Cogniti ve Th erapy and Research , Vo l. 23, No. 6, 1999, p p.

573-585

A nxiety in Ch ronic Obstructive Pulm onary D isease: The

Role of Illness Spe ci® c Catastrophic Thoughts
K are n Su tton,1 Myra Coope r,1,4 Jo hn Pim m ,2 an d Louise Wallace 3

The de velopm ent of a self-report m easu re design ed to assess illn ess-speci® c cata-
strophic though ts in chronic obstructive pulm onary disease (CO PD ) is described.
The m easu re is then used to test hyp otheses ab out the relatio nship betw een catastro phic
though ts an d an xiety in CO PD . Prelim in ary ® nd in gs suggest that the m easu re, the
Interpretatio n of B reath in g Problem s Q uestion naire (IB PQ ), has go od psych om etric
properties. Tests of speci® c hyp otheses in dicated that m ore se vere catastro phic
though ts w ere asso ciated w ith high er le vels of an xiety. Catastro phic though ts an d
an xiety w ere also m ore severe in unsafe than in safe situ atio ns. Se verity of catastro phic
though ts w as a sign i® can t predictor of an xiety, particu larly of situ atio n speci® c
(IB PQ ) an xiety. Satisfactio n w ith social support, bu t not age, duratio n, or severity o f
illn ess, was also im portan t, particu larly in safe situ atio ns. Im plicatio ns for a cogn itive
m odel of an xiety in CO PD , an d for treatm ent of an xiety in this diso rder, are brie¯ y
discu ssed. L im itatio ns of the study are noted. Su ggestio ns are m ad e for further re-
search.
K E Y WOR D S: cognition; anxiety: chronic obstructive pulmonary disease .

The te rm ``chronic obstructive pulm onary disease ’ ’ (CO PD) re fe rs to a varie ty

of re spiratory dise ases including asthm a, chronic bronchitis, and e mphyse ma. Pa-
tie nts with CO PD typically have high le ve ls of psychologic al disturbance and psychi-
atric morbidity (e .g., Yellowle e s, A lpers, B owde n, B ryant, & Ruf® n, 1987; Karajgi,
Rifkin, Doddi, & Colli, 1990) . In particular, leve ls of ``panic fe ar’ ’ are high (e.g.,
Kinsman, Fe rnade z, Schocke t, Dirks, & Covine , 1983) and panic disorde r is common
(e .g., van Pe ski-O oste rbaan, Spinhove n, van de r Doe s, Wille ns, & Ste rk, 1996) .
A lthough less fre que ntly re porte d, le vels of ge ne ral anxie ty also appe ar to be high
and a diagnosis of anxie ty disorde r, apart from panic disorde r, is also common
(e .g., Yellowle es e t al., 1987) . The presence of psychologic al disturbance has be en

1
Isis E ducation Centre, Warneford Hospital, O xford, UK.
2
Rayners’ Hedge, Ayle sbury, UK.
3
Horton General Hospital, B anbury, UK.
4
Corre spondence should addre ssed to Myra Cooper, Isis E ducation Centre, W arne ford Hospital, Oxford,
O X3 7JX, UK; e-mail: myra.coope r@oxmhc-tr-anglox.nhs.uk

573
0147-5916/99/1200-0573$1 6.00/0 Ó 1999 Ple num Publishing Corporation
574 Su tton, Coo pe r, Pimm , and Wallace

