite place in such cases. In particular, selective serotonin reuptake inhibitors (SSRIs), such as fluoxetine (Prozac®), or a newer drug, velafaxine (Effexor®), may be given; they have anti-anxiety properties as well.
The older antidepressants - the tricyclic drugs like amitriptyline (Elavil®) - should be held in reserve, as they have pronounced side effects; benzodiazepines (like Valium®) should be avoided, as they tend to depress respiration.

Conclusions

Emotional problems like depression, anxiety, and panic, worsen the symptoms of COPD. The healthcare professional should be aware that they may be present, should screen for them, and treat them if present. This will improve the patients quality of life considerably, which is important for someone suffering from such a distressing disease.

Source

• Chronic obstructive pulmonary disease: Assessing and treating psychological issues in patients with COPD BA. Burgess , KME. Kunik , SMA. Stanley , , 2005, vol. Geriatrics, pp. 1818--1821

Footnotes
1. Cognitive behavior therapy (CBT) combines two very effective kinds of psychotherapy - cognitive therapy and behavior therapy. Behavior therapy helps you weaken the connections between troublesome situations and your habitual reactions to them, such as fear, depression, or anger. It teaches you how to calm your mind and body, so you can feel better, think more clearly, and make better decisions. Cognitive therapy shows you how certain thinking patterns are causing your symptoms, by giving you a distorted picture of what's going on, and making you anxious, depressed or angry. When combined into CBT, behavior therapy and cognitive therapy provide powerful tools for stopping your symptoms and getting your life on a more satisfying track.

Related Links
Cognitive Behavioral Therapy - The Basics
MedlinePlus: COPD
Pulmonology Channel: COPD

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