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Cognitive Therapy and Research, Vol. 26, No. 1, February 2002 (°


C 2002), pp. 143–155

Anxiety and Panic in Chronic Obstructive Pulmonary


Disease: The Role of Catastrophic Thoughts
Ben Gurney-Smith,1 Myra J. Cooper,1,3 and Louise M. Wallace2

A short form of the Interpretation of Breathing Problems Questionnaire (the IBPQ-S)


was developed in 30 patients with chronic obstructive pulmonary disease (COPD). It
was then used to test specific hypotheses, derived from Clark’s cognitive model of
panic (D. Clark, 1986). Findings indicated that IBPQ-S catastrophic cognitions were
related to anxiety triggered by COPD symptoms but not to general anxiety, or to
panic. Severity of IBPQ-S catastrophic cognitions contributed unique variance to the
prediction of anxiety triggered by COPD symptoms (in safe and unsafe situations), and
to the prediction of behavioral avoidance in unsafe situations. In all 3 cases IBPQ-S
cognitive variables added significant incremental variance beyond that explained by
disease, demographic variables, and the Agoraphobic Cognitions Questionnaire. The
measure also has promising psychometric properties. The findings are consistent with
Clark’s model; they highlight the importance of catastrophic cognitions in COPD-
related anxiety.
KEY WORDS: cognition; anxiety; panic; chronic obstructive pulmonary disease (COPD).

Chronic obstructive pulmonary disease (COPD) is a progressive condition. It is


characterised by airways obstruction and irreversible impairment of lung function.
There is no cure for COPD and the effect of COPD on daily life and day-to-day
functioning can be profound; when COPD is severe, regular self-administered oxy-
gen therapy may be required. Psychological distress and psychiatric morbidity are
frequently found in COPD (and other respiratory diseases). Panic disorder is par-
ticularly common (for COPD specifically, 24% of a 50-patient sample, Yellowlees,
Alpers, Bowden, Bryant, & Ruffin, 1987; 37% of a 48-patient sample, Porzelius,
Vest, & Nochomovitz, 1992). Levels of anxiety also appear to be high in COPD, and
a diagnosis of anxiety disorder, as well as panic disorder, can often be made (10%
in addition to those with panic disorder, Yellowlees et al., 1987). These findings are

1 Isis
Education Centre, Warneford Hospital, Oxford, United Kingdom.
2 University
of Coventry, United Kingdom.
3 Correspondence should be directed to Myra Cooper, Isis Education Centre, Warneford Hospital, Oxford
OX3 7JX, United Kingdom; e-mail: myra.cooper@oxmhc-tr.anglox.nhs.uk.

143
0147-5916/02/0200-0143/0 °
C 2002 Plenum Publishing Corporation
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144 Gurney-Smith, Cooper, and Wallace

