- Email: [email protected]
Psychological Aspects of Chronic Obstructive Pulmonary Disease
Symposium on Psychiatry in Internal Medicine
Psychological Aspects of Chronic Obstructive Pulmonary Disease David P. Agle, M.D.,* and Gerald L. Baum, M.D.**
The close relationship between respiratory function and psychological factors is well known. The combined voluntary and involuntary control of breathing allows close involvement with psychological processes. From birth onward, respiration is intimately involved in communicating with others and expressing emotions. Laughter, crying, sighing, anger, fear, and sexual excitement are expressed through variation in respiratory rate and depth. This interrelationship is also revealed in many idiomatic expressions in our language. A person may, for instance, be able to "breathe easier" after he has "gotten something off his chest" by "ventilating his feelings." Numerous studies have attempted to demonstrate a pathogenic role for psychological factors in reversible bronchospastic disease. These studies have led to the still controversial notion that bronchial asthma is a psychophysiologic disorder. Surprisingly little study, however, has been directed to psychological factors in chronic obstructive lung diseases. This lack of interest persists, although these disorders may be second only to chronic cardiac disease as a cause of permanent and total disability.5 This paper discusses psychological factors relevant to the understanding and care of patients with chronic lung diseases. Chronic obstructive pulmonary disease (COPD) refers to a group of disorders that produce permanent impairment oflung function. The clinical characteristics are shortness of breath on exertion, cough, and progressive disability. Methods of treatment are, for the most part, palliative and designed to prevent further impairment due to infection. Pessimism about the irreversible and progressive course of these disorders partially explains the lack of attention to psychological considerations. For the most part, doctors tend to avoid close association with the emotions of patients with poor prognoses. *Associate Professor, Department of Psychiatry, The Case Western Reserve University School of Medicine and University Hospitals of Cleveland ""Chief, Pulmonary Division, The Chaim Sheba Medical Center, Tel-Hashomer, Israel; Formerly Chief, Pulmonary Division, Department of Medicine, The Veterans Administration Hospital of Cleveland Supported in part by Grant 13-P-55324/5-02 of the Social and Rehabilitation Services of the Department of Health, Education and Welfare, U.S. Public Health Service.
Medical Clinics of North America-Vol. 61, No. 4, July 1977
749
750
DAVID
P.
AGLE AND GERALD
L. BAUM
The importance of psychological factors in management of chronic obstructive lung disease, however, has been suggested through a study of rehabilitation potential. 2 For this study, 24 of 150 male candidates were accepted for rehabilitation and 21 of these completed the project. Clear-cut improvements occurred, despite the fact that only one of them showed significant improvement in physiologic respiratory measurements at the end of a year's observation. Eighteen of the 21 patients who completed the rehabilitation project significantly improved their treadmill performance. In addition, they markedly decreased their number of hospital admissions during the year follow-up period and described a dramatic increase in useful life activity. In contrast to the lack of physiological change, psychological variables were positively associated with improvement. These included a lessening in severity of symptoms of depression, anxiety, and body preoccupation between the onset of training and a year's follow-up. In contrast, poor responders to rehabilitation tended to have more severe psychiatric symptoms initially and to show little or no improvement in these measures. This study, then, suggested the importance of psychological variables in the management of patients with chronic obstructive pulmonary disease. In order to treat such patients effectively, the managing physician will need some knowledge of the emotional stresses imposed by this disease, the common responses to these stresses, and the relevance of these factors to comprehensive care.
SOURCE OF DATA The COPD rehabilitation project provided unique opportunities to observe the relationship between psychological and physical factors.2 Fifty of the initial candidates for the project were evaluated by means of a psychiatric interview. More intensive observations were possible with the 23 patients who took part in the project. Each member of this group had at least three psychiatric interviews: at the beginning of the project, after eight weeks of rehabilitation, and at one year follow-up. Each was seen twice weekly in group therapy during the rehabilitation period, and data regarding family behaviors were recorded by the project social worker. In addition, all staff met weekly to share observations concerning the patients' behavior both in the hospital and as outpatients.
DIRECT EFFECT ON MENTAL FUNCTION The disease directly affects mental function when the central nervous system itself is impaired. Hypoxia, hypercapnia, and excessive medications may lead to transient confusional and delusional states. Permanent brain damage leading to dementia or chronic impairment of mental function may occur. Subtle deficits in cognition and levels of consciousness may be confirmed by a mental status examination. 9 The
PSYCHOLOGICAL ASPECTS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
751
presence of delirium is an indication for blood gas studies and other investigations necessary to diagnose and correct the underlying medical condition. 7 Continuous ambulatory oxygen therapy may relieve impaired mental function in some patients. 8
EMOTIONAL STRESSES AND PSYCHOLOGICAL RESPONSES The term "emotional stress" refers to those disease-related events that distress the patient. This distress may be measured in terms of: the production of symptoms such as anxiety and depression; behavioral changes including increased irritability or withdrawal; or increased use of various psychological defenses such as denial or rationalization. The insidious onset of chronic obstructive pulmonary disease generally subjects the patient to a slowly deteriorating course rather than to a sudden catastrophic event that overwhelms his mental resources. Yet psychological disequilibrium is commonly observed.
Anxiety States Initially, 22 of the 23 patients followed closely displayed symptoms of anxiety sufficient to interfere with performance. 2 This affective state was clinically defined as unexplained tension, jumpiness, tremulousness and a sense of impending doom. Factors apparently responsible for anxiety include dyspnea itself and a closely associated fear of suffocation and death. Anxiety and fear of dyspnea often result in an avoidance of even realistic physical activi,ty. This "phobia" about physical activity constitutes a major problem in the management of the patient with chronic obstructive pulmonary disease. 3 N eff has pointed out that such "respiratory panic" may cause a patient to struggle harder and less efficiently for breath. 11 Miller described the "physical deconditioning" induced by the patient's fear of breathlessness. 10 Anxiety resulting from dyspnea makes the perception of dyspnea more acute. Any activity that produces even moderate shortness of breath is avoided as though this signals that death is imIninent. Alleviating the patient's anxiety and phobic avoidance of activity is crucial in management.
