Asthma and panic in young adults: a 20-year prospective community study

Association between asthma and risk of cardiovascular disease in Korean adults

OBJECTIVES

Cardiovascular disease (CVD) is a major cause of death in Korea, and studies have reported that asthma can have a negative impact on CVD. This study aimed to identify the association between asthma and CVD, including the current status, treatment status, and duration of asthma in Korean adults.

METHODS

The Korea National Health and Nutrition Examination Survey (2016-2021) was used, and 34,384 adults aged 19 years or older were included. Exposures were asthma-related characteristics, and outcomes were hypertension, ischemic heart disease, and stroke. The association between asthma characteristics and CVD was analyzed using the chi-square test and multiple logistic regression analysis.

RESULTS

The asthma diagnosis experience rate of the population was 3.1%; 1.6% were currently suffering from asthma, 1.0% were receiving asthma treatment, 0.6% were receiving regular medication, and 1.5% had a disease duration of 11 years or more. The CVD diagnosis rates in the population were 20.2% for hypertension, 2.3% for ischemic heart disease, and 1.8% for stroke. Compared to those who had no asthma diagnosis, those who had been diagnosed with asthma (OR = 2.06, 95% CI = 1.47-2.87), received asthma treatment (OR = 1.93, 95% CI = 1.22-3.04), and had a long duration of asthma (OR = 3.54, 95% CI = 1.71-7.33) had a significantly higher risk of ischemic heart disease. However, hypertension and stroke were not significantly correlated with asthma-related characteristics.

CONCLUSIONS

Asthma diagnosis and asthma-related characteristics were associated with an increased risk of ischemic heart disease. Our study suggests that research on risk assessment and management of CVD in patients with asthma would be needed.

Breathing Pattern Disorder: Introduction and Diagnostics

Breathing pattern disorder (BPD) refers to a heterogenous condition, which features altered normal respiratory functioning that cannot be fully attributed to organic causes at the current time. Characteristic symptoms of this condition include dyspnea, and irregular ventilation. The diagnosis of BPD is made utilizing a combination of patient-reported experiences in the form of validated questionnaires, direct observation by experienced clinicians, and objective testing in the form of cardiopulmonary exercise testing.

Prevalence and characteristics of dysfunctional breathing in patients with asthma in the Japanese population

BACKGROUND

Dysfunctional breathing (DB) is a major asthma comorbidity; however, it is not well recognized in Japan. Moreover, it has rarely been reported in the asthma population, and its clinical characteristics are unclear. We aimed to clarify the clinical characteristics of DB as a comorbidity in patients with asthma in Japan. Questionnaire surveys were conducted among patients with asthma at medical facilities in three regions of Japan (Niigata, Kumamoto, and Tokyo).

METHODS

This cross-sectional questionnaire survey targeting patients with asthma who had regularly visited medical institutions and their doctors was conducted from September to November 2021. The questionnaire addressed the control status and method of treatment. The diagnosis of DB was evaluated using the Nijmegen questionnaire (NQ).

RESULTS

There were 2087 eligible participants. Based on their NQ scores, 217 patients were classified into the DB group (NQ ≥ 19). There were significant differences with respect to sex, disease duration, Asthma Control Test (ACT) scores, Patient Health Questionnaire-9 (PHQ-9) scores, type-2 biomarkers, pulmonary function indices, treatment methods, severity, and asthma exacerbations in the previous year between the DB and non-DB groups. In the multivariate analysis, there were significant differences in sex, disease duration (≥15 y), ACT scores (<20), and PHQ-9 scores (≥10). The cluster analysis of cases with DB classified the population into four clusters.

CONCLUSIONS

The asthma population with DB exhibited several characteristics, including depression and poorly controlled asthma. Further large-scale interventional investigations with longer follow-up periods are necessary to verify these findings.

The influence of asthma on neuroinflammation and neurodevelopment: From epidemiology to basic models

Asthma is a highly heterogeneous inflammatory disease that can have a significant effect on both the respiratory system and central nervous system. Population based studies and animal models have found asthma to be comorbid with a number of neurological conditions, including depression, anxiety, and neurodevelopmental disorders. In addition, maternal asthma during pregnancy has been associated with neurodevelopmental disorders in the offspring, such as autism spectrum disorders and attention deficit hyperactivity disorder. In this article, we review the most current epidemiological studies of asthma that identify links to neurological conditions, both as it relates to individuals that suffer from asthma and the impacts asthma during pregnancy may have on offspring neurodevelopment. We also discuss the relevant animal models investigating these links, address the gaps in knowledge, and explore the potential future directions in this field.

Predictors of asthma control differ from predictors of asthma attacks in children: The Swiss Paediatric Airway Cohort

BACKGROUND

It is unclear if predictors of asthma attacks are the same as those of asthma symptom control in children.

OBJECTIVE

We evaluated predictors for these two outcomes in a clinical cohort study.

METHODS

The Swiss Paediatric Airway Cohort (SPAC) is a multicentre prospective clinical cohort of children referred to paediatric pulmonologists. This analysis included 516 children (5-16 years old) diagnosed with asthma. At baseline, we collected sociodemographic information, symptoms, personal and family history and environmental exposures from a parental baseline questionnaire, and treatment and test results from hospital records. Outcomes were assessed 1 year later by parental questionnaire: asthma control in the last 4 weeks as defined by GINA guidelines, and asthma attacks defined as any unscheduled visit for asthma in the past year. We used logistic regression to identify and compare predictors for suboptimal asthma control and asthma attacks.

RESULTS

At follow-up, 114/516 children (22%), reported suboptimal asthma control, and 114 (22%) an incident asthma attack. Only 37 (7%) reported both. Suboptimal asthma control was associated with poor symptom control at baseline (e.g. ≥1 night wheeze/week OR: 3.2; 95% CI: 1.7-6), wheeze triggered by allergens (2.2; 1.4-3.3), colds (2.3; 1.4-3.6) and exercise (3.2; 2-5), a more intense treatment at baseline (2.4; 1.3-4.4 for Step 3 vs. 1), history of preschool (2.6; 1.5-4.4) and persistent wheeze (2; 1.4-3.2), and exposure to tobacco smoke (1.7; 1-2.6). Incident asthma attacks were associated with previous episodes of severe wheeze (2; 1.2-3.3) and asthma attacks (2.8; 1.6-5 for emergency care visits), younger age (0.8; 0.8-0.9 per 1 year) and non-Swiss origin (0.3; 0.2-0.5 for Swiss origin). Lung function, exhaled nitric oxide (FeNO) and allergic sensitization at baseline were not associated with control or attacks.

CONCLUSION

Children at risk of long-term suboptimal asthma control differ from those at risk of attacks. Prediction tools and preventive efforts should differentiate these two asthma outcomes.

Biofeedback Training to Increase P co2 in Asthma With Elevated Anxiety: A One-Stop Treatment of Both Conditions?

OBJECTIVE

Anxiety is highly prevalent in individuals with asthma. Asthma symptoms and medication can exacerbate anxiety, and vice versa. Unfortunately, treatments of comorbid anxiety and asthma are largely lacking. A problematic feature common to both conditions is hyperventilation. It adversely affects lung function and symptoms in asthma and anxiety. We examined whether a treatment to reduce hyperventilation, shown to improve asthma symptoms, also improves anxiety in asthma patients with high anxiety.

METHOD

One hundred twenty English- or Spanish-speaking adult patients with asthma were randomly assigned to either Capnometry-Assisted Respiratory Training (CART) to raise P co2 or feedback to slow respiratory rate (SLOW). Although anxiety was not an inclusion criterion, 21.7% met clinically relevant anxiety levels on the Hospital Anxiety and Depression Scale (HADS). Anxiety (HADS-A) and depression (HADS-D) scales, anxiety sensitivity (Anxiety Sensitivity Index [ASI]), and negative affect (Negative Affect Scale of the Positive Affect Negative Affect Schedule) were assessed at baseline, posttreatment, 1-month follow-up, and 6-month follow-up.

RESULTS

In this secondary analysis, asthma patients with high baseline anxiety showed greater reductions in ASI and PANAS-N in CART than in SLOW ( p values ≤ .005, Cohen d values ≥ 0.58). Furthermore, at 6-month follow-up, these patients also had lower ASI, PANAS-N, and HADS-D in CART than in SLOW ( p values ≤ .012, Cohen d values ≥ 0.54). Patients with low baseline anxiety did not have differential outcomes in CART than in SLOW.

