Cultural Adaptation of CBT for Asthma and Panic Disorder for

LatinosJonathan M. Feldman, Ph.D.

Ferkauf Graduate School of PsychologyYeshiva University

Funded by National Institute of Mental Health: 1R34MH087679-01

Overview of today’s talk:

Asthma and PD comorbidity: general issues

CBT for Asthma and PD

Asthma and PD: issues affecting Latino population

Cultural Adaptation of CBT protocol for Latinos

ASTHMA Chronic respiratory disease

Reversible airway obstruction

Airway hyperresponsiveness to a variety of stimuli (e.g., allergens)

Asthma Exacerbation

Inflammation– Airways Swell– Mucus Forms

Bronchoconstriction– Muscles Tighten

SUBJECTIVE VS OBJECTIVEEstimate of lung function Peak flow

• PRN medication use (Apter et al., 1997; Main et al., 2003)

• Health care utilization (Dirks et al. 1977, 1980)

• Restriction of activities (Carranza et al., 2004)

• Physician Decision-Making (Dirks et al. 1978)

Predicts:

Increased prevalence of PD among patients

with asthma (range: 6.5 – 24%, mean: approx. 10%)

• Respiratory diseases are approximately 3 times more common in PD patients vs. other psychiatric patients or general population (Spinhoven et al., 1994; Zandbergen et al., 1991)

ASTHMA + PANIC DISORDER

Shortness of breath Hyperventilation Feelings of choking Chest tightness Rapid pulse Sweating Fear of losing control Fear of dying

ASTHMA OR PANIC ATTACK?

Teasing apart asthma from PD• Pattern of symptoms: wheezing, mucus production,

coughing

• Pattern of onset of symptoms

• Situations where attacks occur: asthma triggers?

panic triggers?

Avoidance of situations

•90% of asthma-panic patients met criteria for panic disorder with agoraphobia (Feldman et al., 2005)

•Agoraphobia versus healthy avoidance of asthma triggers

CONFUSION BETWEEN ASTHMA VS. PANIC ATTACK

Mistake panic as asthma

Take quick-relief medication

Body sensations

Catastrophic thoughts

Treatment of Asthma + PD

• Psychoeducation

• Progressive Muscle RelaxationReduce anxiety and autonomic responsivityBeneficial for asthma

• Peak Flow Monitoring: objective measure of lung function

Treatment of Asthma + PD

• CBT for PD (with adaptations)Cognitive restructuring: identify and correct catastrophic misinterpretations of bodily sensationsExposure: produce anxious feelingsInternal bodily sensations (interoceptive)External situations (shopping mall)

CBT for PD Adaptations for Asthma• Cognitive Restructuring: complicated by frightening and life-

threatening nature of physical symptoms• Key: discriminate between asthma vs. panic symptoms in

order to correctly address misinterpretation of bodily sensations

• Exposure to interoceptive stimuli: • avoid voluntary hyperventilation and use imagery• Avoid production of chest tightness by holding a breath • Exercise: Use medication before if necessary• Exposure to situations: versus avoidance of asthma triggers

Overall goals of CBT for asthma + panic disorder

• Goal: patient to gain control over asthma and panic• Learn to differentiate between asthma vs. panic

and implement correct tx. strategy• Similarities between asthma and panic:

-reversibility, both can occur on irregular basis-both triggered by stress-similar symptoms

• Differences: -Identify asthma triggers vs. panic triggers-Differences in symptoms

Treatment Manual

• Close consultation with patient’s physician• Learn patient’s medication regimen

• Complete medical exam prior to psychotherapy (rule out physical vs. psychological symptoms)

• 10 sixty minute sessions

Differentiating asthma vs. panicTrigger: stress from being late to work

Guide: What is the value of my peak flow reading?

Peak flow is at least 20% below my personal best

Action Plan:

Follow asthma medication decision tree

Peak flow is in normal range

Is there mucus or coughing?

Yes No

Does attack reach its peak < 10 mins?

