Defense style and the perception of asthma

Repression and coping styles in asthmatic patients

The objectives of this study were to (a) determine prevalence of the dispositional repressive coping style as well as other situational coping styles in a sample of asthmatic patients and (b) to analyze the capacity of these styles to predict subsequent morbidity (emergency room visits or hospitalizations due to asthma) during a 12-month follow-up. A sample of 75 adult asthmatic patients was selected and information about sociodemographics, asthma severity, and patient's perception of illness severity was collected. Repressive coping style was defined by a combination of scores obtained on the Trait Anxiety Inventory and the Marlowe-Crowne Social Desirability Scale. Coping styles were assessed with the dispositional version of the Coping Orientation to Problems Experienced Inventory. Eighteen patients (24%) were classified as repressors. Repressor asthmatics obtained scores significantly lower on Emotion-Focused Coping compared to non-repressors (F ((1,72)) = 5.15, p = .026). Patients who perceived their asthma as severe reported to use Emotion-Focused Coping more than those who judged it as mild or moderate (F ((2,71)) = 4.83, p = .011). A higher use of Denial (an Emotion-Focused strategy of coping) explained 8% of variance of the frequency of emergency room visits during the 12-month follow-up. The prevalence of repressive coping style in the asthmatic population is similar to that registered in other populations of chronic patients, and it is also associated with the tendency to report a lower use of strategies traditionally considered as maladaptive. The use of Emotion-Focused Coping strategies seems to be related to a worse perception of the physical status, and among this group of strategies, Denial also could favor a poor clinical course in bronchial asthma.

Inaccurate perception of asthma symptoms: a cognitive-affective framework and implications for asthma treatment

Inaccurate perception of respiratory symptoms is often found in asthma patients. Typically, patients who inaccurately perceive asthma symptoms are divided into underperceivers and overperceivers. In this paper we point out that this division is problematic. We argue that little evidence exists for a trait-like stability of under- and overperception and that accuracy of respiratory symptom perception is highly variable within persons and strongly influenced by contextual information. Particularly, expectancy and affective cues appear to have a powerful influence on symptom accuracy. Based on these findings and incorporating recent work on associative learning, attention and mental representations in anxiety and symptom perception, we propose a cognitive-affective model of symptom perception in asthma. The model can act as a framework to understand both normal perception as well as under- and overperception of asthma symptoms and can guide the development of affect-related interventions to improve perceptual accuracy, asthma control and quality of life in asthma patients.

Current perspectives on symptom perception in asthma: a biomedical and psychological review

Symptom perception in patients with asthma is often inadequate. Patients may fail to perceive serious airway obstruction or suffer from breathlessness without objective cause. These extremes are associated with fatal asthma and excessive use of medicines, respectively. This article covers symptom perception in a multidisciplinary perspective. A presentation of current definitions and methods for studying symptom perception in asthma is followed by a summary of theories on the origin of breathlessness. Next, biomedical and psychological factors influencing symptom perception are examined. Preliminary biomedical research emphasizes neural pathway impairment, but causal factors remain inconclusive, particularly regarding the overperception of symptoms. Psychological studies suggest that the accuracy of symptom perception is influenced by (a) competition between asthmatic and nonasthmatic sensory information, (b) negative emotions, and (c) acquired response tendencies (e.g. habituation to symptoms, repression of symptoms, selective perception, and false interpretation of symptoms). These factors may favor either blunted perception or overperception. Empirical data in support of psychological factors are still insufficient. Methodological problems and procedures to improve symptom perception are discussed.

Advancing the science of perceptual accuracy in pediatric asthma and diabetes

OBJECTIVES

To review research on perceptual accuracy in pediatric asthma and diabetes and to provide recommendations for future research efforts and clinical applications of the construct in these populations.

METHODS

A literature search was conducted using Medline and PsychInfo databases as well as the bibliographies of relevant articles.

RESULTS

Children and adolescents with asthma or diabetes evidence considerable variability in perceptual accuracy and frequently make clinically relevant errors that have the potential to affect self-management behavior.

