20/02/2017. Working with anxious patients. Bio-psycho-social Model. Identifying anxiety

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1 Psychological Intervention in Non-Malignant Respiratory Disease: working with anxious patients By Margreet Hendriks Cpsychol AFBPsS Registered Highly Specialist Psychologist Barking & Dagenham Long Term Conditions Psychology Service Respiratory Clinical Health Psychology Service Working with anxious patients Cognitive Behavioural Therapy Approach Active listening Treatment Adherence What can you do? Onward referral Bio-psycho-social Model Meet Bob. Frustration: Low mood 09T2sGHVarw/UVlqn7fvPEI/AAAAAAAAAms/GATB54Eg23 Q/s1600/Infographic+(biopsychosocial+model)2.jpg Sometimes I get really frustrated that I can t do things like before. What s the point? I will only get breathless Worry and Panic: Embarrassment: Feeling breathless makes me panic and I think I am going to die. I don t want to go out because I am worried I will get breathless and start coughing and everyone will stare at me. Situation/Trigger What was going through your mind? Identifying anxiety Discuss: What are the signs that your patient is anxious? What did you do? (behaviour) How were you feeling? (emotions) What do you notice about their thoughts, feelings, physical sensations, behaviours? What was happening in your body? (Physiological changes) 1

2 Anxiety symptoms Excessive worrying thoughts Irritability Poor concentration Sleep disturbance Fatigue Muscle tension Restlessness Normalising anxiety Anxiety is a normal physiological response Feeling breathless often leads to anxiety Fight or flight response Adapted from DSM-IV-TR (2009) p. 476 Panic: fight/flight response Body s Reaction What we may notice Mind s reaction Breathing gets quicker so more oxygen can reach muscles Heart rate speeds up to pump blood to the muscles Muscles tense up ready for action Digestive muscles slow down as blood is diverted to the major muscles (e.g. legs) More breathless, tightness in chest, feel dizzy Pounding heart or palpitations Tense muscles especially in the shoulders and neck, which would be straining to help with breathing Nausea, dry mouth or a heavy stomach Thought: Something bad is going to happen Anxiety or exacerbation? What are the symptoms of anxiety/panic and what are the symptoms of a COPD flare up? Pupils open up to increase vision Mind in on high alert, focusing on possible danger, filtering out other things Blurred vision Apprehension, feeling keyed up, on high alert, difficult to concentrate on anything else Anxiety or Exacerbation? SYMPTOMS OF ANXIETY/PANIC SYMPTOMS OF BOTH SYMPTOMS OF A COPD FLARE UP Intense fear and anxiety that usually Coughing up more phlegm. comes on fairly suddenly but goes down after a short time. More Breathless Anxiety mechanisms & vulnerabilities Females: Low marriage satisfaction Males: Low self-efficacy in disease management and poorly adapted coping strategies & poor social support Smoking increases risk for anxiety in both Strong thoughts that something awful is about to happen. Change in colour or thickness of phlegm. Anxiety related symptoms are not affected by severity of airflow obstruction Anxiety is risk factor in starting to smoke in adolescents Physical symptoms that are part of the fight or flight response. A high temperature. History of anxiety-related disorders - more anxiety upon cessation of smoking than general public More difficult to do normal activities. 2

3 - Feelings such as anger and frustration are identified as potent triggers for anxiety, which in turn, heightens the sensation of dyspnoea. - No immediate cause and effect mechanism between anxiety and levels of exertion or rest. - No convincing relationship has been found either between pharmacological therapy or exercise training and levels of anxiety so it is likely other factors contribute to the relationship between dyspnoea and anxiety. - (from Anxiety & Depression in end stage COPD -K Hill, R Geist, R.S. Goldstein & Y Lacasse, European Respiratory Journal : ) What can I do? - Take the time to listen DO NOT DISMISS CONCERNS Showing you are listening: - Body language - Basic encouragement - Validate patient s feelings/situation - Empathy - Reflection and summarising. NOT having to always solve problems or reassure! Good vs bad listener Maintains eye contact Makes few distracting movements Leans forward, faces speaker Has an open posture Allows few interruptions Signals interest with encouragers and facial expressions Makes little eye contact Makes distracting movements Faces away from speaker Has a closed posture (eg:arms crossed) Interrupts speaker Does too many other things while listening Has a flat affect, speaks in a monotone, gives few signals of interest Asking questions: open vs closed Open questions Generally start with what, how, why or could Questions serve to: Gather lots of general information Encourage discussion For example: Nurse: How has the baby been eating? Nurse: What is the bedtime routine? Nurse: Could you tell me about giving the baby medicine in the morning? Generally start with is, are, or do Serve to: Gather lots of specific information quickly Tend to close down discussion For example: Nurse: Are you giving the medicine every day? Nurse: Is the baby able to tolerate the medicine in the morning? Treatment adherence Clinician s role: fails to give explicit instructions, fails to find out and resolve ambiguity, failing to explain the reasons for specific treatment Clinical trials have shown that the following factors will improve adherence: Improved patient-doctor communication Use of reminders and follow-ups A patient centred approach Remember Bob? Bob has COPD. That morning he was in a hurry. He needed to walk to the car and his family were waiting. He was worried about being late for his appointment. As usual his breathing got faster, but today it felt worse than normal. He didn t have time for his usual rest. He began to worry about missing his appointment. His breathing got worse and he started to feel alarmed and fearful I can t get my breath back His heart was pounding, he was gasping for breath, and he felt sick, sweaty and dizzy. It s getting worse I am going to die He felt out of control and was really panicking. Tailoring information to the patient Use of lay-helpers (i.e. family/carers) Ley, 1997 His family were frightened seeing him struggling for breath and rushed over to him to try and help. He couldn t get any words out. His family did not know what to do. Shall we call an ambulance? Seeing his family worried made Bob panic more. He was thinking They are panicking too, it must be serious This is it and thought he needed an ambulance. He was in total panic. His family dialled