Depression Initially, 17 of the group of 23 patients were noted to have some crippling degree of depression. 2 Complaints of frequent sadness, tearfulness, lack of motivation, a sense of worthlessness, and suicidal ideatIon are indicative of this diagnosis. Loss of appetite and sleep disturbance are commonly seen as well. The diagnoses of depression may be difficult in patients with chronic obstructive pulmonary disease because many of the symptoms can be produced by the disease process. Lassitude, fatigue, and weight loss related to the illness must be distinguished from the psychomotor retardation and lack of self-care common to depression. Sleep disturbance, a cardinal symptom of depression, frequently occurs in pulmonary patients because of nocturnal coughing. The most common error is to attri-
752
DAVID
P.
ACLE AND GERALD
L. BAUM
bute all such symptoms to physiological causes. This may result in overlooking a dangerous depression that can progress to suicidal behavior, either directly or more covertly through lack of self-care. Depression is closely associated with the painful losses that patients with chronic obstructive pulmonary disease experience. Most, for instance, are threatened with loss of occupation and earning capacity. There is generally also a progressive loss of physical strength, of meaningful interpersonal activity, and of sexual potency. These factors decrease the patient's self-esteem and threaten his position as a man of worth in his family and community. Role reversal sometimes occurs whereby the wife becomes the breadwinner and the patient becomes confined to tasks in the home more usually thought to be "a woman's work." These events are particularly intolerable for men whose selfesteem is based upon earning capacity and masculine pursuits. This is the usual explanation for the common complaint "I feel like half a man." Comparable losses and propensity to depression likely occur in women with chronic obstructive pulmonary disease but this has not been part of our clinical experience. Body Preoccupation Excessive body preoccupation was noted in 18 of the 23 patients followed. 2 This judgment is based on a clinical assessment that the intensity of the patient's physical complaints is not warranted by his physical condition. This is a difficult judgment in that it presumes that the physician has a quantitative knowledge of what the patient should be feeling. The most valuable indicator is the degree of distract ability from complaints. Patients judged to have the most severe degree of body preoccupation want to talk only about their multiple complaints. Often their symptoms involve other body organs not directly related to the cardiovascular respiratory systems. The degree of this preoccupation suggests that somatic complaints sometimes are used for psychological purposes-for example, to avoid an awareness of some more painful affective state such as depression. Alcoholism Alcoholism was common in our sample. Nearly 20 per cent of the patients evaluated initially were obvious alcoholics. This was the major cause for exclusion from the rehabilitation project on psychiatric grounds. Some patients claimed that their drinking problem began because alcohol afforded some relief from respiratory symptoms. It was impossible to determine the accuracy of this claim. Perhaps chronic obstructive pulmonary disease does increase the propensity for alcohol abuse, or this notion merely represents the rationalization of a primary alcoholic. Paranoid States Paranoid thinking and paranoid psychoses also seemed prominent in our sample. Three applicants for rehabilitation were refused on this basis. One in the study group became overtly paranoid and four others
PSYCHOLOGICAL ASPECTS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
753
demonstrated paranoid thinking, featuring marked jealousy and an unrealistic concern that their wives might be unfaithful to them. The frequency of paranoid processes in our sample does not necessarily mean that this is common in all chronic obstructive pulmonary disease populations. We speculate, however, that the loss of functions that provide reassurance of manliness, such as the ability to provide economically and perform sexually, may lead to paranoid responses in susceptible individuals. The wife of one patient reported that he slept with a gun under his pillo"Y because, in his delusion, he was convinced that her lover intended to kill him. This patient had been totally impotent for several years.
SEXUAL FUNCTION Knowledge of the patient's sexual function is of considerable importance. Sexual ability often is compromised particularly in more advanced states of disease. Such impairment is itself a considerable blow to a man's self-esteem and contributes to depression. Decreased libido and ability to erect was reported by 19 of the 23 patients in the rehabilitation group. Six of these said that they had been totally impotent for one or more years. Sexual impairment usually is attributed to shortness of breath and easy fatigability. Nevertheless, there seems to be no direct relationship between measurable physiologic impairment and the degree of interference with sexual performance. It is an unanswered question how often sexual dysfunction is a direct consequence of the physical disorder and how often it may be related to psychological phenomena. The unrealistic fear of effort-related shortness of breath is likely to contribute to sexual impairment as well as interfere with other life activities. Patients who develop impaired potency on a physical basis become anxious regarding their abilities to perform. The fear of failure markedly inhibits their remaining physical abilities. It was hoped that an improvement in sexual performance would accompany other changes related to rehabilitation. In fact, only one of 19 patients who admitted to impairment reported significant improvement. This may mean that either the sexual impairment in our group was largely on a physical basis, or that our methods of dealing with it were not sufficient. The pessimistic nature of our experience is not fully in agreement with that ofKass, Updegraff, and Muffly. They found only 17 who admitted to impotence out of 100 men with chronic obstructive pulmonary disease in their study. In their group, sexual dysfunction was not common in patients with early stages of disease and when present, seemed more related to marital and intrapsychic conflicts rather than attributable to the disease state. These investigators also noted interference with sexual function in more advanced stages of the disease, particularly when dyspnea at rest existed. Even then adjustments in the sexual role of each partner such
754
DAVID
P.
