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There are several psychological models which can be drawn upon to assist in our understanding of Respiratory Diseases. The stress model will be outlined in this report.
COPD as a Stressful Life Event
Chronic illness demands continual psychological adjustment as the disease progresses through different stages from no symptoms to mild, then moderate and severe symptoms. Respiratory patients must cope with a wide variety of stressors including: shortness of breath, cough, sputum production, wheeze, pain, changing body image, loss of independence, social stigma, social isolation and uncertainty about the future.
Along with these respiratory associated stressors COPD patients must also deal with changing environments, family pressures and other critical events which occur during this time of their life span. Although successful adaptation to the disease process (and critical life events) is normal, adverse psychological reactions can commonly occur at some time during the chronic disease process. Such reactions include - depression, anxiety/worry, panic attacks, irritability and confusion.
The word stress can be confusingly used to mean two different things. Sometimes the word stress is used to describe a stressor. A stressor is something that people perceive as a threat and that calls upon the individuals coping mechanisms. They include situations which cause uncertainty or where people feel a lack of control, or harmful or unpleasant situations which lead to stressful reactions (eg. "giving that presentation was very stressful").
At other times stress can be taken to mean the stress reactions which occur in response to the stress such as thoughts, feelings, behaviours and physiological responses (e.g. showing "signs" of stress).
Therefore stress is a process which can be seen as an interaction between the coping skills of the individual and the demands of his/her environment. The following account will use the 3 part stress model to try and explain some of what patients may experience and how Patient Support Groups may help.
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1. Physical and Psycho-social Stressors
As previously defined stressors are situations which put
demands on coping skills. The COPD patient comes into contact with and
must cope with a wide variety of physical stressors which include
shortness of breath and other respiratory symptoms, environmental
pollution, changes in temperature, exposure to infection/disease,
taking medication and hospitals/medical clinics.
As we all live and function in a social context these attributes of our
environment (psycho-social stressors) can also put demands on our
ability to cope. The COPD patient must be able to manage the chronic
disease while still trying to maintain effective relationships with
their spouse, friends, acquaintances and health care staff. However,
due to the disabling nature of the disease it can cause relationships
to be strained and may result in many patients being socially isolated
and not seeking treatment.
One of the aims of Patient Support Groups (PSG's) is to empower
patients with better coping skills to deal with both the physical and
psycho-social stressors. This can be achieved through encouraging
patients to help each other and presentations from guest speakers to
reinforce what they have already learned in pulmonary rehabilitation.
2. Psychological Stress Reactions
The psychological responses that COPD patients have to stress
include the thoughts, feelings and concerns they have about their
perceived threats. These are their interpretation of the situation and
each patient can interpret the same situation in a different way. Such
expectations of coping can become distorted in COPD as they may be
based on past experiences in which patients did not cope well. Examples
of some distorted and unrealistic interpretations include "This attack
is going to become severe", "I'll end up in hospital," "I can't do
anything any more because I get short of breath," "I'm a useless
individual", "My life is not worth living."
These thoughts can lead to negative feelings such as anxiety, anger,
tension, frustration, hopelessness and depression. In fact, two
Australian based studies (including our own) and other studies have
shown that there is a significant prevalence of psychiatric morbidity
in COPD. The prevalence of depression and anxiety in COPD can range
between 40 - 90% compared to 8 - 20% in the normal population.
Such psychological disturbance can compound the disability and handicap
faced by people with COPD, leading them to withdraw from life, becoming
more socially and physically inactive which in turn enhances the
psychological symptoms and a vicious cycle appears.
PSG's can give patients the opportunity to discuss their feelings and
emotions (which in itself is extremely therapeutic) as well as
physically getting out and participating in activities which are both
enjoyable and rewarding. This type of treatment (support groups which
incorporate activity) has been shown in clinical trials to be effective
in alleviating anxiety and depression. Our randomised control
rehabilitation trial showed that small group rehabilitation and support
significantly reduced psychiatric morbidity in our COPD sample.
