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Cognitive Therapy and Research [cotr] PP366-366460 January 8, 2002 14:11 Style file version Nov. 19th, 1999
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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Cognitive Therapy and Research [cotr] PP366-366460 January 8, 2002 14:11 Style file version Nov. 19th, 1999
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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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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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.
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.
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
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.
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
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).
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
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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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.
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.
DISCUSSION
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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Cognitive Therapy and Research [cotr] PP366-366460 January 8, 2002 14:11 Style file version Nov. 19th, 1999
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.
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