ACLE AND GERALD
L.
BAUM
that the patient was able to be more passive often resulted in both partners' continued sexual enjoyment. These data emphasize that clinicians should not assume that complaints of sexual dysfunction are necessarily caused by hypoxia and distressed breathing. Rather the areas of psychological conflict suggested by Kass should be considered as well as the usual medical approach. Reassurance that the shortness of breath accompanying sexual intercourse is not more dangerous than other well tolerated exercise may be enormously helpful.
DEFENSES AND COPING BE HA VIOR Chronically ill patients respond to the stresses imposed by their illness with a variety of psychological adjustments and coping behaviors. Some knowledge of these methods of adaptation, or maladaptation, is useful to understand the patient better and to plan appropriate management. The purpose of such psychological adjustments or defenses is to reduce to a minimum uncomfortable affects. Most such defenses operate without the individual being aware of their existence, some being adaptive but others interfering with optimal adjustment. Denial, repression, suppression, projection, and displacement are frequently seen in patients with chronic obstructive pulmonary disease. Repression and suppression refers to a pushing away of uncomfortable feelings or ideas. They are removed from awareness as though they never existed. Some patients rigidly insist that they are not subject to uncomfortable feelings. They deny tension or anger, maintaining that they "just take life as it comes." Dudley has pointed out that the autonomic discharge accompanying intense affective states may be dangerous to patients with severely compromised cardiovascular respiratory systems. 4 He notes that emotional states of action (anxiety, anger) or non-action (apathy, depression) may dangerously upset a previous precarious balance and lead to decompensation. Accordingly, he sees such gross repression and suppression of affect as being adaptive. Yet the excessive use of repression and suppression puts some patients in an emotional "straight jacket." Their lack of responsiveness isolates them from their families and medical staffthose they need the most for support. At times this mechanism is easy to observe. In a group therapy session, a patient with chronic obstructive pulmonary disease vehemently denied that he could even become anxious or upset. He thought that the discussion of such things was ridiculous and a waste of time. As he left the meeting he was heard to mutter loudly, "That's probably what caused my heart attack." Denial refers to a belief that an unpleasant fact is simply not so. This mechanism is displayed by patients who deny the seriousness of their illness or need for realistic limitations. Such a pretense may be dangerous if it leads to avoidance of necessary treatment or restrictions. Denial also is seen in some patients who continue to smoke cigarettes despite their obvious detrimental effect. Some state that cigarettes have nothing to do with their condition, insisting that their disease is worsened by
PSYCHOLOGICAL ASPECTS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
755
other factors such as air pollution. They deny their own self-injury and attribute their impairment entirely to factors outside their own control. Others deny the effects oftheir disease and, instead, blame their decreasing function on other factors such as old age, thus identifying themselves with a large population of men who are not desperately ill. Patients using mechanisms of projection and displacement blame all their life failures upon their pulmonary disease. Others attempt to avoid overwhehning fear about their serious lung disease by preoccupying themselves with some relatively minor discomfort such as indigestion or sore knees. Such displacement may cause the excessive body preoccupation so commonly found in our patient group. Feelings regarding sexual impairment sometimes are handled in a similar manner. For example, some blame their loss of sexual prowess on aging rather than their physical disorder. The problem is thus denied any special significance because, supposedly, it is shared by all men of their age. One man who reported no intercourse for over a year blamed his wife. Allegedly she was so troubled by his shortness of breath that she refused intercourse in order to protect him. Another man blamed his impotence on a circumcision. Blaming the surgeon's knife for his infirmity was more acceptable than acknowledging his own deficiency. Rationalizations such as these enable patients to avoid direct confrontation with their own lost abilities. The use of mental defenses and behavior reactions are not necessarily maladaptive. For example, denial of the serious implications of an illness may help a patient maintain hope and avoid serious and incapacitating depression. A number of patients focus on past successes and reminisce as a coping device. Commonly seen in aging individuals, this mechanism helps patients forget present weaknesses through the recall of times when they felt both strong and virile. Similarly sexually impotent men often reminisce about feats of real or fanciful sexual prowess. Sexually suggestive remarks to female hospital staff is a less acceptable behavior. This form of bravado also was used most commonly by sexually impotent men. Any mental activity that supports hope for continued life and even improvement promotes more comfortable mental equilibrium. Strong religious beliefs serve this purpose for some while others profess an almost magical faith in their physicians. Physical activity within the appropriate limits of their disability also promotes mental adaptation. Pride and pleasure can be seen in patients as they gradually are able to increase exercise tolerance. This repetitive experience contributes to the control of unrealistic fear and offers hope for the future. MANAGEMENT The physician's primary goal is to provide effective medical care and prophylaxis. Chronic disease demands a comprehensive approach, including an understanding and use of psychological factors in manage-
756
DAVID
P.
AGLE AND GERALD
L.