CONCLUSIONS

For asthma patients with high anxiety, our brief training designed to raise P co2 resulted in significant and sustained reductions in anxiety sensitivity and negative affect compared with slow-breathing training. The findings lend support for P co2 as a potential physiological target for anxiety reduction in asthma.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT00975273 .

Association between asthma and generalized anxiety disorder-7 (GAD-7) in Korean adolescents

BACKGROUND

Asthma is known to be associated with a variety of psychological disorders, such as anxiety, but the association between adolescent asthma and anxiety has not been investigated in detail.

METHODS

We analyzed 2,322 physician-diagnosed adolescent asthma patients and 38,696 non-asthmatic adolescent participants from the 2020 Korean Youth Risk Behavior self-administered Survey. Anxiety status was assessed using the Generalized Anxiety Disorder-7 (GAD-7) questionnaires. Multiple logistic regression analyses with complex sampling was performed with adjustments for multiple confounding variables (socioeconomic, health behavior, and psychological factors) to explore the association between GAD-7 scores and adolescent asthma.

RESULTS

The asthma group had higher rates of anxiety (GAD-7 score ≥ 10) than the non-asthma group (5.0% and 6.7%, respectively; p < 0.001). After adjustment for multiple confounders, asthma was significantly associated with an increased risk of anxiety (GAD-7 score ≥ 10) (odds ratio [OR]: 1.09; 95% confidence interval [CI]: 1.06-1.12).

CONCLUSION

Asthma is associated with an increased prevalence of anxiety in Korean adolescents.

Respiratory psychophysiology and COVID-19: A research agenda

After multiple waves of the COVID-19 pandemic, it has become clear that the impact of SARS-CoV-2 will carry on for years to come. Acutely infected patients show a broad range of disease severity, depending on virus variant, vaccination status, age and the presence of underlying medical and physical conditions, including obesity. Additionally, a large number of patients who have been infected with the virus present with post-COVID syndrome. In September 2020, the International Society for the Advancement of Respiratory Psychophysiology organized a virtual interest meeting on 'Respiratory research in the age of COVID-19', which aimed to discuss how research in respiratory psychophysiology could contribute to a better understanding of psychophysiological interactions in COVID-19. In the resulting current paper, we propose an interdisciplinary research agenda discussing selected research questions on acute and long-term neurobiological, physiological and psychological outcomes and mechanisms related to respiration and the airways in COVID-19, as well as research questions on comorbidity and potential treatment options, such as physical rehabilitation.

Neuroimmune mechanisms in fear and panic pathophysiology

Panic disorder (PD) is unique among anxiety disorders in that the emotional symptoms (e.g., fear and anxiety) associated with panic are strongly linked to body sensations indicative of threats to physiological homeostasis. For example, panic attacks often present with feelings of suffocation that evoke hyperventilation, breathlessness, or air hunger. Due to the somatic underpinnings of PD, a major focus has been placed on interoceptive signaling and it is recognized that dysfunctional body-to-brain communication pathways promote the initiation and maintenance of PD symptomatology. While body-to-brain signaling can occur via several pathways, immune and humoral pathways play an important role in communicating bodily physiological state to the brain. Accumulating evidence suggests that neuroimmune mediators play a role in fear and panic-associated disorders, although this has not been systematically investigated. Currently, our understanding of the role of immune mechanisms in the etiology and maintenance of PD remains limited. In the current review, we attempt to summarize findings that support a role of immune dysregulation in PD symptomology. We compile evidence from human studies and panic-relevant rodent paradigms that indicate a role of systemic and brain immune signaling in the regulation of fear and panic-relevant behavior and physiology. Specifically, we discuss how immune signaling can contribute to maladaptive body-to-brain communication and conditioned fear that are relevant to spontaneous and conditioned symptoms of PD and identify putative avenues warranting future investigation.

Severe, but not moderate asthmatics share blood transcriptomic changes with post-traumatic stress disorder and depression

Asthma, an inflammatory disorder of the airways, is one of the most common chronic illnesses worldwide and is associated with significant morbidity. There is growing recognition of an association between asthma and mood disorders including post-traumatic stress disorder (PTSD) and major depressive disorder (MDD). Although there are several hypotheses regarding the relationship between asthma and mental health, there is little understanding of underlying mechanisms and causality. In the current study we utilized publicly available datasets of human blood mRNA collected from patients with severe and moderate asthma, MDD, and PTSD. We performed differential expression (DE) analysis and Gene Set Enrichment Analysis (GSEA) on diseased subjects against the healthy subjects from their respective datasets, compared the results between diseases, and validated DE genes and gene sets with 4 more independent datasets. Our analysis revealed that commonalities in blood transcriptomic changes were only found between the severe form of asthma and mood disorders. Gene expression commonly regulated in PTSD and severe asthma, included ORMDL3 a gene known to be associated with asthma risk and STX8, which is involved in TrkA signaling. We also identified several pathways commonly regulated to both MDD and severe asthma. This study reveals gene and pathway regulation that potentially drives the comorbidity between severe asthma, PTSD, and MDD and may serve as foci for future research aimed at gaining a better understanding of both the relationship between asthma and PTSD, and the pathophysiology of the individual disorders.

Change in Asthma Is Associated with Change in PTSD in World Trade Center Health Registrants, 2011 to 2016

The WTC Health Registry (WTCHR) is a closed, longitudinal cohort of rescue/recovery workers and survivors exposed to the 11 September 2001 disaster. WTCHR enrollees diagnosed with asthma after 11 September 2001 continued to experience poor control despite treatment. Asthma is associated with mental problems, although their bidirectional movement has not been studied. This study tested whether a clinical change in mental problems was associated with a difference in asthma control, and whether a change in asthma control varied with a change in quality of life (QoL). Difference in the Asthma Control Test (ACT) on the WTCHR from 2011-12 to 2015-16 was compared with the change in the Post-traumatic Stress Disorder Checklist (PCL-17), the Patient Health Questionnaire depression scale, self-reported heartburn, and change of physical and mental QoL over this period. In adjusted multinomial multivariable logistic regression, improved PCL-17 was associated with a better ACT score, odds ratio (OR) = 1.42 (95% C.I. 1.01, 1.99), and a worsened PCL-17 score was associated with a worsened ACT score, OR = 1.77 (95% C.I. 1.26, 2.50). Decreased ACT was associated with poor physical QoL, OR = 1.97 (95% C.I. 1.48, 2.62). Change in mental health measures tracked with change in asthma control, which correlated with a change in QoL. Careful follow-up and treatment of all three are indicated to improve these inter-related issues.

Premature death and causes of death among patients with panic disorder and comorbid psychiatric disorders: A nationwide cohort study

OBJECTIVES

Panic disorder (PD) is associated with high psychiatric and physical comorbidity, but the cause of mortality has not been well studied. This study investigated mortality rates and causes of death in an Asian cohort with PD.

METHODS

We enrolled a nationwide retrospective cohort of 298,466 persons diagnosed with PD from January 1, 2001, to December 31, 2016. Each cohort member was matched with a comparison one randomly selected from the general population with the same sex, age at entry, and birth year. The data of both the PD cohort and the comparison group were linked with the national mortality database to obtain each individual's mortality status. We used mortality rate ratios (MRRs) to compare mortality risks between the patients with PD and the general population. Stratified analysis of mortality risks was performed based on sex and psychiatric comorbidities.

RESULTS

PD was associated with a slightly increased mortality risk (MRR, 1.14 [99% CI, 1.11-1.17]). The risk of unnatural death (MRR, 2.83 [99% CI, 2.59-3.10]) was significantly higher among the individuals with PD than among the general population, whereas the risk of overall natural death across all categories was not (MRR, 1.01 [99% CI, 0.98-1.04]). The mortality risk was the highest for suicide (MRR, 4.94 [99% CI, 4.32-5.72]) and was higher in women (MRR, 6.37 [99% CI, 5.25-7.96]) than in men (MRR, 3.77 [99% CI, 3.14-4.64]). Comorbid substance use disorders increased the risk of mortality from natural (MRR, 3.23 [99% CI, 2.59-4.14]) and unnatural (MRR, 9.45 [99% CI, 6.29-17.85]) causes.

CONCLUSION

PD was associated with increased all-cause mortality, especially suicide. Substance use further increased mortality risk in persons with PD. Targeted treatment for substance use and suicide prevention are essential among persons with PD.