CONCLUSIONS

Recommendations for future research include studying distinct types of perceptual errors, empirically supporting the relationship between perceptual accuracy and relevant outcomes, identifying factors related to perceptual inaccuracy, and conducting longitudinal research and intervention studies. Recommendations for applying the construct in clinical practice include adopting an individualized approach to symptoms to guide patient education and management, identifying patients prone to making clinically relevant errors, and developing and implementing interventions to improve accuracy.

Dyspnea: the role of psychological processes

Breathlessness or dyspnea-the subjective experience of breathing discomfort-is a symptom in many pulmonary, cardiovascular, and neuromuscular diseases. It occurs in normals as well during intense emotional states and heavy labor or exercise. In clinical cases, it generally causes severe suffering. Dyspnea has multifactorial causes and the explanation for the symptom may differ largely among patients. Explanatory models imply the involvement of mechanisms at several levels of functioning, such as afferent signals from the respiratory muscles or blood gas levels related to hypercapnia and hypoxia. Depending on the relative involvement of specific mechanisms and their interactions, dyspnea may be experienced differently and subtypes can be distinguished. More recently, perceptual-cognitive and emotional processes related to symptom perception and interpretation have been investigated in the context of dyspnea. In this review, we focus on the psychological processes that play part in the perception of dyspnea and formulate some practical guidelines for those who are confronted with dyspnea.

Psychological aspects of 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. Defensiveness is associated with inaccurate perception of airway resistance and stress-related bronchoconstriction. Asthma education programs that teach about the nature of the disease, medications, and trigger avoidance tend to reduce asthma morbidity. Other promising psychological interventions as adjuncts to medical treatment include training in symptom perception, stress management, hypnosis, yoga, and several biofeedback procedures.

Boys' and girls' responses to stress: affect and heart rate during a speech task

PURPOSE

To examine gender differences in heart rate and reports of negative and positive affect among adolescents during a speech task.

METHODS

Subjects were 133 adolescents, 73 girls and 60 boys, ages 14-18 years. Subjects were randomly assigned to speak for 10 minutes and asked either to free associate or to describe the most stressful event in their lives. Their heart rate was assessed at baseline and at 5 and 10 minutes after the task began. Self-ratings of negative and positive affect were assessed at baseline and at 10 minutes after the beginning of the task. Data were analyzed by Student's t-tests for independent samples, analyses of covariance, and Spearman rank-order correlation coefficients.

RESULTS

Girls rated their negative affect significantly higher at baseline in comparison to boys. In addition, girls had a higher baseline heart rate. However, boys' increase in heart rate 5 minutes into the speech task was significantly greater than that of girls. Also, the free association task elicited significantly greater increases in heart rate compared to a task in which the adolescent described his or her most stressful life event. However, the stressful event task elicited greater negative and less positive affect. Significant relationships between change in heart rate and ratings of post-task affect were found among girls but not among boys, suggesting that the girls' ratings of their affect are more congruent with their physiological reactions to a stressful speech task.

CONCLUSIONS

These results suggest that gender and task differences must be considered in assessing adolescents' stress.

Trauma and personality correlates in long-term pediatric cancer survivors

To explore the relationship between PTSD and trauma-spectrum symptoms, including personality and functional correlates, in long term pediatric cancer survivors (N = 40), we assessed these constructs with a structured interview for PTSD, a clinical interview, and self-report questionnaires. Thirty-five out of 40 participants (88%) currently met at least one trauma symptom at a functionally significant level. These survivors demonstrate high levels of restraint and low levels of distress, representative of a repressive adaptive style. After more than 5 years since treatment completion, the relatively high levels of current trauma-spectrum symptoms may reflect the long-term deleterious impact of childhood cancer.

