Home-based COPD psychoeducation: A qualitative study of the patients' experiences
D.G. Bove, et al.
Journal of Psychosomatic Research (2017),
doi: 10.1016/j.jpsychores.2017.05.013
http://www.jpsychores.com/article/S0022-3999(17)30011-9/fulltext
COPD患者のうち、不安症状 7-51%、うつ症状 10-57%とされ、健康関連QOLの阻害、入院リスクの増加に関係する。心理教育を含む認知行動療法（CBT）は呼吸困難、不安、うつの症状管理上有効だが、参加比率は少なく、リハビリテーションプログラムの阻害要素となっている。進行期COPD居宅内で過ごし、訴え多く、QOLも低下、緩和ニーズも解決されない。居宅ベースの心理教育介入の重要性についてpost-trial qualitative studyを行った報告。
20名の患者全員で介入によるベネフィットあるも、その既存の知識・好奇心・受け入れ準備のレベルばらつきがある。新しい知識として与えられたり、知識を補充したり、完成化もあった。3名の患者は介入により新しい知識や考えを得ることができなかったが、ポジティブで意味あることとして居宅での会話の間に看護師が示したケアやそのinterestへ評価を示した。
不安を視覚化して、管理し易くする ・・・ このことが、安らぎを与える
（最下段の図を用いる方法）
患者自身は不安に対して語ることは困難で、状況を自ら理解して身内につたえることも困難。かくして孤独感を感じ、不安や悩みをもつこととなり、その緩和する機会さえ持てなくなる。不安に着眼し会話上探ることで、孤独感は減少し、安らぎ、穏やかさを持ち直す。
配偶者と不安や呼吸困難の状況に関してコントロールに関してアシストできるかにより意見は異なる。4名は同室にあり、肩に手を置いて慰めているが、6名は触れるだけあるいはやっかいと述べる状況。（最下段の）図をラミネートして、視覚化することでその介入を理解し、リフレッシュする。患者の日々の課題を記載し
不安はプライバシーに関するものと思っている患者がいる。不安状況下で思考され、その知覚は不安と呼吸困難さにより影響される。死そのものや死の過程への思考が多く、患者・配偶者を悩ます。死、特に、窒息死への恐怖が厳然と存在、この自己認識は個人の内部のリソースに依存し、脆弱で、疾患進行するにつれ自らの解決リソースは減少し不安感増加する。
ネガティブサークルは思考や感情を衰弱させ不安・呼吸困難増加をもたらす。感情・思考・行動・sensationについて知っていること、COPD進行期の臨床的特徴の一部であるという認識を患者に信頼性をもって情報提供する。ポジティブサークルは内部のリソースを増加させ、不安・呼吸困難の状況を中断する一方法であり感情をコントロールことができるため有意義。この状況下で、受動的にのみ待つことではなく、行動することが可能となればよい
不安と呼吸困難とともに孤独
今回の研究での患者たちは、不安・呼吸困難制御の上で孤独の感情を示す。介入により不安・困難のエピソード中患者自身を守る。2相のメカニズム。第１相では、患者が不安増大認識となるような状況で感情をre-establishできるようになること。第２相は、増大する不安に対して”過剰認知”であるととらえることで不快な感情を管理制御することが可能となり、それが和らぎに至る。患者は呼吸困難と不安管理に関し、孤独さを経験するも、孤独はひとりぼっちという意味でも無く、身体的な孤独というわけでもない。孤独とは考察上の存在で、長年の呼吸困難エピソードと関連不安の経験で築かれるもの。エピソードにより自己投影をもたらすが、自己固体内のリソースの柔軟性がその緩和に必要で不安制御増大させる。介入は魔法的治療ではなく、包括的自己管理スキルに寄与するいくつかのメソッドの一つ
内容は以下の論文そのもの
ベースのマニュアル
Efficacy of a minimal home- based psychoeducative intervention versus usual care for managing anxiety and dyspnoea in patients with severe chronic obstructive pulmonary disease: a randomised controlled trial protocol.
Bove DG, Overgaard D, Lomborg K, Lindhardt BO, Midtgaard J
BMJ Open 2015;5:e008031-2015-008031.
http://bmjopen.bmj.com/content/5/7/e008031
The manual
Build a relationship You arrive as a guest in the patients home and greet the patent and any relatives Take the initiative to lead a neutral conversation about anything and everything with the aim of establishing a relationship and a good atmosphere. Ask the patient if any spouses or other relatives should participate in the dialogue.