associate d with gre ater and e xce ssive use of medication (Carr, Le hre r, & Hochron,
1995) and more fre que nt and longe r hospital admissions (e .g., Yellowle es, Hayne s,
Potts, & Ruf® n, 1988) among patie nts with CO PD. It has also be e n sugge ste d that
it inhibits ade quate coping and e ngage ment in rehabilitation program s (A gle &
B aum, 1977) . Phenome nologically, some of the symptom s of panic disorde r are
similar to the symptoms associate d with CO PD ( Spinhove n, Ros, We stge e st, & van
de r Does, 1994) . In particular, patie nts with CO PD are pre sente d with chronic or
chronic-e pisodic exposure to bodily se nsations, some of which are similar to those
associate d with the onse t of panic. The re is also a high de gre e of avoidance of
situations in which bre athing may be disrupte d or temporarily obstructe d (Yel-
lowle es e t al., 1987) . The se similaritie s have re sulte d in the application of psychologi-
cal mode ls to e xplain the pre se nce of panic in CO PD, including the cognitive
mode l of panic (Clark, 1986) . Clark’ s mode l propose s that panic results from the
catastrophic misinte rpre tation of certain bodily se nsations. A s applie d to CO PD,
this mode l pre dicts that only those who also expe rience catastrophic 5 thoughts
(e ithe r misinte rpretations or ove rinte rpre tations 6) in addition to the physiological
symptom s and bodily se nsations associate d with CO PD will e xpe rie nce panic. E x-
isting studie s provide some support for the importanc e of cognition in CO PD and,
the refore , support for this theory. Thre e studie s have found that patie nts with
CO PD who report panic attacks, compare d to those who do not, have highe r le ve ls
of catastrophic cognitions, although the y do not diffe r on demographic or illne ss-
re late d variable s ( Porze lius, V e st, & Nochom ovitz, 1992; Carr, Le hre r, Rausch, &
Hochron, 1994; van Peski-O oste rbaan e t al., 1996) . O ne study has found that cata-
strophic cognitions pre dict more variance in speci® c and ge ne ral panic fe ar than
illne ss variable s, including pulmonary function (Carr e t al., 1995) . Howe ve r, de spite
pre liminary evide nce, no study has e xam ined the pre cise conte nt and focus of
catastrophic cognitions in CO PD: many existing studie s use a measure de signe d
for use in panic and anxie ty without physical illne ss, the A goraphobic Cognitions
Q uestionnaire (A CQ ; Chamble ss, Caputo, B right, & Gallaghe r, 1984) . O ur clinical
e xpe rie nce sugge sts that CO PD patie nts focus particularly on symptoms of the ir
physical illne ss, i.e ., re spiratory disease , and that the se are the symptom s that they
fre que ntly inte rpre t ne gative ly and catastrophi cally. O ur e xpe rie nce sugge sts that
catastrophic inte rpre tation of respiratory symptoms is relate d not only to panic but
also to high le ve ls of anxie ty. O ur obse rvations of patie nts with CO PD also sugge st
that they fre que ntly show le ss anxie ty and fewer catastrophic cognitions in certain
``safe’ ’ situations, e ven when the ir physical symptom s are se ve re. This include s
hospital se ttings and situations in which a familiar or truste d pe rson is present. This
obse rvation may account for the ofte n obse rve d failure of good progre ss in hospital-
base d re habilitation program s to gene ralize to othe r se ttings Ð for e xam ple , going
5
For the purpose s of this paper, the te rm ``catastrophic’ ’ is de® ne d using Clark’ s (1986, p. 461) de ® nition
in which catastrophic, as applied to cognition, involve s ``perceiving . . . sensations as much more
dange rous than they re ally are.’ ’
6
A s others have pointed out, some of the he alth risks that patients with CO PD fear may well be re alistic.
Thus it may be more appropriate , in some cases, to refe r to catastrophic thoughts as overinte rpretations
rathe r than misinterpretations. O ur clinical expe rie nce sugge sts that both type s of interpretation may
be important in CO PD. Clark’ s de ® nition of catastrophic thoughts appears able to e ncompass both
type s of interpre tation.
A nxiety in COPD 575

out from home alone . The pre se nt study re ports on the de ve lopm ent of a se lf-
re port que stionnaire de signe d to asse ss the conte nt and se verity of catastrophic
cognitions spe ci® cally re le vant to the re spiratory symptom s associate d with CO PD.
This me asure is used to te st the following hypothe ses: (1) that se ve rity of catastrophi c
thoughts rele vant to respiratory symptoms will be relate d to ge ne ral and situation
spe ci® c anxie ty; (2) that in situations perceived as more threate ning or ``unsafe ,’ ’
patie nts will e xpe rie nce more anxie ty and thoughts will be more catastrophi c; and
(3) that se verity of catastrophic thoughts will predict more of the variance in ge ne ral
and situation-sp eci® c anxie ty, particularly in unsafe situations, than de mographic,
illne ss, and social support variable s.

ME THOD

Particip an ts
Thirty-se ve n patie nts (19 fe male , 18 male ) with a current diagnosis of CO PD
took part. Spe ci® c diagnose s were as follows: asthm a, 16 patie nts; bronchitis and /
or emphyse ma, 20 patie nts; lung dise ase re late d to asbe stos e xposure , 1 patie nt.
Patie nts were re cruite d from a hospital che st clinic, from a ge ne ral practice re spira-
tory clinic, and from patie nts who had re cently atte nde d a hospital-base d pulmonary
re habilitation clinic. Diagnosis of CO PD was made by the consultant che st physician
or physician curre ntly involve d in the patie nts’ care . Pote ntial participants were
not re fe rre d if the y were known to have signi® cant additional physical illne ss or a
history of me ntal disorde r. In practice , only a small number of patie nts were exclude d
be cause of signi® cant additional physical illne ss and none were e xclude d for psychi-
atric history.

