Presentation delivered by Dr Jo Ashcroft, Clinical Health Psychologist, Royal Brompton Hospital, at the Pan London Airways Network Meeting

1. Severe Asthma Psychology
Service
Dr Jo Ashcroft
Clinical Health Psychologist
Royal Brompton Hospital
DISCLAIMER: The views and opinions expressed in this presentation are those of the authors and do not necessarily represent
the views and policy of PLAN(Pan London Airways Network).

2. Outline
 Definitions of severe asthma
 Benefits of specialist services
 Systematic Assessments of Refractory Asthma
(SARAs)
 Role of specialist clinical psychology

3. Definition of Severe Asthma
World Health Organisation (WHO)
1. Untreated severe asthma
2. Treatment resistant asthma
3. Difficult to treat (but potentially responsive) asthma
Innovative Medicine Initiative (IMI) “problematic asthma”
» Difficult asthma
Disease may not be severe, poor control due to adherence/treatment of
confounders
» Severe Refractory asthma
Persistent poor control, freq exacerbations with adherence, treatment co-
morbidities
Majority of severe asthma pts have freq. &/or severe exacerbations, low
baseline LF & near daily sx, in context of high dose inhailed &/or OCS

4.  Correct diagnosis
 Correct treatment
 Reducing treatment burden/co-morbidities (where possible)
 Reducing frequent hospital admissions
 Improving symptoms and control (where possible)
 Improving QoL
 Improving psychological wellbeing
 Financial implications
Benefits of Specialist Services

5. Systematic Assessments of
Refractory Asthma
• For all pts with ongoing sx or lung function impairment at step 4 or 5 of
BTS/SIGN asthma guidelines
• No ‘gold standard’ diagnostic test
• MDT assessment
 Specialist medical team (history/examination, investigations)
 Asthma CNS
 Specialist respiratory physiotherapist
 ENT
 SALT/Voice
 Allergy specialist
 Specialist Clinical Psychologist

6. SARA Protocol
• Investigations
 Haemotology
 Sputum: inc. eosinophil & neutrophil percentage
 Skin prick tests
 Imaging: CXR, HRCT
 Pulmonary function tests: spirometry, lung vols & gas transfer,
bronchodilator reversibility, Histamine PC20, peak flow, arterial blood
gas
 Other investigations to consider:
 Sleep studies
 Esophageal pH monitoring
 CLE testing
 DEXA scan
 Broncoscopy
 Prednisolone absorption tests

7. SARA Outcomes
 Clarification of diagnosis
 Medical treatment optimised
 Referral back to local services
 On-going OP review by RBH asthma service
 In patient stays for weans and therapies input
 Inpatient stays for cyclical IV treatment
 Referral on to ‘Complex breathlessness service’ at RBH*
* Patient population who presents with significant “often handicapping” symptoms of
breathlessness that is perceived to be disproportionate to the extent or indeed the
severity of any underlying organic disease (e.g. asthma or COPD). Examples of
complex breathlessness includes cases of inducible laryngeal obstruction and
dysfunctional breathing.
There may be psychological co-morbidities involved in the aetiology and/or
maintenance of symptoms.

8. Pre-existing MH/psychological Asthma/Upper issues
Airway
Role of Clinical Psychology
Experience asthma/upper MH/psychological
airway issues

9. Evidence Base
 Numerous studies highlight the association b/w asthma & psychological
comorbidities, esp. anxiety, depression and personality disorders (Nowobilski et
al., 1999; Nowobilski et al., 2007; Furgal et al., 2009)
 Anxiety & depression more common than general population (Zielinski et al.,
2000; Mancuso et al., 2001; Sherwood et al., 2000)
 Aprox. half those with severe, life-threatening disease have been found to have
psychological difficulties (Campbell et al., 1995; Heaney et al., 2005)
 Depression reported as a risk factor for asthma-related morbidity and mortality
(Picado et al., 1989; Allen et al., 1994)
 Depression may have an additive adverse impact on patient’s asthma-related
quality of life, & negatively related to treatment adherence (Opolski & Wilson,
2005)
 Significant associations b/w asthma & anxiety in several major studies (Badoux
& Levy, 1994; Yellowlees & Kalucy, 1990; Yellowlees et l., 1987)
 Higher levels of anxiety in patients admitted to hospital with acute asthma
compared to a community control group (Kolbe et al., 2002)
 Anxiety disorders often undetected, undiagnosed and undertreated in
community and general medical settings (Brown, 2003).

