Chapter 1

• Introduction: Anxiety and Panic Attacks in COPD
• In the Words of People with COPD
• Important Observations
• We All are not Exactly Alike
• Suggestions: How to Get What You Want Out of this Book; Easiest and Quickest!

Main Messages of this Presentation

• Anxiety and Panic attacks are not uncommon in COPD. Some estimates indicate that symptoms of anxiety and panic attacks may be experienced by 25% to 60% of people with COPD.
• Many COPD patients may also experience symptoms of depression and other forms of emotional stress with or without anxiety. However, we focus on anxiety and panic symptoms in this presentation
• If you experience anxiety, panic attacks, depression or any other emotional challenge, it does not mean you are "weak" or "going crazy." Actually, the presence of anxiety or depression simply shows you are human and react like a normal human being
• Seeking help or accepting treatment does not mean, "I've lost control," "I have failed" or "I am falling apart." It is smart to seek help when you need it.
• Breathing problems can increase anxiety and anxiety can increase breathlessness. For example, over breathing, rapid and shallow breathing can trap too much stale air in the lungs making it more difficult to get in the fresh air in the lungs (called "dynamic hyperinflation') which can also result in shortness of breath, Dyspnea (breathing discomfort) and/or panic attacks. Corrective breathing and physical and mental relaxation can change this chain reaction.
• Untreated anxiety and anxious breathing pattern can negatively affect your health and your ability to exercise or perform other activities.
• Right breathing can reduce anxiety. Utilize right breathing techniques to manage and control anxiety.
• Physical and mental relaxation can be a powerful tool for dealing with breathlessness and anxiety. Learn the master skill, that is, the "Relaxation skill." Relax those tense muscles, anxious thoughts, and anxious mind with the techniques described here.

• Tips for changing anxious thoughts and symptoms and learn about the "worry busters"
• Tips for breathing correctly to reduce anxiety and/or hyperventilation
• And, the "nuts and bolts" of relaxation techniques.

* This section is a part of the book, "Overcoming Anxiety and Depression and Breathing Correctly in COPD/Emphysema: A Self Care Book for People with COPD & Psychosocial Manual for Professionals" by Vijai Sharma, intended for future publication
Copyright Vijai Sharma, PhD
All inquiries to be directed to [email protected]

In the Words of People with COPD

About Fear, SOB (Shortness of Breath), heart racing, etc.

Below, are a few samples of e-mails I have received from people with COPD who have had problems with anxiety and/or panic attacks. In order to protect their identity, assumed names are used. This first hand experience illustrates the nature of the problem and makes a few important observations.

"I must be having some sort of breakdown as I am constantly sad, worried and live in fear each and every day I fear getting up each morning because I am fearful of feeling not well again I cannot enjoy my family as I feel I am not part of there life anymore as I am always not well, I cannot enjoy my food or social life. I have become almost reclusive as I fear becoming breathless and spoil my partner's time out. I find myself constantly holding my breath and fear that my COPD is raging on."

"The more breathless and anxious I feel, the more I notice myself holding my breath. I feel there is no quality of life. I seriously think Emphysema gives me that chronic fatigue, aches and pains and depression, NOT the Fibromyalgia. I am frightened that emphysema may be progressing rapidly. Sorry for moaning but I can't seem to get in control."

"Exercise is proving difficult as I am anxious of starting of a flare of pain and becoming more breathless which in turn makes it harder for me to manage my life. I fear living as I feel very isolated and trapped in this body that doesn't work."

"My aim is to try to be more positive and take each day as it comes, and focusing on my self and my well being, hopefully without fear."

"It is wonderful to know there is someone out there who is going through the same* (Yes, I too have grappled with anxiety problems from time to time-Sharma) and is offering there expertise and experiences."
"Julia"

"I think my "panic" attacks result from not getting enough oxygen in my system. Please don't confuse this with a "normal" person panting for breath and hyperventilating. Not the same thing. Panic/anxiety is the feeling I have when I can't get my breath. Then I begin to tense up, feeling overwhelmed, jittery and very nervous."
"John"

"I have been to a cardiologist, pulmonary doctor, psychiatrist, and no one can tell me why I am having heart palpitations and shortness of breath. Some days I don't have it at all. Some days I have it all day long and all night long. It drives me right up the wall. I have had anxiety disorder most of my adult life and never experienced anything like this before. I did finally sleep last night but when I woke up, I woke up with palpitations and shortness of breath. So I took Combivent after I took Foradil (may not be a good idea to take them one after another-Sharma), but it didn't help."
"Rhonda"

"My heart races at times, I get sweaty and I am short of breath when I move around. I am on O2 when I am up doing things. I sometimes wonder if it is possibly atrial fibulation? Should I get a sleep study done or ask my doctor if I should wear a Holter monitor for 24 hours or more? (Holter provides a continuous recording of heart rhythm) My friend told me I may even need an "event monitor" (tiny ECG) implanted to monitor any suspicious heart activity. It could be a combination of all the meds I take. I do try to stay calm and use the PLB (Pursed Lip Breathing). Sometimes it works and sometimes it doesn't. Can you tell me what else I can do?
"Don"

"I have had shortness of breath and heart palpitation and tremors for last several years and yet to date all testing has shown is "nothing." At times, I feel the onset of these things is from excitement or stress. So, I take a Xanax (anxiety pill) to calm me before the breathlessness sets in. The only thing the heart monitor can show is that my heart was beating extra early beat and fast. We still haven't got to the bottom of it."
"Brenda"

