Psychiatry articles

Stress Reduction

Stress Reduction for COPD Patients With Mind Fullness Basic Stress Reduction: A Pilot Study

Mahshid Sadeghi, MRCP1, Ahmad Hattim soleiman,MRCP1, Hassan Allah Sadeghi,BH2 HOSSEIN Danaee,UM3

1- Department of Psychology Medicine, Faculty of Medicine, University Malaya MEDICAL center, Lembah Pantai, Kuala Lumpur, Malaysia

2- Bahman Hospital, Tehran, Iran

3- University of Malaya, R&D


This pilot study was detected to evaluate of efficacy of mind fullness basic stress reduction (MBSR) among chronic obstructive pulmonary disease (COPD) patients in IRAN . Twenty COPD patients with anxiety were selected and randomly assigned to intervention or control group. All COPD patients completed the HADS, Sheehan disability, quality of life (SF12) and CAT questionnaires. Then, the intervention group attended body scan audio session which is part of MBSR for 45 minutes. The control group just received their COPD medications. Result of analysis of this study showed markedly improvement anxiety and quality of life in the intervention group compared with control group. According of the finding of this study. There is no doubt that The MBSR could be useful in anxiety reduction among COPD patients and it can use as a non- pharmacological method for stress reduction.

1. Introduction

Chronic respiratory diseases (CRD) are chronic diseases of the airways and other structures of the lung. One of the most common of CRD is chronic obstructive pulmonary disease (COPD).According to word health organization (WHO) estimates (2004) 64 million people have COPD and 3 million people died of COPD in the word. Also, WHO predicts that COPD will become the third leading cause of death worldwide by 2030 (1). The term “chronic obstructive pulmonary disease” (COPD) describes pathological states characterized by persistent obstruction to expiratory airflow and the most common symptoms of COPD are breathlessness, chronic cough and excessive sputum production. (2). The COPD diagnosis is confirmed by a simple test called Spirometry, which measures how deeply a person can breathe and how fast air can move into and out of the lungs (3).Also, previous studies have demonstrated prevalence rates of 19–40% for depression and 28– 36% for anxiety in patients with COPD(4). In addition, a systematic review and meta-analysis reported the prevalence of clinically significant anxiety and depression as approximately 36% and 40%, respectively (5). Psychological conditions such as anxiety and depression have been reported in surveys to be common in people with COPD may be associated with poor control. For example anxiety and depression coexist frequently in COPD and compound the impact of the disease on quality of life and functional status (6).

Moreover, psychological dysfunction is often unrecognized in people with COPD and it has been associated with worse COPD outcomes leading to recommendations for systematic screening which should be performed as part of a clinical revision(6). In the past 50 years psychological research on COPD patients has evolved considerably. These researches illustrate how the patient with COPD has increasingly become the central person in the process of medical and psychological care over the decades. The one of the most recent focuses within non- pharmacological psychological research on COPD is mindfulness.

There is some consensus on defining mindfulness as the act of “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally”(7). Moreover, results from randomized controlled trials are increasingly supporting the efficacy of mindfulness for a large number of psychological and physical disorders(8). As an example, Mindfulness based Stress Reduction (MBSR) has been found to reduce pain, stress and psychological problems in healthy individuals, chronic pain patients and cancer patients(9).In addition, There was a large diversity in the chronic somatic diseases of the populations which were examined with MBSR such as fibromyalgia, chronic fatigue, Asthma and rheumatoid arthritis (10) .

Therefore, Mindfulness as known the effectiveness program for reduction of stress in chronic diseases. Unfortunately, the efficacy of MBSR on stress and depression related to COPD which is known as a one of the chronic diseases has not examined until now and so for the first time this study provides an evaluation of the efficacy of mindfulness intervention on psychological problems which will be designed specifically for patients with COPD.

2. Method

2.1. Participants and procedure

This is a randomized controlled trail two groups ,pre-test and post-test , pilot study design. The participants included patients with COPD and psychology problem which diagnosed by a pulmonologist and psychiatric. They were adult patients with 18 years of age and older, who were under pharmacotherapy under supervision of pulmonologist at Bahman Hospital, in Tehran from April 10, 2015 to May 10, 2015. This pilot study designed with cooperation of Psychological department of University Malaysia Medical Centre in Malaysia. After evaluating each COPD patient for meeting the inclusion and exclusion criteria and taking an initial interview, 20 out of forty COPD patients with psychology problem were selected and randomly assigned into the equal groups of intervention and control. Both the control and intervention groups received common pharmacotherapy and pre-test (questionnaire).Buy following section; we will discuss more about questionnaire which we will use in this study.

