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Psychosomatics 2019:&:1 8 © 2019 Academy of Consultation-Liaison Psychiatry. Published by Elsevier Inc. All rights reserved.
Case Report
Jonah N. Cohen, Ph.D., Arun Gopal, M.D., Karsten J. Roberts, M.Sc., R.R.T.,
Eleanor Anderson, M.D., Andrew M. Siegel, M.D.
Perceived Threat
(Wean Trial from
Mechanical
Ventilation/Physical
Senations)
Interpretations of
Body Sensations as
Catastrophic Apprehension
Mr. A had no history of anxiety or mood disorders. 24 hours). Patients filled out baseline questionnaires
He had a tracheostomy due to worsening pneumonia before their first session. Patients completed post-treat-
and he became a challenge-to-wean. He described the ment measures immediately after being successfully
sudden onset of panic symptoms within minutes of weaned off. Mr. A completed post-treatment assess-
weaning from MV, endorsing a pounding heart, smoth- ment at 22 days. Mr. B completed post-treatment
ering sensations, sweating, shaking, feelings of choking, assessment at 36 days, given a medical setback unre-
chest discomfort, and a fear of dying. These symptoms lated to the study. A whiteboard facilitated communica-
would immediately abate upon return to MV. On refer- tion between clinicians and patients.
ral, his maximum time on a tracheostomy collar (TC) CBT had 3 principal components: (1) psychoedu-
was 2.5 hours. cation, (2) cognitive restructuring, and (3) exposure. In
Case 2. Mr. B, a man in his 20’s with a medical his- this treatment, derived from an empirically-supported
tory of diffuse cutaneous systemic sclerosis complicated treatment for panic disorder,15 psychoeducation con-
by restrictive cardiomyopathy and pulmonary hyper- sisted of teaching about the interrelationship between
tension, underwent a combined heart and bilateral lung thoughts, feelings, and physical sensations during
transplant; his course was complicated by an acute kid- weaning. The cognitive component taught patients
ney injury, coagulopathy, and airway ischemia. A tra- how to challenge their thoughts, with a particular
cheostomy was placed 10 days post-transplant focus on identifying thoughts that over-estimated the
secondary to difficulties weaning from the ventilator. probability of negative medical events. The behavioral
His psychiatric history was notable for generalized component consisted of reducing pressure support val-
anxiety symptoms, panic attacks, and demoralization ues and increasing the length of time on a particular
during the current and prior medical hospitalizations. pressure or TC in a step-wise, graduated, manner. Bio-
His primary psychiatric complaint was anxiety precipi- feedback was also used as patients had their vital signs
tated only during wean trials. Immediately upon being displayed.
placed on TC, Mr. B described experiencing several
panic attack symptoms, including a heart racing, dys- Measures
pnea, chills, and a fear of losing control. Mr. B was
referred with a maximum time on TC of less than 1 We assessed respiratory-specific anxiety, panic symp-
hour. toms, generalized anxiety, and depression pre- and
post-CBT. We calculated the number of hours tolerated
Procedure on TC before and after the intervention.
Respiratory anxiety. The Anxiety Inventory for
Our study was conducted in accordance with the Respiratory Disease provides a psychometrically-sound
amended Declaration of Helsinki and had Institutional assessment of anxiety in respiratory patients as other
Review Board approval. Both patients gave written instruments are confounded by the physical elements of
informed consent. CBT was adjunctive to typical venti- somatic disease. A score of 14.5 discriminates between
lator weaning trials in the ICU1. See Figures 2 and 3 for patients with and without anxiety. The measure is reli-
details about medications administered during the CBT able, valid,16 and sensitive to change.17
intervention. No negative events occurred. Panic symptoms. We assessed whether patients expe-
Assessments were conducted pre- and post-CBT. rienced the panic symptoms listed in the Diagnostic and
Psychiatry attempted to see each patient 2 3 times per Statistical Manual of Mental Disorders, 5th edition,18
week with visits lasting between 5 and 30 minutes, con- when weaning from the ventilator or when anticipating
tingent on clinical needs and medical status. Patients weaning and, if they endorsed the symptom, asked
received CBT until they were fully weaned (i.e., when patients to rate symptom severity from 1 to 7 (7 being
they were off of the ventilator for a minimum of the worst).