No YesUse self-statement modifcation, PMR

Prevalence of Asthma-PD in Latinos: Higher prevalence rate of PD in Puerto Rican adults

(6.5%) in general community vs. Non-Latino White (3.4%) and Cuban-American (2.4%) (Alegria et al., 2006)

Inner-city Bronx hospital: Asthma Study- Puerto Ricans (21%) were 3 ½ times more likely to have PD vs. African-Americans (6.6%) based on over 300 brief screenings (PHQ) (Feldman et al., 2010)

Very high rate (40%) of PD in Spanish-speaking vs. English-speaking (15.6%) Puerto Rican and Dominican asthma patients (Feldman et al., 2010)

Role of ataques de nervios? Emotional reaction to stressful event that includes:

screaming, crying, trembling, feeling of heat rising in the body, feeling out of control

Heart palpitations, dizziness, fear of going crazy (Lewis-Fernandez, 2002)

Fear of the negative emotions of anxiety and anger, coupled with a fear of psychological or somatic arousal (Hinton et al., 2009)

Caribbean Latino culture

Ataques vs. PD?

Cultural Interpretations:– A Latino cultural pattern of expressing distress through the

body, representing a link between life experiences and physical vulnerability (Guarnaccia et al., 1996)

Precipitated by a stressful event, whereas panic comes “out of the blue”

longer duration and sense of relief following ataque Ataques more inclusive than panic (Lewis-Fernandez et

al., 2002)

Ataques de nervios-PD-asthma comorbidity in Latinos? Very common experience (70-72% lifetime) of

ataques in Puerto Rican and Dominican participants (Lewis-Fernandez 2002; Salman 1998)

Ataques-PD comorbidity: 17-45% Puerto Ricans: highest prevalence of asthma Connection between all 3: excessive anxiety

focused on breathing (even when lung function is normal)?

Need for additional training between all 3?

Culture supplement to Surgeon General’s report on mental health

Summary of RCT across 10-year period on 4 major psychiatric disorders (DHHS, 2001)

10,000 participants and only 99 (1%) were Hispanic!

Unfeasible to develop treatments that account for all cultural diversity in US

Recommendation: draw from knowledge of existing empirically supported treatments and adapt them to meet needs of racial/ethnic groups

Advantages of Cultural Adaptation Enhance participants’ engagement in treatment Incorporating issues seen as important and

relevant Culturally adapted treatment studies with Latinos

have excellent retention rates (Hovell, 2008; Escobar-Chaves, 2002)

Methodology for cultural adaptation of CBT for Asthma-Panic in Latinos Phase 1: Focus Groups (English and Spanish) How do illness beliefs and contextual variables

relate to help seeking and illness management? How well are participants able to differentiate

between asthma, PD, and ataques? Cultural norms and values Qualitative coding of key themes/issues that

emerge will drive cultural adaptation of protocol

Example of cultural adaptation: Issue: Influence of anxiety in family members

drives participants to overuse rescue asthma inhalers in response to hyperventilation

Cultural values: respect (respeto), familism (familismo)

Adaptations: Addition of family session(s) assist participants to educate their families and

utilize assertiveness, while being sensitive to cultural values

Effects of family members (-) = exposing patient to asthma triggers (-) = encouraging safety behaviors (-) = lack of empathy re: struggles

(+) = encourage use of controller medications and peak flow meter

(+) = following self-management plan

Family session Review treatment strategies: how to help enforce

treatment plan

Psychoeducation to family member

Increase family member’s understanding of pt’s struggles vs. emphasize to pt. normal lifestyle

Cultural Issue: Emotional reaction Intense emotional reaction (anxiety) in response to

asthma Linked to death of a family member or past trauma with

asthma (-) components: significant time worrying about when

next “attack” is going to happen Over-reliance on quick-relief medication Over-reactions to panic triggers (warm, stuffy room) Ideas for cultural adaptation?

