Beruflich Dokumente
Kultur Dokumente
573-585
The de velopm ent of a self-report m easu re design ed to assess illn ess-speci® c cata-
strophic though ts in chronic obstructive pulm onary disease (CO PD ) is described.
The m easu re is then used to test hyp otheses ab out the relatio nship betw een catastro phic
though ts an d an xiety in CO PD . Prelim in ary ® nd in gs suggest that the m easu re, the
Interpretatio n of B reath in g Problem s Q uestion naire (IB PQ ), has go od psych om etric
properties. Tests of speci® c hyp otheses in dicated that m ore se vere catastro phic
though ts w ere asso ciated w ith high er le vels of an xiety. Catastro phic though ts an d
an xiety w ere also m ore severe in unsafe than in safe situ atio ns. Se verity of catastro phic
though ts w as a sign i® can t predictor of an xiety, particu larly of situ atio n speci® c
(IB PQ ) an xiety. Satisfactio n w ith social support, bu t not age, duratio n, or severity o f
illn ess, was also im portan t, particu larly in safe situ atio ns. Im plicatio ns for a cogn itive
m odel of an xiety in CO PD , an d for treatm ent of an xiety in this diso rder, are brie¯ y
discu ssed. L im itatio ns of the study are noted. Su ggestio ns are m ad e for further re-
search.
K E Y WOR D S: cognition; anxiety: chronic obstructive pulmonary disease .
1
Isis E ducation Centre, Warneford Hospital, O xford, UK.
2
Rayners’ Hedge, Ayle sbury, UK.
3
Horton General Hospital, B anbury, UK.
4
Corre spondence should addre ssed to Myra Cooper, Isis E ducation Centre, W arne ford Hospital, Oxford,
O X3 7JX, UK; e-mail: myra.coope r@oxmhc-tr-anglox.nhs.uk
573
0147-5916/99/1200-0573$1 6.00/0 Ó 1999 Ple num Publishing Corporation
574 Su tton, Coo pe r, Pimm , and Wallace
associate d with gre ater and e xce ssive use of medication (Carr, Le hre r, & Hochron,
1995) and more fre que nt and longe r hospital admissions (e .g., Yellowle es, Hayne s,
Potts, & Ruf® n, 1988) among patie nts with CO PD. It has also be e n sugge ste d that
it inhibits ade quate coping and e ngage ment in rehabilitation program s (A gle &
B aum, 1977) . Phenome nologically, some of the symptom s of panic disorde r are
similar to the symptoms associate d with CO PD ( Spinhove n, Ros, We stge e st, & van
de r Does, 1994) . In particular, patie nts with CO PD are pre sente d with chronic or
chronic-e pisodic exposure to bodily se nsations, some of which are similar to those
associate d with the onse t of panic. The re is also a high de gre e of avoidance of
situations in which bre athing may be disrupte d or temporarily obstructe d (Yel-
lowle es e t al., 1987) . The se similaritie s have re sulte d in the application of psychologi-
cal mode ls to e xplain the pre se nce of panic in CO PD, including the cognitive
mode l of panic (Clark, 1986) . Clark’ s mode l propose s that panic results from the
catastrophic misinte rpre tation of certain bodily se nsations. A s applie d to CO PD,
this mode l pre dicts that only those who also expe rience catastrophic 5 thoughts
(e ithe r misinte rpretations or ove rinte rpre tations 6) in addition to the physiological
symptom s and bodily se nsations associate d with CO PD will e xpe rie nce panic. E x-
isting studie s provide some support for the importanc e of cognition in CO PD and,
the refore , support for this theory. Thre e studie s have found that patie nts with
CO PD who report panic attacks, compare d to those who do not, have highe r le ve ls
of catastrophic cognitions, although the y do not diffe r on demographic or illne ss-
re late d variable s ( Porze lius, V e st, & Nochom ovitz, 1992; Carr, Le hre r, Rausch, &
Hochron, 1994; van Peski-O oste rbaan e t al., 1996) . O ne study has found that cata-
strophic cognitions pre dict more variance in speci® c and ge ne ral panic fe ar than
illne ss variable s, including pulmonary function (Carr e t al., 1995) . Howe ve r, de spite
pre liminary evide nce, no study has e xam ined the pre cise conte nt and focus of
catastrophic cognitions in CO PD: many existing studie s use a measure de signe d
for use in panic and anxie ty without physical illne ss, the A goraphobic Cognitions
Q uestionnaire (A CQ ; Chamble ss, Caputo, B right, & Gallaghe r, 1984) . O ur clinical
e xpe rie nce sugge sts that CO PD patie nts focus particularly on symptoms of the ir
physical illne ss, i.e ., re spiratory disease , and that the se are the symptom s that they
fre que ntly inte rpre t ne gative ly and catastrophi cally. O ur e xpe rie nce sugge sts that
catastrophic inte rpre tation of respiratory symptoms is relate d not only to panic but
also to high le ve ls of anxie ty. O ur obse rvations of patie nts with CO PD also sugge st
that they fre que ntly show le ss anxie ty and fewer catastrophic cognitions in certain
``safe’ ’ situations, e ven when the ir physical symptom s are se ve re. This include s
hospital se ttings and situations in which a familiar or truste d pe rson is present. This
obse rvation may account for the ofte n obse rve d failure of good progre ss in hospital-
base d re habilitation program s to gene ralize to othe r se ttings Ð for e xam ple , going
5
For the purpose s of this paper, the te rm ``catastrophic’ ’ is de® ne d using Clark’ s (1986, p. 461) de ® nition
in which catastrophic, as applied to cognition, involve s ``perceiving . . . sensations as much more
dange rous than they re ally are.’ ’
6
A s others have pointed out, some of the he alth risks that patients with CO PD fear may well be re alistic.