Intimate partner violence and asthma in pediatric and adult populations

OBJECTIVE

To evaluate the relationship between intimate partner violence (IPV) and adult and childhood asthma outcomes.

DATA SOURCES

We conducted a systematic literature review using 4 databases (PubMed, Ovid MEDLINE, Ovid Embase, and Ovid PsycINFO) with asthma and IPV-associated terms.

STUDY SELECTIONS

We included published studies, available in English, to October 2021, which included IPV as an exposure and asthma as an outcome. Both adult and pediatric populations were included in the following settings: community, health care, and home.

RESULTS

There were 37 articles identified. There was evidence among multiple studies to support increased prevalence of asthma in adults exposed to IPV and prevalence and incidence in children with parental IPV exposure. There were fewer studies evaluating IPV exposure and adult asthma morbidity, but they found statistically significant associations between IPV and increased rate of asthma exacerbations and worsened asthma control. There was sparse evidence evaluating a relationship between IPV and adult asthma mortality. There were no studies identified evaluating IPV and childhood asthma morbidity or mortality.

CONCLUSION

The association between IPV and increased asthma prevalence, incidence, and worsened morbidity merits recognition and further investigation into potential mechanisms. Health care providers can implement practical strategies to help mitigate the negative effects of IPV on health and asthma. These include addressing potential impactful biopsychosocial factors and comorbidities, implementing routine screening and referrals, and partnering with community advocacy organizations. Given their positions of respect and power in society, health care providers can have lasting impacts on the lives of pediatric and adult patients affected by IPV.

Asthma and early smoking associated with high risk of panic disorder in adolescents and young adults

PURPOSE

Studies have reported a strong link between asthma and panic disorder. We conducted a 17-year community-based large cohort study to examine the relationship between asthma, early smoking initiation, and panic disorder during adolescence and early adulthood.

METHODS

A total of 162,766 participants aged 11-16 years were categorized into asthma and nonasthma groups at baseline and compared within the observation period. Covariates during late childhood or adolescence included parental education, cigarette smoking by family members of participants, and participant's gender, age, alcohol consumption, smoking, and exercise habits. Data for urbanicity, prednisone use, allergic comorbidity, and Charlson comorbidity index were acquired from the National Health Insurance Research Database. The Cox proportional-hazards model was used to evaluate the association between asthma and panic disorder.

RESULTS

Our findings revealed that asthma increased the risk of panic disorder after adjustment for key confounders in the Cox proportional hazard regression model (adjusted HR: 1.70, 95% CI 1.28-2.26). Hospitalizations or visits to the emergency department for asthma exhibited a dose-response effect on the panic disorder (adjusted HR: 2.07, 95% CI 1.30-3.29). Patients with asthma with onset before 20 years of age who smoked during late childhood or adolescence had the greatest risk for panic disorder (adjusted HR: 4.95, 95% CI 1.23-19.90).

CONCLUSIONS

Patients newly diagnosed with asthma had a 1.7-times higher risk of developing panic disorder. Smoking during late childhood or adolescence increased the risk for developing the panic disorder in patients with asthma.

A feasibility trial of a digital mindfulness-based intervention to improve asthma-related quality of life for primary care patients with asthma

Asthma outcomes remain suboptimal, despite effective pharmacotherapy. Psychological dysfunction (such as anxiety) is common, and associated with poorer outcomes. We evaluated a digital mindfulness programme as an intervention to improve asthma-related quality of life for primary care patients, in a prospectively registered randomized-controlled feasibility study. We offered ‘Headspace’, a widely-used digital mindfulness intervention, to adults with asthma through 16 UK GP practices. Participants were randomized on a 2:1 basis to the mindfulness intervention, or waitlist control. Participants completed questionnaires (including asthma symptom control, asthma-related quality of life, anxiety, depression) at baseline, 6-week and 3-month follow-up. 116 participants completed primary outcomes at 3-month follow-up: intervention 73 (79%), control 43 (84%). Compared to baseline, the intervention group but not the control group reported significantly improved asthma-related quality of life, with a between-group difference favoring the intervention group that was not significant (Mean difference = 0.15, 95%CI − 0.13 to 0.42). Intervention use varied (ranging from 0 to 192 times) but was generally high. Digital mindfulness interventions are feasible and acceptable adjunct treatments for mild and moderate asthma to target quality of life. Further research should adapt ‘generic’ mindfulness-based stress-reduction to maximize effectiveness for asthma, and validate our findings in a fully-powered randomized controlled trial.

Trial registration Prospectively registered: ISRCTN52212323.

Further Exploration of Treatment Response in Latinos with Comorbid Asthma and Panic Disorder: A Brief Report of HRV and ETCO2 as Potential Mediators of Treatment Response

Heart rate variability (HRV) and end tidal CO2 (ETCO2) in relation to treatment response have not been studied in Latino populations or in comorbid asthma and panic disorder (PD). An extension of previously published research, the current study explored psychophysiological variables as possible mediators of treatment response. Latino treatment completers (N = 32) in the Bronx with asthma-PD received either Cognitive-Behavioral Psychophysiological Therapy (CBPT) or Music Relaxation Therapy (MRT). CBPT included HRV-biofeedback (HRVB); in-the-moment heart rate data to help an individual learn to influence his/her own heart rate. The sample was primarily female (93.8%) and Puerto Rican (81.25%). Treatment groups did not differ on demographics, except for less education in CBPT. The Panic Disorder Severity Scale (PDSS) and Asthma Control Questionnaire (ACQ) assessed changes in symptoms. HRV and ETCO2 were measured at four of eight therapy sessions. Baseline ETCO2 and changes in HRV from first to last of psychophysiology sessions were investigated as mediators of change on ACQ and PDSS. Mixed model analyses indicated in the CPBT group, changes in both asthma control and PD severity were not mediated by changes in HRV. In the CBPT and MRT groups combined, changes in PD severity were not mediated by baseline ETCO2. These findings may be due to the brevity of HRVB in CBPT, multiple treatment components, ETCO2 not directly targeted, and/or unique physiological pathways in Latinos with asthma-PD.

Anxiety disorders and asthma among adolescents in Uganda: role of early-life exposures

The reasons for the positive association between anxiety disorders and asthma are unknown. We investigated the possible role of shared exposures in early life. We conducted a case-control study among adolescents (age 12-17 years) with and without asthma in urban Uganda, as part of a larger asthma case-control study. Anxiety disorders were diagnosed by psychiatric clinical officers. We focused on generalised anxiety disorder (GAD), panic disorder and social anxiety disorder. Asthma was doctor-diagnosed by study clinicians. We used questionnaires to collect data on early-life exposures. The data were analysed using multiple logistic regression. We enrolled 162 adolescents; 73 of them had asthma. Adolescents with asthma were more likely to have any of the three anxiety disorders studied (46.6%) than adolescents without asthma (21.4%) (adjusted OR (aOR) 2.68, 95% CI 1.30-5.53). The association was strong for GAD (aOR 4.49, 95% CI 1.48-13.56) and panic disorder (aOR 5.43, 95% CI 2.11-14.02), but not for social anxiety disorder. The early-life risk factors associated with anxiety disorders among adolescents were similar to asthma risk factors previously published, including urban residence at birth (aOR 3.42, 95% CI 1.29-9.09) and during most of the first 5 years of life (aOR 2.87, 95% CI 1.07-7.66), father's tertiary education (aOR 2.09, 95% CI 1.00-4.37), and adolescent's history of other allergy-related diseases (aOR 4.64, 95% CI 1.66-13.00). We confirm a positive association between anxiety disorders and asthma among adolescents in urban Uganda. The early-life risk factors associated with anxiety disorders among adolescents were similar to those for asthma in the same age group, suggesting shared underlying environmental exposures.

Can Yogic Breathing Techniques Like Simha Kriya and Isha Kriya Regulate COVID-19-Related Stress?

The global impact of Coronavirus Disease 2019 (COVID-19) is tremendous on human life, not only affecting the physical and mental health of population but also impacting the economic system of countries and individual itself. The present situation demands prompt response toward COVID-19 by equipping the humans with strategies to overcome the infection and stress associated with it. These strategies must not only be limited to preventive and therapeutic measures, but also aim at improving immunity and mental health. This can be achieved by yogic breathing techniques. In this perspective, we emphasize the importance of yogic breathing, Simha Kriya and Isha kriya, the simple yet effective breathing techniques.

