Bronchial Asthma

Bronchial asthma is a syndrome characterized by episodes of obstruction to an adequate exchange of

air in the lungs. Its clinical manifestations include the following:

 Wheezing respirations,
 Dyspnea,
 Cough, and
 Excessive mucus production.

An important characteristic of asthma, as opposed to other conditions which may impair the ability of
the body to transport air, is that the symptoms are reversible, either through adequate and appropriate
pharmacological means or by virtue of normal remission between attacks. This leads to a situation in
which asthma sufferers may have completely normal pulmonary function in the periods between
episodes of asthma. These periods may be as long as several months or even years.

Asthma is considered to be either extrinsic (due to allergic reaction), intrinsic (nonallergic, infectious,
etc.), or mixed. Most patients fall into the latter category, and for most victims, the majority of
asthmatic symptoms are related to allergens. Common asthmogenic allergens include tree, grass, and
weed pollens; molds and fungi; animal danders and feathers; house and occupational dusts; some
foods; insects (but not stings); and some chemicals (but not in their role as irritants).

Non-allergic asthmogenic stimuli include aspirin, exercise, airway irritants, and infections. Exercise
is such an ubiquitous asthmogen that exercise induced broncho-spasm has been suggested as a
defining characteristic of asthma. Usually, exercise-induced asthma reverses non-problematically
with rest and/or appropriate medication.

Common airway irritants include certain chemical gases, aerosal propellants, cold air, and cough. In
many patients, certain situations (e.g., some weather conditions and weather changes) can precipitate
asthma idiosyncratically by as yet unknown means. Respiratory infections represent one of the most
common asthma precipitants and are the cause of some of the most severe and prolonged episodes of
asthma, often requiring hospitalization and life-saving therapy. While it is highly uncertain whether
bacterial infections can provoke asthma, it is now known that viral infections (e.g., colds and
influenza) are very common asthma precipitants.

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One of the characteristics of bronchial asthma appears to be conditioning. It is thus possible that a
patient who is allergic to flowers will also suffer an asthmatic attack on seeing artificial flowers.

Psychological factors associated with bronchial asthma:

Asthma can be affected by stress, anxiety, sadness, and suggestion, as well as by environmental
irritants or allergens, exercise, and infection. It also is associated with an elevated prevalence of
anxiety and depressive disorders. Asthma and these psychological states and traits may mutually
potentiate each other through direct psychophysiological mediation, nonadherence to medical
regimen, exposure to asthma triggers, and inaccuracy of asthma symptom perception.

Historically, asthma was considered one of the classic seven psychosomatic illnesses along with
peptic ulcer, hypertension, colitis, cardiac arrhythmia, neurodermatitis, and hyperthyroidism
(Alexander, 1950). It was believed that asthma was caused by repressed feelings in a biologically
predisposed individual. Although most no longer consider asthma to be a psychosomatic illness or a
behavioural disease, there is evidence indicating that stress and other psychological factors may be
triggers or exacerbants rather than causes of asthma. More specifically, behaviors such as crying and
screaming and psychological factors such as failed expectations or relational stress can trigger asthma
symptoms.

While medicine as a whole continued to view asthma as basically an immunological disorder, the
focus within psychosomatic medicine was formed in the early 1940s by French and Alexander
(1941). From a psychoanalytic standpoint, they promulgated the notion that the origin of asthma was
due to the suppression of intense emotion; specifically, "a suppressed cry for the mother."

Psychological factors in the family environment may, in some cases, play a role in the symptomatic
manifestation of asthma, although undoubtedly not in its aetiology. Clinicians have noticed for many
years that some asthmatic children obtained symptom reduction or remission when separated from
their families for one reason or another. Peshkin (1960) even spoke of "parentectomy" as a therapy
for asthma in selected children. The effectiveness of separation was said to be evidenced by the
significant number of children whose symptoms remitted abruptly when they were sent for treatments
to hospitals such as The National Asthma Center in Denver. Nevertheless, it was possible that the
benefits of separation were due to alterations of the physical rather than the emotional environment.
In a landmark study, Purcell and his colleagues (1969) controlled for physical environment effects by
removing the families of asthmatic children to a hotel for several weeks while the child remained

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home under the care of a child-care worker. When experimentally separated from their families,
children judged to have been experiencing emotional exacerbation of asthma displayed small but
statistically significant changes in several asthma measures.

Investigations seeking to establish the presence of a specific premorbid personality pattern associated
with asthma have been carried out even more energetically than the search for family stress
influence, but with correspondingly less success. Asthma sufferers have been claimed by one or
another writer to be variously over-dependent, hypersensitive, overly aggressive, or overly passive
(Creer, 1978). Asthmatics have been shown to be more neurotic than normals and to describe
themselves in a less favourable light. Nevertheless, when careful comparisons were made between
asthmatic individuals and those suffering from other chronic illnesses, differences completely
disappeared (Neuhaus, 1958). It was however verified by Neuhaus (1958) that the children suffering
from asthma were generally over-dependent.