Thus it may be more appropriate , in some cases, to refe r to catastrophic thoughts as overinte rpretations
rathe r than misinterpretations. O ur clinical expe rie nce sugge sts that both type s of interpretation may
be important in CO PD. Clark’ s de ® nition of catastrophic thoughts appears able to e ncompass both
type s of interpre tation.
A nxiety in COPD 575
out from home alone . The pre se nt study re ports on the de ve lopm ent of a se lf-
re port que stionnaire de signe d to asse ss the conte nt and se verity of catastrophic
cognitions spe ci® cally re le vant to the re spiratory symptom s associate d with CO PD.
This me asure is used to te st the following hypothe ses: (1) that se ve rity of catastrophi c
thoughts rele vant to respiratory symptoms will be relate d to ge ne ral and situation
spe ci® c anxie ty; (2) that in situations perceived as more threate ning or ``unsafe ,’ ’
patie nts will e xpe rie nce more anxie ty and thoughts will be more catastrophi c; and
(3) that se verity of catastrophic thoughts will predict more of the variance in ge ne ral
and situation-sp eci® c anxie ty, particularly in unsafe situations, than de mographic,
illne ss, and social support variable s.
ME THOD
Particip an ts
Thirty-se ve n patie nts (19 fe male , 18 male ) with a current diagnosis of CO PD
took part. Spe ci® c diagnose s were as follows: asthm a, 16 patie nts; bronchitis and /
or emphyse ma, 20 patie nts; lung dise ase re late d to asbe stos e xposure , 1 patie nt.
Patie nts were re cruite d from a hospital che st clinic, from a ge ne ral practice re spira-
tory clinic, and from patie nts who had re cently atte nde d a hospital-base d pulmonary
re habilitation clinic. Diagnosis of CO PD was made by the consultant che st physician
or physician curre ntly involve d in the patie nts’ care . Pote ntial participants were
not re fe rre d if the y were known to have signi® cant additional physical illne ss or a
history of me ntal disorde r. In practice , only a small number of patie nts were exclude d
be cause of signi® cant additional physical illne ss and none were e xclude d for psychi-
atric history.
Measu re s
D emo grap hic Inform atio n
Inform ation was colle cted on age , spe ci® c diagnosis, duration of illne ss, medica-
tion use , and numbe r and duration of hospital adm issions re late d to CO PD.