The impact of mental toughness and postural abnormalities on dysfunctional breathing in athletes

Background: While asthma and exercise-induced bronchoconstriction (EIB) can explain some cases of exertional dyspnea, the differential diagnosis of dyspnea is extensive. Dysfunctional breathing (DB) is a condition that is often overlooked and underdiagnosed. Pharmacologic treatments are available and widely utilized by clinicians for exertional dyspnea, but a better understanding of the non-pharmacologic treatments as well as psychological factors that play a role in DB can provide professional, elite amateurs, and recreational athletes with more therapeutic options.Measurement tools for mental toughness: Given the psychological components involved with these conditions, a tool to measure domains of sports mental toughness in athletes could help medical providers create a more comprehensive athlete profile which can be used in conjunction with standard pharmacologic therapy to provide a more effective treatment plan.Diagnosing DB: While normal breathing mechanics help shape appropriate posture and spinal stabilization, DB has been shown to contribute to pain and motor control deficits resulting in dysfunctional movement patterns, which further contribute to DB. Most respiratory specialists are unaware of how to assess the role of faulty sports technique, especially running gait, in dysfunctional breathing patterns making it difficult to recommend appropriate treatment and offer referrals for relevant therapies.Assessing postural changes: Three key components of proper running gait are reviewed and described in detail including trunk counter-rotation, extension of atlanto-occipital joint in conjunction with a forward tilted trunk, and ankle and hip joint range of motion.Conclusions: When underlying gait abnormalities and mental skills are addressed properly, they can disrupt poor breathing mechanics, facilitating a transition away from DB and toward healthier breathing patterns.KEY POINTS In summary, the following points should be considered when evaluating athletes who are having difficulty breathing even when compliant with their medications or if there is not an indication of asthma or EIB:Assess dysfunctional breathing (DB) with Nijmegen questionnaire (NQ).If DB is present, measure mental skills using the Sisu Quiz to determine an athlete's mental skills profile.Evaluate postural changes that may impact an athlete's ability to breathe.Using the three tools of the NQ, Sisu Quiz, and Postural assessments creates an athlete profile that is clinically useful to improve breathing technique.DB is often mistaken for other conditions for which medications are prescribed. By identifying DB early and making appropriate changes may negate or reduce the need for pharmacotherapy.Improving DB will improve athletic performance.

Impact of respiratory protective devices on respiration: Implications for panic vulnerability during the COVID-19 pandemic

BACKGROUND

The wearing of respiratory protective devices (RPDs) correctly and continually in situations where people are at risk of respiratory infections is crucial for infection prevention. Certain people are poorly compliant with RPDs due to RPD-related annoyance, including respiratory discomfort. We hypothesized that individuals vulnerable to panic attacks are included in this group. No published studies on this topic are available. The evidence for our hypothesis was reviewed in this study as a starting point for future research.

METHODS

We selected a set of experimental studies that measured the respiratory physiological burden in RPD wearers through objective and validated methods. We conducted a bibliographic search of publications in the PubMed database (January 2000-May 2020) to identify representative studies that may be of interest for panic respiratory pathophysiology.

RESULTS

Five studies were included. Wearing RPDs exerted significant respiratory effects, including increased breathing resistance, CO2 rebreathing due to CO2 accumulation in the RPD cavity, and decreased inhaled O2 concentration. We discussed the implications of these effects on the respiratory pathophysiology of panic.

LIMITATIONS

Most studies had a small sample size, with a preponderance of young participants. Different methodologies were used across the studies. Furthermore, differences in physical responses between wearing RPDs in experimental settings or daily life cannot be excluded.

CONCLUSIONS

This research supports the idea that panic-prone individuals may be at higher risk of respiratory discomfort when wearing RPDs, thereby reducing their tolerance for these devices. Strategies to decrease discomfort should be identified to overcome the risk of poor compliance.

Modulation of fear behavior and neuroimmune alterations in house dust mite exposed A/J mice, a model of severe asthma

Fear-associated conditions such as posttraumatic stress disorder (PTSD) and panic disorder (PD) are highly prevalent. There is considerable interest in understanding contributory risk and vulnerability factors. Accumulating evidence suggests that chronically elevated inflammatory load may be a potential risk factor for these disorders. In this regard, an association of asthma, a chronic inflammatory condition, with PTSD and PD has been reported. Symptoms of PD and PTSD are more prevalent in severe asthmatics, compared to those with mild or moderate asthma suggesting that factors that influence the severity of asthma, may also influence susceptibility to the development of fear-related disorders. There has been relatively little progress in identifying contributory factors and underlying mechanisms, particularly, the translation of severe asthma-associated lung inflammation to central neuroimmune alterations and behavioral manifestations remains unclear. The current study investigated the expression of behaviors relevant to PD and PTSD (CO₂ inhalation and fear conditioning/extinction) in A/J mice using a model of severe allergic asthma associated with a mixed T helper 2 (Th2) and Th17 immune response. We also investigated the accumulation of Th2- and Th17-cytokine expressing cells in lung and brain tissue, microglial alterations, as well as neuronal activation marker, delta FosB (ΔFosB)) in fear and panic regulatory brain areas. HDM-exposed mice elicited higher freezing during fear extinction. CO₂-associated spontaneous and conditioned freezing, as well as anxiety or depression-relevant exploratory and coping behaviors were not altered by HDM treatment. A significant increase in brain Th17-associated inflammatory mediators was observed prior to behavioral testing, accompanied by microglial alterations in specialized blood brain barrier-compromised circumventricular area, subfornical organ. Post extinction measurements revealed increased ΔFosB staining within the medial prefrontal cortex and basolateral amygdala in HDM-treated mice. Collectively, our data show modulation of brain immune mechanisms and fear circuits by peripheral airway inflammation, and is relevant to understanding the risk and comorbidity of asthma with fear-associated disorders such as PTSD.

Anxiety Disorders and Medical Comorbidity: Treatment Implications

Anxiety disorders are debilitating psychological disorders characterized by a wide range of cognitive and somatic symptoms. Anxiety sufferers have a higher lifetime prevalence of various medical problems. Chronic medical conditions furthermore increase the likelihood of psychiatric disorders and overall dysfunction. Lifetime rates of cardiovascular, respiratory, gastrointestinal, and other medical problems are disproportionately high in anxiety and panic/fear sufferers. The heightened comorbidity is not surprising as many symptoms of anxiety and panic/fear mimic symptoms of medical conditions. Panic disorder specifically is strongly linked to medical conditions due to its salient somatic symptoms, such as dyspnea, dizziness, numbness, chest pain, and heart palpitations, all of which can signal danger and deterioration for chronic disease sufferers. This chapter identifies shared correlates of medical illness and anxiety disorders and evidence for misinterpretation of symptoms as medically relevant and offers an analysis of implications for treatment of both types of conditions. We will concentrate on medical conditions with high associations for anxiety and panic by aspects of symptomatology, specifically neurological disorders (fibromyalgia, epilepsy, cerebral palsy), diabetes, gastrointestinal illness (irritable bowel syndrome, gastroesophageal reflux disease), and cardiovascular and respiratory illnesses (asthma).

Predictors of severe asthma attack re-attendance in Ecuadorian children: a cohort study

Asthma is a common cause of emergency care attendance in low- and middle-income countries (LMICs). While few prospective studies of predictors for emergency care attendance have been undertaken in high-income countries, none have been performed in a LMIC.We followed a cohort of 5-15-year-old children treated for asthma attacks in emergency rooms of public health facilities in Esmeraldas City, Ecuador. We collected blood and nasal wash samples, and performed spirometry and exhaled nitric oxide fraction measurements. We explored potential predictors for recurrence of severe asthma attacks requiring emergency care over 6 months' follow-up.We recruited 283 children of whom 264 (93%) were followed-up for ≥6 months or until their next asthma attack. Almost half (46%) had a subsequent severe asthma attack requiring emergency care. Predictors of recurrence in adjusted analyses were (adjusted OR, 95% CI) younger age (0.87, 0.79-0.96 per year), previous asthma diagnosis (2.2, 1.2-3.9), number of parenteral corticosteroid courses in previous year (1.3, 1.1-1.5), food triggers (2.0, 1.1-3.6) and eczema diagnosis (4.2, 1.02-17.6). A parsimonious Cox regression model included the first three predictors plus urban residence as a protective factor (adjusted hazard ratio 0.69, 95% CI 0.50-0.95). Laboratory and lung function tests did not predict recurrence.Factors independently associated with recurrent emergency attendance for asthma attacks were identified in a low-resource LMIC setting. This study suggests that a simple risk-assessment tool could potentially be created for emergency rooms in similar settings to identify higher-risk children on whom limited resources might be better focused.

