“My chest is anxious!” – Assessment and intervention for the anxious asthmatic


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    Benjamin Croxford
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"I'm not an anxious person, it's my chest that's anxious!"

Irene (fictitious patient) gave humbling accounts of how her symptoms affected her perception of herself, and her ability to interact with the world around her. Irene often expressed the sentiment of her chest being a separate entity, part of her that she did not have control over, and often referred to in the third person. “No, my chest won’t let me do that…”, “I wanted to play with my grandson at his birthday party but my chest wouldn’t let me that day”. In pulmonary rehab I would often shadow Irene with an arm around her shoulder, giving calm words of encouragement, and willing her to take one more step, and not let her chest hold her back. Despite this, Irene would then collapse back in her chair, and break down in tears. A mix of being overwhelmed at her achievement but equally as relieved the ordeal was over. What made Irene’s case interesting, was this exceptionally severe symptomatic presentation was in the absence of sinister pathology or objectively measured severe disease. 

It is important to note that unexplained or abnormal symptomatic presentations should always be investigated to exclude more sinister pathology or comorbidity. However in the absence of this, anxiety is well recognised in clinical practice for having the potential to significantly impact patients with asthma. A 2004 literature review of twelve cross-sectional studies found asthma with anxiety disorder was present in 6.5-24% of patients with asthma, as opposed to a previous estimate of 1-3% in community populations, and 4-8% in primary care¹. Another study of 3032 patients aged 25-74 years showed those with respiratory disease were subject to a 70% increased likelihood of suffering panic attack². However the challenge that remains is how in clinical practice we uncover a relationship between respiratory symptoms and psychosocial factors, and subsequently measure the degree to which this relationship may be influencing symptom burden.

The relativity of symptoms

A consultant colleague of mine once quipped over coffee, “My most poorly patients are the ones that can’t find a parking space before their appointment!” An apt observation of how the relativity of symptoms mean they can be heightened by anxious states and anxiety-inducing situations. 

Symptoms also appear to be relative to patients perceptions on attainment of desired functional goals. A peer of Irene’s, Dot (alias), had a severe presentation, with exceptionally low lung function scores and poor exercise tolerance. Dot was however one of the most engaged and self-assured members of her pulmonary rehab cohort and did not perceive she was limited by her disease. Her functional ability was sufficient that she could freely mobilise around her one bedroom mobile home on Canvey Island, transfer onto her mobility scooter, and play bingo of an evening at the site’s clubhouse. Irene, despite having greater physiological reserve and mobility, could be seen in clinic regularly benefitting from Dot’s advice and reassurance.

In a Clinical Knowledge Summary (CKS) by NICE (2017), Breathlessness is defined “as a subjective, distressing sensation of awareness of difficulty with breathing”³. Typical triggers of breathlessness include exercise and speech, and on occasion can also be observed at rest⁴. It appears that this subjectivity of symptoms and breathlessness may mean anxiety has the potential to further impact functioning and quality of life. So how may we spot the signs of the anxious asthmatic patient in practice?

Clinical observations of the anxious patient

Anticipatory and sporadic variance of symptoms
Respiratory rate in anxious patients often increases in anticipation of mobilising, as opposed to after a period of exertion. This effect may also occur when the patient is aware they are being formally assessed. Irene became breathless at the point of being asked to stand from her chair and walk to the clinic room. Mobility was slow with frequent rests, breathing audible, and speech not possible, as to not interrupt her laboured breathing pattern. However, on engaging Irene in a conversation about her grandchildren, speech became possible, breathing inaudible, and the walk from waiting area to clinic room possible without rest. It would seem that when an anxious patient’s conscious focus is their condition, symptom burden can increase, with goal attainment and functioning decreasing. However, Irene’s dialogue about her grandchildren is not just a simple distraction technique. The positive thoughts and emotions invoked by our conversation appeared to be key in lifting Irene’s spirits, suppressing fear-avoidance, and establishing a more positive mindset during a usually anxiety-inducing functional task.