important because anxiety in COPD has been found to be related to longer hospital
stays (Yellowlees, Haynes, Potts, & Ruffin, 1988) and lack of engagement in rehabil-
itation programmes (Agle & Baum, 1977). It is also related to avoidance of activities
that involve exertion (Yellowlees et al., 1987), with important implications for the
physical well-being of patients. In other respiratory diseases, for example asthma,
anxiety is also related to excessive use of “as needed”4 medication (Carr, Lehrer, &
Hochron, 1995).
Because many of the physical symptoms associated with COPD are similar to
those associated with panic, Clark’s cognitive model of panic (Clark, 1986) has been
used to explain the presence of panic in COPD. Specifically, as applied to COPD, this
model predicts that only those who have catastrophic thoughts about their somatic
symptoms (such as breathlessness), in addition to the somatic symptoms themselves,
will experience panic. Recently, it has also been observed that catastrophic thoughts
are related to high levels of anxiety (Sutton, Cooper, Pimm, & Wallace, 1999), as
well as to panic. COPD patients’ catastrophic thoughts and anxiety also seem to
be greater in unsafe than in safe situations, that is, when the patient with COPD is
alone (Sutton et al., 1999). Support for the presence of catastrophic cognitions in
respiratory disease (including COPD) comes primarily from studies that have used
the Agoraphobic Cognitions Questionnaire (ACQ; Chambless, Caputo, Bright, &
Gallagher, 1984), a measure of cognitions characteristic of panic and anxiety-related
disorders. For example, one study found that patients with COPD who report panic
attacks, compared to those who do not, experience higher levels of catastrophic
cognitions, as measured by the ACQ, but do not differ on demographic or illness-
related variables (Porzelius et al., 1992). Several studies have also found that catas-
trophic cognitions predict more variance in anxiety triggered by respiratory symp-
toms (primarily in asthma) and general anxiety than do illness variables (Carr, Lehrer,
Rausch, & Hochron, 1994; van Peski-Oosterbaan, Spinhoven, van der Does, Willems,
& Sterk, 1996). However, the ACQ was designed for use in panic and anxiety without
physical illness, and thus may not be an ideal measure of catastrophic cognition in
COPD.
Recently, a new measure has been developed to assess the content and severity
of catastrophic thoughts specifically relevant to the respiratory symptoms associated
with COPD. The measure is the Interpretation of Breathing Problems Question-
naire (IBPQ; Sutton et al., 1999). Preliminary work indicates that the measure has
promising psychometric properties. Severity of catastrophic thoughts is associated
with higher levels of anxiety triggered by symptoms and with general anxiety in
COPD. Severity of catastrophic thoughts also predicts COPD-related and general
anxiety levels better than do demographic and disease variables. Finally, catastrophic
thoughts and anxiety are greater in unsafe than safe situations.
However, further work is needed. The measure (with 14 brief scenarios to read
and complete) is rather long and would benefit from being shortened, particularly
for clinical use. High internal reliability suggests this is feasible. It is also important to
include a measure of panic in order to see whether catastrophic cognitions, as assessed

4 Medication that is prescribed for the patient to take as it is needed rather than at set times of the day.
Often this is salbutamol inhaler.
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Anxiety and Panic in COPD 145

by the IBPQ, are related to and predict panic, as well as anxiety. For questionnaire
development it is important to compare the IBPQ with the ACQ in order to see
whether the IBPQ contributes unique variance to the prediction of anxiety and
panic in COPD. Further questions, not addressed in Sutton et al. (1999), could also
usefully be addressed. For example, it is not known whether catastrophic thoughts
are related to other variables known to be influenced by psychological factors in
COPD, for example, the use of as needed medication, length of hospital stays, and
behavioral avoidance. In addition, unlike Sutton et al. (1999), it would be helpful to
include an objective measure of lung function.
The current study therefore reports on the psychometric properties of a short-
ened form of the IBPQ. It also tested the following hypotheses: (1) that severity
of catastrophic thoughts as assessed by the Interpretation of Breathing Problems
Questionnaire—Short Form (IBPQ-S) will be related to panic (as well as to anxiety
triggered by COPD symptoms and to general anxiety); (2) that severity of catas-
trophic thoughts as assessed by the IBPQ-S, particularly in unsafe situations, will
contribute unique variance to the prediction of anxiety and panic (beyond that ex-
plained by the ACQ, and by demographic and disease variables); (3) that severity
of catastrophic thoughts as assessed by the IBPQ-S, particularly in unsafe situations,
will contribute unique variance to the prediction of medication use, total number
of days in hospital, and behavioral avoidance (again, beyond that explained by the
ACQ, and by demographic and disease variables).

METHOD

Participants
Thirty patients (24 male, 6 female) with a current diagnosis of COPD took part.
Patients were recruited from two hospital chest clinics; all were attending as out-
patients. Diagnosis of COPD was made by the consultant chest physician currently
involved in the patients’ care.5 Potential participants were excluded if they had an air-
ways disease not included in the British Thoracic Society Guidelines (British Thoracic
Society, 1997) for COPD (e.g. intermittent asthma), if COPD was not their primary
diagnosis or if, at interview, they reported a history of psychiatric treatment.