Wittkower and White (1959) found from a study of 10 patients that there were strong feelings of
ambivalence towards the mother who was portrayed as rigid and domineering, yet insecure and
depriving the child of maternal love. In a larger study, Rees (19 63) found a high incidence of
parental over-protectiveness which antedated the asthma. An over-protected child may become over-
dependent and introspective and so be unable to cope adequately with bronchial narrowing. High
dependency level have been shown to be associated causally with high rates of re-hospitalization for
asthma (Dirsks et al., 1977; Staudenmayer et al., 1979).

Psychophysiological investigations have produced results that are more encouraging. A common
clinical observation, often supported by patient report, is that attacks sometimes appear during, or
seem to result from, emotional stress. It is well known that emotional arousal (e.g., anxiety)
frequently accompanies asthmatic episodes (Alexander, 1975). Consequently, a number of attempts
have been made to precipitate asthma using such emotional stressors as disturbing films (54),
discussions or hypnotic suggestions of stressful life situations (Clarke, 1970; Smith, Colebatch, and
Clarke, 1970), recordings of the voice of a patient's mother (Hill, 1975), etc.. Such stimuli have
proved capable, at times, of producing changes in respiratory patterns and/or very small decreases in
pulmonary flow rates, but have never been demonstrated reliably to produce actual asthma attacks.

The most compelling lines of research implicating psychological variables in the control of airways
tone are the studies on suggestion, relaxation, and placebo effects. Several studies, for example,
Luparello, Lyons, Bleecker, and McFadden (1968), have indicated that inhaled aerosolized saline can

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result in broncho-constriction when the subject is led to believe that the substance is one to which he
or she is known to be sensitive, and that the resultant increase in airways resistance can be reversed
by a subsequent inhalation of saline believed by the subject to be a standard bronchodilator.
However, these effects are found only with very sensitive measurement methods, a fact confirmed by
the above investigators. Such evidence further underscores the interpretation that such effects are
most likely real, albeit modest indeed. A series of experiments reviewed in a later section concluded
that relaxation training may result in small but statistically significant decreases in airways resistance.
Finally, it has been shown that premedication with placebo can lead to a significant reduction in the
degree of exercise-induced broncho-spasm (Godfrey and Silverman, 1973).

The possibility that learning or conditioning may influence bronchomotor tone has not gone
unnoticed. As far back as 1886, Sir James McKenzie published an anecdotal report describing a
woman who allegedly developed wheezing simply by viewing a paper rose under glass. By way of
illustration in asthma, the visual and olfactory sensations associated with a weed would represent the
conditioned stimulus, whereas the pollen would be the unconditioned stimulus. Prior to conditioning,
the bronchospasm in this case would represent the "reflexive" allergic reaction to pollen; i.e., the
unconditioned response. Following a sufficient number of pairings between weed and pollen, simply
seeing the weed should be capable of eliciting some conditioned bronchospasm; i.e., a conditioned
bronchospastic response. In the same manner, the stimuli immediately preceding the inhalation of a
pharmachological bronchodilator should soon come to elicit some conditioned relaxation of bronchial
smooth muscle.

Patients with asthma, especially children, appear particularly likely to suffer from psychological
problems, particularly anxiety disorders (Bussing, Burket, & Kelleher, 1996; Vila et al., 1999;
Wamboldt, Schmitz, & Mrazek, 1998). Persons with asthma and comorbid psychiatric disorders have
more impaired functioning in both emotional and physical arenas than persons with either disease
alone, with poorer control of asthma (Afari, Schmaling, Barnhart, & Buchwald, 2001; Siddique et al.,
2000) and greater health care utilization (ten Brinke, Ouwerkerk, Zwinderman, Spinhoven, & Bel,
2001). Those with asthma, especially children, also appear to be more likely than healthy individuals
to experience negative emotions without expressing them (Hollaender & Florin, 1983; Silverglade,
Tosi, Wise, & D’Costa, 1994). Panic disorder appears to be overrepresented among patients with
asthma (Carr, Lehrer, & Hochron, 1992). Approximately 1 asthma patient in 10 has panic disorder.
Also, asthma and other chronic respiratory diseases are three times more common in those with panic

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disorder than among those with other psychiatric disorders or the general population (Spinhoven,
Ros, Westgeest, & van der Does, 1994; Zandbergen et al., 1991).

Panic may elicit or exacerbate asthma symptoms by several pathways. The psychophysiological
stress response that accompanies panic may elicit autonomic and inflammatory responses among
people with asthma, and dyspnea and other unpleasant body sensations accompanying asthma may
trigger panic.