BAUM
ment. In chronic obstructive pulmonary disease particular attention should be given to each of the following factors: the development of a useful working relationship with the patient; the recognition and treatment of major psychiatric disorders; the avoidance of pessimism, disengaging the dyspnea-anxiety cycle; the encouragement of optimal selfcare; and the provision of regular follow-up appointments. The development of a useful working relationship between the doctor and patient is the initial task. History taking should emphasize an interest in a variety of factors troublesome to the patient, not just the recitation of physical complaints. This sets the stage for a more accurate assessment of the patient's overall level of function. Sometimes merely listening to the patient is helpful in itself. The physician should not feel compelled to do something about each individual complaint. The doctor must be alert to patients who may require psychiatric referral. Major psychological dysfunctions include significant depression or anxiety, the phobic avoidance of effort and alcohol abuse. Commonly patients with chronic obstructive pulmonary disease sense the physician's pessimism regarding their future. Repeated emphasis on the need for inactivity such as, "Take it as easy as possible," is interpreted as meaning the patient "is ready for the junk heap." Instead, an interest in and emphasis on improvement in function provides hope for the future and combats despair. Fear of dyspnea leads to the phobic avoidance of activity. Real improvement in performance often can be accomplished by dealing with this psychological phenomenon. The task is to reassure the patient that some shortness of breath is not necessarily a warning of danger but a natural response to effort that can be tolerated within limits. In our experience, merely telling the patient that this is so does not remove their fears. Instead, repeated and increasing exercise in the presence ofmedical personnel while monitoring physical responses is most effective. Thus, the patient is repeatedly exposed to his fear, exertional dyspnea, while receiving continual reassurance. This technique is remarkably similar to a desensitization form of behavior therapy used to treat more common phobias. 12 Most patients so treated begin to view dyspnea as a tolerable physiological event and gradually are able to continue an exercise program without the reassuring presence of medical staff. This disengaging ofthe dyspnea anxiety cycle produces an improvement in exercise tolerance and a more hopeful and less pessimistic outlook. Such an approach does not necessarily require a large staff and can even be accomplished in the physician's office or hospital ward by using frequent pulse and blood pressure measures rather than expensive hardware. Realistic goals for increased activity and effort must be set for each individual. One man in the study, for example, became significantly depressed when he could not match the progress of others. Brief psychotherapy was necessary to help him see that this was not one more failure and sign of weakness and that his own progress was significant. The promotion of appropriate self-care is increasingly recognized as a valuable adjunct in the medical treatment of patients with chronic
PSYCHOLOGICAL ASPECTS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
757
disease. 1 Any tools that assist the patient in personally controlling symptoms increase his sense of mastery and well-being. This encourages him to become a useful ally in medical treatment rather than helplessly dependent upon the doctor. A variety of techniques in medical management lend themselves to self-care concepts. For example, the optimal use of medications and breathing apparatus requires considerable education and encouragement rather than just one time instruction. Breathing retraining can be particularly valuable. Emphasis on these techniques not only directly improves ventilation but provides a tool to combat the fear of dyspnea. As one patient said, "When the old panic started, I kept remembering how I was taught to breathe. Pretty soon I had it under control." Emphasis on self-care may result in a decrease in the number of emergency room visits and even hospital admissions. 2 There are a number of benefits from regular follow-up as opposed to contact only at times of acute illness. Such follow-up emphasizes the doctor's interest in the patient and encourages more wide ranging dialogue than just symptom complaints. In our experience it also tends to maintain gains derived from rehabilitation efforts. The use of professionally led groups of patients with chronic obstructive pulmonary disease may be an efficient way of reaching these goals.
SUMMARY This paper describes a number of psychological variables useful in the care of patients with chronic obstructive pulmonary diseases. Attention to these factors does not replace destroyed lung tissue. Yet such efforts can lead to meaningful improvement in performance for many patients. The prolongation of life is not the only goal of comprehensive care. Equally important to the patient and his family are efforts to function as well and as comfortably as possible throughout the remainder of his life.
ACKNOWLEDGEMENT Participating in the study were: E. H. Chester, M.D., E. Kramer, B.A., R. Gitson, M.Ed., M. Wendt, Ph.D. and S. Zimmerman, B.S.
REFERENCES 1. Agle, D. P.: Psychological factors in hemophilia-The concept of self-care. Ann. N.Y. Acad. Sci., 240:221-225, 1975. 2. Agle, D. P., Baum, G. L., Chester, E. H., et al.: Multidiscipline treatment of chronic pulmonary insufficiency. 1. Psychological aspects of rehabilitation. Psychosomat. Med.,35 (No. 1):41-49, 1973. 3. Dudley, D. L., Martin, C. J., and Holmes, T. H.: Dyspnea: Psychologic and physiologic observations. J. Psychosomat. Res., 11 :325-339, 1968.
758
DAVID
P.
AGLE AND GERALD
L.