Measures

Demographic Information
Information was collected on age, sex, duration of illness, use of as needed
medication, use of oxygen therapy, and number and mean duration (in days) of
hospital admissions related to COPD.

5 The British Thoracic Society Guidelines (British Thoracic Society, 1997), based on impaired lung func-
tion (forced expiratory volume in the first second, that is less than 80% predicted for age, sex, and height,
and that does not change markedly over several months), were used to confirm or exclude a diagnosis
of COPD.
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146 Gurney-Smith, Cooper, and Wallace

Interpretation of Breathing Problems Questionnaire—Short Form (IBPQ-S)


The IBPQ-S is a self-report questionnaire. It was developed specifically for
this study by adapting the IBPQ (Sutton et al., 1999), which was designed to assess
catastrophic thinking related to the physiological symptoms of COPD. It consists of
eight brief scenarios describing the experience of a symptom commonly associated
with COPD, either in a safe or unsafe situation, for example, “You are on a crowded
bus (unsafe situation) and you notice you are wheezing,” “you are at hospital for a
check up (safe situation) and you begin to feel tired and exhausted.”6 Each scenario
is followed by three open-ended questions designed to elicit catastrophic cognitions,
and by four visual analogue scales to assess (a) anxiety in the situation, (b & c) to
provide ratings to assess concurrent (criterion-related) validity of the open-ended
responses, and (d) the extent to which the participant would avoid the situation.
Preliminary data for the full version indicates that IBPQ ratings of catastrophic
cognitions have good reliability (internal consistency, α = .90; test-retest reliability,
r = .47–1.00; interrater reliability, Cohen’s κ = .83) and promising validity (concur-
rent validity, means r = .54 ± .14 and r = .55 ± .12; construct validity, for IBPQ
anxiety, r = .26).

Agoraphobic Cognitions Questionnaire (ACQ)


This is a 14-item self-report questionnaire (Chambless et al., 1984) with good
psychometric properties (Chambless et al., 1984). It was developed to assess anxiety-
related cognitions in psychiatric populations. It is internally consistent, α = .80; sta-
ble, test-retest reliability, r = .74; and discriminates between agoraphobic and non-
patient controls. It has been widely used in studies of respiratory disease. It was used
here to determine whether the IBPQ-S contributes unique variance to the prediction
of panic and anxiety in COPD, beyond that explained by the ACQ.

Pulmonary Function
This was assessed according to standard procedures (Quanjer, Tammeling,
Cotes, Pedersen, & Peslin, 1993), using a spirometer (Micro Medical Ltd). The mea-
sure obtained from this test, which was used in the current study, was Forced Expi-
ratory Volume (FEV1 ).7 It was included as an objective measure of lung function.

St Georges’ Respiratory Questionnaire (SGRQ)


This is a 76-item self-report questionnaire (Jones, Quirk, & Baveystock,
1991) with good, extensively reported psychometric properties (Jones, Quirk,
Baveystock, & Littlejohns, 1992). It is designed to measure health status in airways
disease. The 9-item symptoms subscale was used here in order to assess frequency
and severity of symptoms associated with COPD over the past year.

6A copy of the IBPQ-S can be obtained from the corresponding author.


7 FEV
1 is the volume of air expelled in the first second starting from full inspiration.
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Anxiety and Panic in COPD 147

Medication Diary
This was designed for the current study in order to assess the number of as needed
medications taken for COPD symptoms in the week leading up to the interview.
Participants were asked to list their prescribed medication and then record each time
they took a dose. Total number of doses taken during the week was then calculated
for each participant.

Hospital Anxiety and Depression Scale (HADS)


This is a 14-item self-report questionnaire with good psychometric properties
(Zigmund & Snaith, 1983) designed to assess anxiety and depression amongst med-
ical outpatients. Only the anxiety scale (seven items) was used here. It was chosen
because it does not include somatic symptoms of anxiety, thus limiting the possible
confounding effect with physical symptoms of COPD.