Generalized anxiety. We assessed generalized
1
anxiety with the Generalized Anxiety Disorder 7-item
Further detail about the weaning protocols used is available upon
request. Scale (GAD-7). A score of 10 on the Generalized
Anxiety Disorder 7 represents clinically significant
FIGURE 2. Mr. A: Medications and Their Relative Time of Administration Over the Course of CBT
CBT = cognitive-behavioral therapy
levels of generalized anxiety. The instrument has method for diagnosing delirium, particularly in
strong psychometric properties in medically-ill mechanically-ventilated patients.22
individuals.19 Time on TC. Time on TC was assessed from the
Depression. We assessed depression with the Patient beginning of the intervention until the patient was
Health Questionnaire 2-item (PHQ-2) version. A score weaned. Time on TC before the study was calculated by
of 3 or higher signifies likely clinical depression. The the maximum time reached on the previous wean.
measure has high sensitivity and specificity and is sensi-
tive to change.20 We elected to use the PHQ-2 rather
than the 9-item version, given their psychometrically-
Results
comparable status in deression screening and to reduce
patient burden.21
Delirium. The Confusion Assessment Method for Overall, CBT reduced respiratory anxiety (Anxiety
the ICU (CAM-ICU) assessed delirium. Patients who Inventory for Respiratory), generalized anxiety (GAD-
were found delirious by the CAM-ICU were excluded 7) panic symptoms, depression (PHQ-2), and the time
from the study. The CAM-ICU was administered daily on the ventilator. See Table 1. No patients were
by nursing staff. The CAM-ICU is a valid and reliable excluded for delirium (CAM-ICU).
FIGURE 3. Mr. B: Medications and Their Relative Time of Administration Over the Course of CBT
CBT = cognitive-behavioral therapy
restructuring was helpful in reducing Mr. B's anxiety. symptoms (e.g., Mr. A, fear of losing control; Mr. B,
For example, Mr. B learned that his thoughts about sweating, chest pain). The multiple pathologies of these
feelings in his body being indicative of catastrophic dan- patients may have influenced these symptom reports, par-
ger were untrue. In turn, he used the phrase "although I ticularly symptoms that were somatic in nature. Further-
may experience changes in my body, that does not more, Mr. A did not exhibit a change in depression. He
mean something is wrong; I am under the care of already had sub-clinical levels of depression at baseline,
experts" to combat his anxiety. This cognitive restruc- potentially limiting the range of scores that would illustrate
turing facilitated Mr. B's engagement in the behavioral improvements.
work of reducing pressure support and increasing TC Several limitations of this case series should be
time. He ultimately reached 24+ hours on TC and acknowledged. First, a randomized controlled trial is a
exhibited reductions in respiratory anxiety, panic symp- next step to determine whether the active ingredients of
toms, generalized anxiety, and depression. CBT were indeed responsible for changes. The case series
design demands interpretive caution. Additionally, there
was variation within and between subjects vis-a-vis the
Discussion administration of medications with potential anxiolytic
and anxiogenic effects (Figures 2 and 3), a variable future
This study sought to evaluate whether CBT for the studies may wish to control. Future research may also
mechanically-ventilated patient facilitated weaning and assess and control for pre-ventilation levels of anxiety.
reduced symptoms of respiratory anxiety, panic, gener- Finally, future research should collect follow-up data and
alized anxiety, and depression. CBT reduced respiratory evaluate whether similar results might be achieved in a
anxiety, generalized anxiety, panic symptoms, and more compressed timeframe.
depression (in one patient), and facilitated weaning CBT for the ventilated patient may have significant
from the ventilator. implications. By facilitating weaning from the ventila-
At baseline, both patients had clinically significant tor, CBT may reduce morbidities, length of stay, and
or near clinically significant levels of respiratory anxiety considerable financial cost. In the future, implementa-
(Mr. A had a pre-treatment score of 14, and 14.5 is the tion of CBT by respiratory therapists may be a path of
cutoff) and at post-treatment both patients had subclini- dissemination and implementation.
cal levels of respiratory anxiety. Furthermore, both
patients had clinically significant levels of generalized Funding: No funding support.
anxiety at pre-treatment and at post-treatment both Declarations of Interest: None.
patients had subclinical levels or near sub-clinical levels Disclosure: There are no disclosures. This research
(Mr. B had a GAD-7 score of 11, and 10 is the cutoff). did not receive any specific grant from funding agencies
Both patients also endorsed significant decreases in in the public, commercial, or not-for-profit sectors.
severity of panic symptoms. Mr. B experienced a reduc- Acknowledgments: We would like to extend our
tion in depression from clinical to sub-clinical levels. gratitude to thank Barry Fuchs, M.D., and the rest of the
Both patients increased time on TC by over 800% and staff in the intensive care unit at the Hospital of the Uni-
both were ultimately weaned from the ventilator. versity of Pennsylvania. In addition, a sincere thank you
Although both patients exhibited notable decreases in to Jim Stinnett, M.D, and Richard G. Heimberg, Ph.D.,
severity of overall panic symptoms, they also exhibited a for their consultations.
small increase in severity on a handful of specific panic
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