BAUM
4. Dudley, D. L., Wermuth, C., and Hague, W.: Psychosocial aspects of care in the chronic obstructive pulmonary disease patient. Heart and Lung, 2 :389-393, 1973. 5. Haas, A., and Cardon, H.: Rehabilitation in chronic obstructive pulmonary disease: A five year study of 252 male patients. MED. CLIN. N. AMER., 53 :593-606, 1969. 6. Kass, 1., Updegraff, K., and Muffiy, R. B.: Sex in chronic obstructive pulmonary disease. Medical Aspects of Human Sexuality, 6:33-42, Feb. 1972. 7. Katz, N. M., Agle, D. P., DePalma, R. G., et al.: Delirium in surgical patients under intensive care. Arch. Surg., 104 :310-313, 1972. 8. Krop, H. D., Block, A. J., and Cohen, E.: Neuropsychologic effects of continuous oxygen therapy in chronic obstructive pulmonary disease. Chest, 64 :317-322, 1973. 9. Lipowski, Z. J.: Delirium, clouding of consciousness and confusion. J. Nerv. Ment. Dis., 145:227-255, 1967. 10. Miller, W. F.: Useful methods of therapy. Chest (Suppl.), 60:2S-5S, 1971. 11. Neff, T. A., and Petty, T. L.: Outpatient care for patients with chronic airway obstruction: Emphysema and bronchitis. Chest (Suppl.), 60:11S-17S, 1971. 12. Wolpe, J.: The systematic desensitization treatment of neurosis. J. Nerv. Ment. Dis., 132 :189-203, 1961. University Hospitals of Cleveland 2040 Abington Road Cleveland, Ohio 44106
Psychological Aspects of Chronic Obstructive Pulmonary Disease David P. Agle, M.D.,* and Gerald L. Baum, M.D.**
The close relationship between respiratory function and psychological factors is well known. The combined voluntary and involuntary control of breathing allows close involvement with psychological processes. From birth onward, respiration is intimately involved in communicating with others and expressing emotions. Laughter, crying, sighing, anger, fear, and sexual excitement are expressed through variation in respiratory rate and depth. This interrelationship is also revealed in many idiomatic expressions in our language. A person may, for instance, be able to "breathe easier" after he has "gotten something off his chest" by "ventilating his feelings." Numerous studies have attempted to demonstrate a pathogenic role for psychological factors in reversible bronchospastic disease. These studies have led to the still controversial notion that bronchial asthma is a psychophysiologic disorder. Surprisingly little study, however, has been directed to psychological factors in chronic obstructive lung diseases. This lack of interest persists, although these disorders may be second only to chronic cardiac disease as a cause of permanent and total disability.5 This paper discusses psychological factors relevant to the understanding and care of patients with chronic lung diseases. Chronic obstructive pulmonary disease (COPD) refers to a group of disorders that produce permanent impairment oflung function. The clinical characteristics are shortness of breath on exertion, cough, and progressive disability. Methods of treatment are, for the most part, palliative and designed to prevent further impairment due to infection. Pessimism about the irreversible and progressive course of these disorders partially explains the lack of attention to psychological considerations. For the most part, doctors tend to avoid close association with the emotions of patients with poor prognoses. *Associate Professor, Department of Psychiatry, The Case Western Reserve University School of Medicine and University Hospitals of Cleveland ""Chief, Pulmonary Division, The Chaim Sheba Medical Center, Tel-Hashomer, Israel; Formerly Chief, Pulmonary Division, Department of Medicine, The Veterans Administration Hospital of Cleveland Supported in part by Grant 13-P-55324/5-02 of the Social and Rehabilitation Services of the Department of Health, Education and Welfare, U.S. Public Health Service.
Medical Clinics of North America-Vol. 61, No. 4, July 1977
749
750
DAVID
P.
AGLE AND GERALD
L. BAUM
The importance of psychological factors in management of chronic obstructive lung disease, however, has been suggested through a study of rehabilitation potential. 2 For this study, 24 of 150 male candidates were accepted for rehabilitation and 21 of these completed the project. Clear-cut improvements occurred, despite the fact that only one of them showed significant improvement in physiologic respiratory measurements at the end of a year's observation. Eighteen of the 21 patients who completed the rehabilitation project significantly improved their treadmill performance. In addition, they markedly decreased their number of hospital admissions during the year follow-up period and described a dramatic increase in useful life activity. In contrast to the lack of physiological change, psychological variables were positively associated with improvement. These included a lessening in severity of symptoms of depression, anxiety, and body preoccupation between the onset of training and a year's follow-up. In contrast, poor responders to rehabilitation tended to have more severe psychiatric symptoms initially and to show little or no improvement in these measures. This study, then, suggested the importance of psychological variables in the management of patients with chronic obstructive pulmonary disease. In order to treat such patients effectively, the managing physician will need some knowledge of the emotional stresses imposed by this disease, the common responses to these stresses, and the relevance of these factors to comprehensive care.
SOURCE OF DATA The COPD rehabilitation project provided unique opportunities to observe the relationship between psychological and physical factors.2 Fifty of the initial candidates for the project were evaluated by means of a psychiatric interview. More intensive observations were possible with the 23 patients who took part in the project. Each member of this group had at least three psychiatric interviews: at the beginning of the project, after eight weeks of rehabilitation, and at one year follow-up. Each was seen twice weekly in group therapy during the rehabilitation period, and data regarding family behaviors were recorded by the project social worker. In addition, all staff met weekly to share observations concerning the patients' behavior both in the hospital and as outpatients.
DIRECT EFFECT ON MENTAL FUNCTION The disease directly affects mental function when the central nervous system itself is impaired. Hypoxia, hypercapnia, and excessive medications may lead to transient confusional and delusional states. Permanent brain damage leading to dementia or chronic impairment of mental function may occur. Subtle deficits in cognition and levels of consciousness may be confirmed by a mental status examination. 9 The
PSYCHOLOGICAL ASPECTS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
751
presence of delirium is an indication for blood gas studies and other investigations necessary to diagnose and correct the underlying medical condition. 7 Continuous ambulatory oxygen therapy may relieve impaired mental function in some patients. 8
EMOTIONAL STRESSES AND PSYCHOLOGICAL RESPONSES The term "emotional stress" refers to those disease-related events that distress the patient. This distress may be measured in terms of: the production of symptoms such as anxiety and depression; behavioral changes including increased irritability or withdrawal; or increased use of various psychological defenses such as denial or rationalization. The insidious onset of chronic obstructive pulmonary disease generally subjects the patient to a slowly deteriorating course rather than to a sudden catastrophic event that overwhelms his mental resources. Yet psychological disequilibrium is commonly observed.
Anxiety States Initially, 22 of the 23 patients followed closely displayed symptoms of anxiety sufficient to interfere with performance. 2 This affective state was clinically defined as unexplained tension, jumpiness, tremulousness and a sense of impending doom. Factors apparently responsible for anxiety include dyspnea itself and a closely associated fear of suffocation and death. Anxiety and fear of dyspnea often result in an avoidance of even realistic physical activi,ty. This "phobia" about physical activity constitutes a major problem in the management of the patient with chronic obstructive pulmonary disease. 3 N eff has pointed out that such "respiratory panic" may cause a patient to struggle harder and less efficiently for breath. 11 Miller described the "physical deconditioning" induced by the patient's fear of breathlessness. 10 Anxiety resulting from dyspnea makes the perception of dyspnea more acute. Any activity that produces even moderate shortness of breath is avoided as though this signals that death is imIninent. Alleviating the patient's anxiety and phobic avoidance of activity is crucial in management.
