Psychological Aspects of Asthma - Anton Counseling & Health

21 Pages·2002·0.13 MB·English

JournalofConsultingandClinicalPsychology Copyright2002bytheAmericanPsychologicalAssociation,Inc.
2002,Vol.70,No.3,691–711 0022-006X/02/$5.00 DOI:10.1037//0022-006X.70.3.691
Psychological Aspects of Asthma
Paul Lehrer Jonathan Feldman and Nicholas Giardino
RobertWoodJohnsonMedicalSchool RutgersUniversity,TheStateUniversityofNewJersey
Hye-Sue Song Karen Schmaling
Seoul,Korea UniversityofTexasatElPaso
Asthmacanbeaffectedbystress,anxiety,sadness,andsuggestion,aswellasbyenvironmentalirritants
or allergens, exercise, and infection. It also is associated with an elevated prevalence of anxiety and
depressivedisorders.Asthmaandthesepsychologicalstatesandtraitsmaymutuallypotentiateeachother
through direct psychophysiological mediation, nonadherence to medical regimen, exposure to asthma
triggers, and inaccuracy of asthma symptom perception. Defensiveness is associated with inaccurate
perceptionofairwayresistanceandstress-relatedbronchoconstriction.Asthmaeducationprogramsthat
teachaboutthenatureofthedisease,medications,andtriggeravoidancetendtoreduceasthmamorbidity.
Other promising psychological interventions as adjuncts to medical treatment include training in
symptomperception,stressmanagement,hypnosis,yoga,andseveralbiofeedbackprocedures.
Asthma is a chronic respiratory disease of unclear etiology, ment, assessed, respectively, by tests of statistical and clinical
characterized by reversible airway obstruction and heightened significance. Recovery is usually defined as movement into the
airwayirritabilityusuallyaccompaniedbyinflammationoftissues normalrange,althoughcompleteremissionissometimesnotpos-
oftheairways,mucuscongestion,orconstrictionofairwaysmooth sible(Jacobson,Roberts,Berns,&McGlinchey,1999),andsmall
muscles (Busse & Reed, 1988; National Heart, Lung, and Blood improvementcanbeclinicallysignificant(Kazdin,1999).Suchis
Institute [NHLBI], 1997). Asthma flares are commonly triggered often the case with asthma. For asthma, there are two types of
byallergens,airwayirritants(frequentlytobaccosmoke),exercise, relevantchanges:acutechangesduringanasthmaflareandtonic
coldair,andviralinfection(NHLBI,1997). changesinasthmacondition.Theclinicalsignificanceofachange
can be conservatively defined as moving in or out of normal
Measurement of Asthma pulmonary function levels or the appearance or disappearance of
asthma symptoms (NHLBI, 1997). None of the studies we re-
Methodology for Assessing Presence and Severity of
viewed used the exact criteria promulgated in NHLBI, primarily
Asthma
becausethesecriteriaappearedonlyrecently.
Asthma is usually diagnosed by periodic experience of asthma
symptoms (primarily wheezing, nocturnal awakening from
Assessment of Change During a Flare
asthma,cough,difficultybreathing[dyspnea],andchesttightness),
episodicdecreasesandvariabilityinpulmonaryfunction(primar-
For patients’ home use, the NHLBI’s (1997) guidelines also
ily FEV , FEV /FVC, and peak flow),1 and reversibility of these
1 1 defined three zones of urgency for clinical intervention, labeled
symptoms and signs or evidence of bronchoreactivity to metha-
accordingtothecolorsofatrafficsignal.Thegreenzoneindicates
choline or histamine (American Thoracic Society, 2000; Chai et
normalfunctionforthatindividual.Intheyellowzonethepatient
al.,1975).
isadvisedtotakeemergencymedicationandtocontacthisorher
Kendall, Marrs-Garcia, Nath, and Sheldrick (1999) made the
physician.Intheredzonethepatientisadvisedtotakelargedoses
distinction between improvement and recovery following treat-
ofrescuemedicationandtogotoanemergencyroom.According
tothesecriteria,enteringtheyelloworredzonewouldconstitute
aclinicallysignificantasthmaexacerbation.Forpeakflowvalues,
PaulLehrer,UniversityofMedicineandDentistryofNewJerseyand
Department of Psychiatry, Robert Wood Johnson Medical School;
Jonathan Feldman and Nicholas Giardino, Department of Psychology, 1FEV isthevolumeofairexhaledduringthefirstminuteofaforced
1
RutgersUniversity,TheStateUniversityofNewJersey;Hye-SueSong, expiratory maneuver from full vital capacity (FVC). Peak flow is the
independent practice, Seoul, Korea; Karen Schmaling, Department of maximumflowofexhaledairduringsuchamaneuver.Bothmeasuresare
HealthScience,UniversityofTexasatElPaso. routinelytakenintheclinicusingaspirometer.Inexpensiveplasticdevices
The preparation of this article was supported in part by Grants R01 canbeusedforhomeassessmentofpeakflow.Recentimprovementsin
HL58805andR21MH58196afromtheNationalHeart,Lung,andBlood computer technology have led to the appearance of home assessment
Institute,NationalInstitutesofHealth. devicesthatcanrecordawidevarietyofpulmonaryfunctionmeasuresand
Correspondence concerning this article should be addressed to Paul detect poor technique or submaximal effort (Burge et al., 1999; Izbicki,
Lehrer,DepartmentofPsychiatry,RobertWoodJohnsonMedicalSchool, Abboud,Jordan,Perruchoud,&Bolliger,1999),butnobehavioralstudies
671HoesLane,Piscataway,NewJersey08854.E-mail:[email protected] haveyetappearedusingthem.
691
692 LEHRER,FELDMAN,GIARDINO,SONG,ANDSCHMALING
normal functioning is considered to be either 80% expected (ac- any asthma symptoms) before a psychological intervention is
cording to norms for height, weight, age, sex, and ethnicity) or applied.Theeffectoftheinterventioncanthenbeassessedbythe
80%of“personalbest”(thehighestvaluesfromtwice-dailyhome ability to titrate the medication further downward without reap-
peak flow values achieved in the past 2–3 weeks), along with pearanceofsymptomsorimpairedpulmonaryfunction.However,
absenceofwheezing,chesttightness,ordyspnea(NHLBI,1997). this strategy may be impossible for studies examining behavioral
AnimprovementinFEV of(cid:1)12%and200mLisconsideredto triggers of asthma. Also, in psychological studies of self-care
1
besignificantunderordinarycircumstances,butachangetonor- behavior,medicationusemaybealegitimatedependentvariable,
mal levels, although not obtainable by all patients, is the goal of soadjustingforitwouldobviouslybeinappropriate.
treatment for an asthma flare and can be used as a conservative
measureofclinicallysignificantimprovement. Quality of Life
Measuresofasthmaqualityoflifealsocanbeusefulforassess-
Assessment of Tonic Change in Asthma Condition ingchangesinasthma.Currentreviewsofvariousasthmaquality
oflifeinstrumentsaremaintainedontheWebsiteoftheAmerican
Althoughtheseverityofdiseasestatusisusuallyconsideredto
Thoracic Society’s Behavioral Science Assembly (www.thoraci-
beatraitmeasure,assessedpriortotreatment,itispossibletouse
c.org).Althoughthesemeasuresaremostlynotspecificallytiedto
changeincurrentstatusofasthmaseverityasameasureofchange.