Proposed Adaptation (+) feature: illness-specific panic-fear Allow participant to discuss intense emotional

reaction to asthma (support & empathy) Adaptive features: detecting early phase asthma

symptoms, using peak flow meter, taking controller medications

Challenge maladaptive beliefs Vignettes to help patients distinguish between

adaptive vs. maladaptive anxiety

Mistrust of providers; lack of communication re: CAM Social disadvantage within health care system problems in doctor-patient communication,

alliance, perceived discrimination within systems of care

“doctors are too quick to prescribe medications” CAM can be harmful: alternative (adherence

issues) vs. complementary what exactly is in CAM? (e.g., marijuana) ideas for cultural adaptation?

Cultural Adaptation intervention “I think we sometimes forget that just because you’re a

doctor of psychologist, you’re not any different.” Assertiveness training, problem solving, & written list of

questions for provider Pt empowerment: increasing patient’s role in health care &

need to discuss all treatments with providers Motivational interviewing: Discrepancy between ideal (good asthma control) & actual

(links between poor asthma control and poor adherence) What do you make of this information? What would your life be like if controller medication worked?

Social Adversity Social environment: social adversity,

discrimination, lack of empowerment Role of high stress social environment as

triggers: asthma, panic, ataques Stress can trigger all 3

Learning skills in Asthma-Panic treatment should generalize to other life problems

How to integrate Ataques into treatment?

Issue: ataques interfere with management of asthma and/or PD

Adaptation: psychoeducation focused on triggers, differentiation, and self-management tools for all 3

Use of decision trees for self-diagnosis

Panic attacks and ataque de nervios “I feel they are a bit similar…….Because for me

when I have a nervous attack I tremble, just like a panic attack………it is difficult to distinguish.” (SSFG)

“…you get confused. So I don’t know if I am having a panic attack or both or….it is so confusing.” (ESFG)

Familism (Familismo) – Spanish Speaking Focus Group (SSFG) “….A Hispanic values more the family, in my case

we are very united. If that person cries, all of us cry. We are very attentive, well at least my family is very united…And special days are very special.”

“All the time, my family, and my brothers…my daughter. They are always attentive and they are calling, how are you…”

Familism (Familismo) – English Speaking Focus Group (ESFG) “….for some reason me and my mother do not

get along.” “Latino families……are very strict. To this day I

bow my head to my dad. But he is not proud of me because I have not given him a grandson….”

“…..he does not understand why I cannot breath.”

CAM

“But almost all the doctors are not in agreement with home remedies. When you tell them I take that, they say no those home remedies do not work. It is rare that a doctor that is in agreement with home remedies…” (SSFG)

CAM and communication with their doctors “We (patient and doctor) fight a lot.” “We don’t speak to our doctors” (ESFG)

Respect (Respecto) “But we were educated that we have to respect

our elders. Towards your elders you do not…….. one does not disrespect. And ones neighbors you do not dare either to raise your eyes, to look at them.”

Fear of dying “….(then) comes the fear that will I be able to

come out of this or not.” (SSFG) “…that you are going to die.” (SSFG) “I can’t breath…and I get scared.” (ESFG)

Deaths of relatives due to asthma

Coping strategies used by participants: “Distract oneself.” “…..relax a bit….the meditation, I am one of the

ones that eh, eh…I like to lay down…relax, and sometimes I put a prayer and I start to talk to God, I mean… I talk to God.”

“The medications.” – Spanish Speaking Focus Group

LUCHAR “You have to have like ….I would say something

that will make you feel that you have a reason to live, because you have to fight. You know it is like they say…I cannot let myself die because of this asthma attack, I have to find a way to come out from this, because I have someone that is awaiting me…someone that needs me or that is living for me.” (SSFG)

Patient Empowerment and use of controller medications “I didn’t understand the balance between

medicine and prevention…it was like fix it and let’s get it over. But when I found the word ‘prevention’, that is when I understood my asthma and taking a better interest.” (ESFG)

Teaching point: How to use the medications “……………I want to explain when one has a

crisis of asthma one needs to know how to take their medication. Some people you know they take their pump and you know they throw out (4: they do not know how to use it…) and no, and no….”

Next Steps: Cultural adaptation of CBT Manual for

Asthma-Panic Disorder Pilot participants RCT: Culturally adapted treatment vs. Active

Control (Music therapy/breathing at resting respiration rate)