Panic Attack Questionnaire-Revised (PAQ)


This is a self-report measure of panic disorder symptoms and frequency (Norton,
Harrison, Hauch, & Rhodes, 1985) based on DSM-IV criteria (American Psychiatric
Association, 1994). It was used in the Norton et al. (1985) study to diagnose panic
disorder. The version used here was that adapted for use in respiratory disorders
by van Peski-Oosterbaan et al. (1996). No psychometric data appear to have been
reported for this version of the questionnaire.

Procedure
Seventy-six patients were invited, by letter, to participate. Of the 42 who re-
sponded, 36 indicated a willingness to participate. Thirty subsequently took part
(three cancelled interviews because of illness, one could not be contacted, two met
the exclusion criteria at interview). All completed the medication diary in the week
leading up to the interview, which took place individually at home. During the inter-
view, demographic information was obtained, questionnaires were completed, and
lung function was assessed. Twenty patients also agreed to complete the IBPQ-S a
second time, 4–6 weeks after the initial interview, in order that test-retest reliability
could be calculated. Fifteen subsequently did this, returning the completed question-
naire by post.

RESULTS

Demographic and Disease Characteristics


Mean age of the total sample in years was 67.1 ± 8.2. The mean duration of illness
in years was 5.6 ± 4.4. Using the British Thoracic Society guidelines (British Thoracic
Society, 1997), lung function tests indicated that 2 patients had mild COPD, 4 had
moderate COPD, and 22 had severe COPD (data was unobtainable for 2 patients).
Mean FEV1 score was 0.78 ± 0.36 L, whereas mean percentage predicted/observed
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148 Gurney-Smith, Cooper, and Wallace

ventilatory capacity was 30.2 ± 13.2. Mean score on the SGRQ was 69.8 ± 10.7. In
the 7 days leading up to the interview an average of 18.1 ± 16.8 doses of as needed
medication were taken.8 Nine participants had oxygen supplied for their COPD.
Mean number of hospital admissions related to COPD was 1.5 ± 1.7. Mean length
of hospital admission related to COPD was 5.0 ± 4.7 days. For the analyses reported
below a new variable, total number of days in hospital related to COPD, was created
by summing all days spent in hospital across all admissions.

Anxiety and Panic Self-Report Questionnaires


Mean score on the HADS anxiety subscale was 8.2 ± 4.2 (possible range 0–21);
16 participants (53.3%) scored above the cutoff point on the HADS for clinically
significant levels of anxiety. Sixteen (53.3%), according to their scores on the PAQ,
also met the DSM-IV criteria for a panic attack, with 12 (40%) having experienced
at least one attack within the last 2 weeks.

IBPQ-S Psychometric Properties

Interrater Reliability
Ratings were made of the severity of the catastrophic cognitions elicited by the
open-ended questions. These were then categorized as noncatastrophic, mildly catas-
trophic, moderately catastrophic, or severely catastrophic.9 Written criteria were
provided for each category; these can be seen in the Appendix. For 25 participants
responses were rated independently by a second rater—a total of 200 responses.
Overall 150 (75%) had perfect agreement, and Cohen’s kappa yielded a value of
.63 ± .04, indicating good agreement (Landis & Koch, 1977) between the two raters.

Internal Consistency
Open-ended responses were assigned a rating from 0 to 3, with higher values
representing more severely catastrophic thoughts. A Cronbach’s alpha coefficient
value was then calculated to assess homogeneity of responses to the eight items. The
overall value was .87, indicating good homogeneity.