Detailed reporting of history on assessment
Our anxious patients are able to report remarkable levels of detail during their healthcare professional’s history taking. Irene was an exceptional historian during subjective assessment, being able to tell me exact times, to the minute, of when she was last breathless and her perception of what triggered that particular episode. It was clear Irene’s condition occupied a great degree of her consciousness, seemingly always monitoring the sensations of breathlessness while undertaking her activities of daily living. Often these episodes being anecdotes of how someone or something had triggered her anxiety and made her performance of a task more challenging (remember my consultant colleague’s observation!).

Variance of symptom reporting and task performance
In addition to the detailed accounts of symptoms, our anxious patients can report seemingly disproportionate levels of symptom burden to what can be observed objectively in clinic. Irene reported a remarkably high number of breathlessness episodes in a 24 hour period, at times describing days where rescue medicine use was exceptionally high. Moreover, Irene recalled instances when her breathlessness prevented her from mobilising from her chair to the bathroom without rest. Conversely Irene was not in receipt of any social care input and thus remained independent in her self care, also visiting the hair salon and shopping regularly. Seemingly when Irene had to, she would put herself through great discomfort and turmoil to ensure her personal care and other tasks were performed.


It should be said, if a patient experiences anticipatory symptoms, responds well to distraction, or at times displays high levels of functioning, this does not highlight an attempt of the patient to deceive the healthcare professional, nor does this indicate that symptoms are reported inaccurately. This variance we see is due to the relativity component in the context of the specific situation, and the subjective distressing sensation³ our patients are experiencing.

The above are observations that can be made in clinical practice that may prompt us to investigate the potential co-existence of asthma and anxiety. In addition to our observations, objective and patient reported outcome measures can further support our clinical reasoning.

Medical Research Council dyspnoea scale
Obtaining an objective measure of dyspnoea, such as the MRC dyspnoea scale⁵, is invaluable in establishing a baseline and repeatable measure to track symptoms and changes in disease. It can also be constructive to reassess during varying tasks and situations to screen for variability in functional performance.

Nijmegen Questionnaire
While not validated to detect the presence of specific disease or syndrome, the Nijmegen questionnaire has been shown to accurately reflect clinical presentations where stress, anxiety, and respiratory symptoms overlap⁶. A high score on the Nijmegen is a particularly useful patient-reported measure of the subjective component of respiratory symptoms, providing a score that may indicate an association between anxiety and disease.

While Irene’s MRC dyspnoea scores could indicate a relatively low level of breathlessness on exertion, her Nijmegen score would suggest an exceptional degree of distress was felt during these periods of breathlessness. If observing these scores independently from one another, you may not have expected them to have been generated by the same patient presentation. This disproportionality aided in confirming the team’s observation that Irene’s disease was also being compounded by high levels of stress and anxiety.

Onward referral

Outpatient Respiratory Physiotherapy
Often conducted in secondary care settings, respiratory physiotherapy consists of techniques to address dysfunctional breathing patterns with breathing control exercises and respiratory muscle training. While sample sizes tend to be small, respiratory physiotherapy has been shown to be effective at reducing stress and anxiety scores in measures such as St Georges Respiratory Questionnaire and Hospital Anxiety and Depression Scale. Dyspnoea and quality of life was also improved as per Modified Medical Research Council Dyspnoea Scale, European Quality of Life Questionnaire, and DSM-IV-R ⁷,⁸.

Pulmonary Rehabilitation
Many of the aforementioned respiratory physiotherapy techniques are prescribed as part of the pulmonary rehabilitation clinic. The additional component the pulmonary rehab clinic provides is training of these techniques during and after aerobic exercise, often a key trigger of symptoms. A 2013 study in 101 COPD patients showed significant reductions in anxiety and depression scores following a course of pulmonary rehabilitation. A Thorax poster presentation displayed similar improvements in Hospital Anxiety and Depression scores, MRC dyspnoea scores, and exercise tolerance in 111 patients diagnosed with severe asthma¹⁰.