Measu re s
D emo grap hic Inform atio n
Inform ation was colle cted on age , spe ci® c diagnosis, duration of illne ss, medica-
tion use , and numbe r and duration of hospital adm issions re late d to CO PD.
Interpretatio n of B reath in g Problem s Q uestionnaire (IB PQ )
The IB PQ was designe d to asse ss catastrophi c thoughts associate d with the
symptom s characte ristic of CO PD. It was de ve lope d on the basis of clinical e xpe ri-
e nce and in e xtensive pilot work with 6 patie nts with CO PD. The 6 patie nts were
chosen to re pre se nt the most common disorde rs (asthm a, bronchitis, and e mphy-
se ma), and thus symptoms, comprising CO PD. The se patie nts were que stione d in
de tail about the ir spe ci® c symptoms as well as about thoughts re late d to the se
symptom s, and about activitie s and situations that they avoide d in orde r to avoid
e xpe rie ncing symptoms. In the pilot work, que stions about symptom s were base d
on the A sthma Symptom Check-list (Kinsman, Lupare llo, O ’ B anion, & Spe ctor,
1973) and the B ronchitis and E mphyse ma Symptom Che ck-list (Kinsman et al.,
576 Su tton, Coo pe r, Pimm , and Wallace

1983) . O pportunity was also give n for patie nts to ide ntify any symptom s not include d
on the se two che ck-lists. The ® nal version of the que stionnaire consiste d of 14 brie f
scenarios de scribing the e xpe rie nce of one of se ve n symptoms commonly associate d
with CO PD, e ithe r in a safe or unsafe situation, e .g., ``You are on a long walk
alone [unsafe situation] and you be gin to fe e l short of bre ath.’ ’ The symptom s
chosen were those obse rved by us to be most common and those re porte d most
fre que ntly by the pilot patie nts. E ach scenario was followe d by three ope n-ende d
que stions, base d on que stions found to be use ful in pilot work, de signe d to elicit
catastrophic cognitions. The que stions were as follows: ``What might you do in this
situation? ’ ’ ``What thoughts go through your mind? ’ ’ ``What is the worst thing that
you think may happe n to you? ’ ’ Patie nts were the n aske d to rate anxie ty in the
situation and, for that situation, belie f that they would become ill and be lief that
the y would die . Finally, patie nts were aske d whe ther or not they would avoid the
situation. O btaining be lie f ratings e nable d concurre nt (crite rion-re late d) validity of
the ope n-ende d re sponse s to be assessed. A copy of the que stionnaire , including
all 14 scenarios, ope n-ended que stions, and rating scales, can be see n in A ppe ndix A .
Hosp ital A nxiety an d D epression Scale (HA D S)
This is a 14-ite m self-report que stionnaire with good psychom e tric prope rtie s
(Z igmond & Snaith, 1983) de signe d to asse ss anxie ty and de pre ssion in me dical
outpatie nts. O nly the anxie ty scale (7 items) was used he re. It was chose n be cause
it doe s not include somatic symptom s of anxie ty; thus re sponse s are unlike ly to be
confounde d with the physical symptom s of CO PD.
St. G eorges’ Respirato ry Q uestionnaire (SG RQ )
This is a 76-ite m se lf-re port que stionnaire (Jone s, Q uirk, & B ave ystock, 1991)
with good psychome tric prope rties (Jones, Q uirk, B ave ystock, & Littlejohns, 1992) .
It is designe d to me asure impaire d health and pe rceive d well-be ing in airways
disease . The 9-ite m symptom s subscale was used he re in orde r to asse ss freque ncy
and se verity of symptom s associate d with CO PD. Scores on this subscale are highly
correlate d with actual physiological impairm ent, i.e ., measure s of lung function
(Jones e t al., 1991) .
Sh ort Fo rm So cial Su pport Q uestionnaire (SSQ 6)
This measure is a 6-ite m se lf-report que stionnaire , with good psychom etric
prope rtie s (Sarason, She arin, Pie rce, & Sarason, 1987) , de rive d from the Social
Support Q ue stionnaire ( Sarason, Levine , B asham, & Sarason, 1983) . It was used
he re to asse ss satisfaction with curre nt social support.

Procedure
With the agre e ment of the re sponsible clinician, 65 patie nts were invite d, by
lette r, to participate . Fifty-thre e patie nts re sponde d to the le tte r and, of the se ,
thirty-se ve n agre e d to participate . A ll those who agre ed to take part were see n
individually at home . Demographic information was colle cted and patie nts com-
plete d the se lf-re port que stionnaire s. E ighte e n patie nts also agre e d to comple te the
A nxiety in COPD 577

IB PQ a se cond time , 4± 6 wee ks after the initial inte rvie w, in orde r that te st± re test
re liability could be calculate d. O n this occasion the IB PQ was se nt out and returne d
by post. A ll que stionnaire s se nt in this way were comple te d and re turne d.

