, Julie Burkin1, Catherine Moffat1 and Anna Spathis1
(1)
Department of Palliative Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Abstract
The association between anxiety and breathlessness is well documented. Indeed some studies have been conducted which highlight the activation of the amygdala, part of the limbic system which plays a key role in the processing of emotions, in inducing breathlessness in healthy individuals, indicating this link. There is no substantial evidence to recommend a definitive intervention for anxiety management for the breathless patient and much of the research to date calls for further, more robust investigation in to interventions which aim to reduce anxiety related to breathlessness. However, there is an increasing body of evidence to suggest that anxiety management techniques such as relaxation, mindfulness and cognitive behavioural therapy (CBT) can help with managing symptoms such as pain, stress and anxiety. Booth et al (2011) found that although anxiety management is frequently used with breathless patients, there is a need for definition and further research. Bauswein et al (2008) also found insufficient data to analyse these interventions specifically for breathlessness. Studies are often small with limited numbers thus making it difficult to draw any conclusions from the research. However, complex interventions aimed to improve multiple symptoms, including breathlessness, such as pulmonary rehabilitation programmes or a multi-disciplinary team intervention for breathlessness, which incorporate a large element of anxiety management techniques such as relaxation, breathing control, challenging unhelpful thoughts and realistic goal setting, have strong evidence to support their effectiveness.
Evidence
The association between anxiety and breathlessness is well documented. Indeed some studies have been conducted which highlight the activation of the amygdala, part of the limbic system which plays a key role in the processing of emotions, in inducing breathlessness in healthy individuals, indicating this link (Banzett et al. 2000). There is no substantial evidence to recommend a definitive intervention for anxiety management for the breathless patient and much of the research to date calls for further, more robust investigation in to interventions which aim to reduce anxiety related to breathlessness. However, there is an increasing body of evidence to suggest that anxiety management techniques such as relaxation, mindfulness and cognitive behavioural therapy (CBT) can help with managing symptoms such as pain, stress and anxiety (Gustavsson and von Koch 2006; Kroner-Herwig 2009; Thompson 2009; Hunot et al. 2010). Booth et al. (2011) found that although anxiety management is frequently used with breathless patients, there is a need for definition and further research. Bauswein et al. (2008) also found insufficient data to analyse these interventions specifically for breathlessness. Studies are often small with limited numbers (Yorke et al. 2009) thus making it difficult to draw any conclusions from the research. However, complex interventions aimed to improve multiple symptoms, including breathlessness, such as pulmonary rehabilitation programmes or a multi-disciplinary team intervention for breathlessness, which incorporate a large element of anxiety management techniques such as relaxation, breathing control, challenging unhelpful thoughts and realistic goal setting, have strong evidence to support their effectiveness (Paz-Diaz et al. 2007).
Introduction
Establishing how a person actually feels about experiencing breathlessness is fundamental and provides an invaluable insight into the impact of this symptom on their lives. It is also important to ask carers and relatives how they feel when the person becomes breathless as this response can often influence subsequent actions, such as decisions to contact emergency services.
Patients will not often report directly that they feel “anxious” about their breathlessness. They may well describe associated emotions of panic, concern, worry, fear or immense frustration. When such sensations are evoked, this triggers the body’s acute stress response also described as the “fight-or-flight-or-freeze” response. This physiological reaction occurs in response to a perceived harmful event or threat to survival, and in this case the perceived threat is breathlessness (Fig. 6.1). Explaining this response to patients and how it can influence breathlessness can go some way to reducing some of the manifestations of anxiety (such as sweating, needing to go to the toilet or palpitations) and can increase understanding as to why these occur. It can also help to reassure patients that there are some strategies and techniques that can help to control this response and, indeed, prevent it from happening altogether. Understanding why something happens and how strategies can be utilized to control these responses can also make it more likely that the patient will try and use the recommended strategies.
Figure 6.1
Fight, flight or freeze response
Physical Symptoms
Headaches/Dizziness: Caused by the brain sending a biochemical message to the pituitary gland which releases a hormone that triggers the adrenal gland to release adrenaline. Headaches caused by constriction of the blood vessels in the head.
Blurred Vision: Caused by dilation of the pupils.
Palpitations and Chest Pains: Caused by breathing becoming faster and shallower, supplying more oxygen to the muscles.
Nausea/Indigestion: Caused by digestion being slowed down or stopped by the body as blood is diverted away from the stomach.
Dry Mouth and Difficulty Swallowing: Caused by body fluid such as saliva being redirected into the blood stream.
Aching Muscles: Caused by the large muscles of the body tensing themselves ready for action.
Aching Neck/Back Ache: Caused by the tensing of the muscles in the neck, shoulders and back.
Excess Sweating/Blushing: Caused by the body cooling itself by perspiring. Blood vessels and capillaries move close to the skin’s surface.
Rapid Breathing: Caused by the body attempting to supply more and more oxygen to the muscles.
Tingly Skin: Caused by excess oxygen being supplied to the muscles as well as calcium being released from the tense muscles.
Frequent Urination/Diarrhoea: Caused by relaxation of the muscles at the opening of the bladder and sphincter.
The tensing of the muscles of the chest and upper body, increasing heart rate and increased breathing rate are of particular relevance for the breathless patient as these symptoms of anxiety will exacerbate the overall feeling of breathlessness.
Feelings of anxiety can often overwhelm an individual to the extent that they become anxious at the slightest trigger, or anticipation of the trigger, resulting in a disabling fear that can prevent engagement in activity. It is important to spend some time listening noting down the contributing factors to the anxiety, if the person can identify them, and separating them out to facilitate dealing with them one at a time. Addressing issues in this way can help things seem more manageable and this approach is akin to the realistic goal setting outlined in the energy conservation chapter.
How do you eat an elephant? A chunk at a time
African Proverb
Case Study 1
Mr Red is a 64 year old man with Chronic Obstructive Pulmonary Disease. He is experiencing worsening breathlessness and becoming increasing anxious about this, which is having a significant impact on his ability to function day to day. Mr Red has had recent cardiac investigations which have found no problems with his heart. His recent respiratory review reports stable disease. On assessment Mr Red happened to mention that his father had heart failure and died of a heart attack, “gasping for breath”. This is something that Mr Red is terrified of happening to him.
Case Study 2
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