UNIT – 4

RESPIRATORY SYSTEMS

*INTRODUCTION PART AND ASTHMA FROM NOTEBOOK

CHRONIC OBSTRUCTIVE PULOMONARY DISEASE

[Psychiatric Aspects of Patients with Chronic Obstructive Pulmonary Disease Donald L. Dudley, Judith
Sitzman, Marelyn Rugg Washington Institute of Neurosciences, and University of Washington School of
Medicine, Seattle, Wash., USA; Massachusetts General Hospital, Institute of Health Professions, Boston,
Mass., USA]

The interaction between the COPO patient's environment and his disease can be examined in a
number of ways [1, 2], each of which is discussed in more detail below:

(1) The lag between reactions of different organ systems.

(2) The overload on an impaired organ system.

(3) The accumulation of disruptive life change.

(4) The use of psychosocial assets.

(5) The social indicators of disease

The Schedule of Recent Experience [9] was developed to provide a 'yard stick' for quantifying
life changes using life change units as the basic measurement of change.A person's overall
ability to deal with his environment can be called 'psychosocial assets'. Psychosocial assets are
broken down into three categories, all of which are measurable to some extent

Category 1 - social support:

(1) being in a setting in which on receives love;

(2) being in a setting in which one is esteemed;

(3) being in a mutual defensive system (if attacked, those around you will come to your aid).

Category 2 - coping ability: the patient's ability to change environments to meet needs.

Category 3 - adaptive ability: the patient's to adapt to existing environments.

A patient with a high score in all of these areas is viewed as having high psychosocial assets.
Currently, the only single test that recognizes all of the above factors is the Berle Index . In
general, patients who score above 80% on this test seldom get sick, get well if they become
sick, and control their disease without a great deal of difficulty. Patients who score below 60%
tend to do more poorly.

Life change requires one to adapt to or cope with a stressful live event. A few individuals display
unlimited ability to muster coping behaviors and mechanisms to deal with life changes. These
people rarely get sick.

Some people rely only on one or two coping behaviors and are more frequently sick. Most of us
fall somewhere in between in the number of coping behaviors that we use.

Coping behaviors may include emotional responses (anger, sorrow, elation), personal habits
(eating, smoking, physical activity, sex), and often unconscious habits (nail biting, sighing, finger
drumming). Furthermore, attention to one's job and hobbies are coping behaviors, as may be
time spent with one's family.

Social Indicators of Disease

Laymen and clinicians alike tend to confuse the symptoms of a disease with the disease itself. A
patient can have a disease, or several diseases, and not be sick. Conversely, a patient may be
terribly sick and have no disease. The word disease is derived from the subjective feelings of
dis-ease

we interpret being sick or ill as experiencing a loss of comfort, productivity, or both. A patient
may have hypertension, a disease, with no loss of comfort or productivity. During a smog alert
he may wheeze, feel miserably ill, uncomfortable, and unproductive, but have no disease.

This complicates the interaction of the patient with a disease with his culture, since people
with many recognizable chronic disease entities, who do not fit the cultural definition of illness,
may be seen as malingerers and be treated with hostility.

DEFENSES AND COPING BEHAVIOR

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 staff those
they need the most for support

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.

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.

PSYCHOLOGICAL MANAGEMENT OF RESPIRATORY DISORDERS

PSYCHOSOMATIC APPROACH TO TREATING PATIENTS WITH REPIRATORY DISORDERS

 MEDICATION
 PSYCHOEDUCATION
 PSYCHOLOGICAL APPROACH
- COGNITIVE
- BEHAVIORAL
 RELAXATION TECHNIQUES
  LIFESTYLE CHANGES

Behavioral therapies
1) Breathing training

Exercises that alter aspects of the breathing pattern have been varyingly
combined into intervention techniques for asthma patients,

 altering speed,
 volume or
 regularity of breathing,
 the balance between nasal versus oral route or abdominal
versus chest compartments, or
 training of breathing in against resistances for improving
inspiratory muscle strength or breathing out against
resistances such as pursed lips to avoid airway collapse.
 A recently developed breathing training that teaches slow,
abdominal, and shallow breathing guided by assessments of
CO2 with a capnometer showed improvements in asthma
symptoms and asthma control, including lung function
variability,
2) Relaxation training
Mindfulness-based stress reduction found intervention effects only
on quality of life and perceived stress at 12-month follow-up, while
lung function and asthma control
 Progressive muscle relaxation
  Autogenic relaxation training developed by Schultz and Luthe
(1959).