R E SU LTS

D e m ograp hic Characte ristics

Me an age of the total sample in years was 59.4 (SD 5 17.5) and mean duration
of illne ss in ye ars was 11.0 (SD 5 16.7) . The whole sample use d basic inhale r
medication, 29 (78%) also took ste roids and, of the se, 6 (16% of the total sample )
also use d oxyge n for a minim um of 16 hours each day. Me an numbe r of hospital
admissions relate d to CO PD was 1.1 (SD 5 1.9) .

Se lf-R e port Que stio nnaire s

Me an score on the HA DS anxie ty subscale was 7.8 (SD 5 4.0; possible range
0± 21) , me an score on the SGRQ was 71.4 (SD 5 20.0; possible range 0± 100) , and
mean score on the SSQ 6 was 4.8 ( SD 5 1.3; possible range 0± 6). O n the se thre e
measure s, highe r scores re ¯ e ct, respe ctively, gre ate r anxie ty, more seve re physical
illne ss, and greate r satisfaction with social support. Twenty-one patie nts (57%) had
mild to mode rate leve ls of anxie ty and score d above the HA DS cutoff for borde rline
clinically signi® cant anxie ty.

IB PQ Psych om e tric Prope rties

Safety Ratin gs
Twenty he alth care profe ssionals with asthma rate d the 14 situations (7 safe
and 7 unsafe ) for safe ty on a four-point ( 1± 4) scale . E nd points were anchore d at
``safe’ ’ and ``unsafe .’ ’ Mean score s for the seve n safe situations and se ven unsafe
situations were signi® cantly diffe rent, using Frie dman’ s two-way analysis of variance
te st x 2 (df 5 13, N 5 20) 5 171.9, p , .0001. Safe situations re ceive d an ove rall
mean safe rating 1.29 (SD 5 .51) and unsafe situations re ceive d an ove rall mean
unsafe rating 3.04 (SD 5 .84) .
Interrater Reliab ility
There we re 518 ope n-e nde d re sponse s. The se were categorize d into one of
thre e categorie s: noncatastro phic, mode rate ly catastrophic, or se verely catastrophic .
Noncatastrop hic response s were those that implie d no adve rse conseque nces of the
symptom in the scenario, e .g., ``I’ ll ignore it and it will go away’ ’ and ``I’ ll be alright
afte r a rest.’ ’ Mode rate ly catastrophic re sponse s were those that implie d one or
more mode rate ly adve rse conse que nce s, e.g., ``I’ ll ge t dizzy and bre athle ss’ ’ and
``I’ m going to have a bre athing proble m.’ ’ Se vere ly catastrophic response s were
re sponse s that cle arly implie d that the symptom would put the patie nt in dange r,
578 Su tton, Coo pe r, Pimm , and Wallace

e .g., ``I’ ll stop bre athing and ge t brain damage ’ ’ and ``I’ ll get bre athle ss and pass out.’ ’
Written crite ria (se e A ppe ndix B ) were provide d for each of the thre e cate gorie s
and all re sponse s we re then code d by two inde pe nde nt judge s. The re was perfe ct
agre e ment on 90% of the re sponse s. Cohen’ s kappa was 0.83, indicating substantial
agre e ment be twe e n the two judge s (Landis & Koch, 1977) .

Internal Consisten cy
O pe n-e nde d response s we re assigne d a value from 1 to 3 with highe r value s
re pre se nting more seve re ly catastrophic thoughts ( noncatastrop hic, score 1; mode r-
ately catastrophi c, score 2; seve re ly catastrophic , score 3). A Cronbach alpha coef® -
cie nt value was calculate d, using mean seve rity of catastrophic thoughts ratings for
e ach ite m, to asse ss homoge ne ity of the 14 ite ms use d to measure se ve rity of
catastrophic thoughts. The value was 0.90, indicating good homoge ne ity.

Construct Valid ity

To assess the construct validity of the anxie ty ratings for e ach of the 14 ite ms,
the se ratings were corre late d with score s on the HA DS anxie ty scale . E xcluding
scores from one outlie r, Pe arson corre lations be twee n the HA DS anxie ty score
and situation-spe ci® c anxie ty scores from the IB PQ were all signi® cant (all p value s
, .05) , although caution is ne ede d in inte rpre ting the signi® cance of the se ® ndings
give n the number of correlations carrie d out. For safe situations, corre lations range d
from 0.32 to 0.64 (mean 0.44, SD 5 0.10) , and for unsafe situations correlations
range d from 0.22 to 0.62 (me an 0.50, SD 5 0.12) .

Concurrent Valid ity

To asse ss the concurre nt validity of re sponse s to the ope n-e nde d que stions,
mean ratings of se verity of catastrophic thoughts we re corre late d, for e ach ite m,
with ratings of be lief in becoming ill and be lief in dying. Separate Spe arman corre la-
tions were calculate d for e ach ite m and all were signi® cant (all p value s , .05) .
Corre lations range d from 0.33 to 0.84 betwe en seve rity ratings and be lie f in becom-
ing ill, and from 0.33 to 0.76 be twee n se ve rity ratings and be lie f in dying.