The curious 2000-year case of asthma

Millions worldwide have asthma, with the numbers succumbing increasing sharply in the past two decades. After 2000 years of scientific study, who succumbs to asthma when is as puzzling as who regains health when and how. The discipline of psychosomatic medicine and science investigates and treats diseases like asthma that typically confound general medicine. Still psychosomatic medicine, like general medicine, only manages but does not remedy asthma, which can currently only be in remission but not cured. This historical review reveals the progress and missteps that have been made in the study and treatment of asthma by comparing the general medicine approach with the major research findings on asthma published over 60 years in Psychosomatic Medicine. Research has identified antecedent, collateral, and subsequent factors to scientifically describe and control this disease in terms of diagnosis, management, and treatment. Paradoxically and regrettably, the prognosis for those with asthma is worse than ever. Curious also that a noninfectious disease should spread so rapidly and mostly for specific groups identified by variables like age, gender, ethnicity, and socioeconomic status. Furthermore, partial, not full, family concordance indicates merely genetic influence, not determination. General medicine now focuses on enumerating the range of environmental and situational triggers, or stimuli, producing asthma and describing the pathophysiology of bronchial inflammation. With a more comprehensive multifactorial approach, psychosomatic medicine seems well suited to investigate further the physiological, psychological, social, and environmental factors implicated in this medical conundrum. A future challenge for psychosomatic medicine is to stem the tide of rising prevalence and cure the disease of asthma.

Reviewing asthma and anxiety

The main characteristic of asthma is sudden and unexpected attacks of impaired breathing. Both the attacks themselves and the prospect of attacks generate much anxiety amongst patients. Several different forms of anxiety can be identified which vary in intensity and the situations in which they appear. Anxiety disorders are more common in asthmatics and have a considerable influence on asthma management because they influence symptom perception. Excessive anxiety about asthma symptoms can affect the patient's response to an asthma attack; anxiety related to asthma triggers can reduce the patient's quality of life and anxiety related to medical treatment can influence compliance. The extent of this influence depends upon an individual's ability to cope. Behavioural therapeutic programmes for patient education offer an opportunity to reduce anxiety and to improve asthma self-management. Physicians should look carefully for anxiety when taking the patient's history, and should support the patient's participation in asthma education programs.

Repressive-defensive style and physiological reactivity among children and adolescents with asthma

OBJECTIVE

This study evaluates the concordance of two self-report methods of operationalizing repressive-defensive style in children with asthma. It was hypothesized that, compared with low-anxious children, repressive-defensive children would exhibit increased physiological reactivity during a stressful laboratory task, despite comparable self-reports of state anxiety.

METHODS

Ninety-one children and adolescents (mean age = 11.5 years) with asthma participated in the study. Repressive-defensiveness was operationalized as self-reported low distress coupled with high defensiveness or restraint. Self-report data reflecting trait anxiety, defensiveness, and personality style were used to classify children as repressive-defensive by two independent methods. Physiological reactivity was operationalized as standardized changes in peripheral temperature, heart rate, and/or skin conductance from baseline to a stressful task. For the stressful task, children spoke into a tape recorder about a stressful or embarrassing event.

RESULTS

Each method classified 20% of children as repressive-defensive. However, of the children classified as repressive-defensive by either method (n = 26), only 38% (n = 10) were classified as repressive-defensive by both methods. In addition, regardless of the classification method, repressive-defensive children did not consistently differ from low-anxious children with respect to physiological reactivity under stress, one of the hallmarks of repressive-defensiveness in adults.

CONCLUSION

These results cast doubt on our ability to measure repressive-defensiveness reliably using self-report measures. Future research should determine whether children and adolescents can be reliably classified as repressive-defensive, whether this classification is related to physiological reactivity as in adults, and whether repressive-defensiveness plays a role in emotionally triggered asthma symptoms.

