Traditional CBT model of anxiety is based on the premise that individuals with anxiety overestimate the likelihood or impact of negative outcomes [31], which leads to maladaptive coping behaviors such as avoidance. Patients with chronic respiratory disorders differ crucially from physically healthy persons with anxiety, in that their health and breathing are objectively threatened [34]. They are often subjected to several risk factors for anxiety and depression, such as functional limitations, lack of control over life circumstances, psychosocial losses and serious life events. Certain specific characteristics of respiratory disorders may also increase the risk of developing anxiety or depression and predispose the patients for these conditions. In patients with COPD, some of the symptoms of the lung disease, such as shortness of breath, lack of energy, chest pain and sleep problems, overlap and thus may also interact with symptoms of anxiety and/or depression. Dyspnea is a central symptom of both anxiety and respiratory disease, and there is evidence indicating that emotional distress contributes to dyspnea, which may cause a loss of breathing control and, in turn, lead to panic [35]. COPD patients also typically suffer from fatigue, and depressive mood may lower the level of energy even further and lead to passivity, which again may exacerbate physical deterioration [36].

Figure 10.2 summarizes the CBT model of anxiety and depression in chronic respiratory diseases.

Although persons with chronic respiratory disorders face very real challenges and adversities, the experience of symptoms, such as dyspnea, is subjective, and therefore ambiguous and open to catastrophic or overly negative interpretations. Applied to chronic respiratory disorders, the cognitive model suggests that patients with anxiety or depression would experience more catastrophic and negative cognitions about their respiratory symptoms compared to patients without anxiety or depression [37]. Support for this model comes mainly from studies that have found higher levels of catastrophic cognitions in respiratory patients who experience panic anxiety, compared to those who do not [38, 39]. Findings by Gurney-Smith et al. [37] indicated that severity of illness-specific catastrophic cognitions predicts the level of anxiety triggered by COPD symptoms, as well as behavioral avoidance in unsafe situations. Other studies have also demonstrated that heightened dyspnea perception and misinterpretation of physical sensations are associated with panic disorder in COPD, independently of respiratory function [40, 41].

Although catastrophic cognitions may be more frequent in patients with panic attacks, or they may accentuate the attacks, they do not necessarily have a causal role. Bouton et al. [42] have proposed that panic disorder develops because exposure to panic attacks causes the conditioning of anxiety to internal or external cues. Individuals with panic disorder also develop anxiety focused on the next potential panic attack, and perceive the attacks as uncontrollable and unpredictable. In respiratory patients, the extremely frightening feeling of breathlessness and suffocation during dyspnea may lead to conditioning of anxiety to internal and external cues associated with dyspnea. Bouton et al. [42] predict that treatment approaches entailing extinction or exposure to conditioned stimuli will most likely be successful.

In addition to panic attacks or more acute episodes of intense anxiety, the cognitive behavioral perspective can also be applied to generalized anxiety and depression in patients with chronic respiratory disease. Fear and avoidance of symptoms of the respiratory disease may result in considerable modifications in lifestyle and attempts to avoid exertion, which then may become a constant source of worry [43]. Eventually, these processes may contribute to more or less constant feelings of anxiety and/or depressive mood.

According to the CBT model, generalized anxiety disorder stems from perceptions of the world as a dangerous place, which lead to maladaptive and habitual cognitive, behavioral and physiological responses [44]. The patients commonly exhibit an attentional bias to threat cues, worrisome thinking, and subtle behavioral avoidance and slowed decision making, as well as excessive muscle tension and an autonomic inflexibility [44, 45]. Patients with chronic respiratory disorder, fearing dyspnea, are often attentive to all potential threats and situations that may cause breathlessness, and they may also spend considerable time planning ahead to avoid exertion, as well as worry about things that may go wrong. In a qualitative study, COPD patients described how planning of daily activities was seen as necessary to control breathlessness, and how it was also associated with worry about trivial things and limited their ability to participate in social activities [43].

Restriction of activity because of functional limitations and fear of respiratory symptoms are likely to lead to loss of pleasurable experiences and social withdrawal, which can be linked to increased levels of depressive mood. Patients also typically suffer from fatigue, and depressive mood may lower the level of energy even further and lead to increased passivity, which again may exacerbate physical deterioration [36]. As a part of the vicious circle of depression-related activity avoidance and deconditioning, isolation and passivity will also influence the patients’ self-esteem and contribute to more negative thoughts about the self, the environment, and the future. In COPD patients, depression has been linked to loneliness, and it is also inversely related to coping by seeking social support [46, 47].

While the CBT treatment for depression and/or anxiety can in many ways be similar when treating patients with or without chronic respiratory disease, there are also some special issues that need to be taken into consideration. Because there is some overlap between symptoms of respiratory disorders and anxiety and depression, a comprehensive approach to assessing both somatic and psychological symptoms is necessary before the CBT intervention. A focus on anxiety or depression should not go at the risk of ignoring progression in the respiratory disease. Although anxiety may contribute to breathing problems and other respiratory symptoms, an exacerbation of the respiratory disease or increase in symptoms as a consequence of disease progression can also be a significant source of anxiety. Complaints of poor sleep, a common symptom in anxiety and depression, can also be caused by fatigue or pain as a consequence of progressing respiratory disease, or by other, comorbid sleep-related disturbances that need to be treated [48]. Thus, a thorough and multifaceted assessment may be required in order to select the right target for treatment and optimize the medical treatment for the respiratory disease. Because of the symptom overlap, the therapist also needs to be competent in distinguishing psychological symptoms from physical symptoms during the treatment.