Sedentary lifestyles can lead to deconditioning of muscles and reduced
fitness. Many patients with COPD develop a phobia towards exercise due
to shortness of breath, embarrassment, misinformation, anxiety and
depression and a vicious cycle of inactivity can occur. PSG's can
provide an environment which encourages people to participate in
physical exercise and also provide exercise classes. They can also
encourage people to be more physically active by organising walks and
tours for its members.
Another aim of PSG's is to change/modify the way people think about
their disease. They may endeavour to change and replace the defeatist
and negative attitudes and thoughts exhibited by many patients with a
more positive outlook. Changing the way people think about their
situation has been shown to effect the way they feel and thus we may be
able to alleviate some of the feelings of depression, anxiety and
hopelessness.
3. Physiological Responses to Stress
The body reacts to stress through a variety of physiological
responses which include: Increases in heart rate, blood pressure, blood
flow, tension in voluntary muscles, perspiration, depth and frequency
of breathing and nausea, diarrhoea, hot flushes, cold chills.
This represents the body's attempt to adapt to the increased load of
coping with the stressor. It is the automatic self-protection mechanism
(termed the "Fight or Flight Response") which prepares the body to
fight the threat or avoid it.
In some instances these physiological responses can be misinterpreted
or not dealt with soon enough and they can become out of control
leading to a panic attack. As the precipitant of a panic attack is
usually shortness of breath it is not surprising that many COPD
patients suffer from such attacks.
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Although strategies for coping with panic attacks are discussed during pulmonary rehabilitation, Patient Support Groups afford the opportunity to reinforce some of these strategies (eg diaphragmatic breathing, relaxation techniques) through practice and discussion.
What happens when the stress response continues?
Stress is a three stage process
1. The Alarm Phase - the initial response of the body (ie the flight or fight response). Little thought involved.
2. Stage of Resistance - Coping and Adaptation
3. Stage of Exhaustion - Shock and Lowered Resistance to Infection.
If the stage of resistance (coping and adaptation) is not effectively performed this can lead to several psychological changes which include alteration in personality and cognition e.g.
- Increased difficulty in solving problems, worry excessively, misinterpret situations, irritability, easily frustrated, lack of energy, loss of interest, forgetful, insomnia, fear loss of control.
- More Aggressive - complain about care, become more demanding, argumentative, stubborn. Stressful situations are increasingly avoided.
- More Passive - difficulty in making decisions, becomes increasingly isolated, waits to be taken care of.
As a result of their COPD many patients have reduced oxygen levels in their blood stream. Oxygen is required by the brain in order for it to function properly and significantly reduced oxygen levels can cause deficits in short term memory, planning and organisation and concept formation. When this is accompanied by the cognitive problems associated with stress, it is not surprising that in a study which was recently conducted by us that 81% of our COPD sample exhibited some form of cognitive deficit. 33% showed visual short-term memory impairment and 44% verbal short-term memory impairment. Therefore ongoing PSG's provide an opportunity to rehearse and review learned material and therefore enhance learning.
The more coping skills COPD patients can use, the more likely it is that they will be able to MAINTAIN, CONTROL AND COPE EFFECTIVELY with their disease and reduce the chances of psychological and cognitive disturbance.
Another psychological benefit of PSG's is that many patient's feelings of isolation and having to cope alone are ameliorated through social comparison. Patients are relieved know that they are not the only ones with respiratory disease problems and that there are others who are just as sick as them, and have similar problems. Many of the patients view PSG's as self-help groups where they learn how to cope through listening to what others have done.
Summary
PSG's provide the ideal opportunity for COPD patients to learn how to cope more effectively by providing information, social comparison, reinforcement, encouragement and support in a caring environment, alleviating fears and anxieties, providing pleasurable and enjoyable activities and changing the way people think about their disease. Such interventions are aimed at decreasing depression and anxiety, improving quality of life and reducing length of stay and hospital admissions.
Patient Support Groups
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Content updated March 10, 2008
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