Psychological factors associated with emergency room visits among asthmatic patients

This study was designed to investigate physiological and psychological characteristics of subjects with high-frequency emergency room (ER) visits. Asthma status, psychological functioning and predispositions, psychosocial adaptation to asthma, and health behaviors were measured for 30 patients who had two or more ER visits during the last 2 years. These subjects were matched for age, sex, and corticosteroid use with 30 subjects who had no unscheduled ER visits for the same period. No significant differences were found for measures of asthma status. Among the asthma-specific variables, the number of hyperventilation-bronchoconstriction symptoms did not distinguish between the groups. High attenders reported more panic-fear symptoms, lower self-efficacy, and more perceived interference. There were no differences for measures of anxiety/depression, self-focused attention, or health locus of control. However, these variables were found to be significant predictors of panic-fear symptoms, lower self-efficacy, and more perceived interference.

Symptom perception in asthma: a multidisciplinary review

Clinical observations and research show that symptom perception in asthma is, at worst, inaccurate or often biased in two directions: (1) blunted perception, (2) overperception (both involving airway obstruction manifested in low or high breathlessness). Theoretically breathlessness occurs during respiratory labor or blood gas changes. However, pathophysiological factors and asthma severity are inconsistently related to perceptual accuracy. Consequently, symptom perception within the biomedical perspective is not well understood. Possible psychological influences, varying from the stimulus level to emotions and high-order reasoning, are discussed.

Personality profiles and breathlessness perception in outpatients with different gradings of asthma

We studied the relationship between personality profiles, breathlessness perception and clinical and functional features in 36 outpatient asthmatics (12 females; age range: 18-52 yr). Each patient underwent psychometric evaluation with Minnesota Multiphasic Personality Inventory (MMPI). Breathlessness perception was evaluated by Borg's scale during methacholine (M) challenge, and PS20 (the perception score obtained when FEV1 fell by 20%) was recorded. Baseline FEV1 values ranged from 70.0 to 126%. PC20 M values ranged from 0.05 to 31.7 mg/ml. According to a symptoms score system (0 to 12 points), 12 asthmatics were classified as mild, 12 as moderate, and 12 as moderate/severe. We did not find any specific personality profile in asthmatic patients. Sixteen asthmatics had at least one MMPI subscale score indicative of psychological disturbances. We found a significant trend from mild to moderate and moderate/severe asthmatics (p < 0.015), when the number of asthmatics with subscale scores indicative of psychological disturbances was compared to that of asthmatics with normal scores. Moreover, we found that the asthmatics with scores indicative of hypochondriasis showed a significant trend from mild to moderate and moderate/severe asthma (p < 0.015). Furthermore, in all asthmatic patients, hypochondriasis scores were positively correlated to asthma severity score (p < 0.02). PS20 values ranged from 0.1 to 8.1. Twelve asthmatics were hypoperceivers (PS20 < or = 1) and four were hyperperceivers (PS20 > or = 5). We observed a significant trend from mild to moderate and moderate/severe asthmatics (p < 0.025) when we compared the number of hypoperceivers to that of normoperceivers. In conclusion, we found that in outpatients with different grading of asthma, severity of disease is linked to psychological disturbances and poor perception of breathlessness, additionally, hypochondriasis was related to disease severity in all patients.

Defensiveness and perception of external inspiratory resistive loads in asthma

This study examined the relationship between defensiveness, as measured by the Marlowe-Crowne Social Desirability Scale (MCSDS), and the perception of an externally applied respiratory resistance among people with asthma. Thirty asthmatic adults breathed through nine levels of inspiratory resistive load. Participants higher on the MCSDS were less accurate than others in psychophysical magnitude estimates of resistive load, and showed a reduced relationship between the physical load and the quality of respiratory sensations associated with exposure to the resistors. Defensive subjects also showed a differentially high increase in correlation between unpleasantness of respiratory sensations and resistance levels after receiving parenteral naloxone. These findings are consistent with the hypothesis that defensiveness may increase risk of asthma morbidity, due to inaccuracy in detecting sensations of dyspnea during asthma exacerbations. The inaccuracy may be caused by elevated endogenous opioids among defensive individuals.

Association of anxiety with perception of histamine induced bronchoconstriction in patients with asthma

BACKGROUND

The perception of bronchoconstriction varies among patients with asthma and this perception may be related to the covariation of sensory and affective aspects of dyspnoea. A study was performed to evaluate whether there are differences in the perception of histamine induced bronchoconstriction between anxious and non-anxious perceivers and whether anxious perception of bronchoconstriction can be predicted by higher levels of baseline anxiety.

