Role of CBT in COPD management

Simon DupontHillingdon Hospital

Resources

Demands

Resources

1. Physical health

2. Skills and experience

3. Emotional make-up

4. Social support

5. Ability to relax

Demands

• Demands of everyday life: daily hassles

• Life changes (e.g. giving up work, bereavement)

• Social factors (problems in relationships, loneliness)

• Health issues (exacerbations of illness)

• Personal factors (feelings of low self-esteem)

STRESS

What is stress?

Physical effects of stress or anxiety

Emotional effects of stress or anxiety

Recognising signs of an exacerbation

“Am I breathless because there is

something wrong with my COPD or is it

because I feel tense and anxious?”

“Am I breathless because there is

something wrong with my COPD or is it

because I feel tense and anxious?”

“Is it anxiety?”“Is it anxiety?”“Is it my lungs?”“Is it my lungs?”

CBT cycle

Rationale for CBT

It is not events themselves that cause distress but what they mean to us

Meaning is influenced by past experiences, past learning, our individual rules and the beliefs that we have developed

The way in which we interpret events can be biased and cause undue distress

CBT Model of Depression

Shortness of Breath

FEELINGS

Discouraged, inadequate,

guilty, depressed

THOUGHTS - NATS

‘There is no point in trying’‘I can’t even cook a meal’

‘I can’t even walk to the shop’

PHYSIOLOGICAL SENSATIONS

Fatigue, sleeplessness, lethargy

BEHAVIOURS

Inactivity, increase in maladaptive behaviours

e.g. smoking, social withdrawal

EVENT(getting dressed)

Bob’s example…

Bob has COPD. That morning he was in a hurry, worrying about being late for an appt. Breathing got worse, increased anxiety “I can’t get my breath back”…further anxiety…

Heart pounding, gasping for breath, sick, sweaty, dizzy, out of control “I’m dying”, “It’s getting worse” = PANIC ATTACK

Family also frightened, feel helpless – call an ambulance

Negative Automatic Thoughts

Just pop into your head

Are involuntary

Do not always fit the facts

Affect how you feel

Affect what you do

Unhelpful thinking

CatastrophisingThoughts about worst possible outcome. “I’m out of breath, my lungs are being damaged, I’m about to die”.

Generalisation“ Because I’m short of breath in this shop, I’ll also be short of breath

in all shops”.

All or nothing thinking“Because I cannot do it as before I will not do it at all”. People give up activities that have become harder

Mind readingPeople think they know what other people are thinking and assume that it is negative without checking it out.

Practical tips- help patient to ID and challenge NATS

Identify NATS/images What went through your mind before you started feeling

that way?

Challenge the thoughts What’s the evidence for and against the thought? Are there any thinking errors? What would happen if the thought remains unchallenged? Is there another way of thinking about this?

Whittington psychology pilot

Psychology-led sessions:

anxiety and breathlessness living with a breathing problem /

managing low mood goal setting managing flare-ups relaxation sleep

Psychology pilot

2 sessions a week for one year

Modifying the education sessions to be more interactive with a focus on supporting self-management and building self-efficacy

Switch from rolling programme to stop-start

Psychologist attended assessments and the PR group once a week

Psychologist offered individual therapy to any patients showing high levels of distress or other potential barriers to completion

Conclusions of Whittington

Addressing psychological barriers to attendance at PR may improve completion rates

Improving completion is important in reducing future hospital resource usage

Targeting self-efficacy (mastery) in the context of PR may be a primary factor in improving self-management skill and completion of PR

Invite to PR

Accept and start PR

If anxious or depressed,

frequent A&E attenders, offer

psychology input

Complete psychology

sessions then offer PR

Complete PR

Complete PR

Issues with attendance at PR/ freq A&E attenders/would

benefit from additional input for anxiety or

depression

Offer psychology

input. Complete alongside

PR or rejoin PR

Combining PR & CBT

How to assess - starter for ten

Do you think

anxiety

has contributed to

any of your hospital admissions?

THE GAD-2

Over the last 2 weeks, how often have you Not Several More than Nearlybeen bothered by the following problems? at all days half the every day

days(Use “✔” to indicate your answer)

1. Feeling nervous, anxious or on edge 0 1 2 3

2. Not being able to stop or control worrying 0 1 2 3

If total score is 3 or more, complete GAD-7

Assessment - anxiety

Assessment - depression

THE PHQ-2

Over the last 2 weeks, how often have you Not Several More than Nearlybeen bothered by the following problems? at all days half the every day

days(Use “✔” to indicate your answer)

1. Little interest or pleasure in doing things 0 1 2 3

2. Feeling down, depressed, or hopeless 0 1 2 3

If total score is 3 or more, complete PHQ-9

Open Style of Consultation

BATHE technique - Lieberman & Stuart 1993

Background – what’s going on in your life?

Affect – how do you feel about this?

Trouble – what troubles you about that?

Handling – how are you handling that?

Empathy – that must be difficult for you

The COPD manual - what is it?

‘Guided self-help’: Client works through programme in their own time at home – guided by facilitator

Focuses on psychological issues in COPD and self-management behaviours (CBT)

Management of SOB/panic and prevention of A&E attendance

5 weeks: home visit to start programme, T/C wk 3 & 6

The COPD Breathlessness

Manual

Breathe better, feel better with this five week manual designed

to help you manage chronic obstructive pulmonary disease (COPD) and help you feel more

in control of breathlessness

Total number of A&E attendances 12 months pre and 12 months post

43% reduction in A&E attendances in the COPD manual group vs

a 10% increase in the BLF booklets group.

Time

Num

ber

Total number of hospital admissions 12 months pre and 12 months post

63% reduction in hospital admissions in the COPD manual

Hospital bed days reduced from an average of 1.6 days 12 months pre, to an average of 0.5 days 12 months post.

Anxiety changes over time Depression changes over time

HA

D s

core

s

HA

D s

core

s

Time Time

Changes in Anxiety and Depression over time

Websites

By Chris Williams: www.livinglifetothefull.com (for users) www.fiveareas.com (for practitioners)

From NHS Choices website: www.fearfighter.com

Books on Prescription

http://readingagency.org.uk/about/BoP%20core%20booklist%20with%20copyright.pdf