Depression Initially, 17 of the group of 23 patients were noted to have some crippling degree of depression. 2 Complaints of frequent sadness, tearfulness, lack of motivation, a sense of worthlessness, and suicidal ideatIon are indicative of this diagnosis. Loss of appetite and sleep disturbance are commonly seen as well. The diagnoses of depression may be difficult in patients with chronic obstructive pulmonary disease because many of the symptoms can be produced by the disease process. Lassitude, fatigue, and weight loss related to the illness must be distinguished from the psychomotor retardation and lack of self-care common to depression. Sleep disturbance, a cardinal symptom of depression, frequently occurs in pulmonary patients because of nocturnal coughing. The most common error is to attri-
752
DAVID
P.
ACLE AND GERALD
L. BAUM
bute all such symptoms to physiological causes. This may result in overlooking a dangerous depression that can progress to suicidal behavior, either directly or more covertly through lack of self-care. Depression is closely associated with the painful losses that patients with chronic obstructive pulmonary disease experience. Most, for instance, are threatened with loss of occupation and earning capacity. There is generally also a progressive loss of physical strength, of meaningful interpersonal activity, and of sexual potency. These factors decrease the patient's self-esteem and threaten his position as a man of worth in his family and community. Role reversal sometimes occurs whereby the wife becomes the breadwinner and the patient becomes confined to tasks in the home more usually thought to be "a woman's work." These events are particularly intolerable for men whose selfesteem is based upon earning capacity and masculine pursuits. This is the usual explanation for the common complaint "I feel like half a man." Comparable losses and propensity to depression likely occur in women with chronic obstructive pulmonary disease but this has not been part of our clinical experience. Body Preoccupation Excessive body preoccupation was noted in 18 of the 23 patients followed. 2 This judgment is based on a clinical assessment that the intensity of the patient's physical complaints is not warranted by his physical condition. This is a difficult judgment in that it presumes that the physician has a quantitative knowledge of what the patient should be feeling. The most valuable indicator is the degree of distract ability from complaints. Patients judged to have the most severe degree of body preoccupation want to talk only about their multiple complaints. Often their symptoms involve other body organs not directly related to the cardiovascular respiratory systems. The degree of this preoccupation suggests that somatic complaints sometimes are used for psychological purposes-for example, to avoid an awareness of some more painful affective state such as depression. Alcoholism Alcoholism was common in our sample. Nearly 20 per cent of the patients evaluated initially were obvious alcoholics. This was the major cause for exclusion from the rehabilitation project on psychiatric grounds. Some patients claimed that their drinking problem began because alcohol afforded some relief from respiratory symptoms. It was impossible to determine the accuracy of this claim. Perhaps chronic obstructive pulmonary disease does increase the propensity for alcohol abuse, or this notion merely represents the rationalization of a primary alcoholic. Paranoid States Paranoid thinking and paranoid psychoses also seemed prominent in our sample. Three applicants for rehabilitation were refused on this basis. One in the study group became overtly paranoid and four others
PSYCHOLOGICAL ASPECTS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
753
demonstrated paranoid thinking, featuring marked jealousy and an unrealistic concern that their wives might be unfaithful to them. The frequency of paranoid processes in our sample does not necessarily mean that this is common in all chronic obstructive pulmonary disease populations. We speculate, however, that the loss of functions that provide reassurance of manliness, such as the ability to provide economically and perform sexually, may lead to paranoid responses in susceptible individuals. The wife of one patient reported that he slept with a gun under his pillo"Y because, in his delusion, he was convinced that her lover intended to kill him. This patient had been totally impotent for several years.
SEXUAL FUNCTION Knowledge of the patient's sexual function is of considerable importance. Sexual ability often is compromised particularly in more advanced states of disease. Such impairment is itself a considerable blow to a man's self-esteem and contributes to depression. Decreased libido and ability to erect was reported by 19 of the 23 patients in the rehabilitation group. Six of these said that they had been totally impotent for one or more years. Sexual impairment usually is attributed to shortness of breath and easy fatigability. Nevertheless, there seems to be no direct relationship between measurable physiologic impairment and the degree of interference with sexual performance. It is an unanswered question how often sexual dysfunction is a direct consequence of the physical disorder and how often it may be related to psychological phenomena. The unrealistic fear of effort-related shortness of breath is likely to contribute to sexual impairment as well as interfere with other life activities. Patients who develop impaired potency on a physical basis become anxious regarding their abilities to perform. The fear of failure markedly inhibits their remaining physical abilities. It was hoped that an improvement in sexual performance would accompany other changes related to rehabilitation. In fact, only one of 19 patients who admitted to impairment reported significant improvement. This may mean that either the sexual impairment in our group was largely on a physical basis, or that our methods of dealing with it were not sufficient. The pessimistic nature of our experience is not fully in agreement with that ofKass, Updegraff, and Muffly. They found only 17 who admitted to impotence out of 100 men with chronic obstructive pulmonary disease in their study. In their group, sexual dysfunction was not common in patients with early stages of disease and when present, seemed more related to marital and intrapsychic conflicts rather than attributable to the disease state. These investigators also noted interference with sexual function in more advanced stages of the disease, particularly when dyspnea at rest existed. Even then adjustments in the sexual role of each partner such
754
DAVID
P.
