Chapter 2

When We Can't Breathe, Panic is the Normal Reaction - But it can be Controlled and Modified by the Mind

• Incidence of Anxiety and Depression in COPD
• Example of Panic Producing Thinking
• Emergency Tip Sheet for Panic Control
• Maintenance Program
• Self-Help Exercise

Incidence of Anxiety and Depression in COPD

Anxiety or panic attacks are among the most common and disabling problems encountered by both mental health professionals and general medical practitioners. Even otherwise healthy people can have an absolutely terrifying experience during anxiety and panic attacks. When a person actually has a breathing disorder, anxiety and panic attacks present even a bigger challenge.

It is estimated that 25 to 65% percent of people with chronic obstructive pulmonary disease (COPD) suffer from depression and/or anxiety. Less than a third of them might be receiving any form of mental health services. Unfortunately, depression and anxiety can intensify the emotional and physical effects of breathing disorders. Breathing disorders alone and even more so in combination with emotional disorders cause progressive impairment in the activities of daily living, employment, family life, social life and participation in any recreational activities or hobbies.

At the Veterans Affairs Medical Center, Houston, Texas, Kunik et al surveyed veteran COPD patients utilizing the Primary Evaluation of Mental Disorders (PRIME-MD) screening questionnaire and Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID).

80% of patients screened with the PRIME-MD screened positive for depression, anxiety, or both. In the subgroup of patients with COPD who received a diagnosis using the SCID, 65% received an anxiety and/or depressive disorder diagnosis. Only 31% of these patients were currently receiving treatment.

"Our results show that healthcare providers are recognizing less than 40% of anxiety or depressive disorders in COPD patients," note the investigators.

Kunik and team suggest that mental health screening should be employed to identify anxiety and depression in medical patients.

(Kunik et al Chest 2005; 127: 1205-1211)

Example of Panic Producing Thinking

Anxiety or panic attacks are among the most common and disabling problems encountered by both mental health professionals and general medical practitioners. Even otherwise healthy people can have an absolutely terrifying experience during anxiety and panic attacks. When a person actually has a breathing disorder, anxiety and panic attacks present even a bigger challenge.

People with normal lung function are terrified by such thoughts as "I might not be able to catch my breath," "I may smother to death" or "I may be having a heart attack (or stroke). For people who actually have lung impairment such fears feel dauntingly real.

However, fears of a person with COPD may not always be proportionate to the seriousness of the problem. For example, if you had a major episode in the past, it's not necessary that chest tightness and more-than-usual shortness of breath you experience right now would result in a medical crisis and hospitalization.

I know a person with emphysema who used to panic every time she felt a common cold coming. The basis of her fear was that one time her cold caused several complications and she ended up having pneumonia. Since then, whenever she had a cold, she would think of lying in an intensive care unit bed with tubes in her throat with uncontrollable coughing and other medical complications. Since cold equaled pneumonia for her, the first signs of a cold she noticed would lead her to endlessly worry about it. Such obsessive worry would then lead to panic attacks.

One time she came to my office with a cold. She was crying and hyperventilating fearing pneumonia was on its way. I asked her why she was so upset, she said, "I don't' want to get that terrible pneumonia again!" This is how the rest of our conversation went:

Sharma: Every time you have a cold, do you end up developing pneumonia?
Client: "No, but that sure happened to me a couple of years ago and it was not pleasant!"
Sharma: What is the guarantee that it would happen again? How do you know it won't just be an awful cold rather than pneumonia?
Client: True I don't know for sure. All I know is that I don't want it to happen to me ever again.

I asked her to join me for Pursed-Lip Breathing (PLB) to get control over the hyperventilation. Then we talked about the treatment and precautions she was taking for her cold. We talked about the steps she would take if she starts developing complications. I told her I could see the benefit in taking precautions for possible complication. She should talk with her doctor about her concerns, but I didn't see any benefit in making herself scared of pneumonia before it happens. At this point she had calmed down, her chest was not heaving any more and instead of whispering, she spoke in an audible voice.