10. Role of Clinical Psychology
Guidance
 Depression in adults with a chronic physical health problem:
recognition & management (NICE, 2009)
 No health without mental Health (Government document, 2011)
 An outcomes strategy for COPD & asthma in England (Government
document, 2011); asthma & mental health
 Long-term conditions and mental health; the cost of co-morbidities
(Kings Fund, 2012)
 British Guideline on the management of asthma (2014, SIGN);
adolescent, anxiety & depression
 Global strategy for asthma management and prevention (GINA Report
2016); anxiety & depression
 In the service specification/guidelines for specialist severe asthma
services

11. Direct clinical work
• Inpatient work: SARAs, severe asthma regulars, complex MDT cases/joint
working, linking with local services
• Outpatient work: Individual therapy (approaches), joint working
• Risk management
• Access to MH CNS and psychiatry
Indirect work
• Liaison with other services e.g. social, MH
• Understanding cases & supporting team
• Training/teaching: Therapy teams, clinical psychologists, external
• Research: data collection, publications
• Psychology staff supervision/trainees
RBH Clinical Psychology Role

12. Psychological In-Patient Services
SARA Review
MDT meeting
Assessment
Local referral
RBH OP waiting
list
In-patient
reviews
Joint/consult to
MDT
(IP or OP)

13. Psychological OP Services
Outpatient
Triage
RBH OP
psychology
Individual OP
sessions
Review as in-
patient
Joint OP MDT
sessions
No psychology
needed/wanted
Local referral

14. 1. Often depends on the physical health presentation
2. Must be related to physical health
• Acceptance/adjustment (re-diagnosis, severity, impact)
• Negotiating sense of self/role
• Mood: Anxiety/depression (e.g. panic, trauma, depression etc.)
• Steroid mood disturbance (inc. self-harm)
• Body image/low self-esteem, self-criticism
• Disordered/dysfunctional eating
• Adherence to treatment
• Symptom management, e.g. pacing
• Communication (HCPs, friends/family/employers)
• Relationships issues (dynamics, roles, identity, sexual)
• Supporting (rather than treating) chronic MH issues
Psychological Issues

15. Personality Disorders (DSM IV)
“an enduring pattern of inner experience & behavior that deviates markedly from the
expectations of the individual’s culture. Manifested in 2+ of the following:
(1) cognition (i.e., ways of perceiving and interpreting self, other people and events)
(2) affectivity (i.e., range, intensity, lability, & appropriateness of emotional response)
(3) interpersonal functioning
(4) impulse control”.
Psychological Issues
Impact
Help-seeking behaviours
Compliance with treatment
Coping styles
Risk-taking
Lifestyle
Social support networks
Therapeutic alliance
Eating and drinking habits
Smoking habits
Sexual habits
Management
Tailored to individual’s needs
Explicit goals, clearly formulated
Realistic goals
Prioritised goals
Long-term time-frame
Attempt to reach shared
expectations
Consistent approach
Tolerant approach
Multi-disciplinary

16. Assessment
Formulation
Intervention
Outcomes
Referral

17.  Motivational Interviewing
 Cognitive Behaviour Therapy
 Schema Therapy (limited)
 Interpersonal Therapy (elements of)
 ‘Third Wave’ Therapies:
- Mindfulness
- Acceptance and Commitment Therapy (ACT)
- Dialectical Behaviour Therapy (DBT)
- Compassion Focused Therapy (CFT)
Don’t do:
 Longer-term psychotherapies
e.g. psychodynamic psychotherapy, personality disorders, complex trauma
 Address issues not directly related to or connected with health
Psychological Approaches

18. MDT Working
• Crucial to have shared understandings
• Joined up thinking & communication with team and patient
• De-stigmatising
• Shared ways of working
• Validating connectedness of the mind-body links; eliminating the ‘divide’
• Better outcomes (in my view!)
• Supporting understanding of re-diagnosis
• Overlap of symptoms (e.g. anxiety, BPD, VCD)
• Barriers: pain, fear, ability to apply strategies
• Supporting management of pre-existing mental health issues and
personality traits/disorders

19. Thank you!
Questions/Comments?