NHLBI’scategoriesfordiseaseseverity,qualityoflife(severityof
NHLBI’s(1997)guidelinesdefinedafour-stepclassificationsys-
symptoms and impairment in daily function) does contribute to
temofasthmaseverity:mildintermittent,mildpersistent,moder-
NHLBI’scriteria.
ate, and severe. The level is based on a complex index of two
domains: symptoms and pulmonary function. Disease severity is
Asthma and Vocal Cord Dysfunction
determined by the domain with the greater severity. One could
considerclinicallysignificantachangeofatleastonecategoryin Asthmaisoftenconfusedwithparadoxicalvocalcorddysfunc-
severity. tion, in which the vocal cords constrict during inhalation rather
thanexhalation.Insuchcasesspirometricmeasuresofflowduring
inhalationareusuallymoreimpairedthanthoseduringexhalation
Adjustment for Medication
(Newman & Dubester, 1994; Newman, Mason, & Schmaling,
Where a psychological intervention is proposed as a substitute 1995).Thereappearstobeamajorpsychologicalcontributionto
for asthma medication or as a method for safely reducing medi- thisproblem(Gavin,Wamboldt,Brugman,Roesler,&Wamboldt,
cationconsumption,medicationusemustbefactoredinaspartof 1998;F.S.Wamboldt,1998).
assessment of asthma severity. Because daily dosage of asthma
“controller” medication is specifically tied to asthma severity Psychological and Psychophysiological
(NHLBI, 1997), medication consumption can be used in psycho- Correlates of Asthma
logicalstudiesasathirddimensionforassessingasthmaseverity,
Stress, the Autonomic Nervous System, and the
particularly in studies where behavioral strategies may be pro-
Exacerbation of Asthma
posedassubstitutesformedication(e.g.,instudiesofbiofeedback,
yoga, or training in avoidance of asthma triggers). However, Asthma patients tend to show greater bronchoconstriction than
medication usage can be affected by idiosyncratic prescribing healthycontrolsinresponsetostress,bothinthelaboratory(B.D.
practicesofphysicians,someofwhommaynotrigorouslyfollow Miller&Wood,1994)andineverydaylife(Afflecketal.,2000;
NHLBIguidelines,andalsobypatients’levelofcompliance.This Ritz,Steptoe,DeWilde,&Costa,2000;Schmaling,McKnight,&
maynotnecessarilyrenderimpossiblethetaskofscoringasthma Afari, in press). Stress-induced asthma exacerbation may be me-
severity,becausetotalseveritycanbescoredasthehighestsever- diated by changes in autonomic function. Beta-sympathetic acti-
itylevelofthethreedimensions(symptoms,pulmonaryfunction, vation produces bronchodilation, whereas alpha-sympathetic ac-
andmedication).Thus,anundermedicatedpatientwillhavemore tivity and parasympathetic activity produce bronchoconstriction
severe symptoms or worsened pulmonary function, which would (Nadel&Barnes,1984).Althoughmildlystressfultasksrequiring
increase the overall severity score. An overmedicated patient, activecopingbehaviors,suchasmentalarithmetic,tendtoproduce
however,mayscoreasmoreseverethanhisorheractualasthma, bronchodilation among both healthy individuals and those with
becauseofanoverlyhighscoreonthemedicationdimension.This asthma (Lehrer et al., 1996; Smyth, Stone, Hurewitz, & Kaell,
canbeasignificantproblemforasthmaresearchers,becausemany 1999) and although patients with panic disorder, whether or not
asthmaspecialistsdeliberatelyovermedicatesymptomaticasthma they have asthma, show lower respiratory resistance than corre-
patients at the beginning of treatment and then gradually titrate spondingpsychiatricallynormalgroups(Carr,Lehrer,Hochron,&
medicationdownward.Thisisparticularlythecaseafterasevere Jackson, 1996), other patterns of stress are associated with the
asthma flare, when asthma is usually treated with high doses of opposite effects. Passive response to stress or embarrassment ap-
oral steroids for several weeks, which are only gradually titrated pears to trigger clinically significant bronchoconstriction in 20–
downward,evenwhensymptomsdisappearimmediately.Thus,a 40% of asthma patients (cf. review by Isenberg, Lehrer, & Ho-
high level of asthma medication is not always a sign of more chron, 1992a). Stress-induced sympathetic activation is often
severecurrentasthmacondition followed by parasympathetic rebound after the stress abates
For these reasons, we recommend that in such studies the (Lehrer,Hochron,etal.,1997;Manto,1969).Thismayexplainthe
patient’smedicinegraduallybereducedtotheminimumrequired frequentoccurrenceofnocturnalasthmasymptoms(Ballard,1999)
toensurestability(definedasoptimalpulmonaryfunctionwithout and,perhaps,theentirephenomenonofstress-inducedasthma.
SPECIALISSUE:PSYCHOLOGICALASPECTSOFASTHMA 693
Consistent with the well-known psychophysiological principle Limitations of the Literature on Psychiatric Morbidity and
of individual response stereotypy (Lacey & Lacey, 1958), Feld- Asthma
man,Lehrer,Hochron,andSchwartz(2002)foundthatinresponse
to various laboratory tasks, defensive2 patients with asthma dis- Most studies rely on samples of patients from specialty pul-
played a response pattern involving bronchoconstriction, lower monologyclinicsandthusmayoversamplepatientswithproblem-
skin conductance levels, and greater respiratory sinus arrhythmia aticasthma,includingsomepatientswhomaybeoverperceiversof
amplitudes:anautonomicresponsepatternsuggestiveofincreased asthmasymptoms.Also,theytendtorelyonself-report(andoften
parasympathetic and decreased sympathetic arousal. Defensive onlyfromacollateralsource)ofdepressiveoranxietysymptoms
peoplewithoutasthmatendtoshowincreasedsympatheticactivity as a proxy for anxiety or mood disorders. In addition, many
(S.B.Miller,1993;Shapiro,Goldstein,&Jamner,1995;Shapiro, population-basedstudieshavenotadequatelyassessedasthmaper
Jamner,&Goldstein,1993). se but rather have used measures of atopy, often from question-
nairesaboutsymptomsandsymptomtriggers,withoutusingpul-
monary function measures. Although the presence of atopy is
The Immune System and Stress-Related Exacerbation of
associatedwithasthma,itisnotcleartowhatextenttheseresults
Asthma
can be generalized to individuals with accurately diagnosed
NHLBI’s(1997)guidelinesdefineasthmaasanimmunesystem asthma, especially because some triggers of asthma may not in-
process,butdonotincludeimmunologictestingaspartofasthma volveallergies(Pearce,Pekkanen,&Beasley,1999).
assessment. They note that the role of inflammation in asthma is
“stillanevolvingconcept”(NHLBI,1997,p.3).Thereisyetlittle Asthma, Panic Symptoms, and Panic Disorder
published research on whether stress can exacerbate asthma di-
Panic disorder appears to be overrepresented among patients
rectly via immune mechanisms. One recent study (Kang et al.,
with asthma (Carr, Lehrer, & Hochron, 1992; Carr, Lehrer,
1997) reported a small increase in Th2 cytokine response profile
Rausch,&Hochron,1994;Karajgi,Rifkin,Doddi,&Kolli,1990;
amongasthmapatientsduringexaminationstress.Theyalsofound
Shavitt, Gentil, & Mandetta, 1992; Yellowlees, Alpers, Bowden,
that IL-5 declined among healthy participants but not asthma
Bryant, & Ruffin, 1987; Yellowlees, Haynes, Potts, & Ruffin,
patients during examination stress. The authors interpreted this
1988). Approximately 1 asthma patient in 10 has panic disorder.
pattern as suggesting a vulnerability to stress-related airway in-
Also,asthmaandotherchronicrespiratorydiseasesarethreetimes
flammatoryreactionsamongpeoplewithasthma.Also,long-term
morecommoninthosewithpanicdisorderthanamongthosewith
exposure to stress can increase susceptibility to respiratory ill-
other psychiatric disorders or the general population (Spinhoven,
nesses(Cohen,Tyrell,&Smith,1991),whichinturncanexacer-
Ros,Westgeest,&vanderDoes,1994;Zandbergenetal.,1991).
bate asthma. A detailed review of stress-induced asthma and the
Among co-occurring psychiatric and respiratory disorders, panic
currentstatusofresearchonmediationbyautonomicandimmune
disordertendstobepreferentiallyassociatedwithasthma,whereas
processes has been published by Rietveld, Everaerd, and Creer
depression is found more often in irreversible airway disease
(2000).
(Kinsman,Fernandez,Schocket,Dirks,&Covino,1983;Kinsman,
Luparello, O’Banion, & Spector, 1973; Spinhoven et al., 1994).