"My O2 sats go up and down. I am now on O2 at bedtime and when I am out and about I am getting these really bad panic attacks here lately. I wake up in the middle of the night with panicky feelings and have hard time trying to fall asleep. Can you tell me anything I can do to lessen these feelings?"
"Rodney"

Important Observations

1. If you too experience some of the problems described by Julia, John, Rhonda, Don, Brenda and Rodney, you are not alone! Perhaps, 30 to 60 % people with COPD experience them.
2. Untreated anxiety can be a full time affair, keeping you constantly worried, fearful and even sad
3. COPD-related concerns can cause significant anxiety and fear
4. COPD with or without anxiety or depression can affect family and marriage relationship and participation in social life in such ways as, feeling isolated from your partner and family and losing all interest and joy in relating to others
5. Breathlessness tends to make us anxious about breathing
6. The more anxious we feel about breathing, the worse the breathlessness gets
7. Anxiety and breathlessness combined can strongly discourage us from performing daily life activities and exercise.

Suggestions

1. Along with the tests for the lung function and heart function, sometimes, we need an assessment for anxiety to fully understand the problem of breathlessness and heart racing. Tell your doctor how you feel on the inside.
2. Learn anxiety reduction breathing techniques such as the abdominal breathing, paced breathing, and PLB, discussed elsewhere in this book.
3. Learn to identify and change your anxious thoughts, also discussed elsewhere in this book.

We All Are Not Exactly Alike

The impact of breathing discomfort on me may be more severe on me than on you. John may have a tendency to be more anxious than Don. Jane might have had an anxiety disorder before she was ever diagnosed with a breathing disorder. Rhonda might have more concerns about her COPD symptoms or other symptoms related to other medical conditions than Brenda. COPD has many faces and we come in all sizes and shapes. And, yet there are many challenges, doubts, hopes and fears that we all share alike.

How bothered are you by the breathing discomfort you are experiencing? Are you bothered "a little" "quite a bit" or "extremely?"

Two people with same degree of shortness of breath (SOB) may differ with regard to the extent SOB bothers them. For example, given the same objective level of breathing discomfort, individual "A" may just say, "I am having trouble breathing" while "B" may experience an alarming sensation, "I will die of suffocation."

Both "A" and "B" will store these experiences in their memory differently setting different levels of apprehension and anticipatory anxiety. "A" would remember it simply as a discomforting experience which is a nuisance but it can be managed. "B" would remember it as "I could have died" or "I really felt I was going to die. I never want to go through that again"

B might have "oversensitivity" to SOB, heart palpitations, and other physical sensations. Some, when anxious hold their breath or start breathing rapidly and some seem to feel the chest tightening and throat closing more than others do. These are all variations of normal human response to our perception of danger or threat of harm.

If you are one on the high end of anxiety, gradually reduce your anxiety related to breathing. For a start, breathe out slowly and say to yourself silently "Relax!"

Reduce the panic about panic itself! Say to yourself something like "By calming down, it will blow over in just a few minutes." Remind yourself of the saying "You have nothing to fear but fear itself!"

Learn to slow down your breathing on purpose and lengthen your exhalation, just a little bit at a time. Many have benefited from a technique, called "Systematic Exposure and Desensitization." Say, you are oversensitive about SOB. In order to decrease your sensitivity, you take charge of SOB than allowing SOB to take charge of you. What that means is look for a time when you are not experiencing SOB and in that moment you would deliberately increase SOB just a tiny bit, say on the breathlessness scale of 0 to 10, where extreme breathlessness is 10, you increase it to point 1 or 2 by breathing a little more rapidly or by walking or using the treadmill. Then do PLB or belly breathing to bring your breathing back to your normal level.

Here is another example of how you can implement the principle of systematic exposure and desensitization: Walk a few steps hurriedly to feel a little bit of SOB, like 1 or 2 breaths per minute more than your usual. For example, if you breathe at the rate of 12 breaths a minute, walk a little faster so the rate of your breathing goes up to 13-15. So, to continue with the example, walk a little faster and bring your breathing at the rate of 13-15. Then slow down your walking and do PLB and/or walk at your normal pace until the rate of your breathing is down to normal. Keep on doing this experiment until you feel you have learned to accelerate and normalize your breathing at will and thus gained some degree of control over it.

There will be more details later on proper breathing techniques and alleviation of anxiety. Please understand this is not a medical advice, but the explanation of a technique for reducing oversensitivity to breathing discomfort for educational purpose only.

It is better to try such techniques first under the guidance of a psychologist, Physical Therapist (PT) or Respiratory Therapist (RT) preferably in a clinical or pulmonary rehabilitation setting.

Suggestions: How to Get What You Want Out of this Book; Easiest and Quickest!

Though we recommend that you read the whole book before you practice any of the techniques presented here. However, there can be exceptions to this rule in which case you can first refer to the chapter you desire, follow the steps and then read the rest of the book at your convenience. For example, you or your health care professional wants you to practice relaxation or slow your breathing right away in which case you may first refer to the chapters 9 and 10, "Correct Breathing" and "Physical and Mental Relaxation."

If you are already experiencing panic attacks and presumably you have discussed panic attack problem with your doctor, refer to the following chapters: 2,4, 6 and 8. Start bringing the panic attacks under control and then read the other chapters as you make progress with panic attacks.

Continue to Chapter 2

Copyright 2008, Mind Publications 
Posted August 2008