2.2. Inclusion Criteria

1-  Informed consent to participate in the sessions.

2-  Minimum age of 18 years old.

3-  Minimum educational qualification of secondary school degree.

4-  The diagnosis of COPD by the pulmonologist with anxiety and depression which is

approved by DSM-IV criteria.

2.3. Exclusion criteria

1- Subjects who were not attend in intervention study.

2- Drugs and substance abuser.

3- Psychosis, delirium disorder.

2.4. Pre and post questionnaire

After a brief screening interview to determine eligibility and obtain informed consent, participants will be asked to complete pretest questionnaires. Actually, in screen interview we will perform a pretest which includes Hospital Anxiety Depression Scale (HADS), SF 12, Sheehan (disability scale) and clinical COPD questionnaire (CCQ). In pretest we will collect data about psychology problem (anxiety and depression), rating, severity of anxiety and depression, quality of life, disability and severity of COPD symptoms. As pretests will be completed, participants will be randomly assigned to either the experimental group or control group. Then all participants will be asked to complete posttest questionnaires at the end of 35 minutes Body scan mindfulness session. Posttest questionnaire was as same as pre-test.

2.5. Intervention study

Participants allocated to the intervention group received a 35 minutes body scan mindfulness session which is performed by audio CD. This Body scan meditation CD which was used during this pilot study was the translation to Persian from Combridge, UK training MBSR material.

These participants were instructed to relax their body, close their eyes and focus their attention on their breathing. They followed instruction as them as by playing this CD. They awarded of them experience in the present. If they noticed any distractions, such as sounds, body sensations, thoughts or feeling, they were told to gently redirect their attention back to their breathing. They were told to focus their attention on their breathing and then to bring them attention to the sense of their different part of their body for 35 order to provide the better understanding in the some of the part of the CD were said: ( Slowly give the attention to the belly, felling of the rhythmic waves of the breath as it moves in and out, the belly rise an falls with each breath and our breath, breathing moment by moment and breath by breath…). After participants completed this intervention were asked them to fill out post-questionnaire.

2.6. Control group

The control groups just received common pharmacotherapy which is prescribed by pulmonologist as a usual .This group attends an interview and completed pre- questionnaire which is performed by a general practitioner or trained nurse. Then, on the next returning to the hospital for follow up them treatment were asked them to fill out post- questionnaire which is as same as pre-questionnaire.

2.7. Data analysis

The analysis were carried out using SPSS version 20.0.All patients were included in the analyses, To compare the change of anxiety and depression score and severity of the COPD between the mindful body scan group and the control group. a two way repeated measure Anova was applied. Prior to data analysis all variables were subjected to normality test.

3. Result

3.1 Comparing of demographic variables between control and intervention groups

The results of comparison between two groups was done using chi square test for categorical variable and t test for age ( interval) and results indicated that there were no significant difference between two groups.

To evaluate the effect of intervention a two way repeated measure Anova was used and the results for

the anxiety (F(1, 18)= 2.804. p =0.111. η2= 0.135) and SHN (F(1, 18)= 0.876. p =0.362. η2=0.046)

showed that the interaction between group and time ( pre and post-test) was not statistically

significant indicated that the changes of anxiety and SHN in both groups were not significantly

different across time. These results indicated that for depression (F (1,18)= 8.161. p <0.01,. η2= 0.312), QOL (F(1,18)= 5.755. p =0.027. η2= 0.242) and CAT (F(1,18)= 15.335. p<0.01,. η2= 0.460) the interaction between group and time (pre and post-test) were statistically significant and indicated that the changes of depression, QOL and CAT in both groups were significantly different across time.

According the result of Bonferroni test ( Table3.2 ) the difference of anxiety mean score between intervention and control group was not statistically different at pre-test for all research variables however in post-test there was significant difference between groups for anxiety (p=0.039) , depression (p=0.02) and QOL (p=0.031). The results for comparing between pre and post-test for both groups showed that only in intervention group the level of anxiety , depression and CAT among respondents were significantly reduced (p<0.05 ) while the mean score of QOL was increased significantly among respondents in intervention group (p<0.05) ( Figure3.1 ).