Asthma and Psychological Disorders: Furthermore, patients with high levels of generalized panic–fear
Anxiety and Depression have been shown to have higher rates of emergency room visits
and general asthma morbidity (Nouwen, Freeston, Labbe´, &
Patients with asthma, especially children, appear particularly
Boulet, 1999). These findings are consistent with earlier work
likelytosufferfrompsychologicalproblems,particularlyanxiety
from the National Asthma Center (Dirks, Kinsman, Jones, &
disorders (Bussing, Burket, & Kelleher, 1996; Vila et al., 1999;
Fross,1978).Thecausaldirectionbetweenasthmaandpanicmay
M.Z.Wamboldt,Schmitz,&Mrazek,1998).Personswithasthma
bebidirectional.
andcomorbidpsychiatricdisordershavemoreimpairedfunction-
Panic may elicit or exacerbate asthma symptoms by several
inginbothemotionalandphysicalarenasthanpersonswitheither
pathways.Asdescribedabove,thepsychophysiologicalstressre-
disease alone, with poorer control of asthma (Afari, Schmaling,
sponse that accompanies panic may elicit autonomic and inflam-
Barnhart, & Buchwald, 2001; Siddique et al., 2000) and greater
matory responses among people with asthma, and dyspnea and
healthcareutilization(tenBrinke,Ouwerkerk,Zwinderman,Spin-
otherunpleasantbodysensationsaccompanyingasthmamaytrig-
hoven,&Bel,2001)despitelackofdifferencesinasthmaseverity
gerpanic.Althoughthepoorcorrelationbetweenasthmaseverity
(ten Brinke, Ouwerkerk, Bel, & Spinhoven, 2001). This associa-
and panic symptoms (ten Brinke, Ouwerkerk, Bel, & Spinhoven,
tioncouldoccureitherthroughdisorganizationofself-carebehav-
2001)mightargueagainstthelatterpathway,therearereasonsto
iororbydirectphysiologicaleffectsofanxietyontheautonomic
believethatbothmildandsevereasthmasymptomsmighttrigger
andimmunesystems.Elevatedanxietyanddepressionhavebeen
panic,butbydifferentpathways.Symptomsofmildasthmamight
found to be positively related to asthma severity in children
moreeasilybeconfusedwithpanicsymptoms,whereassymptoms
(Mrazek, 1992) but not in adults (Afari et al., 2001). Those with
ofmoresevereasthmaaremorerecognizableandleadtoaclearer
asthma, especially children, also appear to be more likely than
path of coping behavior, thus decreasing the panicogenic effect.
healthy individuals to experience negative emotions without ex-
pressing them (Hollaender & Florin, 1983; Silverglade, Tosi,
Wise, & D’Costa, 1994). However, empirical data as to whether 2Defensiveness is a psychological trait associated with avoidance of
and how negative emotions precipitate or exacerbate asthma at- threateningstimuli,minimizationofnegativeaffect,andimpressionman-
tacksareinconsistent(Lehrer,1998). agement(i.e.,atendencytoportrayoneselfinasociallydesirablemanner).
694 LEHRER,FELDMAN,GIARDINO,SONG,ANDSCHMALING
Thefrighteningnatureofseveredyspneamayevokepanicthrough eases,suchascardiovascularandcerebrovasculardisease,among
classicalconditioning.Consistentwiththepossibilitythatasthma panic disorder patients than among those with other psychiatric
can be a contributing cause of panic disorder are findings that disorders or those with no psychiatric disorder (Weissman,
where panic disorder and asthma are comorbid, the respiratory Markowitz, Ouellette, Greenwald, & Kahn, 1990). In addition,
disorder typically precedes the onset of panic disorder (Perna, panicdisorderandasthmaseemtobeindependentlytransmittedin
Bertani,Politi,Colombo,&Bellodi,1997;Verburg,Griez,Meijer, families of those with asthma (Perna et al., 1997). Nevertheless,
&Pols,1995). Baron and Marcotie (1994) reported 20 cases where medical
Other pathophysiological events may elicit both disorders and, treatmentofpanicdisorderinchildrenwithcomorbidasthmahas
inturn,beelicitedbythem.Chiefamongtheseishyperventilation, led to improvement in asthma, thus suggesting a causal
which commonly occurs in panic disorder (Hegel & Ferguson, connection.
1997;Papp,Klein,&Gorman,1993)andcaninducesensationsof
dyspnea (Chonan, Mulholland, Leitner, Altose, & Cherniack,
Asthma and Depression
1990; Hammo & Weinberger, 1999). Hyperventilation can pro-
duceunpleasantbodysensations,thefearofwhichmaycontribute Therelationshipbetweenasthmaanddepression,althoughless
to panic in susceptible people (Chambless, 1984). Panic–fear is wellestablished,alsomaybebidirectional.B.D.MillerandWood
oftenassociatedwithdyspneainpatientswithasthma,andthereis (1997)demonstratedthatfilm-inducedsadnesscanproducebron-
some evidence that the sequelae of dyspnea may contribute to choconstriction among children with asthma. Also, the well-
panicattacksinatleastasubsetofpanicdisorderpatients(Carret known relationship between depression and an attitude of help-
al.,1992).Additionally,airwayobstructioncanleadtohyperven- lessness (Peterson & Seligman, 1984; Seligman, Abramson,
tilation. Individuals with asthma tend to show an exaggerated Semmel,&vonBaeyer,1984)maycreateconditionsforapassive
increaseinrespiratorydriveinresponsetoexperimentallyinduced behavioral response to stress, which appears to be particularly
respiratoryresistance(Kelsen,Fleegler,&Altose,1979).Because associated with vagal activation (Inamori & Nishimura, 1995;
thisresponseismeasuredduringthefirst100msoftheoccluded Roozendaal,Koolhaas,&Bohus,1997).Ontheotherhand,some
breath(i.e.,beforecorticalprocessingoftheocclusioncanoccur; ofthecommoneffectsofasthmaalsocancontributetodepression,
Davenport, Friedman, Thompson, & Franzen, 1986) and before particularly fatigue, disability, and self-perception as being sick.
anyobservablecorticalresponse,itprobablyismediatedbybrain Bell,Jasnoski,Kagan,andKing(1991)foundmoreallergiesand
stemreflexes(Chapman,Santiago,&Edelman,1980).Thisreflex, ahigherrateofasthmaamongpeoplereportingagreaternumber
nevertheless, appears to contribute to hyperventilation indepen- of depressive symptoms in a nonclinical sample of 379 college
dently of panic, although the hyperventilation symptoms, com- students. There also may be a genetic link between asthma and
bined with fear of body sensations in susceptible people, may certain mood disorders (M. Z. Wamboldt, Weintraub, Krafchick,
subsequentlyinducepanic.Hyperventilationalsotendstobevery &Wamboldt,1996;M.Z.Wamboldtetal.,2000).
commoninasthma(Thomas,McKinley,Freeman,&Foy,2001),
anditcancausebronchoconstrictionthroughpathwaysofcooling
Depression, Anxiety, and Life-Threatening Asthma Attacks
and, to a lesser extent, drying of the airways (Gilbert, Fouke, &
McFadden,1988;Kilham,Tooley,&Silverman,1979;McFadden, Ahighprevalenceofdenialandanxietyhasbeenfoundamong
Nelson,Skowronski,&Lenner,1999).Thecontributionofhyper- asthmapatientswhohaveexperiencedanear-fatalattack(Camp-
ventilationtopanicdisorderremainsindispute(Bass,1997;Gars- bell et al., 1995; Martin et al., 1995; Yellowlees et al., 1988;
sen,Buikhuisen,&vanDyck,1996).Itisnotpresentinallcases Yellowlees&Ruffin,1989).Twostudiesfoundthatchildrenwho
ofpanicdisorderandmaybeonlyanepiphenomenonwhenitdoes diedfromasthmaattackshadhigherlevelsofpsychosocialprob-
occur,andanxietycanbeabsentduringhyperventilation(Bass& lems, including depressive symptoms and family dysfunction
Gardner, 1985) or secondary to it (Lum, 1976). However, we (B. D. Miller & Strunk, 1989; Strunk, Mrazek, Fuhrmann, &
believe that it provides a plausible mechanism for the common LaBrecque, 1985), although these latter findings were not repli-
co-occurrence of the two disorders and should be a subject for cated in another study (Barboni, Peratoner, Rocco, & Sabadini,
further, more targeted, research. Its contribution as an asthma 1997).Interpretationofpsychologicalfactorsinnear-deathasthma
triggerhasbeenbettersubstantiated. hasbeenlimitedbyretrospectiveassessmentbecauseincreasesin
Another possible bidirectional pathway is shared respiratory anxiety or denial may be the result, and not the cause, of these
dysregulation that may contribute to the pathophysiology of both severe asthma exacerbations. Strunk, Nicklas, Milgrom, and Ikle
problems (Smoller, Pollack, Otto, Rosenbaum, & Kradin, 1996). (1999)haverecommendedthatprospectivestudiesbedoneanda
Forexample,theexperienceofdyspneainbothdisordersmaybe national database implemented for tracking characteristics of pa-
linkedbyCO sensitivity.Medullarychemoreceptorsandthelocus tientswithfatalornear-fatalattacks.