Interpretatio n of B reath in g Problem s Q uestionnaire (IB PQ )
The IB PQ was designe d to asse ss catastrophi c thoughts associate d with the
symptom s characte ristic of CO PD. It was de ve lope d on the basis of clinical e xpe ri-
e nce and in e xtensive pilot work with 6 patie nts with CO PD. The 6 patie nts were
chosen to re pre se nt the most common disorde rs (asthm a, bronchitis, and e mphy-
se ma), and thus symptoms, comprising CO PD. The se patie nts were que stione d in
de tail about the ir spe ci® c symptoms as well as about thoughts re late d to the se
symptom s, and about activitie s and situations that they avoide d in orde r to avoid
e xpe rie ncing symptoms. In the pilot work, que stions about symptom s were base d
on the A sthma Symptom Check-list (Kinsman, Lupare llo, O ’ B anion, & Spe ctor,
1973) and the B ronchitis and E mphyse ma Symptom Che ck-list (Kinsman et al.,
576 Su tton, Coo pe r, Pimm , and Wallace
1983) . O pportunity was also give n for patie nts to ide ntify any symptom s not include d
on the se two che ck-lists. The ® nal version of the que stionnaire consiste d of 14 brie f
scenarios de scribing the e xpe rie nce of one of se ve n symptoms commonly associate d
with CO PD, e ithe r in a safe or unsafe situation, e .g., ``You are on a long walk
alone [unsafe situation] and you be gin to fe e l short of bre ath.’ ’ The symptom s
chosen were those obse rved by us to be most common and those re porte d most
fre que ntly by the pilot patie nts. E ach scenario was followe d by three ope n-ende d
que stions, base d on que stions found to be use ful in pilot work, de signe d to elicit
catastrophic cognitions. The que stions were as follows: ``What might you do in this
situation? ’ ’ ``What thoughts go through your mind? ’ ’ ``What is the worst thing that
you think may happe n to you? ’ ’ Patie nts were the n aske d to rate anxie ty in the
situation and, for that situation, belie f that they would become ill and be lief that
the y would die . Finally, patie nts were aske d whe ther or not they would avoid the
situation. O btaining be lie f ratings e nable d concurre nt (crite rion-re late d) validity of
the ope n-ende d re sponse s to be assessed. A copy of the que stionnaire , including
all 14 scenarios, ope n-ended que stions, and rating scales, can be see n in A ppe ndix A .
Hosp ital A nxiety an d D epression Scale (HA D S)
This is a 14-ite m self-report que stionnaire with good psychom e tric prope rtie s
(Z igmond & Snaith, 1983) de signe d to asse ss anxie ty and de pre ssion in me dical
outpatie nts. O nly the anxie ty scale (7 items) was used he re. It was chose n be cause
it doe s not include somatic symptom s of anxie ty; thus re sponse s are unlike ly to be
confounde d with the physical symptom s of CO PD.
St. G eorges’ Respirato ry Q uestionnaire (SG RQ )
This is a 76-ite m se lf-re port que stionnaire (Jone s, Q uirk, & B ave ystock, 1991)
with good psychome tric prope rties (Jones, Q uirk, B ave ystock, & Littlejohns, 1992) .
It is designe d to me asure impaire d health and pe rceive d well-be ing in airways
disease . The 9-ite m symptom s subscale was used he re in orde r to asse ss freque ncy
and se verity of symptom s associate d with CO PD. Scores on this subscale are highly
correlate d with actual physiological impairm ent, i.e ., measure s of lung function
(Jones e t al., 1991) .
Sh ort Fo rm So cial Su pport Q uestionnaire (SSQ 6)
This measure is a 6-ite m se lf-report que stionnaire , with good psychom etric
prope rtie s (Sarason, She arin, Pie rce, & Sarason, 1987) , de rive d from the Social
Support Q ue stionnaire ( Sarason, Levine , B asham, & Sarason, 1983) . It was used
he re to asse ss satisfaction with curre nt social support.
Procedure
With the agre e ment of the re sponsible clinician, 65 patie nts were invite d, by
lette r, to participate . Fifty-thre e patie nts re sponde d to the le tte r and, of the se ,
thirty-se ve n agre e d to participate . A ll those who agre ed to take part were see n
individually at home . Demographic information was colle cted and patie nts com-
plete d the se lf-re port que stionnaire s. E ighte e n patie nts also agre e d to comple te the
A nxiety in COPD 577
IB PQ a se cond time , 4± 6 wee ks after the initial inte rvie w, in orde r that te st± re test
re liability could be calculate d. O n this occasion the IB PQ was se nt out and returne d
by post. A ll que stionnaire s se nt in this way were comple te d and re turne d.
R E SU LTS
e .g., ``I’ ll stop bre athing and ge t brain damage ’ ’ and ``I’ ll get bre athle ss and pass out.’ ’
Written crite ria (se e A ppe ndix B ) were provide d for each of the thre e cate gorie s
and all re sponse s we re then code d by two inde pe nde nt judge s. The re was perfe ct
agre e ment on 90% of the re sponse s. Cohen’ s kappa was 0.83, indicating substantial
agre e ment be twe e n the two judge s (Landis & Koch, 1977) .