METHODS

Seventy eight asthmatic subjects referred for a histamine challenge test undertook baseline measures for anxiety symptomatology and forced expiratory volume in one second (FEV1) followed by perceived breathlessness (Borg scale), anxiety (SUDS), and FEV1 measurement before and during induced bronchoconstriction. Based on the correlation between Borg and SUDS scores, the patients were divided into anxious and non-anxious perceivers.

RESULTS

Forty one patients reported no anxiety during the challenge test. The anxious perceivers (n = 20) had higher levels of perceived breathlessness and anxiety at 20% fall in FEV1 and were more accurate in their perception of airways obstruction than non-anxious perceivers (n = 58). However, they did not report higher baseline levels of anxiety symptomatology.

CONCLUSIONS

Anxiety experienced during bronchial challenge testing may result from the accurate perception of physiological changes and further direct attention to airways obstruction.

Criminal recidivism predicted from narratives of violent juvenile delinquents

Youth violence poses a major public health problem. It is important to find treatable predictors of recidivism. Our Subjects had committed offenses of physical and sexual assault. The personality dimensions of restraint and distress were rated by two independent and blind raters from narratives of offender's committing offenses, which were obtained at baseline during incarceration. Inter and intrarater kappas for each narrative were significant. In a 10-13 year follow-up, subjects lowest in self- restraint had significantly higher recidivism and their reoffenses differed in quality. Restraint may be influenced by clinical intervention and constitutes a new target in the treatment of delinquents.

Perception of dyspnoea during acute changes in lung function in patients with either asthma or COPD

The aim of the study was to evaluate the relationship between several lung function indices and perceived dyspnoea during bronchoconstriction. Acute changes in lung function were induced by inhaled histamine followed by terbutaline, in 12 asthmatics and 12 subjects with chronic obstructive pulmonary disease (COPD). A bipolar visual analogue scale (VAS), allowing subjects to report either improvement or worsening when moving off from a 'nochange' midpoint, was used to rate shortness of breath. Large swings in ratings were seen in all asthmatics and in seven out of 12 COPD subjects (high perceivers). Using linear regression of VAS rating against parallel change in lung function, on a within-subject basis, the highest degree of correlation between dyspnoea and objective response was found to involve the change in specific inspiratory resistance (sRin) in the asthmatics. In the five low perceivers, the ability to discriminate an increase in airway obstruction, estimated as the VAS/change in lung function slope, was very poor. Using a stepwise multiple regression analysis, the sensation of dyspnoea was found to be significantly related to the FEV1 and the sRin in the asthmatics, to the inspiratory vital capacity and the maximal inspiratory flow at 50% FVC (MIF50) in the COPD subjects with high perception, and to the MIF50 in the COPD subjects with low perception.

Perceived symptoms and discomfort during induced bronchospasm: the role of temporal adaptation and anxiety

Using a mixed within-between design, this study was designed to evaluate the sensorial and cognitive/evaluative aspects of bronchoconstriction induced by progressive methacholine inhalation. 25 asthmatic patients and 15 normal controls were given two consecutive bronchoconstriction tests, inducing a fall of > 30% of the forced expiratory volume in 1 sec (FEV1), which was measured after each inhalation of methacholine. Immediately before each FEV1 measurement, Ss rated perceived bronchial closing, discomfort of breathing and anxiety, as well as the need to use a bronchodilator. In addition to state-anxiety, after each bronchoconstriction test asthma symptoms were evaluated by means of a Free Symptom Report and the Asthma Symptom Checklist. The results show that during the first test, asthmatic patients perceived their symptoms more accurately than non-asthmatic controls. However, during the second test, asthmatic patients became less accurate, while normal controls increased their accuracy of symptom report. These changes were not parallelled for the Free Symptom Report or the Asthma Symptom Checklist. These results suggest that, depending on situational circumstances, patients rely on their cognitive schemata to report asthma symptoms. Need for bronchodilator use was related to perceived discomfort but not to actual or perceived bronchial closing. Clinical implications of this study are discussed.