What Do We Learn from this Example?

People with impaired lung function can have exaggerated fears, that is to say, but their fears may be disproportionate to the actual breathing problem at the time.

Panic attacks occur because of our highly exaggerated response to the following:

1. Breathing discomfort
2. Unpleasant bodily sensations
3. Due to the catastrophic thoughts that cross our mind in relation to the breathing discomfort and bodily sensations.

Self-help exercise

What you have a major problem with breathing, what are your worry/fear thoughts?
_____________________________________________________________
_____________________________________________________________

What do you think or do when you experience increase in your symptoms?
______________________________________________________________
______________________________________________________________
_______________________________________________________________

"Emergency Tip Sheet" for Panic Control

Please review the "Emergency Tips Sheet" for controlling anxiety and panic attacks. More detailed and extensive tips for panic control will be presented later. However, I must emphasize that there are no short cuts. Please review this presentation in its entirety to formulate your own action plan for controlling panic attacks and stabilizing your breathing.

1. Relax the shoulders, neck and whole body and start doing PLB. Don't strain the breathing, slow, soft, gentle, rhythmical and consistent flow of breath. Count your exhale silently in your head such as 1-2-3-4. Look in front of you and gaze at something to focus your mind at whatever is in front of you, wall paper, some object, table, chair, whatever you can focus on.
2. Remind yourself repeatedly until you can believe that your panic attack is a biological emergency response. During any emergency, your whole system gets into a high gear. It doesn't mean you will pass out or stop breathing or never catch your breath. Believing in a positive outcome helps to reduce the anxiety. Take all precautions as recommended by your doctor. Expect and believe that this moment will turn out all right for you.
3. Constantly repeat to yourself that panic symptoms are no doubt unpleasant, but not as dangerous as you might imagine them to be.
4. Know that just as you have a biological emergency response, you also have a biological "calming response." Yes, with steady practice you can learn to calm yourself out of a panic attack.
5. Unpleasant symptoms of an anxiety/panic attack can be brought under control in five minutes if you start calming down and not pump more adrenaline into your blood by "panicking" about the panic attack. By thinking calming thoughts, you will be able to stop pumping more new adrenaline. Adrenalin that was already released in your system "driving your motors" will eventually be neutralized.
6. Do not "fight" with panic attack symptoms. Fighting and desperately trying to stop them makes it worse. Start PLB. Try to "flow" with the symptoms with correct breathing. Form the intention of becoming calm in spite of what your body seems to be telling you.
7. The moment you notice any signs of a panic or anxiety attack, pace your breathing by counting silently in your head. If your exhalation is shorter than inhalation, first equalize it with the help of PLB and then try to make your exhalation 1 or 2 counts longer than inhalation.
8. Say silently in your head words that are reassuring and calming, such as, "I am becoming calm" "It will take a few minutes" "I can handle it as I have handled it before." "I am calm and steady. "

Maintenance Program

1. Learn a relaxation technique (refer to the Appendices) and practice it daily at least two or three times for 15 to 20 minutes each time. There are many self-taught methods of relaxation available on tapes and books.
2. Monitor your breathing all the time. The moment you notice a breathing irregularity, do PLB and acquire consistent flow of breath. Learn to breathe from your diaphragm. Pay steady attention to your breathing, monitor and normalize it right away. Form a habit of breathing slowly and smoothly.
3. Learn to notice the advance signs of an anxiety attack before it becomes severe. Step up your relaxation to bring about the calming response.

Please review the whole section carefully. Also refer to the "Tips for Anxiety/Panic Control: Calming the Breath, Mind and Body"

Self-Help Exercise

If you have experienced panic attack/s, write here things that have worked for you in the past?
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Do you like any of the "Emergency Tips" you will like to use in future to get a handle on your panic attack?
_________________________________________________________________
__________________________________________________________________
__________________________________________________________________

Continue to Chapter 3

Return to Chapter 1

Copyright 2008, Mind Publications 
Posted August 2008