During the study period (between December 2019 and March 2021), nine patients with severe COPD, severe breathlessness and a wish to be referred for EMDR were assessed for inclusion. Of those, five were not included for the following reasons: one did not consent to be interviewed, two wanted EMDR for non-breathlessness related events, one declined from EMDR after the intake and one died of an acute exacerbation of COPD (AECOPD) shortly after referral. The other four eligible patients were included in the case series. The most relevant scores of their questionnaires before and after EMDR are presented in table 1.
Table 1: Outcomes of most relevant questionnaires before and after the intervention.
|
SQ, anxiety, before EMDR
|
SQ, anxiety, after EMDR
|
HADS-A, before EMDR
|
HADS-A, after EMDR
|
CCQ, mental, before EMDR
|
CCQ, mental, after EMDR
|
CRQ,
emotional, before EMDR
|
CRQ, emotional, after EMDR
|
CRQ,
mastery,
before EMDR
|
CRQ,
mastery,
after EMDR
|
Case 1
|
12
|
7 *
|
missing
|
missing
|
3
|
1 *
|
3.8
|
5.8 *
|
2.3
|
5.3 *
|
Case 2
|
16
|
14 *
|
16
|
12 *
|
5.5
|
3.5 *
|
2.3
|
5.3 *
|
2.5
|
5.8 *
|
Case 3
|
16
|
15 *
|
17
|
11 *
|
4
|
3 *
|
2.7
|
2.7
|
2.5
|
4.3 *
|
Case 4
|
20
|
8 *
|
9
|
4 *
|
3.5
|
2.5 *
|
3.7
|
5.2 *
|
3
|
4.3 *
|
For SQ subset anxiety, values above 11 suggest high levels of anxiety. For HADS-A, values above 8 suggest high levels of anxiety. For CCQ, lower scores indicate a more favourable health status. For CRQ, higher scores indicate a more favourable health status.
*clinically relevant change
Case 1
Patient E., female, aged 63, was referred for EMDR after hospitalization for an AECOPD because of fear for breathlessness. During her intake session, she described a deep fear of suffocation, panic attacks related to her COPD, and fear to go out of the house without taking a benzodiazepine. She had been claustrophobic since she had been rolled into a carpet as a four-year-old by other children and could not get out. After her intake session with the psychiatrist, she was diagnosed with agoraphobia and panic disorder. Previously, she had been diagnosed with carcinophobia. She used oxazepam 10 mg three times daily. She did not drink alcohol.
EMDR was given on both memories and mental images or disaster scenarios. The memories were: being breathless, breathlessness in the shower, being rolled into a carpet. The
mental images or disaster scenarios were: dying by suffocation, the idea of having cancer in her throat, sitting on a chair unable to move, hearing the doorbell ring unexpectedly. She had five sessions (between December ‘19 and February ‘20).
On CCQ, measured before and after EMDR, she showed no (significant) change on symptoms or functioning, but a large improvement (2 points) in mental status. Unfortunately, no HADS was measured in this patient. On CRQ, subscales dyspnea and fatigue remained unchanged but subsets emotion and mastery both showed a large improvement of 2 points. Regarding SQ48, there was a large improvement in anxiety (5 points) and some improvement in vitality. Other subsets remained unchanged.
Case 2
Patient B., male, aged 69 years, asked for referral to undergo EMDR, because of fear of suffocation. He avoided activity for fear of breathlessness and had constant thoughts of suffocating. In his life, several important events happened that concerned breathing: there had been two events of near drowning when he was young; he had caused a fire in his garage (before he had COPD), and he had had a severe breathlessness crisis in his car due to COPD. Of those events, he deemed the breathlessness crisis in his car essential to his anxiety. Previously, he had been diagnosed with depression, agoraphobia and panic disorder. He took oxazepam (5 mg) PRN. He did not drink alcohol.
EMDR was given on both memories and mental images or disaster scenarios. The memories were: breathlessness crisis in the car and becoming breathless while walking to car. Disaster scenarios were dying while in the shower, becoming unable to drive his car, panic attack in the presence of a stranger, and becoming breathless in a crowded cinema. He had four EMDR sessions (between April and May ‘20).