Agenda setting Give the patient a brief overview of the content and course of the dialogue. What will happen during the next hour.
• The goal is that through the questions that you ask and the things that you teach, the patient gains an insight into the associations between thoughts, emotions, behaviours, and bodily sensations. The dialogue will help the patient understand that the way that they appraise a situation has major impact on their emotions
• Tell the patients that together you will practise two breathing techniques.
• Tell the patient when to react to dyspnoea as a sign of acute illness. Stress the importance of being aware that dyspnoea also can be an expression of disease worsening and in that case reauires treatment Teach the patient that signs and symptoms such as fever, altered mucus, pain or other signs of infection, should lead to
contact with their family doctor or the Pulmonary Outpatient Clinic. Tell the patient that in case of acute illness, they have to call 911.
Case formulation Ask the patient to describe a situation where he experienced dyspnoea and associated anxiety. Ask questions such as:
• Which thoughts went through your mind?
• Which emotions did that trigger?
• What was the physical sensation?
• When you felt anxious (use the patients word) and .... what thoughts went through your mind?
• What did you do to get better?
Psychoeducation Show the patient the laminated card where the negative vicious circle of how The way we think influences the way we feel' is illustrated.
• Summarise how the patient previously described a situation with dyspnoea and anxiety, using the words and phrases of the patent to fill in or add to the 'clouds' in the cognitive model.
• To obtain feedback from the patients, ask questions such as:
o Am I correct, thinking that you have thoughts like... o And that makes you feel...
o Use the cognitive model to illustrate your statements by pointing
• Ask or tell the patients about o Catastrophizing, which is irrational thoughts in believing that something is far worse than it actually is. I cannot breathe, I am going to die.
o The tendency to generalize a negative experience to apply to all future situations. I could not breathe and panicked when I went to see some friends. Next time the same will happen, I stay at home. o or Nothing' or 'Black and White' Thinking. I used to do so and
so. I cannot any longer, therefore it is not worth doing anything.
o Mind reading and a tendency to assume that others think badly about one's person. When I am puffing and groaning for breath others are thinking that I'm disgusting and strange.
• Ask the patient if they can recognize any of the above situations?
o Ask if they have any evidence that their interpretation of the situation is correct, is it possible that they could be wrong?
• Tell the patient the following:
o Ninety per cent of anxiety attacks resolve spontaneously within 20 minutes. Mean duration 7 minutes_
o You do not die of suffocating. Go through what happens when you do not get enough oxygen.
o Ask the patient if they have ever heard of anyone dying due to suffocating?
• Ask the patient if, based on his current knowledge, is it possible that his experiences in situations with anxiety and dyspnoea could be interpreted in another way?
Show the patient the laminated card where the positive circle of how The way we think influences the way we feel' is illustrated.
• Go through all 'clouds"; if possible, make the patient read the text aloud to you.
Breathing techniques Make the patients dwell on the 'cloud behaviour' and show the patients the laminated card with the respiratory techniques.
• Use yourself to show the patient first how to breathe with pursed lips, then with diaphragmatic breathing. Be very clear about the focus of breathing is short inhaling and long exhaling.
• Ask the patient to do the breathing techniques with you.
• Tell the patient what happens when you breathe with pursed lips; why it is a smart thing to do and why he should practice it twice a day.
Summarize and homework
• Tell the patient that you have reached the last phase of the dialogue.
o Ask the patient to briefly sum up what he has learned during the last hour, and how he will manage situations with dyspnoea and anxiety in the future.
o If a spouse has been part of the dialogue, ask the patient what their spouse can do during episodes with dyspnea and anxiety to help. Be as specific as possible and make a clear agreementthat can be tested and adjusted by the couple regularly?
• Tell the patient that changing interpretations and patterns of thoughts, behaviours, emotions and bodily sensations is not easy, but it is effective for managing of anxiety, say for example 'you just have to practice, and the more you [practice, the better you get.
• Hand the patient the laminated cards with the negative and the positive circles and the two cards with breathing techniques.
• Ask the patient to look at the cards once a day and practice the breathing techniques twice a day.
ネガティブ（思考）サイクル
ポジティブ（思考）サイクル
ベースのマニュアル
Efficacy of a minimal home- based psychoeducative intervention versus usual care for managing anxiety and dyspnoea in patients with severe chronic obstructive pulmonary disease: a randomised controlled trial protocol.
Bove DG, Overgaard D, Lomborg K, Lindhardt BO, Midtgaard J
BMJ Open 2015;5:e008031-2015-008031.