2
coeruleus may be stimulated by bronchoconstriction in asthma,
inducing the expression of an underlying vulnerability to panic
Behavioral Conditioning and Asthma Symptoms
(Perna et al., 1997; Svensson, 1987). Repeated stimulation of
chemoreceptorsmayleadtodysfunctionofthebrain’ssuffocation Althoughnotanewlyobservedphenomenon,theclassicalcon-
alarmsystem,positedbyKlein(1993)tounderliethedevelopment ditioningofrespiratorysymptomshasbeenthetopicofconsider-
ofpanicdisorder.Thismechanismmaystimulatehyperventilation ableresearchinthelastdecade(seeLey,1994,forareview).Van
(Pappetal.,1993),thusexacerbatingbothpanicandasthma. denBerghandcolleagueshaveshownthatodorsandotherstimuli
The relationship between panic disorder and asthma is not a canserveasconditionalstimuliforelicitingrespiratorysymptoms
specific one. There is a higher prevalence of nonrespiratory dis- andcomplaintsinhealthyindividuals(vandenBergh,Kempynck,
SPECIALISSUE:PSYCHOLOGICALASPECTSOFASTHMA 695
van de Woestijne, Baeyens, & Eelen, 1995) as well as among tests,resistiveloads,estimatingpeakexpiratoryflowrate[PEFR])
individualsreportinghyperventilationcomplaints(vandenBergh, should be used to identify individuals prone to poor symptom
Stegen, & van de Woestijne, 1997). Other studies have demon- perception(NHLBI,1997).
strated conditioned respiratory responses to fear-relevant images
or conditional stimuli associated with stress (Ley, 1994; D. J.
Symptom Perception and Defensiveness
Miller & Kotses, 1995; Stegen, De Bruyne, Rasschaert, van de
Woestijne, & van den Bergh, 1999) and generalization of odor- Thepsychologicaltraitofdefensivenessmaypredictunderper-
conditionedresponsestonewodors(Devrieseetal.,2000). ception of asthma symptoms among adults (Isenberg, Lehrer, &
Hochron, 1997; Steiner, Higgs, Fritz, Laszlo, & Harvey, 1987).
This impaired perceptual accuracy may be related to higher en-
Asthma Symptom Perception
dogenous opioid levels, that have been found in men with high
Theabilitytodetectchangesintheconditionoftheairwaysmay levels of defensiveness but not women (Jamner & Leigh, 1999).
have important clinical implications for people with asthma. Un- Isenberg et al. (1997) showed that perceptual accuracy increased
derestimatorsmaynottakeprescribedmedicationsandmaydelay among defensive adults with asthma after administration of nal-
seeking medical attention, which could lead to disastrous conse- oxone, an opioid receptor antagonist. On the other hand, better
quences, whereas overperceivers may take excessive medication, symptom perception was found among 10 children with asthma
experiencesideeffects,andoverusehealthcareresources.People with a defensive coping style (Fritz, McQuaid, et al., 1996).
tendtorelyontheirsubjectiveperceptionsofsymptomsmorethan Although the construct validity of defensiveness has not been
they do on objective findings to guide medication consumption adequately demonstrated among children (Nassau, Fritz, & Mc-
(Apteretal.,1997;Priel,Heimer,Rabinowitz,&Hendler,1994), Quaid, 2000), it is nevertheless possible that defensiveness may
and numerous studies have found major discrepancies between exert different effects in adults than in children but that, among
perceptionofrespiratorysymptomsandactualairwayobstruction, adults,poorperceptionofasthmasymptomsmayactadditivelyto
caused either by asthma or by external resistive loads (Kendrick, the psychophysiological correlates of defensiveness described
Higgs, Whitfield, & Laszlo, 1993; Nguyen, Wilson, & German, above, suggesting that this personality trait may be an important
1996; Rietveld, Prins, & Kolk, 1996; Rushford, Tiller, & Pain, riskfactorforasthma,deservingoffurtherresearch.
1998). Rietveld, Kolk, Prins, and Colland (1997) showed that
listening to false sounds of wheezing after exercise increases
Negative Affect and Symptom Perception
reportofbreathlessnessamongchildrenwithasthma,independent
ofactualpulmonaryfunction. Negative affect bears a complex relationship with symptom
Bothchildren(Kifle,Seng,&Davenport,1997)andadultswith perceptioninasthma,andthetypeandlevelofemotionalarousal
asthma (Kikuchi et al., 1994) who have experienced near-fatal maybeimportantdeterminants.Spinhoven,vanPeski-Oosterbaan,
asthmaattacksdisplayparticularlyimpairedperceptionofdyspnea vanderDoes,Willems,andSterk(1997)foundthatpatientswith
when breathing through external inspiratory resistive loads. Dav- asthmareportinggreateranxietyduringhistaminechallengetests,
enport,Cruz,Stecenko,andKifle(2000)foundthatapproximately as assessed by the Subjective Units of Distress score (Kaplan,
half of children with life-threatening asthma fail to emit cortical Smith, & Coons, 1995), showed better perception of airway ob-
evoked potentials in response to occlusion of inspiration, in con- struction. These patients did not display elevated levels of trait
trast to virtually all other children, with or without asthma, thus anxiety. Thus, anxiety that is specifically related to asthma may
suggesting impaired neural processing of inspiratory load infor- sensitizetheindividualtoasthma-relatedbodysensationsthrough
mation in the former group. Fritz, McQuaid, Spirito, and Klein attentional processes (Arntz, Dreessen, & DeJong, 1994). Al-
(1996) showed that better symptom perception predicts less though this may promote appropriate symptom recognition and
asthma morbidity (e.g., school absences, emergency room visits) healthcarebehaviors,asdescribedbelow,negativeaffectalsomay
among child asthma patients. Kikuchi et al. (1994) hypothesized lead to overperception of asthma symptoms (Janson, Bjo¨rnsson,
that the relationship is explained by decreased chemoresponsive- Hetta,&Boman,1994;Rietveld&Prins,1998).
nesstohypoxia. Transientemotionalstatesdonotnecessarilyhaveanimpacton
perception of asthma. A study by Apter et al. (1997) found no
relationshipbetweenperceptualaccuracyandmoodvariables(e.g.,
Assessment of Symptom Perception
combinations of active–passive task orientation and pleasant–
Numerous methodological issues are relevant to the study of unpleasantmoodstates).Boulet,Cournoyer,Deschesnes,Leblanc,
symptomperceptioninasthma.Externalresistiveloadshavelim- andNouwen(1994)showedthatstateanxietyduringmethacholine
itedexternalvalidityasanaloguesofasthmabecauseoftheunique challenge tests was not related to symptom perception, although
mechanicalandsensorychangesassociatedwithasthmathatcan- anxietylevelswereunusuallylowinthissample.
notbereplicatedwithmechanicalloads(Harver&Mahler,1998). Clinicallevelsofanxietyordepressiontendtohaveanegative
Studiesofnaturalchangesinpulmonaryfunction(e.g.,estimation impactonasthmasymptomperception.Bothunder-andoverper-
ofpeakflow)maybehamperedbylackofvariabilityinfluctuation ceiversofairflowobstructionappeartohavehigheroverallratesof
of airway obstruction. The range of methodologies used in the psychological disorders than normal perceivers (Rushford et al.,
studies reviewed here illustrates the challenges of defining and 1998).Tiller(1990)showedthatasmallsampleofasthmapatients
measuringperceptualaccuracy(seeFritz,Yeung,etal.,1996,for with panic disorder were less sensitive to changes in external
areviewofchildhoodasthmaissues).Todate,noconsensusexists inspiratory resistive loads than those without. These results are
as to which technique (e.g., methacholine–histamine challenge consistentwithfindingsamongpeoplewithanxietydisordersbut
696 LEHRER,FELDMAN,GIARDINO,SONG,ANDSCHMALING
notasthma(Tiller,Pain,&Biddle,1987).Notalldatahavebeen experiencingnear-fatalattacksdemonstratepoortreatmentadher-
consistent, however. Generalized anxiety (Fritz, McQuaid, et al., ence(Boulet,Deschesnes,Turcotte,&Gignac,1991).