Test± Retest Reliab ility

Test± re test re liability was asse sse d, using score s obtaine d on the two occasions
of testing, for e ach of the 14 ite ms. Reliability was asse sse d for ope n-e nde d re -
sponse s, anxie ty ratings, ratings of belie f in becoming ill, and ratings of belie f in
dying. For ope n-e nde d re sponse s Kendall’ s tau coef® cie nts range d from .47 to 1.00
(all value s p , .051) . Mean pe rcentage of re sponse s rate d in the same category at
re test was 80 ( SD 5 9.5) . Wilcoxon Matche d Pairs Sign Rank Te sts indicate d no
signi® cant diffe re nce s in anxie ty ratings be twee n the two occasions of testing, with
the e xception of re sponse s to three ite ms (all thre e value s p , .05) ; no signi® cant
diffe re nce s be twe en the two occasions of te sting in ratings of be lief in be coming
ill, with the e xce ption of re sponse to one ite m (p , .05) and no diffe re nce s be twee n
the two occasions of te sting in ratings of be lie f in dying.
A nxiety in COPD 579

R e latio nship B etw e en Catastro phic Though ts an d A n xie ty

Spe arman corre lation coe f® cie nts were calculate d be twee n me an ratings of
se verity of catastrophi c thoughts and both ge ne ral ( HA DS) and mean situation-
spe ci® c (IB PQ ) anxie ty ratings. In e ach case an ove rall value and se parate value s
for safe and unsafe situations were calculate d. These corre lation coef® cie nts are
pre se nted in Table I. A s can be se e n in Table I, HA DS anxie ty was signi® cantly
correlate d with se ve rity of catastrophic thoughts. Whe n safe and unsafe situations
were analyze d separate ly, HA DS anxie ty was signi® cantly corre late d with se ve rity
of catastrophic thoughts in unsafe but not safe situations. Situation-spe ci® c anxie ty
was also signi® cantly corre late d with se verity of catastrophi c thoughts. Whe n safe
and unsafe situations were analyze d separate ly, situation-spe ci® c anxie ty ratings in
both safe and unsafe situations re maine d signi® cantly corre late d with se verity of
catastrophic thoughts.

Catastro phic Though ts an d A nxie ty in Safe an d U nsafe Situ atio ns

Differe nce be twe en se ve rity of catastrophic thoughts in safe and unsafe situa-
tions was asse sse d using a Wilcoxon Matche d Pairs Sign Rank Te st. Me an score
in safe situations was 1.27 ( SD 5 0.63) and mean score in unsafe situations was
1.88 (SD 5 0.38) . The se score s were signi® cantly diffe re nt (z 5 4.80, p , .0001,
one taile d), with patie nts re porting more se vere catastrophi c thoughts in unsafe
situations. Diffe re nce be twee n situation-sp eci® c anxie ty ratings in safe and unsafe
situations was asse sse d using a t-test for paire d sample s. The me an score in safe
situations was 3.12 (SD 5 1.79) , and the mean score in unsafe situations was 5.18
(SD 5 2.30) . These score s were signi® cantly diffe re nt (t 5 9.78, df 5 36, p , .0001,
one taile d), with patie nts re porting gre ater anxie ty in unsafe situations. Patie nts
were also more like ly to avoid unsafe than safe situations. Me an numbe r of safe
situations avoide d was 1.03 ( SD 5 1.72) , while mean number of unsafe situations
avoide d was 3.54 (SD 5 2.24) . Using a Wilcoxon Matche d Pairs Sign Rank Test,
the se score s were signi® cantly diffe re nt (z 5 4.94, p , .0001, one taile d).

Sev e rity of Catastro phic Though ts as a Pre dictor of A nxie ty

To inve stigate whe the r se ve rity of catastrophic thoughts was a signi® cant pre-
dictor of anxie ty, two sets of two ste pwise multiple re gre ssion analyse s were run.