Mental Illness Among Youth With Chronic Physical Conditions

BACKGROUND AND OBJECTIVES

Youth with chronic physical conditions (CPCs) may be at greater risk for developing chronic mental health conditions (MHCs), and limitations in the ability to engage in developmentally appropriate activities may contribute to the risk of MHCs among youth with CPCs. We compared the risk of incident MHCs in youth with and without CPCs and explored whether activity limitations contribute to any such association.

METHODS

The 2003-2014 Medical Expenditure Panel Survey provided a nationally representative cohort of 48 572 US youth aged 6 to 25 years. We calculated the 2-year cumulative incidence of MHCs overall and by baseline CPC status. Cox proportional hazard models were used to estimate the association between CPCs and incident MHCs, adjusting for sociodemographic characteristics. Stepwise models and the Sobel test evaluated activity limitations as a mediator of this relationship.

RESULTS

The 2-year cumulative incidence of MHCs was 7.8% overall, 11.5% in youth with CPCs (14.7% of sample), and 7.1% in those without. The adjusted risk of incident MHCs was 51% greater (adjusted hazard ratio 1.51; 95% confidence interval 1.30-1.74) in youth with CPCs compared with those without. Activity limitations mediated 13.5% of this relationship (P < .001).

CONCLUSIONS

This nationally representative cohort study supports the hypotheses that youth with CPCs have increased risk for MHCs and that activity limitations may play a role in MHC development. Youth with CPCs may benefit from services to bolster their ability to participate in developmentally important activities and to detect and treat new onset MHCs.

The Interaction Between Asthma and Anxiety: An Interpretative Phenomenological Analysis of Young People's Experiences

Asthma and anxiety are highly co-morbid, and their interaction leads to exacerbations for both conditions. This study explored the interplay between these two conditions from the perspective of children and adolescents. The objective was to identify potential mechanisms of interaction between asthma and anxiety, and to derive improvements for prevention and treatment. Eleven semi-structured interviews of young people (aged 11-15), who met criteria for both asthma and anxiety, were analysed using interpretative phenomenological analysis. Well-established qualitative research recommendations were followed to promote credibility and rigour in the findings. Eight themes emerged that were organised in three domains: (i) asthma affecting anxiety by inhibiting coping activities or developmental tasks and by triggering unhelpful thinking and behaviour; (ii) anxiety affecting asthma by impairing self-care and triggering hyperventilation; (iii) interactions between asthma and anxiety, including self-perpetuating feedback cycles and symptom confusion. The proposed mechanisms could help tailor cognitive-behavioural interventions to reduce anxiety and asthma complications.

Allergic rhinitis increases the risk of incident panic disorder among young individuals: A nationwide population-based cohort study in Taiwan

BACKGROUND

Studies have reported an association between allergy and panic disorder. However, few studies have explored the relationship between allergic rhinitis and panic disorder. Previous studies were limited by cross-sectional study designs, self-reported symptoms, absence of matched controls, and lack of consideration of the influence of steroid and comorbidities. This study aimed to explore the longitudinal association between allergic rhinitis and panic disorder in a large population-based cohort of young people.

METHODS

In this study, 79,917 new cases of allergic rhinitis between 1998 and 2012 in individuals younger than 20 years were identified from Taiwan's National Health Insurance Research Database. One control (nonallergic rhinitis) per case (allergic rhinitis) was randomly selected from the remaining sample, matching for age, sex, residence, and insurance premium. Both groups were followed until the end of 2013 for incidence of panic disorder. Cox regression analysis was performed, adjusting for sex, age, residence, insurance premium, systemic steroids, asthma, atopic dermatitis, allergic conjunctivitis, attention deficit hyperactivity disorder, depression, and Charlson index.

RESULTS

Allergic rhinitis was associated with a 2-fold increase in risk for panic disorder after adjustment for other variables. Additional independent risk factor of panic disorders were female sex, older age group, and depression.

LIMITATIONS

Lifestyle, substance use, smoking by the patient or family members, and psychosocial stressors were not evaluated.

CONCLUSIONS

Allergic rhinitis was associated with increased risk of panic disorder. Assessment and intervention of allergy rhinitis among young people with panic disorder are critical.

Allergies, asthma, and psychopathology in a nationally-representative US sample

BACKGROUND

Symptoms of depressed mood and anxiety have been associated with immune dysregulation and atopic disorders, however it is unclear whether this relationship spans other forms of psychopathology. The objective of this study was to use a large, population-based sample to examine the association between several common psychiatric conditions and two atopic disorders: seasonal allergies and asthma. This study also examined whether comorbidity between psychiatric disorders confounded the relationship between atopy and each psychiatric disorder.

METHODS

Data come from the Comprehensive Psychiatric Epidemiology Surveys, a nationally-representative sample of US adults (N = 10,309). Lifetime history of major depressive disorder (MDD), generalized anxiety disorder (GAD), panic disorder (PD), and post-traumatic stress disorder (PTSD) was assessed using the Composite International Diagnostic Inventory. History of seasonal allergies and asthma were assessed by self-report. Weighted logistic regression was used to evaluate the association between allergies and asthma and psychopathology. Psychiatric comorbidities were also examined as potential confounders.

RESULTS

Approximately 36.6% had a history of allergies and 11.5% a history of asthma. Seasonal allergies were positively associated with odds of MDD (Odds ratio (OR): 1.24, 95% Confidence Interval (CI): 1.06-1.46), GAD (OR: 1.54 (1.28-1.84)), PD (OR: 1.54 (1.24-1.91)), and PTSD (OR: 1.32 (1.09-1.59)). Asthma was not significantly associated with any psychiatric disorder. All significant associations persisted after adjustment for psychiatric comorbidities.

LIMITATIONS

Limitations include self-reporting of atopic disorder status and of all disorder ages of onset.

CONCLUSIONS

This study confirms the association between MDD and PD and seasonal allergies, and extends this relationship to GAD and PTSD.

Discomfort Intolerance in Relation to Asthma Outcomes

Anxiety symptoms and disorders are common among those with asthma and contribute to poorer health outcomes. Building on work examining anxiety-related cognitive-affective risk factors in asthma, the current study sought to explore associations between discomfort intolerance (i.e., the inability to withstand or tolerate unpleasant bodily sensations) in relation to lung function, asthma control, and quality of life. Participants were 61 adults with asthma (61.9% female; 54.8% African American; M age = 34.72, SD = 13.58) who were administered a self-report assessment battery and a lung function assessment. We found that, above and beyond the effects of anxiety sensitivity-physical concerns, greater discomfort intolerance was significantly associated with poorer lung function (9.5% variance), asthma control (9.9% variance), and overall asthma-related quality of life (11.7% variance) as well as the specific quality of life domains of activity limitations (12.6% variance) and asthma symptoms (6.8% variance). Thus, individuals with asthma who are unable to tolerate physical discomfort may be at risk for poor asthma outcomes and interventions to reduce discomfort intolerance could potentially be useful in this population.

Evaluating the role of mindfulness in terms of asthma-related outcomes and depression and anxiety symptoms among individuals with asthma

The aim of the current study was to examine the unique role of mindfulness skills in terms of: (1) asthma-related outcomes (i.e., asthma control, asthma quality of life); (2) depression symptoms; and (3) anxiety symptomatology (i.e., anxiety sensitivity, panic symptoms, global anxiety) among non-smoking adults with current asthma. Participants were 61 (61.9% female; Mage = 34.72 years, SD = 13.58, range = 18-65) non-smoking adults with current asthma who completed a battery of self-report measures. Results indicated that, after controlling for the effects of race and age, greater ability to describe present moment experiences was significantly associated with better asthma-related quality of life and lower levels of anxiety symptoms. Though mindfulness skills together were associated with lower levels of panic symptoms, there were no significant individual associations between specific skills and panic symptoms. Greater nonjudgment of present moment experiences was associated with lower levels of anxiety and anxiety sensitivity. Greater nonreactivity was significantly associated with lower levels of depression symptoms and anxiety sensitivity. Lastly, a greater ability to observe present moment experiences was associated with lower levels of anxiety sensitivity. Mindfulness was not significantly associated with asthma control. These findings suggest that it may be useful to target the mindfulness skills of describing, nonjudgment, and nonreactivity among individuals with asthma, particularly those with elevated levels of anxiety and depression, in order to improve psychological and asthma-related outcomes.