1996) was not found to be related to symptom perception in a Therearemanyfactorsthatmaycontributetopooradherence,
sample of children with asthma, although anxiety level in this such as the financial costs of medication and difficulties with
sampletendedtobemild. learninghowtoproperlyusemedications.Pooreradherencewith
controllerversusrescuemedicationsmaybeexplainedbylackof
immediateresultswiththeformer(Kelloway,Wyatt,DeMarco,&
Symptom Perception and Suggestion
Adlis,2000).Also,theperceptionofsteroidsasbeingthreatening,
becauseofpotentialsideeffects,isassociatedwithpooradherence
Luparello,Lyons,Bleeker,andMcFadden(1968)developedthe
to an asthma treatment plan (Wo¨ller, Kruse, Winter, Mans, &
method most generally used to evaluate the effects of suggestion
Alberti,1993).Emotionalsupportfromthepatient’sclosestperson
on airway function. The individual inhales a relatively inert sub-
appearstoreducenegativeperceptionsofsteroidmedication.
stance such as saline that she or he is led to believe is a potent
Assessment of adherence presents methodological problems.
bronchoconstrictor or bronchodilator. We have previously re-
The majority of asthma medications are inhaled; only oral medi-
viewed studies showing that this procedure produces a clinically
cations (e.g., theophylline) may be readily measured in sera and
significant effect on pulmonary function among approximately
comparedwithestablishedtherapeuticrangestoinferthepatient’s
40%ofpeoplewithasthma(Isenbergetal.,1992a),althoughthere
levelofadherence.Thereisevidencethatbothadultsandchildren
isevidencethatsuggestionmayhaveagreatereffectonperception
with asthma tend to overreport adherence (Bender, Milgrom,
ofbronchialchangesthanonactualchanges(Isenberg,Lehrer,&
Rand, & Ackerson, 1998; Berg, Dunbar-Jacob, & Rohay, 1998;
Hochron,1992b).
Bosley,Fosbury,&Cochrane,1995;Braunstein,Trinquet,Harper,
& Compliance Working Group, 1996; Gibson, Ferguson, Aitchi-
Future Research on Symptom Perception son, & Paton, 1995; Milgrom et al., 1996). These results suggest
that physicians may not receive an accurate estimate of patients’
The mechanism (e.g., biological or cognitive) that mediates
medicationconsumptionfromself-report.Adherencewithinhaled
alteredperceptionofasthmasymptomsindepressiveandanxious
medicationsmaybeassessedthroughpatientself-reportdiaries,by
states remains to be explored, as does the role of symptom per-
weighing inhaler canisters and comparing the expected weight
ception in patients’ medication use, in cases of both under- and
given the number of prescribed inhalations to the actual weight,
overmedication. Additionally, simple and accurate tests for pre-
andbyattachingmicroprocessorstoinhalersthatcountthenumber
dictingpoorperceiversinaclinicalsettingneedtobedeveloped.
ofinhaleractuations,tocomparetoexpectedactuations.Thereare
limitations to all of these methods that generally result in the
Treatment Adherence overestimationofactualpatientmedicationuse(seeRand&Wise,
1994).Newerdevicesthatassessforceofinhalationasacriterion
NHLBI’s(1997)guidelinesemphasizetheimportanceofadher- for counting an actuation may provide more accurate assessment
ence to all aspects of treatment, including medication and envi- ofmedicationconsumption(Apter,Tor,&Feldman,2001).
ronmental control (i.e., avoidance of allergens). However, the
complexityofsomeasthmatreatmentregimens(theuseofseveral
Family Dysfunction and Treatment Adherence
medicationsatdifferenttimesfordifferentpurposes)oftenrenders
themdifficulttofollow,andadequatelyteachingasthmaself-care Poor self-management behavior is common among dysfunc-
requiresconsiderabletime,patience,andcommunicationskillson tional families. Lower adherence with controller medications
thepartofthephysician.Indeed,30–46%ofpatientswithasthma (Benderetal.,1998;Weinstein&Faust,1997)hasbeenassociated
even fail to fill their prescriptions for asthma medication (Kello- withfamilydysfunction,specifically,absenceofexpressedaffec-
way, Wyatt, & Adlis, 1994; Watts, McLennan, Bassham, & El- tion. Parental criticism, a component of the expressed emotion
Saadi, 1997). Nonadherence at a level associated with clinically construct, has also been associated with poor medication adher-
significantnegativeeffectsondiseasemanagement,suchastaking ence for theophylline as well as oral steroids (F. S. Wamboldt,
less than 70% of prescribed doses, occurs among 30–70% of Wamboldt, Gavin, Roesler, & Brugman, 1995). This study also
patientswithasthma(Rand&Wise,1994).Adherencetoasthma showedthatadolescentsfromfamilieswithhighlevelsofparental
treatment recommendations is lower for controller than rescue criticismshowedgreaterimprovementsinasthmaduringaninpa-
medications(Hand&Bradley,1996). tienthospitalstay,afindingthatmaybesimplyexplainedbythe
Poormedicationadherencehasbeendirectlylinkedtoindicesof child’sseparationfromthefamily.Inonestudy(Weiletal.,1999)
poor outcome, such as increased use of emergency health care the existence of psychopathology among caregivers of children
services (Horn, Clark, & Cochrane, 1990; Milgrom et al., 1996; with asthma almost doubled the likelihood of hospitalization for
Schmaling, Afari, & Blume, 1998; Smith, Seale, Ley, Mellis, & asthma (Weil et al., 1999). The strong results persisted after
Shaw, 1994). Adherence with preventive medication does not controlling for morbidity at baseline. However, psychopathology
appear to improve during asthma exacerbations (Mann, Eliasson, amongthechildrenhadanevenstrongerrelationshipwithvarious
Patel, & ZuWallack, 1992). Patients are often reluctant to follow indexesofasthmamorbidity.
asthma action plans that require them to double their dose of Most of the research on family relationships and asthma out-
inhaledsteroidswhenindicated,evenaftertheyhavecompletedan comeshasfocusedonchildrenwithasthma.Moreresearchonthe
asthmaeducationprogramwheretheimportanceofthisstrategyis relationships of adults with asthma is needed because the scant
stressed (van der Palen, Klein, & Rovers, 1997). Even people extant research is suggestive of the importance of relationship
SPECIALISSUE:PSYCHOLOGICALASPECTSOFASTHMA 697
variables. For example, among 35–60-year-old adults with mild- Particularlylowlevelsofpanicandanxietyaboutasthmasymp-
to-moderate chronic obstructive pulmonary disease necessitating tomsalsohavebeenlinkedtoincreasedasthmamorbidity,because
theuseofinhaledbronchodilators,thebestpredictorofmedication anxiety may be necessary to motivate the individual to seek
adherence was the presence of a significant other (Rand, Nides, appropriate treatment when symptoms appear (Kinsman, Dirks,
Cowles, Wise, & Connett, 1995). Similarly, among couples with Dahlem, & Heller, 1980), although even illness-specific anxiety,
asthma discussing stressful topics, more anxiety seems to be as- whenveryhigh,canconvincephysicianstoprescribehigherlevels
sociatedwithbronchoconstriction,butactiveproblemsolvingap- of corticosteroids than pulmonary function would warrant (Hy-
pears to mitigate pulmonary variability (Schmaling, Afari, Hops, land,Kenyon,Taylor,&Morice,1993).