According of the result of this pilot study, the first research hypostasis is confirmed and MBSR treatment was effective in COPD patient with anxiety and depression and could reduce anxiety and depression among this patient. Also, the second hypostasis of this study is the effectiveness of MBSR technique on quality of life in patient with COPD. This pilot study is showed that MBSR could improve the quality of life among this COPD patient. Furthermore, this research is found some evidence of improvement of the severity of COPD symptoms.

4. Conclusion

According the finding of this pilot study it can be concluded that MBSR technique generally is effective on chronic disease like COPD with psychology problem especially anxiety .Also, this method shows positive impact on improvement of quality of life. Furthermore, we find week correlation between MBSR and reduction of severity symptoms of COPD but the mention result needs to be further discuss to find out the impact of the medicine which patient were taking , on severity of COPD symptoms .in order to understanding how much the consumption of medicine effect of this study we should do more evaluation.


5. Discussion

This is a first randomized pilot study of 35- minutes mindful body scan in the world. It proved that 35- minutes of body scan reduces anxiety of COPD patients and improves their quality of life. Comparing the duration of various mindfulness psychological intervention in other chronic disease, 35- minutes mindful breathing is the shortest (11). Apart from short time of action,35- minute of body scan is easy to performance and very helpful for relief psychology problem in chronic diseases.

The reduction of anxiety and depression was significant in this pilot study. Therefore, in logically point of view multiple session of mindful breathing may be needed to produce a more sustained effect.
Our research had several limitations. This pilot study was initially limited by its small sample size and short time intervention. It was performed because to evaluate time, adverse events and feasibility in an attempt to prevent an appropriate sample size and improve on the study design prior to a full scale study. According of the result of this pilot study, building of the full scale research could be implemented. Also, we believe that despite the short period and deficiencies of current research, this pilot study could be a new approach to the treatment of psychology problem among COPD patients and could be provide a new horizon in this field of treatment.


6. Acknowledgments

We would like to convey are sincere thanks to all patients and health cares who have participated in the study.


7. References

1. Parry GD, Cooper CL, Moore JM, Yadegarfar G, Campbell MJ, Esmonde L, et al. Cognitive behavioural intervention for adults with anxiety complications of asthma: prospective randomised trial. Respiratory medicine. 2012;106(6):802-10.

2. Kurpas D, Mroczek B, Knap-Czechowska H, Bielska D, Nitsch-Osuch A, Kassolik K, et al. Quality of life and acceptance of illness among patients with chronic respiratory diseases. Respiratory physiology & neurobiology. 2013.

3. Fabricius P, Løkke A, Marott JL, Vestbo J, Lange P. Prevalence of COPD in Copenhagen. Respiratory medicine. 2011;105(3):410-7.

4. Hynninen MJ, Bjerke N, Pallesen S, Bakke PS, Nordhus IH. A randomized controlled trial of cognitive behavioral therapy for anxiety and depression in COPD. Respiratory medicine. 2010;104(7):986-94.

5. Nguyen HQ, Donesky-Cuenco D, Wolpin S, Reinke LF, Benditt JO, Paul SM, et al. Randomized controlled trial of an Internet-based versus face-to-face dyspnea self-management program for patients with chronic obstructive pulmonary disease: Pilot study. Journal of Medical Internet Research. 2008;10(2).

6. Kaptein AA, Scharloo M, Fischer MJ, Snoei L, Hughes BM, Weinman J, et al. 50 Years of psychological research on patients with COPD–Road to ruin or highway to heaven? Respiratory medicine. 2009;103(1):3-11.

7. Miller JJ, Fletcher K, Kabat-Zinn J. Three-year follow-up and clinical implications of a mindfulness meditation-based stress reduction intervention in the treatment of anxiety disorders. General hospital psychiatry. 1995;17(3):192-200.

8. Chiesa A, Serretti A. A systematic review of neurobiological and clinical features of mindfulness meditations. Psychological medicine. 2010;40(08):1239-52.

9. Chiesa A, Serretti A. Mindfulness-based stress reduction for stress management in healthy people: a review and meta-analysis. The journal of alternative and complementary medicine. 2009;15(5):593-600.

10. Santanello N, Zhang J, Seidenberg B, Reiss T, Barber B. What are minimal important changes for asthma measures in a clinical trial? European Respiratory Journal. 1999;14(1):23-7.

11. Beng TS, Ahmad F, Loong LC. Distress reduction for palliative care patients and families with 5-minute mindful breathing.2015;6(1).

Psychiatry tests


By doing this test you can evaluate Depression. At the end of this test you get your score which can help you to understand whether you need psychology consultancy or not. In case of not considering false positive, your positive score must be verified and evaluated by psychology consultants or Psychiatry.