ACLE AND GERALD
L.
BAUM
that the patient was able to be more passive often resulted in both partners' continued sexual enjoyment. These data emphasize that clinicians should not assume that complaints of sexual dysfunction are necessarily caused by hypoxia and distressed breathing. Rather the areas of psychological conflict suggested by Kass should be considered as well as the usual medical approach. Reassurance that the shortness of breath accompanying sexual intercourse is not more dangerous than other well tolerated exercise may be enormously helpful.
DEFENSES AND COPING BE HA VIOR Chronically ill patients respond to the stresses imposed by their illness with a variety of psychological adjustments and coping behaviors. Some knowledge of these methods of adaptation, or maladaptation, is useful to understand the patient better and to plan appropriate management. The purpose of such psychological adjustments or defenses is to reduce to a minimum uncomfortable affects. Most such defenses operate without the individual being aware of their existence, some being adaptive but others interfering with optimal adjustment. Denial, repression, suppression, projection, and displacement are frequently seen in patients with chronic obstructive pulmonary disease. Repression and suppression refers to a pushing away of uncomfortable feelings or ideas. They are removed from awareness as though they never existed. Some patients rigidly insist that they are not subject to uncomfortable feelings. They deny tension or anger, maintaining that they "just take life as it comes." Dudley has pointed out that the autonomic discharge accompanying intense affective states may be dangerous to patients with severely compromised cardiovascular respiratory systems. 4 He notes that emotional states of action (anxiety, anger) or non-action (apathy, depression) may dangerously upset a previous precarious balance and lead to decompensation. Accordingly, he sees such gross repression and suppression of affect as being adaptive. Yet the excessive use of repression and suppression puts some patients in an emotional "straight jacket." Their lack of responsiveness isolates them from their families and medical staffthose they need the most for support. At times this mechanism is easy to observe. In a group therapy session, a patient with chronic obstructive pulmonary disease vehemently denied that he could even become anxious or upset. He thought that the discussion of such things was ridiculous and a waste of time. As he left the meeting he was heard to mutter loudly, "That's probably what caused my heart attack." Denial refers to a belief that an unpleasant fact is simply not so. This mechanism is displayed by patients who deny the seriousness of their illness or need for realistic limitations. Such a pretense may be dangerous if it leads to avoidance of necessary treatment or restrictions. Denial also is seen in some patients who continue to smoke cigarettes despite their obvious detrimental effect. Some state that cigarettes have nothing to do with their condition, insisting that their disease is worsened by
PSYCHOLOGICAL ASPECTS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
755
other factors such as air pollution. They deny their own self-injury and attribute their impairment entirely to factors outside their own control. Others deny the effects oftheir disease and, instead, blame their decreasing function on other factors such as old age, thus identifying themselves with a large population of men who are not desperately ill. Patients using mechanisms of projection and displacement blame all their life failures upon their pulmonary disease. Others attempt to avoid overwhehning fear about their serious lung disease by preoccupying themselves with some relatively minor discomfort such as indigestion or sore knees. Such displacement may cause the excessive body preoccupation so commonly found in our patient group. Feelings regarding sexual impairment sometimes are handled in a similar manner. For example, some blame their loss of sexual prowess on aging rather than their physical disorder. The problem is thus denied any special significance because, supposedly, it is shared by all men of their age. One man who reported no intercourse for over a year blamed his wife. Allegedly she was so troubled by his shortness of breath that she refused intercourse in order to protect him. Another man blamed his impotence on a circumcision. Blaming the surgeon's knife for his infirmity was more acceptable than acknowledging his own deficiency. Rationalizations such as these enable patients to avoid direct confrontation with their own lost abilities. The use of mental defenses and behavior reactions are not necessarily maladaptive. For example, denial of the serious implications of an illness may help a patient maintain hope and avoid serious and incapacitating depression. A number of patients focus on past successes and reminisce as a coping device. Commonly seen in aging individuals, this mechanism helps patients forget present weaknesses through the recall of times when they felt both strong and virile. Similarly sexually impotent men often reminisce about feats of real or fanciful sexual prowess. Sexually suggestive remarks to female hospital staff is a less acceptable behavior. This form of bravado also was used most commonly by sexually impotent men. Any mental activity that supports hope for continued life and even improvement promotes more comfortable mental equilibrium. Strong religious beliefs serve this purpose for some while others profess an almost magical faith in their physicians. Physical activity within the appropriate limits of their disability also promotes mental adaptation. Pride and pleasure can be seen in patients as they gradually are able to increase exercise tolerance. This repetitive experience contributes to the control of unrealistic fear and offers hope for the future. MANAGEMENT The physician's primary goal is to provide effective medical care and prophylaxis. Chronic disease demands a comprehensive approach, including an understanding and use of psychological factors in manage-
756
DAVID
P.
AGLE AND GERALD
L.