Toward a personalized therapy for panic disorder: preliminary considerations from a work in progress

Although several treatment options for panic disorder (PD) are available, the best intervention for each individual patient remains uncertain and the use of a more personalized therapeutic approach in PD is required. In clinical practice, clinicians combine general scientific information and personal experience in the decision-making process to choose a tailored treatment for each patient. In this sense, clinicians already use a somehow personalized medicine strategy. However, the influence of their interpretative personal models may lead to bias related to personal convictions, not sufficiently grounded on scientific evidence. Hence, an effort to give some advice based on the science of personalized medicine could have positive effects on clinicians' decisions. Based on a narrative review of meta-analyses, systematic reviews, and experimental studies, we proposed a first-step attempt of evidence-based personalized therapy for PD. We focused on some phenomenological profiles, encompassing symptoms during/outside panic attacks, related patterns of physiological functions, and some aspects of physical health, which might be worth considering when developing treatment plans for patients with PD. We considered respiratory, cardiac, vestibular, and derealization/depersonalization profiles, with related implications for treatment. Given the extensiveness of the topic, we considered only medications and some somatic interventions. Our proposal should be considered neither exhaustive nor conclusive, as it is meant as a very preliminary step toward a future, robust evidence-based personalized therapy for PD. Clearly much more work is needed to achieve this goal, and recent technological advances, such as wearable devices, big data platforms, and the application of machine learning techniques, may help obtain reliable findings. We believe that combining the efforts of different research groups in this work in progress can lead to largely shared conclusions in the near future.

Retrospectively reported childhood adversity is associated with asthma and chronic bronchitis, independent of mental health

Several researchers have raised the concern that the cross-sectional association of retrospectively reported childhood adversity with self-reported onset of asthma and chronic bronchitis in adulthood may be confounded, as well as mediated by an individual's mental health. The aim of this study was to assess the effect of retrospectively reported childhood adversity on self-reported onset of asthma and chronic bronchitis in adulthood, independent of potential confounding and mediating variables (including respondent's mental health). We used data collected in 2007-2008 within the framework of the Tromsø Study (N = 12,981), a representative study of adult men and women in Norway. The associations of childhood adversity with asthma and chronic bronchitis were assessed with Poisson regression models. Relative risks (RR) and 95% confidence intervals (CI) were estimated with bias-corrected bootstrapping. Childhood adversity was associated with a 9% increased risk of asthma (RR = 1.09, 95% CI: 1.02, 1.16) and a 14% increased risk chronic bronchitis (RR = 1.14, 95% CI: 1.03, 1.26) in adulthood, independent of age, sex, parental history of psychiatric problems/asthma/dementia, education, smoking, social support, and respondent's mental health. Controlling for indicators of respondent's mental health reduced the strength of associations of childhood adversity with asthma and chronic bronchitis; however, the associations were still present in the same direction (p < .05). These findings suggest that the association of retrospectively reported childhood adversity with asthma and chronic bronchitis is independent of respondent's mental health. We recommend controlling for indicators of the respondent's mental health to assess an unbiased association of retrospectively measured childhood adversity with self-reported asthma and chronic bronchitis.

Physician perceptions of children's coping with asthma are associated with children's psychosocial and disease functioning

INTRODUCTION

Low-income, ethnic minority children disproportionately face poor asthma control, and poorly controlled asthma is related to psychosocial difficulties. This study assessed physician reports of coping in child patients and examined associations between physician reports of child coping and parent and child reports of children's coping, psychosocial, and asthma outcomes (asthma-related stress, emotional and behavioral problems, asthma control, and school missed due to asthma).

METHOD

Physicians reported on coping in their patients (N = 67) ages 5-17 with asthma. Parents reported on child coping, asthma-related stress, emotional and behavioral problems, asthma control, and school missed due to asthma. Children ages 9-17 provided self-reports.

RESULTS

Physicians' reports of primary control coping (e.g., problem solving) and secondary control coping (e.g., cognitive restructuring) were not associated with parent ratings of corresponding coping strategies, but physician reports of disengagement coping (e.g., avoidance) were correlated with parent reports of disengagement and secondary control coping. Physician perceptions of higher child primary control, and lower disengagement, were correlated with less parent-reported stress, better asthma control, and for primary control, fewer partial days of school missed. Physician reports were not correlated with child reports of coping, but physician reports of disengagement were correlated with child-reported conduct problems.

DISCUSSION

Findings suggest that physician reports of child coping provide independent information from parent and child reports of coping, and could be leveraged to identify and intervene with patients who are at elevated risk for poor outcomes. (PsycINFO Database Record

Predictors of repeated acute hospital attendance for asthma in children: A systematic review and meta-analysis

BACKGROUND

Asthma attacks are common and have significant physical, psychological, and financial consequences. Improving the assessment of a child's risk of subsequent asthma attacks could support front-line clinicians' decisions on augmenting chronic treatment or specialist referral. We aimed to identify predictors for emergency department (ED) or hospital readmission for asthma from the published literature.

METHODS

We searched MEDLINE, EMBASE, AMED, PsycINFO, and CINAHL with no language, location, or time restrictions. We retrieved observational studies and randomized controlled trials (RCT) assessing factors (personal and family history, and biomarkers) associated with the risk of ED re-attendance or hospital readmission for acute childhood asthma.

RESULTS

Three RCTs and 33 observational studies were included, 31 from Anglophone countries and none from Asia or Africa. There was an unclear or high risk of bias in 14 of the studies, including 2 of the RCTs. Previous history of emergency or hospital admissions for asthma, younger age, African-American ethnicity, and low socioeconomic status increased risk of subsequent ED and hospital readmissions for acute asthma. Female sex and concomitant allergic diseases also predicted hospital readmission.

CONCLUSION

Despite the global importance of this issue, there are relatively few high quality studies or studies from outside North America. Factors other than symptoms are associated with the risk of emergency re-attendance for acute asthma among children. Further research is required to better quantify the risk of future attacks and to assess the role of commonly used biomarkers.

Breathlessness amplifies amygdala responses during affective processing

Breathlessness is an aversive symptom in many prevalent somatic and psychiatric diseases and is usually experienced as highly threatening. It is strongly associated with negative affect, but the underlying neural processes remain poorly understood. Therefore, using fMRI, the present study examined the effects of breathlessness on the neural processing of affective visual stimuli within candidate brain areas including the amygdala, insula, and anterior cingulate cortex (ACC). During scanning, 42 healthy volunteers, mean (SD) age: 29.0 (6.0) years, 14 female, were presented with affective picture series of negative, neutral, and positive valence while experiencing either no breathlessness (baseline conditions) or resistive-load induced breathlessness (breathlessness conditions). Respiratory measures and self-reports suggested successful induction of breathlessness and affective experiences. Self-reports of breathlessness intensity and unpleasantness were significantly higher during breathlessness conditions, mean (SD): 45.0 (16.6) and 32.3 (19.8), as compared to baseline conditions, mean (SD): 1.9 (3.0) and 2.9 (5.5). Compared to baseline conditions, stronger amygdala activations were observed during breathlessness conditions for both negative and positive affective picture series relative to neutral picture series, while no such effects were observed in insula and ACC. The present findings demonstrate that breathlessness amplifies amygdala responses during affective processing, suggesting an important role of the amygdala for mediating the interactions between breathlessness and affective states.

The familial aggregation of atopic diseases and depression or anxiety in children

Background

Children with asthma and atopic diseases have an increased risk of depression or anxiety. Each of these diseases has strong genetic and environmental components; therefore, it seems likely that there is a shared liability rather than causative risk.

Objective

To investigate the existence and nature of familial aggregation for the comorbidity of atopic diseases and depression or anxiety.

Methods

Participants came from the Childhood and Adolescent Twin Study in Sweden (CATSS), n = 14 197. Current and ever asthma, eczema, hay fever and food allergy were reported by parents. Internalizing disorders were identified using validated questionnaires. Familial co‐aggregation analysis compared monozygotic (MZ) twins and same‐sex dizygotic (DZ) twins for atopic disease in 1 twin with internalizing disorder in the other to test for genetic liability. Several familial liability candidates were also tested including parental education, recent maternal psychological stress, childhood family trauma and parental country of birth.