Bronchial asthma and personality dimensions: a multifaceted association

Personality dimensions seem to play an important role in chronic diseases by maintaining or increasing the patient's physical complaints. This study examines in bronchial asthma: (a) the relationships among clinical data, baseline lung function, and personality traits; and (b) the patient's characteristics related to the physician's judgement about his or her asthma severity. Five questionnaires measuring anxiety, depression, self-consciousness, and subjective symptoms were completed by 51 asthmatic patients. Responses to questionnaires and clinical and demographic data were factor-analyzed. Factor analysis revealed that the physician's severity judgement is based on elderly age, high scores on depression, and longer duration of asthma.

Perceptions of asthma severity: the role of negative affectivity

The role of negative affectivity on patients' perceptions of and behavior during asthma attacks was explored among 47 asthmatic subjects. Patients completed 17 to 30 daily questionnaires assessing negative affect, asthma perception, additional drug intake, search for medical assistance, and peak-flow measures of respiratory distress. Asthma perceptions were correlated with negative affect and educational level; the perception of the asthma severity, but not negative affect, did predict behavior during an attack. The importance of symptom perceptions for the clinical management of chronic asthma is underscored.

Accuracy of perception of severity of asthma: patients treated in general practice

OBJECTIVE

To determine the frequency of poor perception of severity of asthma in general practice.

DESIGN

Asthmatic patients recorded their perceived severity of asthma, with a visual analogue score, and a coded measurement of their peak expiratory flow up to four times daily for 14 consecutive days.

SETTINGS

11 general practices in and around Bristol.

SUBJECTS

255 asthmatic patients (139 men and 116 women) aged 17-76 who were recruited by random selection from the general practices' disease registers or when they requested prescriptions for inhaled bronchodilators.

MAIN OUTCOME MEASURES

Correlation between visual analogue scores and peak expiratory flow (as a percentage of predicted peak flow).

RESULTS

152 (60%) of the patients showed no significant correlation between visual analogue asthma scores and simultaneous peak flow measurements (p > 0.05) and were termed poor discriminators. The distribution of good and poor discriminators within each general practice was similar (chi 2 = 6.11, df = 10). The two groups were not characterised by differences in the maximum, minimum, or standard deviation of peak expiratory flow or visual analogue score; in age; or in the proportion of men and women in each group.

CONCLUSIONS

In general practice a high proportion of asthmatic patients do not reliably detect changes in their lung function. This reinforces the need for careful objective assessment of lung function in the management of asthma.

Asthma and emotion: a review

This review of the empirical literature on the relationship between asthma and emotion presents an explanatory model of the connection between them. Asthmatics tend to report and display a high level of negative emotion, and asthma exacerbations have been linked temporally to periods of heightened emotionality. Causality may be bidirectional. Hypothesized mediators for the relationship between asthma and emotionality include vagal and alpha-sympathetic hyperreactivity, predominant obstruction in the larger airways, individual response stereotypy, direct effects of emotion-related facial muscle tension on the airways, the emotional effects of asthma medications, heightened respiratory drive, and hyperventilation. Predictions are presented for research on this model of asthma and emotion, and for the psychological treatment of asthma.

Depressive symptoms and adaptive style in children with cancer

OBJECTIVE

This article explores the relationship between a repressive style of adaptation and depressive symptomatology.

METHODS

Thirty-one adolescent cancer patients were compared with 83 healthy high school students. Subjects with repressive adaptation were identified as those reporting low anxiety and high defensiveness. Depressive symptomatology was measured by self-report.

RESULTS

Patients with cancer reported significantly lower levels of depression, and a significantly higher proportion were identified as repressors. Repressor status accounted for significant variance in depression over that explained by illness.

CONCLUSIONS

Adaptive style may be common in medically ill children and may directly and indirectly influence psychological and medical outcome.