4 Bob s cognitive behavioural panic cycle: Bob s example The vicious circle of breathlessness: Trigger: Breathlessness What Bob is thinking I can t breathe Others are panicking too, it must be serious What Bob is doing Focusing more and more on his breathing Calling for an ambulance I am going to die Panic How Bob is feeling Feeling worried... Increasing to panic... Behaviour: Avoid doing things that makes you breathless Don t go out (much) Get very unfit and more breathless. Panic Mind/thoughts It must be serious I m going to die What is happening to Bob physically Faster breathing, heart pounding, sweaty, dizzy, feel sick, more breathless Body: Breathing quicker- need more O2 Nausea, clammy hands, wobbly legs, cold sweats. Pounding heart, shakes Breaking the vicious circle of breathlessness: Thoughts/Images: I will be ok! Meet Mary 62 COPD - retired 3 years ago from being company director s PA 2 years ago Enjoyed swimming, gardening, walking the dog and being an active member of the local Greenpeace group Behaviour: Diaphragmatic breathing Don t call ambulance IN CONTROL Feelings: Calm Met with old friends regularly for lunch/theatre, became known as the listener Recently became severely breathless walking the dog Became house-bound, restless and irritable Physical: Breathing calms down Family & friends noticed she had become withdrawn Give it a try. Situation/Trigger What was going through your mind? Use the example of Mary and try to identify her cognitive behavioural cycle What did you do? (behaviour) How were you feeling? (emotions) What was happening in your body? (Physiological changes) 4

5 How to challenge negative thoughts Questions to ask yourself: What is the evidence to support/not support my thoughts? What alternative views are there? How would I have viewed this situation before I got anxious? What is the effect of thinking the way I do? Does it help or hinder me? What action can I take? Visualise yourself coping Distract yourself: count backwards from Grounding exercise: focus on your surroundings and describe items to yourself. Do lower chest (diaphragmatic) breathing, get into a relaxed position and stop and rest. General behavioural changes Coping with stress and anxiety: - Exercise - Leisure/socialising - Hobbies - Diet and drink - Sleep - Asking for help - Mindfulness/Relaxation exercises Involve family and carers. Important messages to give to patients Panic is not a sign that COPD is getting worse and it does not damage your lungs It is possible to control breathlessness and panic You cannot die from a panic attack Anxiety is not a sign of being mad or being weak Top tips to improve sleep Go to bed at the same time each night and try to get up at the same time each morning. Try to have a ritual to help your body to prepare for sleep. A day time nap up to 30 minutes is ok, longer will affect your sleep at night. Use an alarm if necessary to wake you Relax with a hot bath or shower to prepare for sleep Do not eat or drink before bed. Smoking, caffeinated drinks and alcohol will act as stimulants Exercise during the day to tire yourself physically Keep bedroom temperature around 18 degrees. Duvets are better than blankets. Discuss with partner whether having twin beds or a separate bedroom is desirable Try not to worry about sleeping, write a worry list before sleep Count backwards from 200 to 1 to help switch off, do a meditation or breathing exercise Do not watch television or use a tablet/phone as blue light will interfere with sleep. Should problems with intimacy cause relationship issues, talk about it with partner and/or contact Relate on Depression or Anxiety or both? Surveys show that 60-70% of those with depression also have anxiety. And half of those with chronic anxiety also have clinically significant symptoms of depression. Both anxiety and depression: perceptual process of overestimating risk in a situation and underestimating personal resources for coping. Those vulnerable see lots of risk in everyday things like going to busy supermarket or ask for help. Anxiety and depression share an avoidant coping style. Sufferers avoid what they fear instead of developing the skills to handle the kinds of situations that make them uncomfortable. Often a lack of social skills is at the root. Over-reactivity of the stress response system, sends into overdrive emotional centres of the brain, including the fear center" in the amygdala. Negative stimuli make a disproportionate impact and hijack response systems. Cognitive Behavioural Therapy and SSRi s (selective serotonin reuptake inhibitors) proven effective for both. Which drug a patient should get is based more on what he or she can tolerate rather than on symptoms. Example: Having lots of worries about breathlessness may impact on your sleep which in turn may render you low. GAD 2 quick anxiety screening tool: Over the past two weeks, how often have you been bothered by the following problems? 1. Feeling nervous, anxious or on edge? Not at all Several days More than half the days Nearly every day 2. Not being able to stop or control worrying Not at all Several days More than half the days Nearly every day Assign scores 0-3 to the response categories. A score of at least 3 points is a positive result. 5

6 Depression identification and recognition Be alert to possible depression and ask the following two questions: During the last month, have you often been bothered by feeling down, depressed or hopeless? During the last month, have you often been bothered by having little interest or pleasure in doing things? If the answer is yes refer to an appropriate professional NICE guidelines, 2009 Onward referral Increasing Access to Psychological Therapies (IAPT) can self-refer too Clinical health psychology referral currently only available for IRS B & D team. Pulmonary Rehab Other voluntary support groups/services or charities References Thank you for listening Any Questions Sage, N. Sowden, M. Chorlton, E. & Edeleanu, A. CBT for chronic illness and Palliative Care (2008) : Hill, K. Geist, R. Goldstein, S. Lacasse, Y. Anxiety and Depression in end-stage COPD European Respiratory Journal (2008) Ley, P. (1997) Adherence among patients 6