On CCQ, measured before and after EMDR, he showed an improvement on all subsets (0.8 points on symptoms, 0.5 points on functioning and 2 points on mental status). He had high scores on HADS-A before treatment, which declined significantly with 4 points but not below 9. Regarding SQ48, he showed some improvement on most subsets, except vitality.
Case 3
Patient P. male, aged 79, asked for referral for EMDR because he had heard that it could be effective. He suffered from fear of suffocation and described overwhelming anxiety when he thought of breathlessness and of dying. He had no specific breathlessness episodes in his life, other than general breathlessness related to COPD. He used no psychopharmaca and drank two units of alcohol per day.
EMDR was given on both memories and mental images or disaster scenarios. The memories were: Breathlessness during an exacerbation of COPD and the death of his father. Disaster scenarios: being strangled; dying, choking, while the hospital staff cannot help him. He had four EMDR sessions (between February and June ‘20). Part of the EMDR was done through video calling because of the COVID-19 pandemic.
On CCQ, measured before and after EMDR, he showed a deterioration in symptoms (0.5 points), but a significant improvement in mental status (1 point); functioning remained unchanged. HADS-A showed a great improvement (6 points) but stayed above 8. On CRQ, subscales dyspnea and emotion remained unchanged, fatigue deteriorated (1.5 points), but mastery showed a large improvement (1.75 points). Regarding SQ48, he showed only a small improvement in anxiety and social phobia; the domains vitality and cognitive complaints deteriorated somewhat. Other subsets remained unchanged.
Case 4
Patient H., female, aged 65, had been referred for EMDR before because of fear of suffocation. During the intake, she gave a detailed description of the onset of AECOPD a year before the referral. During this breathlessness crisis, she was unable to wake up her husband. She experienced fear of suffocation, flashbacks and fear to leave the house. She had no previous psychiatric history but at the start of EMDR, PTSS or anxiety disorder was diagnosed. She used one unit alcohol daily, took morphine 10 mg SR twice daily for breathlessness, and had recently started taking oxazepam 10 mg PRN.
Because of visual impairment, EMDR was done with two vibration devices (buzzers). The target memories were the described breathlessness crisis, and a breathlessness episode she had experienced while taking a shower. She had three EMDR sessions (between March and May ‘21).
On CCQ, measured before and after EMDR, she showed a deterioration in symptoms, but a significant improvement in mental status and functioning (both 1 point). HADS-A declined with 5 poins to a normal value. On CRQ, subscale dyspnea could not be assessed because the patient forgot to fill in that part of the questionnaire. She improved markedly on the domains emotion (1.5 points), fatigue (2 points) and mastery (1.3 points). Regarding SQ48, she showed a great improvement in anxiety (12 points), agoraphobia (6 points, score normalized to 0), social phobia (4 points, score normalized to 0), somatic complaints (13 points) and depression (15 points, score normalized to 2). Nonetheless, she deteriorated on the domain vitality with 7 points.
Results qualitative interviews
The initial number of 101 codes could be merged into 18 categories, which were grouped into four themes: trauma, panic and anxiety, breathlessness and effect of EMDR.
Trauma
All four patients described traumatic episodes related to breathing. For patient 1, the main event was being rolled into a carpet by other children when she was five or six. She described how, since then, she was afraid of confined spaces and did not tolerate anything on her face. In her opinion, this event was more significant than the breathlessness she experienced because of her COPD.
“I cannot stand confined spaces anymore, I cannot stand the elevator, I can’t have anything on my head. But I always thought, that is just me, I am neurotic.”
(Patient 1)
The traumatic breathing episodes described by the other three patients were mostly COPD related. Of note, patient 2 described two episodes of near-drowning, as well as being in a fire in his garage, but felt that the breathlessness related to his COPD had much more impact.
“The fire and the drowning were not that bad. But the stepping into the car… (….) I got a panic attack that made me rigid. (…) It was very oppressive and very frightening.”
Panic and anxiety
All four patients described high levels of anxiety related to breathing. One patient described how breathlessness would lead to shaking, suggesting a linkage with fear.
“You feel how you can’t breathe, or hardly. Or you start shaking. When I walk during physio, walk three times, I start shaking.”
(Patient 4.)
They described how certain events triggered anxiety: wind (patient 1), having a shower (patient 1, patient 2, patient 4), having to go to the toilet (patient 1), being alone (patient 2), going out (patient 2, patient 3). Moreover, all four patients described fear of suffocation.