Tab le I. Corre lations B etwe en Me an Se ve rity of Catastrophic

Thoughts and B oth Ge ne ral (HA DS) and Me an Situation-Speci® c
(IB PQ ) A nxie ty Ratings

Catastrophic thoughts scores HA DS anxie ty IB PQ anxie ty

a
Total .49 .86 b
Safe situations .21 .67 b
Unsafe situations .54 b .73 b
a
p , .001.
b
p , .0001.
580 Su tton, Coo pe r, Pimm , and Wallace

Inde pe nde nt variable s in all analyse s were age , duration of illne ss in years, seve rity
of illne ss (SGRQ score ), and satisfaction with social support (SSQ 6 score). In the
® rst se t of analyse s the de pe nde nt variable was HA DS anxie ty score . In the second
se t the de pe nde nt variable was me an total situation speci® c anxie ty. In the ® rst
and second analysis of each se t me an total se verity of catastrophic thoughts in safe
and unsafe situations, re spe ctively, were also e nte re d as inde pe nde nt variable s. In
e ach analysis all inde pendent variable s were ente re d toge the r in ste p 1. Summary
statistics for all four analyse s, showing only signi® cant pre dictors, are pre se nted in
Table II.
A nalyses w ith HA D S A nxiety as the D epen dent Variab le
A ge , duration of illne ss, and se verity of illne ss did not e merge as signi® cant
pre dictors of HA DS anxie ty in e ithe r of the ® rst se t of two multiple re gression
analyse s. In the ® rst analysis, whe re mean total se verity of catastrophic thoughts
in safe situations was e ntered as an inde pe nde nt variable , satisfaction with social
support was the only signi® cant ( negative ) predictor of HA DS anxie ty. In the se cond
analysis, whe re me an total seve rity of catastrophi c thoughts in unsafe situations was
e ntere d as an inde pe nde nt variable , this variable and satisfaction with social support
were the only variable s that were signi® cant pre dictors of HA DS anxie ty. The most
signi® cant pre dictor was mean total seve rity of catastrophic thoughts, followe d by
satisfaction with social support, a ne gative pre dictor.
A nalyses w ith IB PQ A nxiety as the D ependent Variab le
A ge , duration of illne ss, and se verity of illne ss did not e merge as signi® cant
pre dictors of situation-sp e ci® c (IB PQ ) anxie ty in e ithe r of the se cond se t of two

Table II. Summary Statistics for the Two Se ts of Two Multiple Regression Analyse s
Se t 1: HA DS anxiety as the de pe ndent variable

Type of Signi® cant

situation predictors B eta A dj R 2b df F Sig of F c
Safe Social 2 1.73 0.31 1,35 3.94 .001
situations supporta
Unsafe Catastrophic 2.43 2.56 .05
situations thoughts
Social 2 1.49 0.42 2,34 2.46 .05
supporta
Set 2: Situation-speci® c (IB PQ ) anxie ty as the de pe ndent variable

Type of Signi® cant

situation predictors B eta A dj R 2b df F Sig of F c
Safe Catastrophic 3.02 4.64 .0001
situations thoughts
Social 2 0.42 0.47 2,34 2.16 .0001
supporta
Unsafe Catastrophic 2.11 0.46 2,34 5.44 .0001
situations thoughts
a
A sse sse d using the SSQ 6.
b
A dj R 2: adjusted R 2
c
Sig of F: signi® cance of F.
A nxiety in COPD 581

multiple re gre ssion analyse s. In the ® rst analysis, whe re mean total seve rity of
catastrophic thoughts in safe situations was ente re d as an inde pe nde nt variable ,
this variable and satisfaction with social support were the only signi® cant pre dictors
of IB PQ anxie ty. The most signi® cant pre dictor was mean total se verity of cata-
strophic thoughts, followe d by satisfaction with social support, a ne gative pre dictor.
In the se cond analysis, whe re mean total se verity of catastrophic thoughts in unsafe
situations was e nte re d as an inde pe nde nt variable , this variable was the only signi® -
cant pre dictor of IB PQ anxie ty.