Construct Validity
To assess the construct validity of the IBPQ-S open-ended catastrophic cogni-
tion responses, the total score on these was correlated with total score on the ACQ.
There was a significant relationship between the two (r = .41, p < .01). To assess
the construct validity of the anxiety ratings on the IBPQ-S, total score on this was
correlated with total score on the HADS anxiety scale. There was a significant overall

8 In all cases this was salbutamol inhaler in 100-mg doses.


9 A fourth category “mildly catastrophic” was introduced for the IBPQ-S. The original questionnaire had
only three categories.
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Anxiety and Panic in COPD 149

relationship between the two (r = .34, p < .04). However, when unsafe and safe sit-
uations were analysed separately, there was a significant relationship only for unsafe
situations (r = .45, p < .01), and not for safe situations (r = .20, ns).

Concurrent Validity
To assess concurrent validity of responses to the open-ended questions, mean
severity of catastrophic thoughts ratings were correlated, for each item, with ratings
of belief in becoming ill and belief in dying. Separate Kendall’s tau correlation co-
efficients were calculated; all but one ( p < .05) were significant at the .01 level.

Test-Retest Reliability
Test-retest reliability was calculated for each item in each of the eight scenarios.
Wilcoxon Matched Pairs Signed Rank Tests were used. These indicated that there
were no significant differences at retest for open-ended responses, ratings of situation-
specific anxiety, ratings of belief in becoming ill, belief in dying, and all but two
avoidance items ( p < .05 and p < .01 respectively).

Catastrophic Thoughts, Anxiety and Panic


Mean total severity of catastrophic thoughts ratings were correlated with IBPQ
anxiety ratings and HADS anxiety ratings. In each case an overall value and sepa-
rate values for safe and unsafe situations were calculated. Pearson product–moment
correlation coefficients were used, except for the correlations in unsafe scenarios.
Because the distribution of scores in unsafe situations was not normal, Spearman
correlations were calculated. These correlation coefficients can be seen in Table I.
All correlations were significant.
For the analyses of panic, two groups were created; a panic and no panic group.
Participants were included in the panic group if they met DSM-IV criteria for a
panic attack (i.e. at least four symptoms on the PAQ). Mann–Whitney U tests for
independent samples were used to determine whether there were any significant dif-
ferences between the two groups in severity of catastrophic cognitions, as assessed
by the IBPQ-S. Again, an overall value and separate values for safe and unsafe situa-
tions were calculated. There were no significant differences between the two groups.

Table I. Correlations Between IBPQ-S Catastrophic Thoughts and Anxiety


IBPQ-S anxiety HADS anxiety
Severity of catastrophic cognitions (on the IBPQ-S)
Total .79∗∗∗ .41∗
Safe situations .75∗∗∗ .40∗
Unsafe situations .64∗∗∗ .43∗∗
Note. IBPQ-S = Interpretation of Breathing Problems Questionnaire—Short Form. HADS =
Hospital Anxiety and Depression Scale.
∗p < .05. ∗∗p < .01. ∗∗∗p < .001.
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150 Gurney-Smith, Cooper, and Wallace

Table II. Mean Severity of IBPQ-S Catastrophic Thoughts in the Panic and No Panic Groups
Panic No panic
M SD M SD
Severity of catastrophic cognitions (on the IBPQ-S)
Total 11.25 5.65 9.71 6.29
Safe situations 4.62 2.80 4.14 3.32
Unsafe situations 6.62 3.24 5.57 3.30
Note. IBPQ-S = Interpretation of Breathing Problems Questionnaire—Short Form.

Mean scores for the two groups on severity of catastrophic thoughts can be seen in
Table II.10

Predictors of Anxiety and Panic


To investigate whether the IBPQ-S contributed unique variance to the predic-
tion of anxiety in COPD, beyond that explained by disease, demographic variables,
and the ACQ, three sets of two hierarchical multiple regression analyses (safe and
unsafe situations treated separately) were run. Independent variables in all analyses
were age, gender, duration of illness in years, severity of illness (FEV1 ), and total
ACQ score. In the first set of two analyses the dependent variable was mean total
anxiety11 on the IBPQ-S. In the second set of two analyses the dependent variable
was HADS anxiety score. In the third set of analyses a score calculated by multiply-
ing the total number of symptoms by the frequency of panic attacks (both measured
by the PAQ) in the last 2 weeks was the dependent “panic” variable. In the first and
second analysis of each set, mean total severity of catastrophic thoughts in safe
and unsafe situations, respectively, were also entered as independent variables. In
each analysis demographic and disease variables were forced into the equation, fol-
lowed by ACQ score, and then by the appropriate IBPQ-S score. Summary statistics
for all six analyses, showing only significant predictors, are presented in Table III.