The idea of sudden breathlessness in a public space provoked anxiety in patient 2. Patient 1 described loss of control:
“I get so breathless, it becomes a panic attack. Because you just can’t control it anymore.”
(Patient 1)
Patient 2 and 3 described fear of dying.
“That it would be a prolonged process. (…) Yes, waiting until you suffocate.”
(Patient 2)
“Like a very nasty death struggle due to the breathlessness, a very painful affair. I could picture that in my mind.”
(Patient 3)
Patient 2 and 3 described an increase of anxiety after something witnessed in other patients (on the first aid or on the ward).
“He was wheeled in and started arranging his euthanasia, while I was lying next to him. It got to me, it really did. It came really close. I got this panicky feeling, feeling of suffocating and not being able to come out of it. Some sort of stranglehold, I got.”
(Patient 3)
Of note, both patients 1 and 4 described being claustrophobic, both were afraid of confined spaces and did not tolerate anything on their face.
“Yes, just don’t let them touch my face or my head. And I am always on the outside of doors, and the doors must be open, you know.” (Patient 4)
Breathlessness
Patient 1, 2 and 4 described frequent unpredictable breathlessness crises that were not triggered by exercise or an exacerbation. Patient 4 described how the memory of a sudden episode of breathlessness when she was sitting on a specific chair in the house, would come back when she sat in the same chair. Patient 2 described how an episode of breathlessness reminded him of the severe crisis he had while sitting in a car. Patient 2 also described how breathlessness could be induced by thoughts:
“When I go to bed at night, I think, oh I didn’t get breathless, and then that’s when I get it.” (Patient 2)
Effect of EMDR
On anxiety
All four patients described being less anxious after EMDR. In all four patients, fear of suffocation had disappeared or greatly diminished. Patient 2 described that, since EMDR, he no longer feared a sudden breathlessness episode in a public space, and felt more confident to go out. Patient 4 could think of a shower without fear after EMDR, but remained unable to have a shower.
On breathlessness
Concerning breathlessness, all four patients made a distinction between ‘regular’ breathlessness and breathlessness with anxiety. They all stated that the breathlessness in itself did not change, but the intertwined anxiety diminished .
“Because at a certain point, I was breathless all day, also because of the panic. Now I am breathless, but only when I do something. The normal breathlessness that comes with the COPD. That I can handle, by the way. Not always, but most of the time. Panic breathless you just can’t handle. You try, but you can’t.” (Patient 1)
“The breathlessness in itself did not change. Just the link with anxiety disappeared. The breathlessness is there, that won’t disappear with EMDR. I still have that. When I am breathless now, I don’t have the fear that’s linked to it, like o my god here comes that stranglehold.” (Patient 3)
“The breathlessness is still there, but I deal with it differently, I tolerate it better. It’s a different feeling. A lot less fear. Less panick.” (Patient 2)
“Usually when I have to go to the bathroom, I think o I have to go, o God o God. If only I don’t get frightened, I think. (...) But at a certain point I thought, I have been to the bathroom three times without realizing it thinking or about it. O it helps. O it helps!! I called my sister right away, it helps it helps. I have been to the bathroom three times! (Patient 1)
On coping with COPD
Patient 2 described how he was not bothered anymore about what other people think.
“Those things I say, I am going to do things in stages, and I do not care a rap if anybody sits next to me and I get breathless. They know it, they will have to accept it. I don’t have to think about them, they should be thinking about me.”
Patient 1, 2 and 4 described how they had changed their daily routines since EMDR, suggesting a better coping style.
“For example, I have done the laundry and I need to bend over to take it out. Then I need to hang it. You can do it in stages, you can and you should. And I thought, if I just do it all at once, I get it over with. But I don’t do that anymore, not since the EMDR.” (Patient 1.)
Recommendation for other patients
When asked whether they would recommend EMDR for other COPD patients, all four subjects answered positively. Patient 1 and 3 had already advised a fellow patient to try EMDR. Patient 2 noted that EMDR would not benefit all patients with COPD, only those who experience panic. Patient 4 stated that it was helpful for anxiety, but not for breathlessness.
Side-effects
Patient 1 mentioned some fatigue after EMDR. No other side-effects of the intervention (such as increased breathlessness during EMDR) were mentioned by the study subjects.