3) Biofeedback training

A number of biofeedback techniques have been devised with the aim of

improving lung function in asthma patients

Findings with direct feedback of respiratory resistance (controlled for

hyperinflation of the lungs, which can reduce resistance), one of the most
relevant parameters of asthma pathophysiology,

4) Systematic desensitization

In the typical practice of SD the subject relaxes and imagines a graded series
of anxiety provoking situations (Wolpe, 1958). 178 King The possibility of
systematic desensitization being offered to asthmatic children is supported by
the observations of Tal and Miklich (1976). These researchers found that
imagined scenes of anger and fear adversely effected pulmonary functioning
in asthmatic children. However, subsequent relaxation exercises produced an
improvement in airways resistance in the same subjects.

5) Assertive Training

The efficacy of assertive training was examined on the grounds that

"asthmatics are deficient in assertive skills, and are impaired in their
ability to express anger or aggression by (hock et al 1985)

Individual psychotherapy

1) Cognitive-behavior therapy (CBT) for comorbid asthma and anxiety

CBT for anxiety disorders focuses on the repeated exposure to feared
situations and sensations, supported by a set of control-based coping
skills

In these studies, traditional CBT components (i.e., education, breathing

retraining and progressive muscle relaxation, cognitive restructuring,
and interoceptive and in-vivo exposure to feared bodily sensations) were
combined with additional asthma-specific components. In a small
study, Ross, Davis and McDonald (2005) found that an 8-week group
treatment that combined CBT for panic disorder with asthma education
(addressing asthma triggers and control, lung function and symptom
monitoring, medication use, and side-effects) led to long-term reductions
in panic and anxiety, and short term improvements in morning peak flow
and asthma-related quality of life

2) Suggestive methods

It is now well established that 20–40% of patients with asthma respond

to specific suggestions with significant deterioration of their lung
function (Isenberg, Lehrer & Hochron, 1992). In the most common
paradigm, patients are told that they are inhaling a bronchoconstrictive
substance, which in fact is an inert gas or room air. Patients that are
more hypnotizable are more likely to show this effect (Leigh, MacQueen,
Tougas, Hargreave & Bienenstock, 2003). The benefits of hypnotherapy
for asthma have been explored for some time, with the weight of the
evidence suggesting some improvement in self-report of clinical
outcomes rather than lung function

3) Expressive methods

Both theoretical psychodynamic accounts of asthma and empirical

observations (Florin et al., 1993) have directed attention to potentially
detrimental effects of emotional suppression or repression in asthma.

Following earlier positive findings with emotional writing in asthma

(Smyth, Stone, Hurewitz, & Kaell, 1999), in which patients typically write
about negative life experiences in three 20-min sessions, a subsequent
controlled trial with adults was not able to replicate these findings
(Harris, Thoresen, Humphreys, & Faul, 2005), whereas a trial with
children found improvements in symptoms, emotional and behavioral
functioning,

PSYCHOSOCIAL INTERVENTIONS

 FAMILY THERAPY
 COMMUNITY BASED INTERVENTIONS
 GROUP THERAPY

Lifestyle interventions and rehabilitation

1) Physical activity and exercise

Exercise is one of the best known triggers of asthma symptoms

(McFadden & Gilbert, 1992). Therefore, it is not surprising that patients
have an unfavorable attitude toward more demanding physical activity
(Millard, 2003).

The consequence is a sedentary lifestyle that results in deconditioning.

Paradoxically, skeletal muscle activation leads to an initial
bronchodilation by vagal withdrawal, as demonstrated by animal,
exercise, and muscle tension biofeedback studies (Ritz, 2004). Only later
stages of exercise or stronger exhaustion lead to symptoms that are
known as exercise-induced asthma. Interestingly, physical activity in
daily life is linked to better lung function, but it is also related to reports
of stronger symptoms in asthma patients

2) Nutrition and diet

The worldwide epidemics of obesity have also drawn attention to

complications in asthma (Eneli, Skybo, & Carmago, 2008). Although
epidemiological and longitudinal studies suggest an association between
both conditions, the reasons for this relationship are not yet fully
understood (Lugogo et al., 2010). Weight loss intervention with patients
suffering from both asthma and obesity have generally yielded
improvement in asthma

3) Smoking cessation

Smoking in asthma is associated with more symptoms, reduced asthma

control, more health care utilization, reduced sensitivity to
corticosteroids, and an accelerated decline in lung function and
transition into more chronic obstruction (Tomson & Chaudhuri 2009).
Nevertheless, the prevalence of smoking is equal to the general
population, as are age of smoking initiation, smoking patterns, readiness
to quit smoking, and history of quit attempts