Internal Consisten cy
O pe n-e nde d response s we re assigne d a value from 1 to 3 with highe r value s
re pre se nting more seve re ly catastrophic thoughts ( noncatastrop hic, score 1; mode r-
ately catastrophi c, score 2; seve re ly catastrophic , score 3). A Cronbach alpha coef® -
cie nt value was calculate d, using mean seve rity of catastrophic thoughts ratings for
e ach ite m, to asse ss homoge ne ity of the 14 ite ms use d to measure se ve rity of
catastrophic thoughts. The value was 0.90, indicating good homoge ne ity.
Inde pe nde nt variable s in all analyse s were age , duration of illne ss in years, seve rity
of illne ss (SGRQ score ), and satisfaction with social support (SSQ 6 score). In the
® rst se t of analyse s the de pe nde nt variable was HA DS anxie ty score . In the second
se t the de pe nde nt variable was me an total situation speci® c anxie ty. In the ® rst
and second analysis of each se t me an total se verity of catastrophic thoughts in safe
and unsafe situations, re spe ctively, were also e nte re d as inde pe nde nt variable s. In
e ach analysis all inde pendent variable s were ente re d toge the r in ste p 1. Summary
statistics for all four analyse s, showing only signi® cant pre dictors, are pre se nted in
Table II.
A nalyses w ith HA D S A nxiety as the D epen dent Variab le
A ge , duration of illne ss, and se verity of illne ss did not e merge as signi® cant
pre dictors of HA DS anxie ty in e ithe r of the ® rst se t of two multiple re gression
analyse s. In the ® rst analysis, whe re mean total se verity of catastrophic thoughts
in safe situations was e ntered as an inde pe nde nt variable , satisfaction with social
support was the only signi® cant ( negative ) predictor of HA DS anxie ty. In the se cond
analysis, whe re me an total seve rity of catastrophi c thoughts in unsafe situations was
e ntere d as an inde pe nde nt variable , this variable and satisfaction with social support
were the only variable s that were signi® cant pre dictors of HA DS anxie ty. The most
signi® cant pre dictor was mean total seve rity of catastrophic thoughts, followe d by
satisfaction with social support, a ne gative pre dictor.
A nalyses w ith IB PQ A nxiety as the D ependent Variab le
A ge , duration of illne ss, and se verity of illne ss did not e merge as signi® cant
pre dictors of situation-sp e ci® c (IB PQ ) anxie ty in e ithe r of the se cond se t of two
Table II. Summary Statistics for the Two Se ts of Two Multiple Regression Analyse s
Se t 1: HA DS anxiety as the de pe ndent variable
multiple re gre ssion analyse s. In the ® rst analysis, whe re mean total seve rity of
catastrophic thoughts in safe situations was ente re d as an inde pe nde nt variable ,
this variable and satisfaction with social support were the only signi® cant pre dictors
of IB PQ anxie ty. The most signi® cant pre dictor was mean total se verity of cata-
strophic thoughts, followe d by satisfaction with social support, a ne gative pre dictor.
In the se cond analysis, whe re mean total se verity of catastrophic thoughts in unsafe
situations was e nte re d as an inde pe nde nt variable , this variable was the only signi® -
cant pre dictor of IB PQ anxie ty.
D ISCU SSION
nique s might he lp patie nts re duce their anxie ty and thus bene ® t more fully from
re habilitation programs. This might incre ase the ir quality of life Ð for e xam ple , by
facilitating ge neralization of gains made in a relative ly safe situation (a hospital
program) to unsafe situations, as well as reducing se lf-impose d re strictions and
incre asing opportunitie s for social and community support. Decreasing anxie ty
might also preve nt e xce ssive use of medication, and re duce the fre que ncy and
length of hospital admissions. A lthough furthe r work is ne e de d, the IB PQ might
provide a useful me asure of the cognitive change s achie ve d through cognitive
the rapy technique s.
There are some important quali® cations to our results. A ll measure s were se lf-
re port, more highly re late d me asure s were colle cted at the same asse ssment, and
although pre vious studie s have shown that the SGRQ corre late s highly with obje c-
tive measure s, there was no obje ctive measure of dise ase se ve rityÐ for example ,
lung function Ð in our study. Small sample size is also a limitation. Finally, although
the questionnaire was de ve lope d from our clinical e xpe rie nce and detaile d asse ss-
ment of patie nts with CO PD (including a range of re pre se ntative diagnose s), the
number of patie nts inte rvie wed in de tail was relative ly small.