Barnhart, & Buchwald, 2002). Although adherence was not as- Theoriesofhealthbehaviorpositassociationsbetweenspecific
sessedinthislatterstudy,medicationadherenceinvolvesproblem psychological factors and adherence. Although a comprehensive
solving.Areasonablehypothesisforfutureresearchisthatbetter reviewofrelevanttheoriesisbeyondthescopeofthisarticle,we
medication adherence is associated with better problem-solving brieflydescribethemodelsmostfrequentlyappliedtoasthma.The
abilities. health belief model (Becker et al., 1978) emphasizes the role of
Gavin, Wamboldt, Sorokin, Levy, and Wamboldt (1999) hy- certainbeliefsandcognitions,suchasbeliefaboutdiseaseseverity
pothesized that good treatment alliance between physician and andvulnerabilitytodisability,indetermininghealthbehavior.For
patient may be a potential mediator between family functioning example,patientswithasthmawhobelieveditisaseriousillness
andclinicaloutcome,buttheydidnotfindaconsistentrelationship aremorelikelytousecontrollermedicationsthanpatientswhodid
among these measures. Nevertheless, treatment alliance has been not believe asthma is serious (Chambers, Markson, Diamond,
associated with better medication adherence and less frequent Lasch, & Berger, 1999). Negative cognitions, such as concerns
urgentphysicianofficevisits(Gavinetal.,1999).Thisfindingis aboutmedicationsideeffects,havebeenlinkedtolessmedication
consistent with the research of Apter et al. (1998) showing that use(Hand&Bradley,1996).Thetranstheoreticalstages-of-change
patientswhoreportedbarrierstocommunicationwiththeirphysi- theory (Prochaska, DiClementi, & Norcross, 1992) emphasizes
cian displayed poor adherence with inhaled steroid regimens. cognitions regarding self-efficacy and perceived importance,
Finally, Meijer, Griffioen, van Nierop, and Oppenheimer (1995) thereby incorporating elements of the health belief model and
foundthattheimpactoffamilialcohesionandrigidityonchildren other models, such as the theory of planned behavior (Ajzen,
withasthmamaybeadaptive,inthatchildrenfromfamilieswith 1985),self-regulationtheory(Bandura,1986),andself-determina-
these characteristics tended to show better asthma control (as tiontheory(Deci&Ryan,1985).Thetranstheoreticalmodelposits
measuredbyfrequencyofhospitalizationofficevisitsandschool stages of behavior change that are differentiated by the ratio of
absence). Baron, Veilleux, and Lamarre (1992) found that these perceived costs to benefits of engaging in the behavior at each
family characteristics also are associated with higher panic–fear stage, among other factors. Greater perceived necessity of medi-
andhigherdosesofsteroidmedication,bothofwhichcouldeither cation use relative to negative concerns about medications has
be beneficial for control of asthma or indicate overreaction to beenassociatedwithmoreadherenceamongpatientswithasthma
asthmasymptoms.Bothstudieswerecontrolledforasthmasever- (Horne & Weinman, 1999). Greater perceived advantages versus
ity,butneitherstudyusedaprospectivedesign.Itispossiblethat disadvantagesregardingasthmamedicationshavebeenlinkedtoa
these family characteristics may be adaptive for asthma, even greaterintentiontousemedicationsasprescribed,whichhasbeen
though rigidity is usually considered to be a maladaptive trait. associatedwithmoreadherentmedicationuse(Schmaling,Afari,
Perhaps it may be beneficial in the presence of a disease that & Blume, 2000). Schmaling et al. (2000) found an inverted-U
requires a complex medical regimen. In either case, family func- relationshipbetweenpulmonaryfunction(percentageofexpected
tioningmaybeunderstoodasacontributortoasthmamorbidityor, peakflow)andreadinessforchangeinmedicationadherence;that
conversely,asareactiontoit(i.e.,acopingmechanism)(Meijeret is,betterbreathingwasassociatedwithprecontemplation,action,
al.,1995). and maintenance stages, and poorer airflow was associated with
contemplationandpreparation.Perhapspatientsintheprecontem-
plation stage had lacked motivation to take their asthma medica-
Other Psychological Predictors of Adherence
tionbecausetheydidnotexperienceasthmasymptoms.Patientsin
Case studies have provided examples of asthma patients with the contemplation and preparation stages may have been more
panic disorder who overmedicate with asthma drugs because of willing to change their nonadherent behavior owing to greater
confusionbetweenasthmaandpanicsymptoms(Bernstein,Sheri- respiratorydifficulties(i.e.,theirpulmonaryfunctionwasworse).
dan,&Patterson,1991;Shavitt,Gentil,&Croce,1993)giventheir The high adherence among individuals in the action and mainte-
similarity(Schmaling&Bell,1997).Reportofdepression,onthe nance stages may be attributed to negative reinforcement (i.e.,
other hand, has been associated with undermedication (Bosley et takingasthmamedicationisreinforcedbyreductionofunpleasant
al., 1995), but more work is needed with clinical populations. respiratorysymptoms).
CluleyandCochrane(2001)showedthatasthmapatientsclassified Other researchers have developed empirically derived typolo-
as nonadherent (i.e., taking less than 70% of prescribed doses) giesofpsychologicalfactorsimplicatedinadherence.Adams,Pill,
scoredhigherontheHospitalAnxietyandDepressionScale(Zig- andJones(1997)performedin-depthinterviewswithadultasthma
mond&Snaith,1983)thanthoseclassifiedasadherent.However, patients and categorized them either as deniers, who rejected
thisrelationshipmayhavebeenmoderatedbyageandgender,as havingasthmaandreliedonrelievermedication((cid:2)-2-agonists)to
older men were found to be more adherent (Cluley & Cochrane, treat what was perceived as an acute condition, or as acceptors,
2001).Theresearchersdidnottrytocontrolstatisticallyforthese who admitted to having asthma and reported proper adherence
demographicfactors. withpreventivemedication.Futureresearchisnecessarytodevise
698 LEHRER,FELDMAN,GIARDINO,SONG,ANDSCHMALING
assessmenttoolstomeasureandvalidatetheseconstructs,partic- Vicente,2000;Wigaletal.,1993).However,althoughthesepro-
ularlyintheareaofpredictingtreatmentadherence. grams are effective when examining various parameters of mor-
Although self-efficacy has been shown to be a predictor of bidity, it has not yet been shown that changes in self-efficacy or
treatment adherence in other chronic diseases (Bock et al., 1997; locus of control mediate these improvements in asthma self-
Kavanagh,Gooley,&Wilson,1993),thistopichasnotreceivedas management. Understanding the mechanism of behavior change
much attention in the field of asthma. Scherer and Bruce (2001) may allow for further integration of cognitive–behavioral tech-
recently showed a modest relationship between self-efficacy and niques, motivational enhancement, and basic asthma education
self-reportoftreatmentadherence.However,apoorresponserate principles.
to the survey and assessment of adherence through self-report Evaluation of asthma education has been hampered by enor-
substantiallylimitsinterpretationofthesefindings.Usinganelec- mous variability between studies and inadequate reporting of the
tronic counting device to measure adherence, Apter et al. (1998) typeofeducationprovided(Sudre,Jacquemet,Uldry,&Perneger,
found no relationship between health locus of control and adher- 1999).Ameta-analysisofasthmaeducationprogramsforchildren
encewithaninhaledsteroidregimen. revealedsmalleffectsizesforvariousparametersofasthmamor-
bidity(Bernard-Bonnin,Stachenko,Bonin,Charette,&Rousseau,
1995).However,onlyasmallnumberofstudiesmetcriteria(e.g.,
Psychological Interventions for Asthma
thatthestudybearandomizedclinicaltrial)forthismeta-analysis.