Please be informed that your data will not be stored in this website.


Think about your feelings in last week and answer questions honestly, which symptoms did you experience in last week?

1- I am sad.
2- I work slowly.
3- I don’t have hope.
4- I have concentration problem.
5-I should do simple thing with lots of effort.
6- I am tired
7- I am agitated and irritable.
8- I am a guilty person.
9- I am loser.
10- I feel, I am a death person.
11- I think life has no value.
12- I think, how can I kill myself.
13- I feel trapped.
14- I feel depressed even good thing happen to me.
15- I have lost weight without Diet.
16- I have lost interest of in aspects of life.
17- I think negative.
18- I have difficulty making decision.

Psychiatry tests


Anxiety and panic attack test.

By doing this test you can evaluate anxiety and panic attack disorder. At the end of this test you get your score which can help you to understand whether you need psychology consultation or not. In case of not considering false positive, your positive score must be verified and evaluated by psychology consultants or Psychiatry.

Please be informed that your data will not be stored in this website.


Think about your feelings in past 1 month and answer questions honestly, which anxiety symptoms did you experience in last 1 month?

3-Heart palpitation
5-Chest pain
6- Difficult in breathing
8-Feeling of losing control
9- Vertigo
10-Numbness in limb
11-Fear of dying
12- Worry
13- Hot feeling
14-Unable of Relax
16- Feeling of being in unreal
17- Sleep problem
18- Feeling of faint
19-Avoid a situations because of stress
20- Trembling and sweating hands
21-Irritabale and agitated
22- Feeling of dizziness

Psychiatry tests


By doing this test you can evaluate bipolar disorder. At the end of this test you get your score which can help you to understand whether you need psychology consultancy or not. In case of not considering false positive, your positive score must be verified and evaluated by psychology consultants or Psychiatry.

Please be informed that your data will not be stored in this website.


Pleas answer questions honestly.

1- Sometimes I am much more talkative than at other times.
2- I have periods where I feel really irritable.
3- There are large variations in the quality of my work depending on my mood.
4- I have periods of mental dullness and other periods of very creative thinking.
5- I have periods where I feel really optimistic and other times where I feel hopeless.
6-There have been times when I have felt both high and low at the same time.
7-There are times where I have a lot more interest in sex.
8-I have had periods of tearfulness and other times when I laugh excessively.
9-At times I feel really angry.
10- At times I am interested in being with people and at other times I want to be left alone .
11-You felt much more self-confident than usual.
12- There have been times when I was much more active or did many more things than usual.

Psychiatry disorders

Bulimia nervosa

Bulimia is an eating disorder characterized by binge eating followed by purging. Binge eating refers to eating a large amount of food in a short amount of time. Purging refers to the attempts to get rid of the food consumed. This may be done by vomiting or taking laxatives. Other efforts to lose weight may include the use of diuretics, stimulants, water fasting, or excessive exercise.[Most people with bulimia are at a normal weight. The forcing of vomiting may result in thickened skin on the knuckles and breakdown of the teeth. Bulimia is frequently associated with other mental disorders such as depression, anxiety, and problems with drugs or alcohol.[2] There is also a higher risk of suicide and self-harm.




A fixation on the number of calories consumed

A fixation on and extreme consciousness of one’s weight

Low self-esteem and/or self-harming or Suicidal tendencies

An irregular menstrual cycle in women

Regular trips to the bathroom, especially soon after eating

Depression, anxiety disorders and sleep disorders

Frequent occurrences involving consumption of abnormally large portions of food

The use of laxatives, diuretics, and diet pills

Compulsive or excessive exercise

Unhealthy/dry skin, hair, nails and lips

Fatigue or exhaustion




Antidepressants may help reduce the symptoms of bulimia when used along with psychotherapy. The only antidepressant specifically approved by the Food and Drug Administration to treat bulimia is fluoxetine (Prozac), a type of selective serotonin reuptake inhibitor (SSRI), which may help even if you’re not depressed.


Psychiatry disorders


Bipolar disorder, also known as manic depression, is a mental illness that brings severe high and low moods and changes in sleep, energy, thinking, and behavior. People who have bipolar disorder can have periods in which they feel overly happy and energized and other periods of feeling very sad, hopeless, and sluggish.


Periods of depression and elevated mood Mania

Depression period symptoms:

Low mood, low self-esteem, loss of interest in normally enjoyable activities, low energy, pain without a clear cause, sadness, negative thinking, hapless and suicide plan.