Furthe r work is cle arly nee de d, in particular on the concurre nt validity of the
IB PQ . This might be inve stigate d in a varie ty of ways. For e xam ple , it might be
use ful to se e whe the r the IB PQ pre dicts future anxie ty, e ngage ment in re habilitation
programs, and future disability. More de taile d and se nsitive inform ation than was
obtaine d here on avoidance , medication use , and hospitalizat ions would also enable
inve stigation of the relationship of the se variable s to catastrophi c thinking. O f
particular importance , and not inve stigate d he re , is comparison of the predictive
ability of the IB PQ and A CQ in patie nts with CO PD. A measure of panic might
also be use fully include d in such a study. Comparing the re lative merits of the two
que stionnaire s, and assessing panic as well as anxie ty, is like ly to have implication s
for the de ve lopme nt of cognitive theory, both in CO PD and, more ge ne rally, in
physical illne ss. Work comparing cognitions colle cted in vivo with the cognitions
asse sse d he re ( an analogue situation) would also provide a furthe r te st of the validity
of the IB PQ . Future studie s should also e nde avor to obtain more obje ctive measure s
of dise ase seve rity. More gene rally, the applicability of the cognitive mode l, focusing
on illne ss-spe ci® c thoughts, nee ds furthe r inve stigation. This might be achie ve d
using e xpe rime ntal manipulation s to te st furthe r the possibility, sugge sted by the
ability of catastrophic thoughts to pre dict anxie ty, of a causal re lationship be twe e n
illne ss-speci® c catastrophi c thoughts and anxie ty.
A PPE ND IX A
pe ople s’ thoughts in re sponse to various symptoms they e xpe rie nce as a result of
the ir bre athing proble m.
Here are some de scriptions of some of the symptom s you may expe rience in
re lation to your bre athing proble m. A varie ty of situations are described in which
e ach symptom may be expe rie nced. Read e ach one, and then answe r the que stions
be low it ve ry brie¯ y. Write down the ® rst thin g that come s into your mind without
thinking too long about it. You may not have e xpe rie nce d all of the symptoms or
all of the situations de scribe d in the que stions. If this is the case, ple ase answe r the
que stion anyway, by imagining how you would re spond to the symptom in the
situation de scribe d.
E ach que stion also asks you to rate how anxious you think you would be in
e ach situation, and what you belie ve could happe n to you. Ratings are made on a
scale of 1± 10, and instruction s on how to respond are give n for each que stion.
Scenario s7
1. You are in a smoke y pub and your chest be gins to fe e l tight.
2. You are at a friends’ house and your che st begins to fee l tight.
3. You are going up the stairs at a shopping centre and you notice it is
be coming harde r to bre athe .
4. You are in a crowd in town and you be gin to fe e l tire d and e xhauste d.
5. You are going up the stairs at home , and you notice that it is be coming
harde r to breathe .
6. You are sitting at home with a frie nd, and you notice you are whe ezing.
7. You are driving down the motorway, and you notice your che st is becom-
ing conge ste d.
8. You are at your GP surge ry, and you begin to cough he avily.
9. You are visiting a physiothe rapist at the hospital, and you fe e l your che st
is be coming conge ste d.
10. You are on a crowde d bus and you notice you are whee zing.
11. You are working in your garde n with a friend, and you notice you are
short of bre ath.
12. You are in the supe rmarke t, and you be ing to cough heavily.
13. You are at the hospital for a check-up, and you be gin to fe el tire d and ex-
hauste d.
14. You are out on a long walk on your own, and you notice you are short
of bre ath.
7
The safe scenarios are containe d in Questions 2, 5, 6, 8, 9, 11, and 13. The remaining que stions contain
unsafe scenarios.
8
The que stions and rating scale s follow the brief description of each sce nario and are comple ted for
e ach sce nario se parately.
584 Su tton, Coo pe r, Pimm , and Wallace
Ple ase rate how anxious you would be in this situ ation, by marking the scale be low:
1 2 3 4 5 6 7 8 9 10
no anxie ty extre mely
anxious
Please answer the two que stions be low by marking each scale :
1. How much do you be lieve you would be come ill in this situation?
1 2 3 4 5 6 7 8 9 10
I would not I would become
be ill at all extrem ely ill
2. How much do you be lieve you would die in this situation?
1 2 3 4 5 6 7 8 9 10
absolute ly no I would
chan ce of dying de® nitely
die
Would you avoid this situation? Yes/No
Scorin g Instructions
O pe n-e nde d response s are cate gorise d as eithe r noncatastro phic (score 1),
mode rate ly catastrophic (score 2), or se vere ly catastrophi c (score 3). A mean score
is the n calculate d, separate ly for safe and unsafe scenarios, if ne cessary.
A PPE NDIX B
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