Inthissectionwereviewinterventionsforasthmamanagement Devine(1996)conductedameta-analysisonadultasthmapatients
that target patients’ knowledge, beliefs, and behavior. The en- using less stringent criteria, including studies using nonrandom
hancementofknowledgethrougheducationalinterventionsiscru- assignment,andfoundthateducationalprogramsofferedmultiple
cial for disease management and has been well integrated into benefits. For example, large effects were reported for treatment
manydiseasemanagementprograms.Bycontrast,thereisastrik- adherenceandaccuracyofinhalertechnique,andmediumeffects
ing dearth of interventions that address beliefs, behavior, and were found for frequency of asthma attacks, quality of life, and
perceptionsorthatroutinelyscreenforandtreatconditionsasso- psychological symptoms. Clearly, however, future research must
ciatedwithpoorasthmamanagementoroutcomessuchascomor- correctmethodologicalshortcomingsofpreviousstudiesandpro-
bidpsychiatricconditions,familydysfunction,orpoorcommuni- videbetterdocumentationtoallowforreplication.
cation between patient and provider. For example, asthma Furthermore, studies of asthma education have typically com-
managementprogramshaveusedphysicianeducation(e.g.,Hen- paredexperimentalwithcontrolgroupsandexaminedstatistically
dricsonetal.,1994),peereducation(e.g.,Perskyetal.,1999),and significant differences. Research is lacking on demonstration of
innovative educational methods, such as multimedia and clinically significant effects using formal criteria, such as in
computer-basedprograms(e.g.,Bartholomewetal.,2000;Homer NHLBI’s(1997)guidelines,asdescribedabove.Asthmaeducation
etal.,2000)toconveyinformation,butanindividualizedfocuson outcomestudiesdevelopedafterpublicationofthenewguidelines
dysfunctionalcognitive–behavioralvariablesislacking. havenotyetbeenpublished.
Asthma Education Peak Flow Monitoring as a Component in Asthma
Education
The NHLBI’s (1997) guidelines emphasize the importance of
education in the treatment of asthma. They recommend that a An important component in asthma education is training pa-
written action plan instruct patients to take medication and to tientstorecordtheirhomepeakflowvaluesastheirmajorguide
contacthealthcareprovidersaccordingtovariouszonesofasthma forcarryingouttheirasthmaactionplan.However,studiesusing
severitythatcorrespondtothecolorsofatrafficlight.Thezones electronic chips have consistently revealed very low adherence
are based on a combination of symptoms and peak flow values. rates with long-term home peak flow monitoring (Coˆte´, Cartier,
The guidelines also recommend including the following compo- Malo, Rouleau, & Boulet, 1998; Redline, Wright, Kattan, Kercs-
nentsinasthmaeducation:instructingthepatientaboutbasicfacts mar, & Weiss, 1996; Verschelden, Cartier, L’Archeveˆque,
of asthma and the various asthma medications; teaching methods Trudeau, & Malo, 1996). A study of asthma patients who had
forself-monitoringofasthmasymptoms,includingcompetentuse received asthma education revealed that most would not even
of a peak flow meter; teaching techniques for using inhalers and monitor their peak flow during severe asthma exacerbations
avoiding allergens; devising a daily self-management plan; and (Kolbe,Vamos,James,Elkind,&Garrett,1996).Also,ithasbeen
completinganasthmadiaryforself-monitoring. reported that peak flow meters have lower sensitivity than FEV
1
Asthmaeducationhasbeenshowntobecosteffectiveforboth and measures of midexpiratory flow for detecting changes in
children (Greineder, Loane, & Parks, 1999) and adults (Taitel, pulmonaryfunction(Eid,Yandell,Howell,Eddy,&Sheikh,2000;
Kotses, Bernstein, Bernstein, & Creer, 1995). Numerous empiri- Gianninietal.,1997;Miles,Tunnicliffe,Cayton,Ayres,&Miller,
cally validated educational programs are available for asthma 1996;Sly,Cahill,Willet,&Burton,1994).Overrelianceonpeak
patients of all ages, some of which have demonstrated improve- flow measures could thus provide false reassurance during the
ments on measures such as frequency of asthma attacks and early stage of an attack and may lead to delays in carrying out
symptoms, medication adherence, and self-management skills actionplans.
(Kotsesetal.,1995;Wilsonetal.,1996). Most studies comparing peak flow monitoring with symptom
Asthmaeducationalsohasbeenshowntoincreaseself-efficacy monitoring among asthma sufferers have failed to show differ-
and internality on health locus of control (Bruzzese, Markman, ences in clinical outcome (Charlton, Charlton, Broomfield, &
Appel,&Webber,2001;Tieffenberg,Wood,Alonso,Tossutti,& Mullee,1990;GrampianAsthmaStudyofIntegratedCare,1994;
SPECIALISSUE:PSYCHOLOGICALASPECTSOFASTHMA 699
K. P. Jones et al., 1995; Turner, Taylor, Bennett, & Fitzgerald, edge may not necessarily display appropriate behavior during
1998). These findings provide support for symptom monitoring actual attacks (Kolbe, Vamos, Fergusson, Elkind, & Garrett,
because it is easier to carry out than peak flow monitoring. 1996).Bridgingthegapbetweenknowledgeandbehaviorremains
Ignacio-Garcia and Gonzalez-Santos (1995) did find that peak animportantareaofdevelopmentforasthmaeducation.
flowmonitoring,incombinationwithotherself-managementand
educational components, led to reductions in asthma morbidity,
Other Psychological Interventions
although the specific beneficial effects of peak flow monitoring
couldnotbeisolated.Reeder,Dolce,Duke,Raczynski,andBailey Symptom Perception Training
(1990)foundthatpeakflowmonitoringdidnotleadtosignificant
improvements in symptom perception, although daily, long-term Two studies have produced promising findings that suggest it
peakflowmonitoringisstillrecommendedformoderate-to-severe maybepossibletotrainasthmapatientstoimprovetheirpercep-
persistentasthmapatientsandpatientswithpoorsymptompercep- tionofairwayobstruction.Harver(1994)usedabsolutethreshold
tion(NHLBI,1997).Consistentwiththisrecommendation,Cowie, training with external resistive loads and found that patients who
Revitt, Underwood, and Field (1997) recruited asthma patients received feedback after each trial about the accuracy of their
who had experienced a severe exacerbation within the past year estimate performed better on the perception task than those who
and found that home peak-flow monitoring with an action plan did not. This finding was upheld at follow-up when testing was
reducedthefrequencyofsubsequentemergencyroomvisits. repeated without feedback. Stout, Kotses, and Creer (1997) used
difference threshold training and found that feedback combined
with presentation of loads in order of increasing difficulty led to
Individualized Self-Management
improvements in perceptual accuracy. Future research needs to
Inadditiontoadaptingeducationalprogramsforhigh-riskpop- investigatewhetherimprovementswithexternalinspiratoryresis-
ulations, self-management plans can be tailored to the specific tive loads are related to increased perceptual accuracy of pulmo-
needs of individual patients. Typically, personalized plans are nary function and better clinical outcome, and whether including
developed either from interviews with the patient or from self- symptom perception training provides incremental benefits as a
monitoringduringabaselineperiod(Kotses,1998).Individualized componentinanasthmamanagementprogram.
programshavebeenshowntoreducethenumberofasthmaattacks
(Kotses, Stout, McConnaughy, Winder, & Creer, 1996) and Cognitive Interventions, Psychotherapy, and Family
asthmasymptoms(Evansetal.,1999).Wilsonetal.(1993)found
Therapy
thatpersonalizedself-managementwasassociatedwithbetteren-
vironmental control and inhaler technique. However, comparable Thefewstudiesthathaveexaminedtheuseofpsychotherapyas
benefitswerefoundinasmall-groupeducationalprogram,amore anadjunctivetreatmentforasthmahavebeenlimitedbytheuseof
cost-effectiveandsupportiveforum.Individualizedtrainingmight smallsamplesizes.Sommarugaetal.(1995)combinedanasthma
most easily be accomplished in the physician’s office during education program with three sessions of cognitive–behavioral
periodic reviews of asthma status, as recommended by NHLBI therapy (CBT) focusing on areas that may interfere with proper
(1997). medical management. Few significant between-group differences
onmeasuresofanxiety,depression,orasthmamorbidityemerged
Smoking Cessation Interventions as Components of betweenacontrolgroupreceivingmedicaltreatmentaloneandthe
CBT group. In an uncontrolled study, Park, Sawyer, and Glaun
Asthma Education
(1996) applied principles of CBT for panic disorder to children
There has been little attention to smoking cessation as a com- withasthmareportinggreatersubjectivecomplaintsandconsum-
ponent in asthma education programs, either for adult patients or ing excessive medication. In the 12 months following treatment,
parentsofchildrenwithasthma.Severalstudieshavefoundthata rateofhospitalizationforasthmadecreased,butothermeasuresof
brief educational session was ineffective in changing smoking clinical outcome were not analyzed. We have recently combined
behavior of parents whose children have asthma (Irvine et al., components of asthma education and CBT for panic disorder to
1999;McIntosh,Clark,&Howatt,1994;Silagy,1999).Asimilar develop a treatment protocol appropriate for adults with both
intervention for adult smokers with asthma also failed to affect asthma and panic disorder (Feldman, Giardino, & Lehrer, 2000).