Results

Familial co‐aggregation analysis found that if 1 twin had at least 1 current atopic disease the partner twin was at risk of having an internalizing disorder regardless of their own atopic status (adjusted OR 1.22 (95% CI 1.08, 1.37). Similar results were found for each atopic disease ever and current. MZ associations were not higher than DZ associations, suggesting that the liability is not genetic in nature. Including other familial candidates to the models made little difference to effect estimates.

Conclusions and Clinical Relevance

Atopic diseases and depression or anxiety tend to occur together in families; therefore, when treating for 1 disease, the physician should consider comorbidity in both the individual and the individual's siblings. We did not find evidence to support a genetic explanation for comorbidity, and further exploration is needed to disentangle the environmental and epigenetic reasons for familial aggregation.

Tobacco-Free Cigarette Smoke Exposure Induces Anxiety and Panic-Related Behaviours in Male Wistar Rats

Smokers, who generally present with lung damage, are more anxious than non-smokers and have an associated augmented risk of panic. Considering that lung damage signals specific neural pathways that are related to affective responses, the aim of the present study was to evaluate the influence of pulmonary injury on anxiety and panic-like behaviours in animals exposed to cigarette smoke with and without tobacco. Male Wistar rats were divided into the following groups: a control group (CG); a regular cigarette group (RC); and a tobacco-free cigarette (TFC) group. Animals were exposed to twelve cigarettes per day for eight consecutive days. The animals were then exposed to an elevated T-maze and an open field. The RC and TFC groups presented increases in inflammatory cell inflow, antioxidant enzyme activity, and TBARS levels, and a decrease in the GSH/GSSG ratio was observed in the TFC group. Exposure to RC smoke reduced anxiety and panic-related behaviours. On the other hand, TFC induced anxiety and panic-related behaviours. Thus, our results contradict the concept that nicotine is solely accountable for shifted behavioural patterns caused by smoking, in that exposure to TFC smoke causes anxiety and panic-related behaviours.

Is panic disorder a disorder of physical fitness? A heuristic proposal

Currently, panic disorder (PD) is considered a mental disorder based on the assumptions that panic attacks (PAs) are “false alarms” that arise from abnormally sensitive defense systems in the central nervous system and that PD is treated with therapies specifically acting on anxiety or fear mechanisms. This article aims to propose an alternative perspective based on the results of some experimental studies. Our heuristic proposal suggests not only that PD may be a mental disorder but also that patients with PD have real abnormal body functioning, mainly involving cardiorespiratory and balance systems, leading to a decline in global physical fitness. PAs, as well as physical symptoms or discomfort in some environmental situations, may be “real alarms” signaling that the adaptability resources of an organism are insufficient to respond appropriately to some internal or external changes, thus representing the transient conscious awareness of an imbalance in body functioning. The antipanic properties of several modern treatments for PD may include their beneficial effects on body functions. Although anxiety or fear mechanisms are evidently involved in PD, we hypothesize that a reduction of physical fitness is the “primum movens” of PD, while anxiety or fear is induced and sustained by repeated signals of impaired body functioning. We propose considering panic in a broader perspective that offers a central role to the body and to contemplate the possible role of somatic treatments in PD.

Cytokine alterations in panic disorder: A systematic review

BACKGROUND

Panic disorder (PD) occurs in 3.4-4.7% of the general population. Although accumulating evidence suggests that some inflammatory processes play a role in the pathophysiology of mental disorders, very few studies have evaluated cytokine levels in patients with PD. The aim of the present study was to systematically review the characteristic cytokine profile of PD patients and discuss some possibilities for future trials on this common and disabling disorder.

METHODS

A comprehensive literature search was carried out in PubMed and Web of Science databases (search terms: "panic disorder" or "panic attacks" and IL-1, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12, IL-13, TNF-alpha and INF-gamma).

RESULTS

Eleven studies involving measurements of cytokines in PD patients were included in this review article. Increased serum levels of some inflammatory markers such as IL-6, IL-1β and IL-5 were reported in PD patients compared with control subjects. There are some conflicting results regarding IL-2, IL-12, and INF-γ in association with PD.

LIMITATIONS

There are discrepant findings in the existing literature regarding PD and cytokines. A significant portion of the recognized heterogeneity may be attributable to variability in assay procedures. The discrepant findings may also have been due to differences in the study populations.

CONCLUSIONS

Cytokines induce the production of acute-phase proteins and are linked to neurogenesis, modification of the HPA axis, microglial activation, tryptophan metabolism and an imbalance in excitatory and inhibitory neurotransmission. Investigation of inflammatory biomarkers in PD could contribute to understanding the pathophysiological mechanisms in this debilitating disorder.

The role of anxiety sensitivity-physical concerns in terms of quit day withdrawal symptoms and cravings: A pilot test among smokers with asthma

OBJECTIVE

The aim of the current study was to conduct secondary analyses of data collected from a study examining a self-guided quit attempt of smokers with and without asthma in order to examine the unique predictive ability of precessation (i.e., baseline) anxiety sensitivity physical concerns in terms of quit day withdrawal symptoms and cravings among abstinent smokers with asthma.

METHODS

Participants were 24 regular cigarette smokers with asthma (50% female, M_age = 37.63 years, SD = 12.20) who participated in a self-guided-quit attempt and were able to maintain abstinence on their quit day.

RESULTS

After controlling for the effects of the cognitive and social concerns domains of anxiety sensitivity, anxiety sensitivity-physical concerns significantly predicted greater quit day withdrawal symptoms (20.8% unique variance) and urges to smoke (38.0% unique variance).

CONCLUSIONS

These findings suggest that smokers with asthma who fear anxiety-related sensations due to their feared physical consequences are more likely to experience intense withdrawal symptoms and desire to smoke at the beginning of a quit attempt. Clinically, smokers with higher levels of anxiety sensitivity physical concerns may benefit from smoking cessation interventions that specifically target anxiety sensitivity as well as prolonged use of nicotine replacement therapies to target withdrawal symptoms and cravings.

Panic-like escape response elicited in mice by exposure to CO2, but not hypoxia

Exposure to elevated concentrations of CO₂ or hypoxia has been widely used in psychiatric research as a panic provoking stimulus. However, the use of these respiratory challenges to model panic-like responses in experimental animals has been less straightforward. Little data is available, from behavioral and endocrine perspectives, to support the conclusion that a marked aversive situation, such as that experienced during panic attacks, was evoked in these animals. We here compared the behavioral responses of male CB57BL/6 mice during exposure to 20% CO₂ or 7% O₂ and its consequence on plasma levels of corticosterone. We also evaluated whether clinically-effective panicolytic drugs affect the behavioral responses expressed during CO₂ exposure. The results showed that whereas hypoxia caused a marked reduction in locomotion, inhalation of CO₂-enriched air evoked an active escape response, characterized by bouts of upward leaps directed to the border of the experimental cage, interpreted as escape attempts. Corticosterone levels were increased 30min after either of the respiratory challenges used, but it was higher in the hypoxia group. Chronic (21days), but not acute, treatment with fluoxetine or imipramine (5, 10 or 15mg/kg) or a single injection of alprazolam (0.025, 0.05 or 0.1mg/kg), but not of the anxiolytic diazepam (0.025, 0.05 or 0.1 and 1mg/kg) reduced the number of escape attempts, indicating a panicolytic-like effect. Altogether, the results suggest that whereas hypoxia increased anxiety, exposure to 20% CO₂ evoked a panic-like state. The latter condition/test protocol seems to be a simple and validated model for studying in mice pathophysiological mechanisms and the screening of novel drugs for panic disorder.

Anxiety in youth with asthma: A meta-analysis

OBJECTIVES

Anxiety often presents comorbidly with asthma in youth under 18; however, prevalence rates are unclear. The aim of this review was to provide an up-to-date analysis of the literature investigating the prevalence of anxiety disorders, and comparisons of anxiety disorders and symptomatology in youth with asthma, compared to those without.

METHODS

A systematic search was conducted using the databases PsycINFO, MEDLINE, EMBASE, and CINAHL.

RESULTS

The search process produced 15 studies (n = 7443) reporting data on youth with asthma and anxiety disorders, 11 studies (n = 10 332) reporting data on youth with and without asthma and anxiety disorders, and 28 studies (n = 5848) reporting data on youth with and without asthma and anxiety symptomatology. Youth with asthma had an anxiety disorder prevalence rate of 22.7%. Youth with asthma also had a greater number of anxiety disorders, compared to those without asthma (d = 0.37, 95%CI: 0.24-0.50, P < 0.001), and higher levels of anxiety symptomatology than youth without asthma (d = 0.29, 95%CI: 0.19-0.39, P < 0.001).

