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The relationship between illness perceptions and panic in chronic obstructive pulmonary disease

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Abstract

Background

Elevated levels of anxiety and panic are common in respiratory disease. To date the cognitive-behavioural model of panic has been utilised to help explain and manage panic in respiratory disease. This cross-sectional study investigated the relationship between illness perceptions and panic in chronic obstructive pulmonary disease (COPD) within a self-regulatory framework of adaptation to physical illness.

Methods

Fifty-nine participants with COPD completed questionnaires measuring illness perceptions, anxiety and depression, frequency and severity of panic attacks and impact of disease on daily life and well-being. The percent forced expiratory volume in the first second (FEV1%) was used as an objective measure of lung function.

Results

High levels of clinical anxiety and depression were reported (35% and 19% respectively). Sixty-three percent of participants reported experiencing a panic attack during the previous year and of these 51% during the previous month. Panic was unrelated to level of disease severity. Specific illness perceptions (beliefs relating to illness identity, timeline, consequences and emotional representations) were important in differentiating between panickers and non-panickers.

Conclusions

The results highlight the importance of assessing illness perceptions within the framework of the self-regulatory model to provide an additional theoretical perspective for investigating and managing panic in chronic respiratory disease.

Introduction

Chronic obstructive pulmonary disease (COPD) is a chronic degenerative disease characterised by irreversible obstruction of the airways and encompasses diseases such as emphysema, chronic bronchitis and some cases of chronic asthma. The aetiology is most significantly related to history of cigarette smoking. COPD is characterised by the insidious onset of symptoms such as breathlessness (dyspnoea) accompanied by a reduction in ability for physical exertion, fatigue, persistent cough, sputum production and an overall decline in everyday function and quality of life.

The consequences of living with COPD are wide ranging. The restricted ability to perform activities of daily living and fear of becoming breathless may lead to avoidance of activities and social isolation. Sleep disruptions also appear to be common and may impair a person's ability to employ coping strategies (Hallas & Wray, 2003). Living with COPD and the associated huge life adjustments can also impact upon work and home life, financial resources, social, emotional and sexual role functioning (Agle and Baum, 1977, Knebel et al., 1999, Labott, 1998, McSweeney et al., 1982, McSweeney and Labuhn, 1990). Psychological repercussions include panic, depression, low self-esteem, frustration, loss of confidence, denial, fear and isolation (Agle and Baum, 1977, Moore and Zebb, 1998, Moore and Zebb, 1999, Porzelius et al., 1992, Yellowlees et al., 1988).

The experience of breathlessness has been described in numerous ways including the feeling of fighting for air, gasping, panic and fear of impending death (Skevington, Pilaar, Routh, & MaCleod, 1997) and is now recognised as developing through a complex interplay between physical, psychological, emotional and functional factors (O'Driscoll, Corner, & Bailey, 1999). For example, psychological factors, in particular anxiety and panic can often make the sensation of breathlessness more acute and out of proportion to disease severity. Research has consistently shown an increased prevalence of anxiety and panic among respiratory patients, compared to the general public (Gurney-Smith et al., 2002, Kim et al., 2000, Moore and Zebb, 1999). The reverse is also true in that the lifetime prevalence of respiratory disease was found to be 47% in people with panic disorder compared to other psychiatric diagnoses (Zandbergen et al., 1991). The presence of anxiety and panic in COPD is important because it has been related to more frequent hospital admissions and longer stays (Yellowlees et al., 1988), greater use of medication (Carr, Lehrer, & Hochron, 1995) and is associated with greater restrictions on mobility and energy, difficulties with activities of daily living, greater dependence on others for care and impaired functional status (Moore and Zebb, 1998, Weaver et al., 1997).

There is a complex relationship between panic attacks and respiratory disease because many of the symptoms of respiratory disease (i.e. dyspnoea) overlap with those of panic attacks. Various models such as the hyperventilation model, the hypersensitivity/suffocation false alarm model (Klein, 1983) and the dyspnoea-fear theory (Ley, 1989) have been proposed to describe the physiological mechanisms underlying panic attacks in respiratory disease. However, evidence supporting these theories is inconsistent because previous research has found no significant difference in pulmonary function abnormalities between patients that experience panic attacks compared to those that do not (Moore and Zebb, 1998, Moore and Zebb, 1999, Pollack et al., 1996). Conversely, significant differences have been reported in levels of catastrophic cognitions and fears of bodily sensations between panickers and non-panickers (Gurney-Smith et al., 2002, Moore and Zebb, 1998, Moore and Zebb, 1999, Sutton et al., 1999) suggesting there is considerable variability in patient experiences of respiratory disease.

More recently the ‘self-regulatory theory’ (Leventhal, Meyer, & Nerenz, 1980) has been applied to explain adaptation and coping in long-term illness and could provide a theoretical framework for explaining why only a proportion of patients develop negative and maladaptive emotional responses to pulmonary symptoms and function. Research on the formation of illness perceptions within the self-regulatory model consistently suggests that patients construct their own implicit models or beliefs about their illness that includes perceptions surrounding the symptoms, cause, consequences, controllability, timeline of disease, understanding of disease and emotional reaction. Illness perceptions have been shown to be significantly associated with outcomes such as treatment adherence, psychological adjustment, health-related behaviours and functioning in various long-term illnesses (Petrie et al., 1995, Petrie et al., 1996, Scharloo et al., 1998, Scharloo et al., 2000, Weinman and Petrie, 1997) and more specifically to physical, role and social functioning in COPD patients (Scharloo et al., 1998, Scharloo et al., 2000).

This study investigated the relationship between illness perceptions and panic in a COPD population. Specifically, levels of anxiety, panic and depression were measured as well as self-reported impact of disease on daily life. In addition, the study investigated whether there were any significant differences between individuals reporting panic attacks (previous year and previous month) compared to those that did not, on illness perceptions, mood and level of disease severity.

Section snippets

Procedure

Participants were recruited from a specialist cardiothoracic centre in the UK. Criteria for inclusion were: diagnosis of COPD for a minimum of one year, currently under the adult respiratory service of the hospital trust, able to provide informed consent and not to have previously received a lung transplant. All patients (n = 120) on the hospital database who met the criteria were sent a letter, together with an information sheet, a consent form and the questionnaires. If willing to participate,

Demographic characteristics of patients

Participants had a mean age of 62.4 years (range 38–86 years, SD 12.0), and a mean length of diagnosis of 9 years (SD 6.1). Sixty-one percent (n = 35) were female. A large percentage of participants were married or co-habiting (61%, n = 38) and 25% (n = 15) were widowed, divorced or separated. Sixty-five percent (n = 36) had received secondary school education. From the data that was available, a large percentage of participants were ex-smokers (48%, n = 13), with four participants still currently

Discussion

The results support previous findings of high levels of anxiety, panic, depression as well as a significant impact of disease on daily life in COPD patients (e.g. Kim et al., 2000, Moore and Zebb, 1999, Okubadejo et al., 1996, Okubadejo et al., 1997, Pollack et al., 1996, Porzelius et al., 1992, Sutton et al., 1999, Yellowlees et al., 1987). Furthermore, consistent with previous research (Karajgi et al., 1990, Moore and Zebb, 1998, Pollack et al., 1996, Porzelius et al., 1992) there was no

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