Cognitive Behavioural Therapy
Cognitive Behavioural Therapy (CBT) is a psycho-social talking therapy aimed at altering and improving maladaptive beliefs and behaviours while developing coping mechanisms for emotionally unpleasant situations. CBT should be conducted by a Cognitive Behavioural Therapist or suitably qualified CBT practitioner and thus requires onward referral. A 2016 Cochrane Review investigated the effects of CBT in 407 patients with asthma across nine randomised controlled trials¹¹. While the results should be interpreted carefully due to inability to blind to respective treatment arms, CBT showed improved scores versus usual care in asthma control and Asthma Quality of Life Questionnaire (AQLQ). At this stage there is no evidence of improvement in other important outcomes such as asthma exacerbations.

Conclusion

Current evidence highlights a high prevalence of anxiety in patients with a diagnosis of asthma. However a challenge remains in detecting the presence of this anxiety and the effect it is having on asthma symptoms. The subjectivity of symptoms, such as breathlessness, is a key consideration when assessing the impact of anxiety in asthma. This subjectivity may contribute to patients reporting higher levels of unpleasant symptoms and sensations than expected considering objective disease severity and observed levels of functioning. Clinical observations and outcome measures, including the MRC dyspnoea scale and Nijmegen Questionnaire, are useful to investigate associated asthma and anxiety. When clinical assessment does indicate asthma compounded by anxiety, the evidence suggests promising benefits in anxiety, quality of life, and dyspnoea scores from onward referral to specialist clinics and services.

After an extended period of pulmonary rehabilitation, respiratory physiotherapy principles, and telephone talking therapy (local council-run), Irene began to turn a corner. As each pulmonary rehab clinic passed and her confidence grew, more and more Irene could be heard offering advice to newer members of the clinic. And as Irene became a role model for others, her exercise tolerance and functioning began to increase. “Shall I go and bring the car round, mum?” Irene’s daughter would ask at the end of clinic. “No don’t be daft, it’s not worth the bother. I can get that far now!”


References

1) Katon WJ, Richardson L, Lozano P, McCauey E, 2004, The Relationship of Asthma and Anxiety Disorders, Psychosomatic Medicine, 66:349–355.
2) Goodwin RD, Pine DS, 2002, Respiratory disease and panic attacks among adults in the U.S., Chest, 122:645–650.
3) National Institute for Health and Care Excellence 2017, Breathlessness, NICE, https://cks.nice.org.uk/breathlessness#!topicSummary (last accessed May 2020).
4) Simon ST, Higginson IJ, Benalia H, Gysels M, 2013, Episodic and Continuous Breathlessness: A New Categorization of Breathlessness, Journal of Pain and Symptom Management, Volume 45, Issue 6, Pages 1019-1029.
5) Medical Research Council 2020, MRC Dyspnoea scale / MRC Breathlessness scale, UKRI – MRC, https://mrc.ukri.org/research/facilities-and-resources-for-researchers/mrc-scales/mrc-dyspnoea-scale-mrc-breathlessness-scale (last accessed May 2020)
6) Dixhoorn JV, Folgering H, 2015, The Nijmegen Questionnaire and dysfunctional breathing, ERJ Open Research, 1: 00001–2015.
7) Valenza MC, Valenza-Peña G, Torres-Sánchez I, González-Jiménez E, 2014, Effectiveness of Controlled Breathing Techniques on Anxiety and Depression in Hospitalized Patients With COPD: A Randomized Clinical Trial, Respiratory Care 59(2):209–215.
8) Laurino RA, Barnabé V, Beatriz M. Saraiva-Romanholo, Rafael Stelmach, 2012, Respiratory rehabilitation: a physiotherapy approach to the control of asthma symptoms and anxiety, CLINICS, 67(11):1291-1297.
9) Tselebis A, Bratis D, Pachi A, Moussas G, 2013, A pulmonary rehabilitation program reduces levels of anxiety and depression in COPD patients, Multidisciplinary Respiratory Medicine, 8:41. 
10) Agbetile J, Singh S, Bradding P, et al. 2011, P147 Outcomes of pulmonary rehabilitation in severe asthma, Thorax 2011;66:A127.
11) Kew KM, Nashed M, Dulay V, Yorke J, 2016, Cognitive behavioural therapy (CBT) for adults and adolescents with asthma. Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD011818.

PM-GB-ASU-WCNT-200010 May 2020

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March 2019