Analyses With IBPQ-S Anxiety as the Dependent Variable


In the analysis of safe situations, the only variable that emerged as a signifi-
cant predictor of IBPQ-S anxiety was mean total severity of IBPQ-S catastrophic
thoughts. This indicated that IBPQ-S catastrophic thoughts contributed unique vari-
ance beyond that explained by disease, demographic variables, and ACQ score. In
the analysis of unsafe situations three variables emerged as significant predictors:
mean total severity of IBPQ-S catastrophic thoughts, total score on the ACQ, and
gender (with women scoring more highly than did men). As before, the results indi-
cated that IBPQ-S catastrophic thoughts contributed unique variance, beyond that
explained by demographic variables, disease, and ACQ scores.

10 There was, however, a significant difference between the two groups in mean ACQ scores: panic group =
20.3 ± 4.3, no panic group = 15.6 ± 2.0, Mann Whitney U = 38, p < .001.
11 Eitherin unsafe or safe situations.
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Anxiety and Panic in COPD 151

Table III. Summary Statistics for the Hierarchical Multiple Regression Analyses With IBPQ-S Anxiety
as the Dependent Variable Predictor
Significance of
Situations Significant predictors β Adjusted R 2 df F F
Safe situations Catastrophic .53 .73 6, 23 3.64 .002
(IBPQ-S) thoughts
Unsafe situations Gender .35 2.90 .01
Catastrophic .33 2.51 .02
(ACQ) thoughts
Catastrophic .68 .82 6, 23 5.43 .001
(IBPQ-S) thoughts
Note. IBPQ-S = Interpretation of Breathing Problems Questionnaire—Short Form.

Analyses With HADS Anxiety as the Dependent Variable


In the analysis of safe situations, and in the analysis of unsafe situations, no
variable emerged as a significant predictor of HADS anxiety.

Analyses With Panic as the Dependent Variable


In the analysis of safe and unsafe situations no variable emerged as a significant
predictor of panic.

Predictors of COPD-Related Behavior


To investigate whether severity of IBPQ-S catastrophic thoughts contribute
unique variance to the prediction of behaviors associated with COPD (medica-
tion use, total number of days in hospital, and behavioral avoidance), three sets
of two hierarchical multiple regression analyses were run. Independent variables in
all analyses were age, gender, duration of illness in years, severity of illness (FEV1 ),
and total ACQ score. In the first set of two analyses the dependent variable was
medication use (number of doses of as needed medication in the week preceding
the interview). In the second set of two analyses the dependent variable was total
number of days in hospital related to COPD. In the third set of analyses behavioral
avoidance, as measured on the IBPQ-S, was the dependent variable.12 In the first
and second analysis of each set, mean total severity of catastrophic thoughts in safe
and unsafe situations, respectively, were also entered as independent variables. In
each analysis demographic and disease variables were forced in first, followed by
ACQ score, and then by the appropriate IBPQ-S score. Summary statistics for all six
analyses, showing only significant predictors, are presented in Tables IV and V.

Analyses With Medication Use as the Dependent Variable


In the analysis of safe and unsafe situations no variable emerged as significant
predictor of medication use.

12 Either in unsafe or safe situations.


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152 Gurney-Smith, Cooper, and Wallace

Table IV. Summary Statistics for the Hierarchical Multiple Regression Analyses With Avoidance as the
Dependent Variable
Significance of
Situations Significant predictors β Adjusted R 2 df F F
Unsafe situations Catastrophic .57 .66 6, 22 3.36 .004
(IBPQ-S) thoughts
Note. IBPQ-S = Interpretation of Breathing Problems Questionnaire—Short Form.

