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Cognitive Behavioral Therapy to Manage Anxiety in Chronic Respiratory Disease

Cognitive Behavioral Therapy to Manage Anxiety in Chronic Respiratory Disease

Ingeborg Farver-Vestergaard1,2 & Liz Steed3

1 Department of Medicine, Lillebaelt Hospital, Vejle, Denmark

2 Department of Regional Health Research, University of Southern Denmark

3 Centre for Primary Care, Wolfson Institute of Population Health, QMUL, England

Anxiety is a pervasive challenge for patients with chronic respiratory diseases (CRD) such as chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD) and severe asthma, exacerbating symptom severity and impacting a range of clinical and psychosocial health outcomes.1 Despite advances in respiratory care and Pulmonary Rehabilitation (PR), the level of anxiety symptoms remains high in this population,2,3 with reports of between 10 to 55% dependent on method of assessment and patient characteristics.4 Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for anxiety that has shown promising outcomes in managing the psychological challenges patients with CRD face, yet questions remain about its specific benefits and optimal implementation in this patient group.

The impact of anxiety in chronic respiratory disease

Anxiety is more than a by-product of respiratory disease; it is a co-conspirator in the cycle of respiratory symptoms, and it impacts the physical as well as psychological health of patients with CRD.5 Respiratory clinicians are well-aware that breathlessness, one of the most distressing symptoms in CRD, can be closely linked with anxious states. Patients with COPD, for instance, often find that the mere anticipation of shortness of breath is enough to trigger a change in breathing pattern. Anxiety can interact with breathlessness to cause maladaptive cycles of avoidance, physical deconditioning and disease aggravation that CBT can help to interrupt.

Why Cognitive Behavioral Therapy?

CBT directly targets these maladaptive cycles by addressing the cognitive and behavioral factors that drive anxiety. The therapy is built on two primary tenets: that our thoughts directly impact our emotions, and that behaviors – often conditioned by these emotions – can be modified to create positive feedback loops, informing more helpful thinking patterns over time.6 In the context of respiratory disease, CBT focuses on helping patients recognize and reframe their automatic thoughts about breathlessness, physical limitations and risk of death.7

Consider a patient with asthma who, after a frightening exacerbation, becomes hypervigilant about every breath, fearing that even small changes in breathing could be the signal of a life-threatening event. Through CBT, this patient can learn to identify and evaluate the validity of catastrophic thoughts and – based on graded exposure to feared activities – replace them with more balanced perspectives. Over time and with practice, the patient becomes less reactive to minor fluctuations in breathing, reducing the intense anxiety that would otherwise have impacted the respiratory system.

An example from clinical practice

Maria is a 62-year-old woman with COPD who, after a particularly difficult winter, developed pervasive symptoms of anxiety. She feared that if she left her home, any exposure to cold air or germs would trigger an exacerbation. The CBT intervention began by working with Maria to understand the thoughts underlying her fear. She explained, "I feel like if I step outside, my breathing will fail and before I know it I will be back in hospital”. Through CBT exercises, she was able to identify this as a form of ‘catastrophizing’, a common cognitive distortion where the mind spirals toward the worst possible outcome and behaviour is based on a ‘better safe than sorry’-principle.

The uncovering of Maria’s anxiety-related thoughts gave way for more targeted information from her healthcare providers about how the lungs react to cold weather and bacteria. Through this information and through graded exposure to feared activities, in conjunction with breathing techniques, Maria’s thoughts gradually reframed and expanded into a more balanced perspective, such as, "Going outside may make me short of breath, but I have the tools to manage it, and shortness of breath does not mean immediate danger”. In time, Maria’s relationship with her symptoms was gradually transformed, allowing her to reintegrate into her community and reclaim an aspect of her independence that her fear did previously not allow her to.

The evidence for Cognitive Behavioral Therapy in chronic respiratory disease
CBT has been widely validated for anxiety disorders in the general population.8 However, the evidence for CBT in CRP remains inconclusive. A systematic review and meta-analysis of 33 studies of CBT interventions in COPD published between 1996 and 2019 showed an overall small, significant effect of CBT across the outcomes of anxiety, depression, dyspnea, exercise capacity and quality of life.9 However, when taken into account the control conditions of the studies, the effect remained only for studies comparing high-intensity CBT interventions to no intervention, i.e., usual care. This suggests that the isolated, CBT-specific effects are more uncertain. More recently, the TANDEM study,10 a large randomized controlled trial involving 423 patients with moderate to very severe COPD and mild to moderate anxiety or depression, examined the effects of a tailored cognitive behavioural approach, where respiratory professionals were trained and supervised to deliver basic cognitive behavioural techniques but not full therapy. After a structured six- to eight-week intervention, the trial found no clinically significant reductions in anxiety or depression scores at six or twelve months when compared to usual care. Additionally, there were no notable improvements in quality of life, social engagement or healthcare resource use in the CBT group. It was noted in this study the complexity of the patient group with many patients suffering from multiple co-morbidities.11

Limitations of CBT in CRD: what remains unclear?

Hence, several questions remain regarding the precise role and longevity of CBT benefits in CRD. Current studies deliver CBT in various formats and settings and by various healthcare professionals, leaving uncertainties about the degree to which components of the treatment drives the effect and under which circumstances, and what is required for maintenance of change. For example, as PR includes exercise training supported by a healthcare professional, this may address breathlessness-related cognitive and emotional factors, although a full CBT intervention is not given.9,12 Moreover, CBT is often introduced at a point in the disease trajectory where anxiety and breathlessness-related patterns has become an inherent part of patients’ being in the world, and vicious cycles may therefore be more difficult to break. Introducing CBT earlier in the disease course might yield more substantial benefits, potentially enhancing patients’ ability to manage their condition more effectively over time.13 The TANDEM intervention showed fidelity of delivery amongst trained and supervised respiratory professionals but more training may be needed for the most psychologically complex patients.14

Moving toward a stepped, multimodal approach to anxiety management in CRD

The common misconception that psychological interventions are secondary to medical treatment of chronic diseases overlooks the interdependence between mental and physical health.15 While CBT shows potential, further research is needed to determine when and with whom this may be a helpful approach, and how best to integrate psychological intervention and support into a comprehensive management plan for patients with CRD.15 A stepped care approach could move from early education on the respiratory disease and the role that thoughts, behaviours and emotions play, continued active monitoring of the biopsychosocial condition with early low intensity intervention, towards more specialised and tailored interventions if and when symptoms or the complexity of the patient become more severe.9 Further, ongoing reinforcement of cognitive behavioural strategies so skills are learnt and applied in the long term may be necessary. Mental health specialist should be included as second line supervisors and educators of frontline providers in earlier steps and as first line treatment providers in later steps.

A personalized approach to patient care is essential, recognizing the individual suffering and existential terror that breathing difficulties can imply. The goal should always be to view the patient’s experience as a whole, rather than reducing it to isolated symptoms categories and mechanical solutions.16

Conclusion

Psychological interventions such as CBT hold promise as an adjunctive tool to address the significant anxiety burden faced by patients with chronic respiratory disease. Evidence indicates that for some, when added to standard care, CBT can reduce anxiety symptoms, improve management of respiratory symptoms and enhance quality of life. Nonetheless, considerable gaps remain regarding its isolated effectiveness, delivery modes and integration with other treatment modalities.

References

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