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Tunnell NC, Corner SE, Roque AD, Kroll JL, Ritz T, Meuret AE. Biobehavioral approach to distinguishing panic symptoms from medical illness. Front Psychiatry 2024; 15:1296569. [PMID: 38779550 PMCID: PMC11109415 DOI: 10.3389/fpsyt.2024.1296569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 03/19/2024] [Indexed: 05/25/2024] Open
Abstract
Panic disorder is a common psychiatric diagnosis characterized by acute, distressing somatic symptoms that mimic medically-relevant symptoms. As a result, individuals with panic disorder overutilize personal and healthcare resources in an attempt to diagnose and treat physical symptoms that are often medically benign. A biobehavioral perspective on these symptoms is needed that integrates psychological and medical knowledge to avoid costly treatments and prolonged suffering. This narrative review examines six common somatic symptoms of panic attacks (non-cardiac chest pain, palpitations, dyspnea, dizziness, abdominal distress, and paresthesia), identified in the literature as the most severe, prevalent, or critical for differential diagnosis in somatic illness, including long COVID. We review somatic illnesses that are commonly comorbid or produce panic-like symptoms, their relevant risk factors, characteristics that assist in distinguishing them from panic, and treatment approaches that are typical for these conditions. Additionally, this review discusses key factors, including cultural considerations, to assist healthcare professionals in differentiating benign from medically relevant symptoms in panic sufferers.
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Affiliation(s)
- Natalie C. Tunnell
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Department of Psychiatry & Behavioral Sciences, The University of Kansas Medical Center, Kansas City, KS, United States
| | - Sarah E. Corner
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
| | - Andres D. Roque
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Primary Care Department, Miami VA Healthcare System, Miami, FL, United States
| | - Juliet L. Kroll
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
- Department of Palliative, Rehabilitation and Integrative Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Thomas Ritz
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
| | - Alicia E. Meuret
- Department of Psychology, Southern Methodist University, Dallas, TX, United States
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Norweg A, Hofferber B, Maguire S, Oh C, Raveis VH, Simon NM. Breathing on the mind: Treating dyspnea and anxiety symptoms with biofeedback in chronic lung disease - A qualitative analysis. Respir Med 2024; 221:107505. [PMID: 38141864 PMCID: PMC10897906 DOI: 10.1016/j.rmed.2023.107505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/26/2023] [Accepted: 12/17/2023] [Indexed: 12/25/2023]
Abstract
RATIONALE Chronic obstructive pulmonary disease (COPD) is characterized by dysfunctional breathing patterns that contribute to impaired lung function and symptoms of dyspnea, anxiety, and abnormal carbon dioxide (CO2) levels. OBJECTIVE The study objective was to measure the acceptability of a new mind-body intervention we developed called Capnography-Assisted, Learned Monitored (CALM) Breathing, implemented before pulmonary rehabilitation. METHODS CALM Breathing is a 4-week (8-session) intervention designed to treat dyspnea and anxiety in adults with COPD by targeting dysfunctional breathing behaviors (guided by end-tidal CO2 levels). CALM Breathing consists of ten core breathing exercises, CO2 biofeedback, and motivational interviewing. Using qualitative methods and semi-structured interviews immediately post-intervention, we evaluated the acceptability and participation process of CALM Breathing. Themes were identified using constant comparative analysis. RESULTS Sixteen participants were interviewed after receiving CALM Breathing. Three main themes of CALM Breathing were identified: (1) Process of learning self-regulated breathing, (2) Mechanisms of a mind-body intervention, (3) Clinical and implementation outcomes. CONCLUSIONS Positive themes supported the acceptability of CALM Breathing and described participants' process of learning more self-regulated breathing to manage their dyspnea and anxiety. Positive signals from qualitative participant feedback provided support for CALM Breathing as an intervention for COPD, but larger scale efficacy trials are needed.
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Affiliation(s)
- Anna Norweg
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA.
| | - Brittany Hofferber
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Sophia Maguire
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Cheongeun Oh
- Department of Population Health (Biostatistics), New York University Grossman School of Medicine, New York, NY, USA
| | - Victoria H Raveis
- Department of Cariology and Comprehensive Care, College of Dentistry, New York University, New York, NY, USA
| | - Naomi M Simon
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, USA
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Norweg A, Hofferber B, Oh C, Spinner M, Stavrolakes K, Pavol M, DiMango A, Raveis VH, Murphy CG, Allegrante JP, Buchholz D, Zarate A, Simon N. Capnography-Assisted Learned, Monitored (CALM) breathing therapy for dysfunctional breathing in COPD: A bridge to pulmonary rehabilitation. Contemp Clin Trials 2023; 134:107340. [PMID: 37730198 DOI: 10.1016/j.cct.2023.107340] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 07/20/2023] [Accepted: 09/15/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Although dyspnea is a primary symptom of chronic obstructive pulmonary disease (COPD), its treatment is suboptimal. In both COPD and acute anxiety, breathing patterns become dysregulated, contributing to abnormal CO2, dyspnea, and inefficient recovery from breathing challenges. While pulmonary rehabilitation (PR) improves dyspnea, only 1-2% of patients access it. Individuals with anxiety who use PR have worse outcomes. METHODS We present the protocol of a randomized controlled trial designed to determine the feasibility and acceptability of a new, four-week mind-body intervention that we developed, called "Capnography-Assisted Learned, Monitored (CALM) Breathing," as an adjunct to PR. Eligible participants are randomized in a 1:1 ratio to either CALM Breathing program or Usual Care. CALM Breathing consists of 10 core, slow breathing exercises combined with real time biofeedback (of end-tidal CO2, respiratory rate, and airflow) and motivational interviewing. CALM Breathing promotes self-regulated breathing, linking CO2 changes to dyspnea and anxiety symptoms and targeting breathing efficiency and self-efficacy in COPD. Participants are randomized to CALM Breathing or a Usual Care control group. RESULTS Primary outcomes include feasibility and acceptability metrics of recruitment efficiency, participant retention, intervention adherence and fidelity, PR facilitation, patient satisfaction, and favorable themes from interviews. Secondary outcomes include breathing biomarkers, symptoms, health-related quality of life, six-minute walk distance, lung function, mood, physical activity, and PR utilization and engagement. CONCLUSION By disrupting the cycle of dyspnea and anxiety, and providing a needed bridge to PR, CALM Breathing may address a substantive gap in healthcare and optimize treatment for patients with COPD.
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Affiliation(s)
- Anna Norweg
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA.
| | - Brittany Hofferber
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Cheongeun Oh
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Michael Spinner
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Kimberly Stavrolakes
- Outpatient Pulmonary Rehabilitation Program, New York Presbyterian Hospital, New York, NY, USA
| | - Marykay Pavol
- Department of Rehabilitation and Regenerative Medicine, Columbia University Irving Medical Center, New York, NY, USA; Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Angela DiMango
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Victoria H Raveis
- Department of Cariology and Comprehensive Care, College of Dentistry, New York University, New York, NY, USA
| | - Charles G Murphy
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - John P Allegrante
- Department of Health and Behavior Studies, Teachers College, Columbia University, New York, NY, USA; Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - David Buchholz
- Department of Primary Care, Columbia University Irving Medical Center, New York, NY, USA
| | - Alejandro Zarate
- Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY, USA
| | - Naomi Simon
- Department of Psychiatry, New York University Grossman School of Medicine, New York, NY, USA
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