D ISCU SSION

E xisting studie s of catastrophic cognitions in CO PD have mostly use d the

A CQ , a measure designe d for use in anxie ty disorde rs. In contrast, this study has
de scribe d the deve lopme nt of a measure de signe d to assess catastrophic cognitions
spe ci® cally re levant to the re spiratory symptoms associate d with CO PD. It has used
this measure , the IB PQ , to te st a varie ty of hypothe ses about the re lationship
be twe e n the se catastrophi c cognitions and anxie ty in patie nts with CO PD. O ur
pre liminary ® ndings indicate that the IB PQ has prom ising psychom etric prope rties.
Good inte rrate r re liability can be achie ve d for categorizing catastrophic thoughts;
inte rnal consiste ncy of the scale ite ms used to measure se verity of catastrophic
thoughts is high; preliminary data on construct and concurre nt validity is e ncourag-
ing and the te st± re test re liability of the diffe re nt subse ctions of ite ms on the ques-
tionnaire is ge ne rally good.
O ur ® ndings indicate that more than half of the patie nts with CO PD had mild
to mode rate, clinically signi® cant leve ls of anxie ty. This con® rms pre vious re ports
of high le ve ls of anxie ty in the se patie nts. The speci® c hypothe se s inve stigate d
indicate d that more se ve re catastrophi c thoughts were associate d with highe r le vels
of ge neral anxie ty (ove rall and in unsafe situations) and with highe r le vels of
situation speci® c anxie ty (ove rall and in both unsafe and safe situations) . Cata-
strophic thoughts and anxie ty were more seve re in unsafe than in safe situations,
and patie nts re porte d greater avoidance of unsafe situations. Multiple re gre ssion
analyse s indicate d that se ve rity of catastrophic thoughts was a signi® cant predictor
of anxie ty, particularly of situation speci® c (IB PQ ) anxie ty, whe re it e merge d as
the best pre dictor of anxie ty in both safe and unsafe situations. Social support was
also important, particularly in pre dicting general anxie ty in safe situations. The
® ndings thus provide support for the importance of illne ss speci® c catastrophi c
thoughts in CO PD. In addition, the y sugge st that a cognitive mode l might provide
a useful frame work for e xplaining anxie ty in this group of patie nts. The ® ndings
from the multiple re gre ssion analysis also sugge st that situation may be an important
mode rator of the se ve rity of catastrophic thoughts: this may nee d to be take n into
account in a cognitive mode l. It has be e n note d that high le ve ls of anxie ty may
pre vent patie nts with CO PD from e ngaging in rehabilitation program s (A gle &
B aum, 1977) and that cognitive restructuring may be use ful in reducing anxie ty in
CO PD patie nts (e.g. Carr e t al., 1995) . O ur ® ndings support this sugge stion: a
cognitive formulation of patie nts’ anxie ty and the use of cognitive therapy te ch-
582 Su tton, Coo pe r, Pimm , and Wallace

nique s might he lp patie nts re duce their anxie ty and thus bene ® t more fully from
re habilitation programs. This might incre ase the ir quality of life Ð for e xam ple , by
facilitating ge neralization of gains made in a relative ly safe situation (a hospital
program) to unsafe situations, as well as reducing se lf-impose d re strictions and
incre asing opportunitie s for social and community support. Decreasing anxie ty
might also preve nt e xce ssive use of medication, and re duce the fre que ncy and
length of hospital admissions. A lthough furthe r work is ne e de d, the IB PQ might
provide a useful me asure of the cognitive change s achie ve d through cognitive
the rapy technique s.
There are some important quali® cations to our results. A ll measure s were se lf-
re port, more highly re late d me asure s were colle cted at the same asse ssment, and
although pre vious studie s have shown that the SGRQ corre late s highly with obje c-
tive measure s, there was no obje ctive measure of dise ase se ve rityÐ for example ,
lung function Ð in our study. Small sample size is also a limitation. Finally, although
the questionnaire was de ve lope d from our clinical e xpe rie nce and detaile d asse ss-
ment of patie nts with CO PD (including a range of re pre se ntative diagnose s), the
number of patie nts inte rvie wed in de tail was relative ly small.
Furthe r work is cle arly nee de d, in particular on the concurre nt validity of the
IB PQ . This might be inve stigate d in a varie ty of ways. For e xam ple , it might be
use ful to se e whe the r the IB PQ pre dicts future anxie ty, e ngage ment in re habilitation
programs, and future disability. More de taile d and se nsitive inform ation than was
obtaine d here on avoidance , medication use , and hospitalizat ions would also enable
inve stigation of the relationship of the se variable s to catastrophi c thinking. O f
particular importance , and not inve stigate d he re , is comparison of the predictive
ability of the IB PQ and A CQ in patie nts with CO PD. A measure of panic might
also be use fully include d in such a study. Comparing the re lative merits of the two
que stionnaire s, and assessing panic as well as anxie ty, is like ly to have implication s
for the de ve lopme nt of cognitive theory, both in CO PD and, more ge ne rally, in
physical illne ss. Work comparing cognitions colle cted in vivo with the cognitions
asse sse d he re ( an analogue situation) would also provide a furthe r te st of the validity
of the IB PQ . Future studie s should also e nde avor to obtain more obje ctive measure s
of dise ase seve rity. More gene rally, the applicability of the cognitive mode l, focusing
on illne ss-spe ci® c thoughts, nee ds furthe r inve stigation. This might be achie ve d
using e xpe rime ntal manipulation s to te st furthe r the possibility, sugge sted by the
ability of catastrophic thoughts to pre dict anxie ty, of a causal re lationship be twe e n
illne ss-speci® c catastrophi c thoughts and anxie ty.