Mania period symptoms:

Elevated mood (either euphoric or irritable), flight of ideas and pressure of speech, increased energy, decreased need and desire for sleep and hyperactivity.


Medications may include: Mood stabilizers. You’ll typically need mood-stabilizing medication to control manic or hypomanic episodes. Examples of mood stabilizers include lithium (Lithobid), valproic acid (Depakene), divalproex sodium (Depakote), carbamazepine (Tegretol, Equetro, others) and lamotrigine (Lamictal).



Psychiatry disorders


Depression is a state of low mood . It can affect a person’s thoughts, behavior, motivation, feelings, and sense of well-being. It may feature sadness, difficulty in thinking and concentration and a significant increase or decrease in appetite and time spent sleeping. People experiencing depression may have feelings of hopelessness and, sometimes, suicidal thoughts. It can either be short term or long term. The core symptom of depression is said to be anhedonia, which refers to loss of interest or a loss of feeling of pleasure in certain activities that usually bring joy to people. Depressed mood is a symptom of some mood disorders such as major depressive disorder or dysthymia; it is a normal temporary reaction to life events, such as the loss of a loved one; and it is also a symptom of some physical diseases and a side effect of some drugs and medical treatments.


Hopeless, Lost interest, Increased fatigue and sleep problems, Anxiety, Irritability, Changes in appetite and weight, Uncontrollable emotions and Looking at death.


If you have had some of the mentioned symptoms for more than two weeks, you might be suffering from major depression disorder.

there are varying treatments available, from lifestyle changes to medications.

Three of the more common methods used in depression treatment include cognitive behavioral therapy, interpersonal therapy, and psychodynamic therapy.

Selective serotonin reuptake inhibitors (SSRIs) is now the most common class used for depression. Examples include citalopram (Celexa), escitalopram (Lexapro), paroxetine (Paxil, Pexeva), fluoxetine (Prozac, Sarafem), and sertraline (Zoloft).



Psychiatry disorders


Anxiety disorders are a group of mental disorders characterized by significant feelings of fear.Anxiety is a worry about future events, while fear is a reaction to current events.

There are several anxiety disorders, including

1- generalized anxiety disorder,

2-specific phobia,

3- social anxiety disorder,

4- separation anxiety disorder,

5- agoraphobia ,

6- panic disorder.


Increased heart rate, shakiness, headache, paresthesias, fasciculations, vertigo, presyncope

as palpitations, tachycardia, or Muscular, as fatigue, tremors or tetany.


Psychotherapy. Also known as talk therapy or psychological  counseling, psychotherapy involves working with a therapist to reduce your anxiety symptoms. Cognitive behavioral therapy is the most effective form of psychotherapy for generalized anxiety disorder.

Firstline medications are the selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Benzodiazepines are not recommended for routine use. Other treatment options include pregabalin, tricyclic antidepressants, buspirone, moclobemide and others.



Psychiatry disorders


Panic disorder is an anxiety disorder characterized by reoccurring unexpected panic attacks. Panic attacks are sudden periods of intense fear that may include palpitations, sweating, shaking, shortness of breath, numbness, or a feeling that something terrible is going to happen. The maximum degree of symptoms occurs within minutes. There may be ongoing worries about having further attacks and avoidance of places where attacks have occurred in the past.


Sudden periods of intense fear, palpitations, sweating, shaking ,shortness of breath and numbness.

Risk factors:

Family history, smoking, psychological stress and history of child abuse.


Panic disorder is generally treated with psychotherapy, medication, or both. Talk with your doctor about the best treatment for you. Psychotherapy. A type of psychotherapy called cognitive behavioral therapy (CBT) is especially useful as a first-line treatment for panic disorder.

Medications can help reduce symptoms associated with panic attacks as well as depression if that’s an issue for you. Several types of medication have been shown to be effective in managing symptoms of panic attacks, including:
Selective serotonin reuptake inhibitors (SSRIs). Generally safe with a low risk of serious side effects, SSRI antidepressants are typically recommended as the first choice of medications to treat panic attacks. SSRIs include fluoxetine (Prozac), paroxetine (Paxil, Pexeva) and sertraline (Zoloft).
Serotonin and norepinephrine reuptake inhibitors (SNRIs).
Benzodiazepines. These sedatives are central nervous system depressants and include alprazolam (Xanax) and clonazepam (Klonopin).