Chapter 5

Understanding Anxiety, Panic and Related Conditions

• Anxiety and Depression
• Anxiety and Possible Impact on Appetite
• Appetite and Weight loss in COPD

Anxiety and Depression

Many times, depression is mixed with anxiety. Many people develop depression after the onset of suffering from a serious chronic medical condition. Some develop a significant level of anxiety related to their medical condition. Chronically severe anxiety can also cause or contribute to depression.

Studies show that depression and anxiety go hand in hand in about sixty percent of cases. Some depressed individuals feel restless and agitated. Restlessness and agitation, which may be caused by heightened anxiety and despair resulting from worthlessness, hopelessness, sense of failure and indecision.

Loss of job and of the role as an earner and family nurturer or as a provider, disability, confinement or overall impairment in the ability to function in daily life are severe stressors and among the most powerful circumstances leading to depression. Incidence of depression and anxiety is high in the COPD population. Anxiety often accompanies depression and vice versa.

Renee D. Goodwin of Columbia University and a team led by her reported evidence of suicidal thoughts with patients diagnosed with pulmonary disease. These suicidal thoughts seem to be more prominent than those with major depression. In her study of 3000 patients she found that 11 percent had thoughts of suicide or hurting themselves, and this 11 percent had no diagnosis of depression. Goodwin notes several reasons as to why patients would want to hurt themselves. One, diseases dealing with COPD may create "a sense of hopelessness and despair". Secondly, medications could account for these suicidal thoughts. Medications such as steroid based drugs, which could increase "feelings of sadness and anxiety". Cigarette and alcohol use can also attribute to the cause. "Pulmonary diseases often induce panic attacks, which could contribute to thoughts of killing oneself …" 4 (Bower, Bruce, 2003)

Another study was done investigating whether "psychological factors predict outcome after emergency treatment for obstructive pulmonary disease". The study found that 40 % (17 patients) had anxiety/depression, and that of the 17 patients 53% (9 patients) were admitted to the hospital or had a relapse within 1 month. These patients were compared with 19 % (5 patients) who did not have anxiety/depression. The study indicated that "anxiety and depression are related to the outcome of emergency treatment in patients with obstructive pulmonary disease." 5 (Inger Dahlen, Jansen Chirster, 2002)

Pulmonary Rehabilitation (PR) can improve anxiety and depression in patients with COPD. 29.2% of patients studied had significant amounts of anxiety and 15% had significant depression. After a 6-month follow up the use of Pulmonary Rehabilitation helped in reducing the amount of anxiety and depression in patients. "Anxious patients showed statistically greater improvements in exercise capacity following PR." 6 (Withers NJ., Rudkin ST., White RJ, 1999)

Dr. Kozora studied the Neurobehavioral Improvement in patients with depression after three weeks of rehabilitation. "Decline in depressive symptoms and increased exercise capacity occurred in patients with COPD after brief rehabilitation. Clinical improvement in visual attention, verbal memory, and visuospatial functions occurred in the impaired patients with COPD participating n treatment." 7 (Kozora E., Tran ZV., Make B, 2002)

In a study done to determine the risk of depression in patients with COPD an its determinants found that "the prevalence of depression in COPD patients with severe airways obstruction was 25 % and that they had a 2.5 times greater risk of depression than controls who were comparable for demographic variables and the presence of comorbidity." 8 (van Manen JG, et al, 2002)

Anxiety and its possible impact on appetite

Changes in appetite and eating behavior are generally associated with depression, but lesser known is the fact that anxiety can also cause an eating disorder.

Anxiety and depression affect the appetite and eating behavior quite differently. Depression tends to suppress most biological functions, especially the drives and desires related to hunger: thirst, sex, movement or exploration of the environment.

Anxiety seems to over stimulate and overcharge the same systems. Therefore, when anxious, we become "hyper," "fidgety," over focused and super vigilant.

For sake of simplicity, let's say that in depression a person becomes "under reactive" and in anxiety, "over reactive." Pursuing this line of thinking, we can see that, by and large, in depression the appetite and eating should be reduced, while in anxiety, the same should be increased. Sounds logical? Right?

But, in real life things are often unpredictable and inconsistent. In depression, patients can experience either increase or decrease in the appetite or alternately both. Some depressed individuals develop a hyper appetite and crave for food all the time. Likewise, anxiety can either kill appetite or turn a person into a voracious eater. How is that possible? How come the anxiety and depression both can take us to the opposite extreme?

It's possible that the increase in appetite and craving for food seen in depression is really caused by anxiety. I am not offering this as just "food for thought," but it can be important for the treatment of eating disorders associated with anxiety and depression.

Therefore, a depressed individual who also exhibits hyper appetite and craving for food should be evaluated for presence of anxiety. If there is a significant level of anxiety, then therapy should obviously include techniques for anxiety reduction.

Some anxious individuals report severe loss of appetite. They can become emaciated. They should, of course, be evaluated for depression, but, keep in mind that anxiety can also cause the same symptoms.

Here is one explanation regarding how anxiety can kill the appetite and suppress eating behavior: Anxiety causes excessive secretion of acids in the stomach causing low-grade nausea and giving the feeling of fullness in the stomach. Furthermore, a feeling of fullness in the throat and difficulty in swallowing experienced in anxiety can also suppress the desire to eat.

Other associations between anxiety and eating disturbance are not yet clearly understood. For instance, social fears and thoughts of being negatively judged or evaluated by others are sometimes associated with loss of appetite or food refusal.

Relationship conflicts, or "tangles," are also associated with both under eating and over eating. Perhaps, anger and anxiety are responsible for this. The reverse is also true. Anxiety and eating problems improve as relationships improve.

In the case of people with COPD, loss of appetite and/or weight is even more complicated. Lung impairment is often associated with loss of appetite and digestive track problems such as Irritable Bowel Syndrome (IBS), diarrhea, flatulence, constipation and the like. Side-effects of some medications people with COPD take can also cause digestive tract problems.

Appetite and weight loss in COPD

One friend with COPD shared the following: "I feel better with little or no food, but that's not going to help me gain weight. I've lost another 5 lbs. since this last March. I look anorexic and was sent to a eating disorder clinic, but I don't fit into this category. It's because I am struggling to breathe---which uses up a lot of calories and I don't know what to do about this too- full feeling. It's not constant, but happens three or four times a week and lasts for hours."

Many people with COPD have significant level of anxiety and depression problems. For those people, loss of appetite could be an interaction of anxiety, depression and complication of lung impairment. If anxiety alone is causing overeating or under eating, calming the over reactivity of the nervous system can be helpful. And, you should calm the mind as well. Obviously, if there is a situation that is keeping you tensed up, it needs to be modified.

Continue to Chapter 6

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Copyright 2008, Mind Publications 
Posted August 2008