A PPE ND IX A

Inte rpre tatio n of B re ath in g Problem s Que stio n naire

Instructions
This que stionnaire has be e n de ve lope d spe ci® cally for pe ople with breathing
proble ms, including asthma, bronchitis and e mphyse ma. It is de signe d to asse ss
A nxiety in COPD 583

pe ople s’ thoughts in re sponse to various symptoms they e xpe rie nce as a result of
the ir bre athing proble m.
Here are some de scriptions of some of the symptom s you may expe rience in
re lation to your bre athing proble m. A varie ty of situations are described in which
e ach symptom may be expe rie nced. Read e ach one, and then answe r the que stions
be low it ve ry brie¯ y. Write down the ® rst thin g that come s into your mind without
thinking too long about it. You may not have e xpe rie nce d all of the symptoms or
all of the situations de scribe d in the que stions. If this is the case, ple ase answe r the
que stion anyway, by imagining how you would re spond to the symptom in the
situation de scribe d.
E ach que stion also asks you to rate how anxious you think you would be in
e ach situation, and what you belie ve could happe n to you. Ratings are made on a
scale of 1± 10, and instruction s on how to respond are give n for each que stion.

Scenario s7
1. You are in a smoke y pub and your chest be gins to fe e l tight.
2. You are at a friends’ house and your che st begins to fee l tight.
3. You are going up the stairs at a shopping centre and you notice it is
be coming harde r to bre athe .
4. You are in a crowd in town and you be gin to fe e l tire d and e xhauste d.
5. You are going up the stairs at home , and you notice that it is be coming
harde r to breathe .
6. You are sitting at home with a frie nd, and you notice you are whe ezing.
7. You are driving down the motorway, and you notice your che st is becom-
ing conge ste d.
8. You are at your GP surge ry, and you begin to cough he avily.
9. You are visiting a physiothe rapist at the hospital, and you fe e l your che st
is be coming conge ste d.
10. You are on a crowde d bus and you notice you are whee zing.
11. You are working in your garde n with a friend, and you notice you are
short of bre ath.
12. You are in the supe rmarke t, and you be ing to cough heavily.
13. You are at the hospital for a check-up, and you be gin to fe el tire d and ex-
hauste d.
14. You are out on a long walk on your own, and you notice you are short
of bre ath.

Q u estions an d Ratin g Scales 8

What might you do in this situation?
What thoughts go through your mind?
What is the worst thing that you think may happe n to you?

7
The safe scenarios are containe d in Questions 2, 5, 6, 8, 9, 11, and 13. The remaining que stions contain
unsafe scenarios.
8
The que stions and rating scale s follow the brief description of each sce nario and are comple ted for
e ach sce nario se parately.
584 Su tton, Coo pe r, Pimm , and Wallace

Ple ase rate how anxious you would be in this situ ation, by marking the scale be low:

1 2 3 4 5 6 7 8 9 10
no anxie ty extre mely
anxious
Please answer the two que stions be low by marking each scale :
1. How much do you be lieve you would be come ill in this situation?

1 2 3 4 5 6 7 8 9 10
I would not I would become
be ill at all extrem ely ill
2. How much do you be lieve you would die in this situation?

1 2 3 4 5 6 7 8 9 10
absolute ly no I would
chan ce of dying de® nitely
die
Would you avoid this situation? Yes/No
Scorin g Instructions
O pe n-e nde d response s are cate gorise d as eithe r noncatastro phic (score 1),
mode rate ly catastrophic (score 2), or se vere ly catastrophi c (score 3). A mean score
is the n calculate d, separate ly for safe and unsafe scenarios, if ne cessary.

A PPE NDIX B

Crite ria for R atin g Ope n-E nde d R e sponse s

Non catastro ph ic (Score 1)
A ny response that implie s no adve rse conse que nce s of symptom be coming
more seve re . Include s response s that imply that the patie nt is not at all worrie d
about the symptom de scribe d, e .g., ``I’ ll be ® ne,’ ’ ``I’ ll cope O K,’ ’ ``Nothing will
happe n,’ ’ etc. Include s reactions re ¯ ecting irritation or e mbarrassm ent at e xpe rie nc-
ing proble ms that are inconve nie nt, but that do not imply adve rse conseque nces
of symptom pe r se , e.g., ``I’ ll ® nd a toile t whe re I can cough without anyone se e ing
me,’ ’ ``I’ ll be late , but I’ ll be O K,’ ’ e tc.
Moderately Catastro phic (Score 2)
A ny re sponse that implie s mode rately adve rse conse que nce s of symptom be -
coming more seve re . Include s exace rbation of symptom s, but with the implication
that this is not distre ssing, or that the patie nt is able to cope , e.g. ``My bre athing
will be come worse,’ ’ ``If I don’ t sit down, I’ ll become more bre athle ss,’ ’ e tc.
A nxiety in COPD 585

Se verely Catastro phic (Score 3)

A ny re sponse that implie s se ve re ly adve rse consequences of symptom becom-
ing more se ve re . Include s clear expre ssion of a conse que nce that may place the
patie nt in dange r, e .g. ``I’ ll collapse ,’ ’ ``I’ ll suffocate ,’ ’ ``I’ ll die ,’ ’ e tc.

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