smoking behavior (Wilson et al., 1993). Smoking also has been Thistreatmentiscurrentlybeingempiricallyevaluated.
identified as a predictor of low attendance at asthma education There also is evidence from two controlled studies that family
programs among parents of young children with asthma (Fish, therapy can lead to improved asthma symptom control in some
Wilson,Latini,&Starr,1996).Thesestudiesdemonstratetheneed casesofseverechildhoodasthma(Gustafsson,Kjellman,&Ced-
to devise and implement formal smoking cessation programs erbald,1986;Lask&Matthew,1979).However,thesamplesand
amongpeoplewithasthmaandtheirfamilies. effect sizes in these studies were small, and the results were
inconsistent.Itispossiblethatfamilytherapymaybemosthelpful
for families in which interpersonal difficulties interfere with car-
Limitations of Asthma Education
ryingoutthecomplexmedicalregimenrequiredbychildrenwith
A major obstacle to successful implementation of asthma edu- severeasthma.
cationispoorpatientattendance(Abdulwadudetal.,1997;Yoon, To the best of our knowledge, there have been no controlled
McKenzie, Miles, & Bauman, 1991). Another problem is that treatmentoutcomestudiesapplyingpsychotherapytopatientswith
patients who score high on measures of self-management knowl- comorbidasthmaandpsychiatricdisease.Itisimportanttodeter-
700 LEHRER,FELDMAN,GIARDINO,SONG,ANDSCHMALING
mine whether decreases in psychopathology lead to concomitant improvedtonormallevelsinthetreatmentgroupafter6monthsof
improvements in quality of life, symptom perception, treatment treatment. Children in the treatment group showed a significant
adherence,andclinicaloutcome.Nevertheless,theNHLBIguide- reduction in specific IgE responses against the most common
lines for asthma treatment recommend referral to mental health allergeninthestudypopulation.StimulationofIgEresponsesby
professionals when stress appears to interfere with medical man- environmental allergens is an important contributor to asthma
agementofasthma(NHLBI,1997).InastudybyGodding,Kruth, exacerbations. Treatment group children also exhibited increased
andJamart(1997),pediatricpatientswithpoorlycontrolledasthma naturalkillercellactivityandasignificantlyaugmentedexpression
demonstratedimprovedtreatmentadherenceandclinicaloutcome oftheT-cellreceptorforIL-2.Naturalkillercellsproduceagents
when treatment was coordinated between a pediatrician and psy- thatinhibitIgEsynthesis,andIL-2,animmunesystemmessenger
chiatrist. We have found no similar studies on adult asthma pa- molecule, acts to suppress lymphocyte activity associated with
tients.Withrecentimprovementsinscreeningdevicesforpsycho- atopy.3
logical disorders in primary care (Spitzer, Kroenke, & Williams,
1999), the time is ripe for behavioral scientists to explore the Direct Effects of Psychological Treatments on the
efficacyofpsychotherapyamongpatientswithasthma. Pathophysiology of Asthma
Several studies have evaluated cognitive interventions specifi-
cally derived from the health beliefs and transtheoretical models. Inadditiontopsychologicalinterventionstargetedathealthcare
P. K. Jones, Jones, and Katz (1987) found that patients with behaviors or stress management, research is continuing on the
asthmawhohadreceivedaninterventionbasedonthehealthbelief methodsbywhichpeoplecanlearntoexercisedirectcontrolover
modelweremorelikelytomakeandkeepfollow-upappointments physiological processes involved in asthma. These methods have
than patients who had received treatment as usual. Schmaling, included various relaxation methods, biofeedback, hypnosis, and
Blume, and Afari (2001) found that modifying patients’ specific yoga.
beliefsaboutmedicationsusingeducationplusmotivationalinter-
viewing(W.R.Miller&Rollnick,1991),aninterventionbasedon Relaxation Training
the transtheoretical model, enhanced patients’ reasons for using
In an earlier review, Lehrer, Sargunaraj, and Hochron (1992)
medications.Thedecisionalbalance(prosvs.cons)changedinan
concludedthatrelaxationtraininghasoftenstatisticallysignificant
advantageous direction (with more “pros” and fewer “cons” for
but small and inconsistent effects on asthma, particularly after
using medication as prescribed) among participants who had re-
severalweeksoftraining,althoughtheimmediateeffectmaybea
ceived the motivational interviewing than among people who
worseningofpulmonaryfunctionduetoparasympatheticrebound.
receivedonlyeducation.
More recent studies have yielded a similar pattern (Table 1),
although in some studies clinically significant improvements in
Written Emotional Expression Exercises
pulmonary function did occur. Outcome measures, populations,
and relaxation procedures differ across studies and may explain
Inrecentyears,severalreportshavebeenpublishedpromoting
some of the inconsistencies. Although possibly helpful for pre-
the health benefits of emotional disclosure of psychologically
venting stress-induced asthma exacerbations, relaxation training
traumatic experiences through writing (e.g., Esterling, Antoni,
does not produce reliable effects of clinically significant magni-
Fletcher,Margulies,&Schneiderman,1994;Pennebaker,Kiecolt-
tude for treating or preventing asthma. Further research is war-
Glaser,&Glaser,1988).Smythetal.(Smyth,1998;Smyth,Stone,
ranted on their use among asthma patients showing emotion- or
etal.,1999)askedstudyparticipantstowriteanessayexpressing
stress-induced asthma symptoms and possible mediation of these
theirthoughtsandfeelingsaboutatraumaticexperienceandfound
effectsbyinflammatoryprocesses.
a clinically significant improvement in FEV among asthma pa-
1
tientsaftera4-monthfollow-up,withnoimprovementnotedina
controlgroupwhowroteoninnocuoustopics.Inalateranalysis, Biofeedback Techniques
they reported that these effects were not mediated by perceived
Surface eletromyographic (EMG) biofeedback. In contrast to
stress, quality of sleep, affect, substance use, or medication use
the general relaxation approaches to treating asthma described
(Stone,Smyth,Kaell,&Hurewitz,2000).
above,Kotsesandhiscolleagueshypothesizedthatonlyrelaxation
Other Psychosocial Interventions
3Immunoglobulins (Igs) are proteins that act as antibodies in the im-
Onestudyevaluatedtheeffectsofapsychologicalintervention munesystem.Antibodiesreacttoantigens,substancesthatinduceimmune
on the immune–inflammatory system in asthma. Caste´s et al. sensitivityorresponsiveness.Igsareclassified(A,D,E,G,M)onthebasis
(1999) provided children with asthma a 6-month program that of the structural and antigenic properties of their protein chains. An
includedrelaxation/guidedimagery,cognitivestress-management important component of asthma is the stimulation of IgE responses by
environmental allergens. This stimulation leads to mast cell activation,
therapy,andaself-esteemworkshop.Improvementoccurredboth
whichresultsinthereleaseofvasoactiveandbronchoconstrictiveagents,
in clinical measures of asthma and in asthma-related immune-
which attract inflammatory cells to the area. Interleukin-2 is a cytokine
systemmeasures.Thetreatmentgroup,butnotacontrolgroupthat
derivedfromThelperlymphocytesthatcausesproliferationofTlympho-
receivedonlymedicaltreatment,significantlydecreasedtheiruse
cytesandactivatedBlymphocytes.Thislymphocyteactivity,calledaTh-1
of(cid:2)-2stimulantmedication,showedimprovementsinFEV1,and, profile,actstosuppresslymphocyteactivityassociatedwithatopy(i.e.,the
attheendoftreatment,nolongershowedaresponsetobroncho- Th-2 profile). T helper cells are a subset of lymphocytes that secrete
dilators (consistent with improvement in asthma). Basal FEV variouscytokinesthatregulatetheimmuneresponse.
1