Analyses With Total Number of Days in Hospital as the Dependent Variable


In the analysis of safe and unsafe situations, only duration of illness emerged
as a significant predictor. However, there was a nonsignificant trend for mean total
severity of IBPQ-S catastrophic thoughts to contribute unique variance, beyond that
explained by disease, demographic variables, and ACQ scores in safe situations.

Analyses With Behavioral Avoidance as the Dependent Variable


In the analysis of safe situations no variable emerged as a significant predictor.
In unsafe situations the only variable that emerged as a significant predictor was
mean total severity of IBPQ-S catastrophic thoughts.

DISCUSSION

The findings support the importance of illness specific catastrophic cognitions in


accounting for anxiety in situations (safe and unsafe) in which symptoms of COPD
are experienced. Not only are they related to IBPQ-S anxiety, but they contribute
unique variance to the prediction of this anxiety, beyond that explained by cognitions
characteristic of anxiety and panic disordered patient populations (and by disease
and demographic variables). They also contribute unique variance to the prediction
of avoidance (in unsafe situations).
Anxiety related to COPD symptoms thus appears to be closely tied to severity
of IBPQ-S catastrophic cognitions, rather than to those catastrophic cognitions that
are typical of a panic disordered and anxiety disordered psychiatric population. The
same seems to be true for avoidance of unsafe situations in which symptoms of COPD
might be experienced; IBPQ-S cognitions contribute unique variance not explained
by ACQ cognitions. These findings support the suggestion that the IBPQ-S is a useful

Table V. Summary Statistics for the Hierarchical Multiple Regression Analyses With Total Days in
Hospital as the Dependent Variable
Significance of
Situations Significant predictors β Adjusted R 2 df F F
Safe situations Duration of illness .61 6, 22 3.11 .007
Catastrophic .42 .27 6, 22 1.83 .09
(IBPQ-S) thoughts
Unsafe situations Duration of illness .57 .66 6, 22 3.36 .004
Note. IBPQ-S = Interpretation of Breathing Problems Questionnaire—Short Form.
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Anxiety and Panic in COPD 153

measure of catastrophic cognitions in COPD, with unique predictive power beyond


that of the ACQ (and beyond that of demographic and disease variables).
The findings support the suggestion that a cognitive model, based on that of
Clark (1986), might provide a useful framework for explaining anxiety in COPD. A
cognitive formulation of patients’ anxiety and the use of cognitive therapy techniques
might also help patients reduce their anxiety. Such a formulation and treatment
approach might usefully be based round catastrophic thoughts related specifically
to the symptoms of COPD. In turn, this may facilitate engagement in rehabilitation
programmes, and ultimately reduce avoidance of feared (unsafe) situations. Both
may be important in maintaining physical fitness and general well-being in patients
with COPD.
HADS anxiety was not predicted by the IBPQ-S or by any other variable, in-
cluding the ACQ. This suggests that, in so far as patients with COPD are generally
anxious, this anxiety may not be tied closely to cognitions characteristic either of
COPD or of panic or anxiety disordered psychiatric patients. In addition, and con-
trary to the hypotheses, panic was not related to IBPQ-S catastrophic cognitions, or
to catastrophic cognitions as assessed by the ACQ. One possibility is that the panic
measure, with no published data on its psychometric properties, is not a robust mea-
sure. Alternatively, there may be little or no relationship between panic and IBPQ-S
catastrophic cognitions in COPD. Some support for this suggestion comes from the
finding that ACQ scores did distinguish panic from no panic groups.
The fact that gender predicted IBPQ-S anxiety in unsafe situations is interesting,
although numbers are too small to draw definite conclusions. Although it may be an
artefact of low numbers of women, another possibility is that it reflects a higher
prevalence of agoraphobia in women.
Preliminary findings indicate that the IBPQ-S has promising psychometric prop-
erties. There was good agreement between the two raters who categorized the
catastrophic thoughts. Internal consistency of ratings assigned to the open-ended
responses was high. Construct validity was promising as was data on concurrent
validity. Test-retest reliability was generally good. These findings indicate that the
IBPQ-S may be a useful measure of catastrophic cognitions in COPD.
More than half the participants had clinically significant levels of anxiety (53.3%)
and more than half met DSM-IV criteria for a panic attack (53.3%). These findings
support previous reports of high levels of anxiety and panic in COPD (Porzelius et al.,
1992; Yellowlees et al., 1987). Indeed, rather higher levels were found here than in
previous studies. This may be because the patients in the current study had more
severe COPD symptoms than those in previous studies. Examination of FEV1 values
(preadmission for comparability with our own nonhospitalized sample) in the study
by Yellowlees et al. (1987) indicated that these were rather higher (1.1 L) than in
the current study (0.78 L). Mean percentage predicted/observed ventilatory capacity
was lower in the current study (30.24) than in the study by Porzelius et al. (1992), in
which it was 53.8. Suggestion of greater severity is supported by the finding that the
majority in our sample fell into the severe COPD category (using British Thoracic
Society Guidelines, 1997).
There are some limitations to our study. In particular, the number of respondents
was relatively small, all measures were self-report (except for the measure of lung
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154 Gurney-Smith, Cooper, and Wallace