BAUM
ment. In chronic obstructive pulmonary disease particular attention should be given to each of the following factors: the development of a useful working relationship with the patient; the recognition and treatment of major psychiatric disorders; the avoidance of pessimism, disengaging the dyspnea-anxiety cycle; the encouragement of optimal selfcare; and the provision of regular follow-up appointments. The development of a useful working relationship between the doctor and patient is the initial task. History taking should emphasize an interest in a variety of factors troublesome to the patient, not just the recitation of physical complaints. This sets the stage for a more accurate assessment of the patient's overall level of function. Sometimes merely listening to the patient is helpful in itself. The physician should not feel compelled to do something about each individual complaint. The doctor must be alert to patients who may require psychiatric referral. Major psychological dysfunctions include significant depression or anxiety, the phobic avoidance of effort and alcohol abuse. Commonly patients with chronic obstructive pulmonary disease sense the physician's pessimism regarding their future. Repeated emphasis on the need for inactivity such as, "Take it as easy as possible," is interpreted as meaning the patient "is ready for the junk heap." Instead, an interest in and emphasis on improvement in function provides hope for the future and combats despair. Fear of dyspnea leads to the phobic avoidance of activity. Real improvement in performance often can be accomplished by dealing with this psychological phenomenon. The task is to reassure the patient that some shortness of breath is not necessarily a warning of danger but a natural response to effort that can be tolerated within limits. In our experience, merely telling the patient that this is so does not remove their fears. Instead, repeated and increasing exercise in the presence ofmedical personnel while monitoring physical responses is most effective. Thus, the patient is repeatedly exposed to his fear, exertional dyspnea, while receiving continual reassurance. This technique is remarkably similar to a desensitization form of behavior therapy used to treat more common phobias. 12 Most patients so treated begin to view dyspnea as a tolerable physiological event and gradually are able to continue an exercise program without the reassuring presence of medical staff. This disengaging ofthe dyspnea anxiety cycle produces an improvement in exercise tolerance and a more hopeful and less pessimistic outlook. Such an approach does not necessarily require a large staff and can even be accomplished in the physician's office or hospital ward by using frequent pulse and blood pressure measures rather than expensive hardware. Realistic goals for increased activity and effort must be set for each individual. One man in the study, for example, became significantly depressed when he could not match the progress of others. Brief psychotherapy was necessary to help him see that this was not one more failure and sign of weakness and that his own progress was significant. The promotion of appropriate self-care is increasingly recognized as a valuable adjunct in the medical treatment of patients with chronic
PSYCHOLOGICAL ASPECTS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE
757
disease. 1 Any tools that assist the patient in personally controlling symptoms increase his sense of mastery and well-being. This encourages him to become a useful ally in medical treatment rather than helplessly dependent upon the doctor. A variety of techniques in medical management lend themselves to self-care concepts. For example, the optimal use of medications and breathing apparatus requires considerable education and encouragement rather than just one time instruction. Breathing retraining can be particularly valuable. Emphasis on these techniques not only directly improves ventilation but provides a tool to combat the fear of dyspnea. As one patient said, "When the old panic started, I kept remembering how I was taught to breathe. Pretty soon I had it under control." Emphasis on self-care may result in a decrease in the number of emergency room visits and even hospital admissions. 2 There are a number of benefits from regular follow-up as opposed to contact only at times of acute illness. Such follow-up emphasizes the doctor's interest in the patient and encourages more wide ranging dialogue than just symptom complaints. In our experience it also tends to maintain gains derived from rehabilitation efforts. The use of professionally led groups of patients with chronic obstructive pulmonary disease may be an efficient way of reaching these goals.
SUMMARY This paper describes a number of psychological variables useful in the care of patients with chronic obstructive pulmonary diseases. Attention to these factors does not replace destroyed lung tissue. Yet such efforts can lead to meaningful improvement in performance for many patients. The prolongation of life is not the only goal of comprehensive care. Equally important to the patient and his family are efforts to function as well and as comfortably as possible throughout the remainder of his life.
ACKNOWLEDGEMENT Participating in the study were: E. H. Chester, M.D., E. Kramer, B.A., R. Gitson, M.Ed., M. Wendt, Ph.D. and S. Zimmerman, B.S.
REFERENCES 1. Agle, D. P.: Psychological factors in hemophilia-The concept of self-care. Ann. N.Y. Acad. Sci., 240:221-225, 1975. 2. Agle, D. P., Baum, G. L., Chester, E. H., et al.: Multidiscipline treatment of chronic pulmonary insufficiency. 1. Psychological aspects of rehabilitation. Psychosomat. Med.,35 (No. 1):41-49, 1973. 3. Dudley, D. L., Martin, C. J., and Holmes, T. H.: Dyspnea: Psychologic and physiologic observations. J. Psychosomat. Res., 11 :325-339, 1968.
758
DAVID
P.
AGLE AND GERALD
L.
BAUM
4. Dudley, D. L., Wermuth, C., and Hague, W.: Psychosocial aspects of care in the chronic obstructive pulmonary disease patient. Heart and Lung, 2 :389-393, 1973. 5. Haas, A., and Cardon, H.: Rehabilitation in chronic obstructive pulmonary disease: A five year study of 252 male patients. MED. CLIN. N. AMER., 53 :593-606, 1969. 6. Kass, 1., Updegraff, K., and Muffiy, R. B.: Sex in chronic obstructive pulmonary disease. Medical Aspects of Human Sexuality, 6:33-42, Feb. 1972. 7. Katz, N. M., Agle, D. P., DePalma, R. G., et al.: Delirium in surgical patients under intensive care. Arch. Surg., 104 :310-313, 1972. 8. Krop, H. D., Block, A. J., and Cohen, E.: Neuropsychologic effects of continuous oxygen therapy in chronic obstructive pulmonary disease. Chest, 64 :317-322, 1973. 9. Lipowski, Z. J.: Delirium, clouding of consciousness and confusion. J. Nerv. Ment. Dis., 145:227-255, 1967. 10. Miller, W. F.: Useful methods of therapy. Chest (Suppl.), 60:2S-5S, 1971. 11. Neff, T. A., and Petty, T. L.: Outpatient care for patients with chronic airway obstruction: Emphysema and bronchitis. Chest (Suppl.), 60:11S-17S, 1971. 12. Wolpe, J.: The systematic desensitization treatment of neurosis. J. Nerv. Ment. Dis., 132 :189-203, 1961. University Hospitals of Cleveland 2040 Abington Road Cleveland, Ohio 44106