Atemnot-Angst vor körperlicher Aktivität: Welche Rolle spielt Vermeidung?

Author

Monika Tempel, psychopneumologie.de. Published in Alpha1 Journal 1/2022.

Should patients with anxiety about shortness of breath always avoid avoidance – or rather, avoid it ‚deliberately‘?

Always avoid avoidance!

This is roughly how one could casually phrase what "old school" behavioral therapists urgently advise patients with anxiety: "You mustn't run away from your fear! You have to go right through it!" This works quite well for spider phobia—and sometimes also for the fear of crossing a wide open space without fainting. But what might a "path right through the fear" look like when the problem involves an Alpha-1 disorder?
Patients who experience shortness of breath and anxiety before physical activity?

Could avoidance work for anxiety related to shortness of breath?

Recent studies on anxiety and avoidance raise the question of whether avoidance can be a useful strategy for coping with pronounced anxiety under certain conditions. Researchers distinguish between maladaptive and adaptive avoidance. Examples of adaptive avoidance strategies include:

Avoidance in the form of disengaging coping behavior (= disengagement)
Avoidance through escape
Proactive avoidance through proactive action
Prevention through retrospective security measures

It sounds complicated – but it becomes very clear with the help of examples.

Detachment coping behavior is used, for example, in Acceptance and Commitment Therapy (ACT) in its distancing exercises. When you experience anxiety, taking a step back and describing the frightening situation from an observer's perspective usually leads to emotional calming.

Screen-based techniques are also a distancing exercise. You imagine yourself playing the frightening situation on a monitor, holding the remote control. Depending on how you feel, you can pause, fast-forward, rewind, slow down, or fast-forward the scene. Avoidance through escape can certainly be appropriate if it protects you from real harm. With proactive avoidance, you try to prevent frightening situations from arising in the first place, or at least mitigate their effects, through anticipatory actions.

Retrospective precautionary behavior can be vividly described during a pandemic. Frequent handwashing is currently an appropriate avoidance behavior. In non-pandemic times, excessive handwashing can be a sign of fear of infection.

What does avoidance have to do with the fear of shortness of breath during physical activity?

All therapists agree that inactivity worsens the overall physical and mental situation in almost all experiences of shortness of breath.

„"Patients with shortness of breath and anxiety about physical activity need targeted support to maintain their everyday abilities through a healthy mix of appropriate activity and adapted avoidance."“

Monika Tempel

Being active and avoiding being complacent: it's all about the mix!

Shortness of breath as a sensible "avoidance mechanism" protects you from the real danger of being overwhelmed.

Shortness of breath when "thinking about physical exertion" is the result of an anxiety-triggered and anxiety-intensifying learned association (prior). An unpleasant experience has created connections in your brain between potential trigger situations, anxiety, and the experience of shortness of breath. Unfortunately, these are often situations that must be practiced to maintain your everyday abilities (ADLs).

How can appropriate activity be implemented in practice to address shortness of breath anxiety?

The good news: Studies show it's possible! The even better news: You can only win with a measured approach to ADL training – namely, the following:

a feeling of control
less shortness of breath when "thinking about it"„
less fear in the specific situation

How is this achieved? Through techniques that increase the feeling of control by avoiding shortness of breath and thereby apparently contribute to a "untangling" of learned connections in the brain.

Which adapted avoidance patterns do the techniques of controlled training utilize? Presumably, the following techniques lead to an increased sense of control and thus to reduced anxiety related to shortness of breath:

Distancing (through observer practice in the situation and in the lead-up to the training)
Escape in case of real deterioration (e.g., in case of impending exacerbation – for this you should master the discrimination exercise: Is it fear or is it my lungs?)
Proactive avoidance through proactive planning of the units of the dosed ADL training (e.g. climbing stairs at an individual pace and using resistance breathing)
Retrospective safety behavior through follow-up (e.g., "speech test": Can I hold a conversation during and after the exercise session without shortness of breath?)

But beware: Belief in miracles is not (!) an adapted form of avoidance!

You've probably already realized this by now. Nevertheless, let me reiterate: there are different types of avoidance. Avoidance behavior isn't always counterproductive. However, the desire for problems to magically disappear "as if by a miracle" is counterproductive.

Because only regular ADL training will gradually make you a master of the levels!

What to do when "everything" doesn't help?

Sometimes non-pharmacological approaches reach their limits when dealing with anxiety related to shortness of breath during physical activity.

Pulmonologists then recommend, among other things, opioids to influence the perception of shortness of breath. Opioids primarily affect automatic respiratory regulation (via the brainstem).
However, more recent studies suggest that opioids also affect the interplay between learned associations (priors) and anticipated shortness of breath.

In experimental settings with healthy subjects, they reduce the perception of the unpleasantness of shortness of breath. This apparently occurs through the activation of the body's own opioid system (usually referred to as "endorphins").

Admittedly, careful consideration is required when using opioids to treat shortness of breath. Nevertheless, this very specific aspect of influencing learned associations deserves further investigation. Promising results could potentially allow for more targeted interventions to benefit patients with shortness of breath and anxiety about physical activity.

Shortness of breath and fear of physical activity: What role does avoidance play?