CONCLUSIONS

Youth with asthma display a prevalence rate for anxiety disorders that is more than three times higher than the prevalence in healthy youth. For the specific anxiety disorders investigated, elevated prevalence rates for youth with asthma were also found. Future research needs to focus on the factors that mediate or predict the development and maintenance of anxiety in youth with asthma and the development of clinically efficacious treatments.

Impact of Panic Attacks on Bronchoconstriction and Subjective Distress in Asthma Patients With and Without Panic Disorder

OBJECTIVE

Panic disorder (PD) is common among asthma patients and is associated with worse asthma outcomes. This may occur because of psychophysiological factors or cognitive/affective factors. This study evaluated the impact of panic attacks (PAs) on bronchoconstriction and subjective distress in people who have asthma with and without PD.

METHODS

A total of 25 asthma patients (15 with PD who had a PA [PD/PA], 10 without PD who did not have a PA [no PD/no PA]) were recruited from an outpatient clinic. They underwent a panic challenge (one vital capacity inhalation of 35% carbon dioxide [CO2]) and completed the Panic Symptom Scale, the Subjective Distress Visual Analogue Scale, and the Borg Scale before and after CO2. Forced expiratory volume in 1 second was assessed pre- and post-CO2; respiratory (i.e., CO2 production, minute ventilation, tidal volume) was continuously recorded, and physiological measures (i.e., systolic and diastolic blood pressure [SBP/DBP]) were recorded every 2 minutes.

RESULTS

Analyses adjusting for age, sex, and provocative concentration of methacholine revealed no significant differences between groups in forced expiratory volume in 1 second change after CO2 inhalation (F(1, 23) < 0.01, p = .961). However, patients with PD/PA reported more panic (F(1, 22) = 18.10, p < .001), anxiety (F(1, 22) = 21.93, p < .001), worry (F(1, 22) = 26.31, p < .001), and dyspnea (F(1,22) = 4.68, p = .042) and exhibited higher levels of CO2 production (F(1, 2843) = 5.89, p = .015), minute ventilation (F(1, 2844) = 4.48, p = .034), and tidal volume (F(1, 2844) = 4.62, p = .032) after the CO2 challenge, compared with patients with no PD/no PA.

CONCLUSIONS

Results, presented as hypothesis generating, suggest that asthma patients with PD/PA exhibit increased panic-like anxiety, breathlessness, and a respiratory pattern consistent with hyperventilation that was not linked to statistically significant drops in bronchoconstriction.

Addressing unmet needs in understanding asthma mechanisms: From the European Asthma Research and Innovation Partnership (EARIP) Work Package (WP)2 collaborators

Asthma is a heterogeneous, complex disease with clinical phenotypes that incorporate persistent symptoms and acute exacerbations. It affects many millions of Europeans throughout their education and working lives and puts a heavy cost on European productivity. There is a wide spectrum of disease severity and control. Therapeutic advances have been slow despite greater understanding of basic mechanisms and the lack of satisfactory preventative and disease modifying management for asthma constitutes a significant unmet clinical need. Preventing, treating and ultimately curing asthma requires co-ordinated research and innovation across Europe. The European Asthma Research and Innovation Partnership (EARIP) is an FP7-funded programme which has taken a co-ordinated and integrated approach to analysing the future of asthma research and development. This report aims to identify the mechanistic areas in which investment is required to bring about significant improvements in asthma outcomes.

Mental Health Services Claims and Adult Onset Asthma in Ontario, Canada

BACKGROUND

Living with asthma is associated with a decrease in quality of life due to reductions in activities of daily living and increased psychological stress, both of which are associated with poor mental health outcomes.

OBJECTIVE

The objective of this study was to quantify the burden of mental disorders on the adult asthma population and compare the risk of mental health services claims (MHSCs) in the 1 year before and 1 year after asthma diagnosis.

METHODS

Ontario residents aged 25 to 65 years with incident physician-diagnosed asthma between April 1, 2005, and March 31, 2012, were included. MHSCs, which consisted of hospitalizations, emergency department (ED), and outpatient physician visits, were identified from universal health administrative data. Poisson regression models with repeated measures were used to estimate the relative risk (RR) of MHSCs for 2 time periods: 1 year after asthma diagnosis compared with the 1 year before and 2 years after compared with 2 years before.

RESULTS

A total of 145,881 adults had incident asthma. In the 1 year after asthma diagnosis, 27% had an MHSC. The risk of ED visits for any mental disorders increased by 13% in the 1 year after asthma diagnosis compared with the 1 year before (adjusted RR [aRR], 1.13; 95% confidence interval [CI], 1.06-1.21). This increased risk of ED visits was not found when comparing 2 years after asthma diagnosis with 2 years before. The risk for outpatient physician visits for substance-related disorders increased by 21% at 1 year (aRR, 1.21; 95% CI, 1.14-1.28) and 37% at 2 years (aRR, 1.37; 95% CI, 1.28-1.46).

CONCLUSIONS

The significant comorbid burden of mental disorders in adults with newly diagnosed asthma highlights the need for primary care physicians to assess mental health needs and provide appropriate care.

Panic Disorder Comorbidity with Medical Conditions and Treatment Implications

Panic disorder (PD) is unique among the anxiety disorders in that panic symptoms are primarily of a physical nature. Consequently, comorbidity with medical illness is significant. This review examines the association between PD and medical illness. We identify shared pathophysiological and psychological correlates and illustrate how physiological activation in panic sufferers underlies their symptom experience in the context of the fight-or-flight response and beyond a situation-specific response pattern. We then review evidence for bodily symptom perception accuracy in PD. Prevalence of comorbidity for PD and medical illness is presented, with a focus on respiratory and cardiovascular illness, irritable bowel syndrome, and diabetes, followed by an outline for potential pathways of a bidirectional association. We conclude by illustrating commonalities in mediating mechanistic pathways and moderating risk factors across medical illnesses, and we discuss implications for diagnosis and treatment of both types of conditions.

Evaluation of smokers with and without asthma in terms of smoking cessation outcome, nicotine withdrawal symptoms, and craving: Findings from a self-guided quit attempt

INTRODUCTION

The aim of the current study was to evaluate smoking cessation outcome, nicotine withdrawal symptoms, and craving between smokers with (n=47; 46.8% male, Mage=40.0years, SD=11.7) and without (n=45; 51.1% male, Mage=37.5years, SD=11.1) asthma during a self-guided quit attempt.

METHODS

After completing a baseline assessment visit, participants attended study sessions on their scheduled quit day as well as follow-up visits (3days, 7days, 14days, and 28days) after their quit day.

RESULTS

Smokers with and without asthma did not differ in abstinence rates, smoking lapse, and rate of change in urge to smoke to reduce negative affect. However, smokers with asthma demonstrated a slower rate of decline in nicotine withdrawal symptoms and craving over time.

CONCLUSIONS

These findings suggest that smokers with asthma may benefit from specialized smoking cessation treatments to address prolonged withdrawal symptoms and craving.

Psychological treatment of comorbid asthma and panic disorder in Latino adults: Results from a randomized controlled trial

Confusion between panic and asthma symptoms can result in serious self-management errors. A cognitive behavior psychophysiological therapy (CBPT) intervention was culturally adapted for Latinos consisting of CBT for panic disorder (PD), asthma education, differentiation between panic and asthma symptoms, and heart rate variability biofeedback. An RCT compared CBPT to music and relaxation therapy (MRT), which included listening to relaxing music and paced breathing at resting respiration rates. Fifty-three Latino (primarily Puerto Rican) adults with asthma and PD were randomly assigned to CBPT or MRT for 8 weekly sessions. Both groups showed improvements in PD severity, asthma control, and several other anxiety and asthma outcome measures from baseline to post-treatment and 3-month follow-up. CBPT showed an advantage over MRT for improvement in adherence to inhaled corticosteroids. Improvements in PD severity were mediated by anxiety sensitivity in CBPT and by depression in MRT, although earlier levels of these mediators did not predict subsequent improvements. Attrition was high (40%) in both groups, albeit comparable to CBT studies targeting anxiety in Latinos. Additional strategies are needed to improve retention in this high-risk population. Both CBPT and MRT may be efficacious interventions for comorbid asthma-PD, and CBPT may offer additional benefits for improving medication adherence.