In the beginning of the CBT intervention, in addition to educating patients about the mental health symptoms and the treatment approach, the psychoeducation should include specific elements about the respiratory disease, and how the symptoms of the respiratory disease may interact with symptoms of anxiety and depression (“Being anxious can make your breathlessness feel worse”). The goal is to become aware of dyspnea- or depression-related vicious circles, with activity avoidance, deconditioning and more respiratory symptoms (“Avoidance of exertion will lead to reduced fitness, maintenance of fear and low mood, which again can make your breathlessness worse”). Patient’s misconceptions or unhelpful beliefs (“Breathlessness is always dangerous or harmful”), and maladaptive patterns of behavior related to the respiratory disease (e.g., overuse of inhalators, emergency admissions to hospital because of anxiety) can be assessed and addressed at the same time [49].

Exploring the patient’s current lifestyle and limitations as well as expectations for the future can be helpful, in order to shape and adapt the therapy for the patient’s needs. The therapist should also encourage the patient to start monitoring his or her psychological symptoms (physical symptoms, thoughts, feelings and behavior), and help the patient to differentiate between respiratory symptoms and anxiety or depression (“Am I breathless because of an exacerbation or is it because I feel anxious?”).

Other components included in the CBT treatment should be based on the initial case formulation. A case formulation is the summation of the clinician’s understanding of how the patient’s problem develops, perpetuates and evolves over time. Based on this understanding, specific interventions aimed at reducing the impact of causal and/or maintaining factors are planned [50]. Since patients with chronic respiratory disorders often suffer from mild to moderate, mixed symptoms of both anxiety and depression, rather than having a “pure” depressive or anxiety disorder, an approach that incorporates components for treating both anxiety and depression can be chosen (e.g., [51]). However, more severe psychiatric disorders, such as panic disorder, are likely to require targeted interventions [34].

In patients with chronic respiratory disorders, common causal or maintaining factors for anxiety and depression are passivity and avoidance behaviors, such as avoidance of exertion and anxiety-provoking activities and situations. Avoidance behaviors can be challenged by graded exposure or behavioral experiments, whereas goal setting, activity scheduling and pacing activities can be effective approaches to counteract passivity and inactivity. The patient may devise a list of activities or situations that they either avoid or wish to do, and create an activity hierarchy with easy activities or situations on the top of the list and more difficult ones at the bottom. The therapist helps the patient to choose appropriate activities and make concrete, step-by-step plans for homework assignments, breaking more complex or difficult tasks into achievable and realistic goals. Patients who are mainly suffering from anxiety and anxiety-related avoidance can be encouraged to choose exposure tasks, whereas pleasurable activities that will improve mood can be scheduled for patients with mainly depressive symptoms. For exposure tasks, realistic goals need to be set and the exposure program should be developed in consultation with patient’s respiratory physician, taking into account patient’s current health and stage of illness [34].

Pacing activities and alternating planned periods of activity with regular rest periods may be necessary with some patients, in order to avoid that the patient pushes himself or herself to do too much, and ends up having to rest for a long time to recover. Teaching coping skills to manage symptoms of anxiety and depression, such as relaxation, breathing techniques and attention management (e.g., distraction), is also often helpful and necessary before the patient can be expected to face their fears in exposure tasks or increase their activity levels. In CBT for anxiety in healthy individuals [52, 53], safety behavior is considered to be countertherapeutic, providing only temporary relief from symptoms, and safety-seeking behavior may also eventually be a maintaining factor in persisting anxiety. Although activity pacing and breathing techniques can be characterized as safety behaviors, in chronic respiratory disorders they are an important method for self-management of dyspnea [54], and the treatment may be less focused on extinguishing safety behaviors than on teaching effective coping skills. The aim is to seek a balance between some degree of control over breathlessness and other respiratory symptoms, while also increasing tolerance and reducing the fear of symptoms.

Patient’s unhelpful beliefs, maladaptive thought patterns or catastrophic thinking that may contribute to anxiety and depression, as well as maintain passivity and avoidance, could be addressed with cognitive restructuring. Cognitive restructuring is a set of techniques for becoming more aware of thoughts and for modifying them when they are maladaptive or unhelpful. The aim is to use reason and evidence to replace thought patterns that are overly negative (“I can’t do anything anymore, I am hopeless!”) or anxious (“What if I become breathless and can’t get any help?”) with more accurate and functional alternatives (“I may not be as quick and strong as I used to be, but I can do this, one step at a time”; “I may not be able to avoid breathlessness altogether, but I will be okay”).

When it comes to chronic respiratory disorders, some degree of anxiety about the respiratory symptoms can be adaptive and motivate the patient for appropriate action, such as using preventive medication. Conversely, low level of illness-related anxiety may be associated with ignoring symptoms and delaying use of symptom relievers, and with a coping style associated with denial of the disease, which is unfavorable for good disease management [55]. However, a constant worry and focus on the symptoms is neither adaptive nor helpful, and worrying also has tendency to occur at inappropriate times, e.g., when trying to get to sleep at night. With patients who are overly attentive to physical symptoms or who constantly worry about their symptoms and things that may go wrong, distraction or worry postponement techniques are sometimes used. Distraction can be helpful as a short-term tool in overcoming a brief anxiety-inducing situation, but it is generally recognized that using distraction as a long-term coping strategy often makes symptoms worse and is not a cure for anxiety. Distraction by focusing one’s attention to the present moment (e.g., sensory experience, the task one is engaged in) can, however, also help to “postpone” worries. Postponing worries to a chosen time and place is often easier than suppressing them completely (“I’ll think about this later, now is not the right time”), and it can also lead to either dismissal of worries as unimportant or to more constructive problem solving during the chosen “worry time.”

Other components, such as sleep skills or problem-solving skills, may be included in the intervention according to the patient’s needs. See Table 10.1 for an overview of key components in CBT treatment for anxiety/depression in chronic respiratory disorders (e.g., [51, 56]).