Chest
Volume 77, Issue 3, March 1980, Pages 413-420
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Special Report
Psychosocial Concomitants to Rehabilitation in Chronic Obstructive Pulmonary Disease: Part I. Psychosocial and Psychological Considerations

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This is the first of a three-part series (to appear in consecutive issues) exploring the psychosocial and psychological concomitants of chronic obstructive pulmonary diseases (COPD), with emphasis on anxiety and depression. The reciprocal nature of dyspnea, anxiety and depression is clarified. Isolation, denial, and repression are the classic defenses of COPD patients and some, not all, patients can be aided by psychotherapy. This counseling many times may best be administered by the primary physician. If the patient requires additional long-term therapy, referral to a specialist is recommended. The following treatment modalities, in addition to basic medical therapy to facilitate respiration, also are discussed: breathing retraining, meditation, relaxation training, experimental use of biofeedback, behavior modification, goal setting, life-change monitoring, and education of patient and family in patient self-care. One section delineates the use of psychoactive medications, patient responses to various medications, and clearly identifies contraindications. For ease of assimilation the series is divided into three parts of equal importance. Part I is primarily concerned with a selected relevant literature summary, psychosocial evaluation of patients, general guidelines for treating psychosocial aspects of COPD, and patient/family education.

Part II is concerned with various specific psychosocial and psychological treatment modalities for anxiety and depression, and their application to COPD patients.

Part III concentrates on psychiatric disease that may coexist with COPD, and the use of psychopharmacologic agents in treatment of psychiatric disease.

The three parts will enable the reader to identify areas of interaction between the primary physician, social workers, psychologists and psychiatrists in the treatment of the COPD patient with emotional difficulties.

Section snippets

Psychological Characteristics of the COPD Patient

While there are some similarities in the composite clinical picture of the COPD patient, there also are considerable variations in individual personality, disease stages, degree of impairment, and socioeconomic, educational, or cultural resources. In a study of 45 patients, Lustig et al10 described COPD patients as “highly anxious, socially isolated, lonely, and afraid to commit themselves to vocational activities.” Dudley et al3 observed that many severely disabled COPD patients tended to live

EMOTIONAL STATES AND PSYCHOPHYSIOLOGY ASSOCIATED WITH COPD

To understand the patient with COPD, it is helpful to consider some of the elements of basic pulmonary psychophysiology. Psychological states of action, such as significant degree of anxiety, anger, and euphoria, are associated with increased energy expenditure, elevated ventilation, high oxygen consumption, and skeletal muscle tension; while psychological states of nonaction, such as apathy, depression, and deep relaxation, are associated with reduced energy expenditure, decreased ventilation,

GENERAL GUIDELINES FOR TREATING PSYCHOSOCIAL ASPECTS OF COPD

As the patient comes to realize that changes in his emotional state increase his incapacity and disability, he may protect himself through isolation, denial, and repression. In addition, his fear of alienating those who provide access to medical care may lead to an inability to express anger or resentment, and assumption of either a passive-dependent or passive-aggressive role. As the patient encounters the severe problems associated with the more advanced stages of disease, he may believe he

INITIAL PSYCHOSOCIAL EXAMINATION

The dual purpose of the psychosocial examination is to give the patient the opportunity to talk about problems and to relate information necessary to the formation of a treatment plan. If mutual understanding and rapport are established in the initial examination, the patient is likely to develop a long-lasting sense of confidence in the physician.

The initial examination also affords the physician an opportunity to contribute to the development of the patient's attitude about his disease. It is

PATIENT AND FAMILY EDUCATION

To educate the patient and his family about COPD, it is important to identify psychological and social situations that tend to contribute to disability and insufficiency. This can be done by including family members in office visits or by visiting the patient's home. The Visiting Nurse Association and Home Health Programs are valuable in extending contacts into the patient's home and can also provide ongoing education for those patients and families experiencing particular difficulty in coping

COMMENT

This paper reviews the interaction of the COPD patient's physical state with his psychosocial assets and psychological state. It stresses the importance of identifying and treating concomitant emotional changes. Subsequent parts will focus on treatment modalities that aim at modifying affect and behavior, as well as strengthening the ability of the patient to cope with COPD.

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