Negative affect bears a complex relationship with symptom perception in asthma, and the type and
level of emotional arousal may be important determinants. Spinhoven, van Peski-Oosterbaan, van der
Does, Willems, and Sterk (1997) found that patients with asthma reporting greater anxiety during
histamine challenge tests, as assessed by the Subjective Units of Distress score (Kaplan, Smith, &
Coons, 1995), showed better perception of airway obstruction. These patients did not display
elevated levels of trait anxiety. Thus, anxiety that is specifically related to asthma may sensitize the
individual to asthma-related body sensations through attentional processes (Arntz, Dreessen, &
DeJong, 1994). Although this may promote appropriate symptom recognition and health care
behaviors, as described below, negative affect also may lead to over-perception of asthma symptoms
(Janson, Bjo¨rnsson, Hetta, & Boman, 1994; Rietveld & Prins, 1998).

Like many other diseases, asthma should be considered as a disease of the whole body. “it is more
important to know what sort of person has a disease than to know what sort of disease a person has”
– Hippocrates. The position of the patient in his/ her environment in both physical and a psychosocial
sense should be considered of great importance in the overall management of the patient with asthma.
Just as the external physical environment (cold air, smoke, allergens, and infections) can be
responsible for triggering the hypersensitive bronchial muscle to constrict and cause asthmatic
symptoms, so the internal environment (chemical, hormonal, neurological or psychological) may also
be responsible for the same symptoms. If it is accepted that the central abnormality in asthma is
hypersensitivity of the smooth muscle, it can easily be appreciated that emotional perturbations can
precipitate an attack of asthma. The greater the degree of hypersensitivity of the muscle, the smaller
the degree of psychological disturbance required to trigger the attack. Similarly, in a highly
emotionally labile individual, vast swings of emotion may precipitate asthma even in patients with
very mild bronchial hypersensitivity.

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Management of bronchial asthma:

Relaxation Training – Relaxation therapy has been accepted as a valuable part of asthma self-
management. A systematic review of all available published randomized controlled trials on
relaxation training and asthma concluded that there was a lack of evidence for the efficacy of
relaxation therapies for asthma management (Huntley, White, & Emst, 2002). Another systematic
review of available research concluded that relaxation training did have a small but inconsistent
effect on asthma and that relaxation may be very beneficial in preventing stress-induced asthma
(Lehrer et al., 2002). Given the link between strong emotion and respiratory effects, there may be a
role for relaxation on mitigating states of extreme anxiety to prevent asthma exacerbation.

Written Emotional Expression Exercises – Recently, research has been reported on the health
benefits of disclosure of psychologically traumatic experience through writing. This approach is
referred to as written emotional expression exercises. In one study, asthma patients were asked to
write down their thoughts and feelings about traumatic experiences, and significant improvements in
forced expiratory volume in the first second were found, even after a 4- month follow-up (Smyth,
1998).

COGNITIVE-BEHAVIORAL THERAPY – Typically, cognitive-behavioural therapy (CBT) is

useful and effective in modifying automatic thoughts, intermediate beliefs, and maladaptive schema.
In addition, there are a number of specific treatment targets for CBT interventions with asthma. A
particularly important target is modifying treatment-interfering illness representations. Other
treatment-interfering factors that can be treatment targets for CBT with asthma patients include
procrastination, difficulty focusing, and relational issues. Opolski and Wilson (2005) reported on a
study by Grover et al. of 10 asthma patients assigned either to a control group that received asthma
medication or an experimental group that received CBT, including asthma education, muscle
relaxation, behavioral techniques, cognitive restructuring, and coping skills as well as asthma
medication. Although the control group did not experience significant changes, the experimental
group reported significant decreases in asthma symptoms, anxiety, and depression, along with
increased quality of life.

Hypnotherapy – Hypnotherapy has long been used with asthma patients. Unfortunately, there is
relatively little published research on its efficacy. One controlled study of hypnosis in the treatment
of children with asthma found symptom improvement but not increased pulmonary function,
decreased visits to the emergency room, and fewer missed school days (Kohen, 1995). A critical
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review of the literature on hypnosis and asthma concluded that hypnotherapy can be beneficial,
particularly for asthmatics who are highly hypnotizable (Hackman, Stem, & Gershwin, 2000).

Family Therapy – Given the large number of children and adolescents with asthma and the role of
family dynamics, it should not be too surprising that family therapy is an often-used intervention.
Two controlled studies (Gustafsson, Kjellman, & Cederbald, 1986; Lask & Matthew, 1979) found
that family therapy can lead to improvement in asthma symptoms in children with severe asthma and
in families exhibiting interpersonal difficulties that impede a complex medical protocol. It may well
be that family therapy is most beneficial for families in which interpersonal problems interfere with
the complex medical regimen of children with severe asthma (Lehrer et al., 2002).

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