function), and more highly related measures were collected at the same point in time.
It is noteworthy, however, that there was a trend for IBPQ-S catastrophic cognitions
to predict total number of days in hospital (a measure unlikely to suffer from shared
method variance); a finding that might well be significant in a larger sample. As Sutton
et al. (1999) note, further work is also needed, particularly on the concurrent validity
of the IBPQ-S and on the applicability of the cognitive model in COPD. Further
work might also usefully examine the role of anxiety sensitivity (Reiss, Peterson,
Gursky, & McNally, 1986), using the Anxiety Sensitivity Index (Reiss et al., 1986).
It might also examine, in a longitudinal design, whether preexisting trait anxiety is
a predictor of the development of IBPQ-S cognitions and behavioral avoidance in
COPD, or whether it simply predicts the development of general anxiety responses
(as has been established in the psychiatric literature). Finally, it should be noted that
our findings, although consistent with Clark’s model of panic (Clark, 1986) could, at
present, also be explained by noncognitive theories of anxiety in COPD.

APPENDIX: CRITERIA FOR RATING OPEN-ENDED RESPONSES

Noncatastrophic (Score 0): Any response that implies no adverse consequences of


symptom becoming more severe. Includes responses that imply that the patient
is not at all worried about the symptom described, for example, “I’ll be fine,”
“I’ll cope OK,” “Nothing will happen,” and so forth. Includes reactions reflecting
irritation or embarrassment at experiencing problems that are inconvenient, but
that do not imply adverse consequences of symptoms per se, for example, “I’ll
find a toilet where I can cough without anyone seeing me,” “I’ll be late, but I’ll be
OK,” and so forth.
Mildly catastrophic (Score 1): Any response that implies mildly adverse consequences
of symptom becoming more severe. Includes reactions reflecting irritation or em-
barrassment, if mildly adverse consequences of symptoms are mentioned or im-
plied, for example, “People will notice me and I will feel embarrassed,” “I won’t
be able to find somewhere to rest,” and so forth.
Moderately catastrophic (Score 2): Any response that implies moderately adverse
consequences of symptom becoming more severe. Includes expression of a con-
sequence that is distressing or dangerous but not necessarily life threatening, for
example, “I will be admitted to hospital,” “I will lose control of my bladder,” “I
will panic and pass out.”
Severely catastrophic (Score 3): Any response that implies severely adverse conse-
quences of symptom becoming more severe. Includes clear expression of a con-
sequence that may place the patient at risk of dying, for example, “I will stop
breathing,” “I will die,” “I will have a heart attack.”

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