The manual
Build a relationship You arrive as a guest in the patients home and greet the patent and any relatives Take the initiative to lead a neutral conversation about anything and everything with the aim of establishing a relationship and a good atmosphere. Ask the patient if any spouses or other relatives should participate in the dialogue.
Agenda setting Give the patient a brief overview of the content and course of the dialogue. What will happen during the next hour.
• The goal is that through the questions that you ask and the things that you teach, the patient gains an insight into the associations between thoughts, emotions, behaviours, and bodily sensations. The dialogue will help the patient understand that the way that they appraise a situation has major impact on their emotions
• Tell the patients that together you will practise two breathing techniques.
• Tell the patient when to react to dyspnoea as a sign of acute illness. Stress the importance of being aware that dyspnoea also can be an expression of disease worsening and in that case reauires treatment Teach the patient that signs and symptoms such as fever, altered mucus, pain or other signs of infection, should lead to
contact with their family doctor or the Pulmonary Outpatient Clinic. Tell the patient that in case of acute illness, they have to call 911.
Case formulation Ask the patient to describe a situation where he experienced dyspnoea and associated anxiety. Ask questions such as:
• Which thoughts went through your mind?
• Which emotions did that trigger?
• What was the physical sensation?
• When you felt anxious (use the patients word) and .... what thoughts went through your mind?
• What did you do to get better?
Psychoeducation Show the patient the laminated card where the negative vicious circle of how The way we think influences the way we feel' is illustrated.
• Summarise how the patient previously described a situation with dyspnoea and anxiety, using the words and phrases of the patent to fill in or add to the 'clouds' in the cognitive model.
• To obtain feedback from the patients, ask questions such as:
o Am I correct, thinking that you have thoughts like... o And that makes you feel...
o Use the cognitive model to illustrate your statements by pointing
• Ask or tell the patients about o Catastrophizing, which is irrational thoughts in believing that something is far worse than it actually is. I cannot breathe, I am going to die.
o The tendency to generalize a negative experience to apply to all future situations. I could not breathe and panicked when I went to see some friends. Next time the same will happen, I stay at home. o or Nothing' or 'Black and White' Thinking. I used to do so and
so. I cannot any longer, therefore it is not worth doing anything.
o Mind reading and a tendency to assume that others think badly about one's person. When I am puffing and groaning for breath others are thinking that I'm disgusting and strange.
• Ask the patient if they can recognize any of the above situations?
o Ask if they have any evidence that their interpretation of the situation is correct, is it possible that they could be wrong?
• Tell the patient the following:
o Ninety per cent of anxiety attacks resolve spontaneously within 20 minutes. Mean duration 7 minutes_
o You do not die of suffocating. Go through what happens when you do not get enough oxygen.
o Ask the patient if they have ever heard of anyone dying due to suffocating?
• Ask the patient if, based on his current knowledge, is it possible that his experiences in situations with anxiety and dyspnoea could be interpreted in another way?
Show the patient the laminated card where the positive circle of how The way we think influences the way we feel' is illustrated.
• Go through all 'clouds"; if possible, make the patient read the text aloud to you.
Breathing techniques Make the patients dwell on the 'cloud behaviour' and show the patients the laminated card with the respiratory techniques.
• Use yourself to show the patient first how to breathe with pursed lips, then with diaphragmatic breathing. Be very clear about the focus of breathing is short inhaling and long exhaling.
• Ask the patient to do the breathing techniques with you.
• Tell the patient what happens when you breathe with pursed lips; why it is a smart thing to do and why he should practice it twice a day.
Summarize and homework
• Tell the patient that you have reached the last phase of the dialogue.
o Ask the patient to briefly sum up what he has learned during the last hour, and how he will manage situations with dyspnoea and anxiety in the future.
o If a spouse has been part of the dialogue, ask the patient what their spouse can do during episodes with dyspnea and anxiety to help. Be as specific as possible and make a clear agreementthat can be tested and adjusted by the couple regularly?
• Tell the patient that changing interpretations and patterns of thoughts, behaviours, emotions and bodily sensations is not easy, but it is effective for managing of anxiety, say for example 'you just have to practice, and the more you [practice, the better you get.
• Hand the patient the laminated cards with the negative and the positive circles and the two cards with breathing techniques.
• Ask the patient to look at the cards once a day and practice the breathing techniques twice a day.
ネガティブ（思考）サイクル
ポジティブ（思考）サイクル
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