Psychiatric morbidity in patients with life-threatening asthma: initial report of a controlled study

The role of inflammation in anxiety and depression in the European U-BIOPRED asthma cohorts

BACKGROUND

Growing evidence indicates high comorbid anxiety and depression in patients with asthma. However, the mechanisms underlying this comorbid condition remain unclear. The aim of this study was to investigate the role of inflammation in comorbid anxiety and depression in three asthma patient cohorts of the Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes (U-BIOPRED) project.

METHODS

U-BIOPRED was conducted by a European Union consortium of 16 academic institutions in 11 European countries. A subset dataset from subjects with valid anxiety and depression measures and a large blood biomarker dataset were analysed, including 198 non-smoking patients with severe asthma (SAn), 65 smoking patients with severe asthma (SAs), 61 non-smoking patients with mild-to-moderate asthma (MMA), and 20 healthy non-smokers (HC). The Hospital Anxiety and Depression Scale was used to measure anxiety and depression and a series of inflammatory markers were analysed by the SomaScan v3 platform (SomaLogic, Boulder, Colo). ANOVA and the Kruskal-Wallis test were used for multiple-group comparisons as appropriate.

RESULTS

There were significant group effects on anxiety and depression among the four cohort groups (p < 0.05). Anxiety and depression of SAn and SAs groups were significantly higher than that of MMA and HC groups (p < 0.05. There were significant differences in serum IL6, MCP1, CCL18, CCL17, IL8, and Eotaxin among the four groups (p < 0.05). Depression was significantly associated with IL6, MCP1, CCL18 level, and CCL17; whereas anxiety was associated with CCL17 only (p < 0.05).

CONCLUSIONS

The current study suggests that severe asthma patients are associated with higher levels of anxiety and depression, and inflammatory responses may underlie this comorbid condition.

Psychopathological profile in chronic bronchial asthma

The psychopathological profile in a sample of 43 adult chronic asthmatic outpatients is analyzed. The SCL-90-R Self-Report Questionnaire was applied. The symptomatic profile in our sample is characterized by a main elevation of the dimension of somatization (1.80) followed by the areas of depression (1.64), obsession-compulsion (1.53) and anxiety (1.45). These dimensions contribute to the leading features of psychopathology in our patients.

Panic and asthma: a dangerous mislabeling

A case is presented in which asthma and panic disorder co-existed, and in which the mislabeling of the latter as the former proved dangerous.

Psychological characteristics of patients with asthma

INTRODUCTION

Psychological distress of patients with asthma may be reduced when they learned to live with their illness. Asthma can change the psychological and personality characteristics. We aim to investigate the psychological and personality characteristics of patients with asthma using MMPI (Minnesota Multiphasic Personality Inventory).

METHODS

Thirty-three adult patients with asthma (23 female and 10 male) and 20 healthy controls (14 females and 6 males) were enrolled in this study. Psychometric evaluation was made with the Turkish version of the MMPI. The patients were separated into two groups according to the duration of symptoms (recent-onset asthma < 10 years, long-standing asthma ≥10 years).

RESULTS

Patients with asthma compared with control group had significantly higher the rate of clinical elevation on depression, hysteria, psychasthenia and social introversion. Patients with recent-onset asthma compared with long-standing asthma have significantly higher the rate of clinical elevation on depression, hysteria, psychopathic deviate, psychasthenia and social introversion. MMPI mean t score in patients with recent-onset asthma was higher than patients with long-standing asthma. MMPI mean t score in patients with asthma was negatively associated with the symptom duration in multivariate model.

CONCLUSIONS

Patients with asthma have relatively more inactivity, anergia, guilt, pessimism, nonspecific physical complaints, irrational fears and introvert. Patients with long-standing asthma have less psychological distress, suggesting that learned to cope with his illness.

Current and Future Perspectives of Liaison Psychiatry Services: Relevance for Older People's Care

A large number of people admitted to medical wards have co-morbid mental health problems, and these predominantly include depression, dementia and delirium. An additional one third of medically ill patients remain in hospitals with undetected and, therefore, undiagnosed mental health problems. The comorbidity of mental and physical illnesses leads to poor health outcomes, prolonged inpatient stays and use of inpatient resources, involvement of various affiliated health services, introduction of medications and discharge to long-term facilities, including residential and nursing 24-h care, increased both readmission rates and mortality. The establishment of Liaison psychiatry services to meet the needs for people with mental health problems admitted to medical wards is a priority for many acute health Trusts. This has an economical background in terms of cost-savings, especially in relation to the older adults, with decreasing readmission rates and quicker hospital discharges. In the current review, we address the latest policies regarding Liaison psychiatry services; especially those for older people with dementia and delirium, and discuss their future shaping.

Psychopathology in difficult asthma

OBJECTIVE

Within the asthma population, difficult asthma (DA) is a severe condition in which patients present with frequent exacerbations, hospitalizations and emergency room visits. The identification and treatment of psychopathology is included in the management of DA. Psychopathology is supposed to predispose patients to DA or vice versa; psychopathology may develop as a consequence of DA. We reviewed the available literature on empirical findings regarding psychopathology in adult patients with DA.

METHODS

Studies in English language journals using MEDLINE, Cochrane and PsycINFO databases, were retrieved by an electronic search published from 1990 till July 2014.

RESULTS

Literature on psychopathology in DA is scarce. The search identified 16 articles of which only 6 articles were specifically about psychopathology in adult patients with DA. Almost half of the patients with DA had evidence of psychopathology at both syndrome and symptom level. Moreover, psychopathology appeared to be related to frequent exacerbations in patients with DA.

CONCLUSIONS

This literature review suggests a high prevalence of psychopathology of patients with DA, although it remains unclear whether psychopathology occurs more often in DA compared to "stable asthma". More research is needed on a possible role of psychopathology on clinical signs and symptoms in DA.

Global health benefits of being raised in a rural setting: results from the National Comorbidity Survey

AIM

The aim of this study was to examine the association between being raised in a rural setting and physical and mental health among adults in the USA.

METHODS

Data were drawn from the National Comorbidity Survey (n = 8098), a household probability sample representative of adults aged 15-54 years in the USA. Multiple logistic regression analyses were used to determine the association between being raised in a rural area and the likelihood of mental disorders, physical disorders, suicide behavior, and parental mental health. Odds ratios (OR) with 95% confidence intervals were calculated, adjusting for differences in demographic characteristics.

RESULTS

Being raised in a rural setting was associated with decreased odds of ulcer (OR = 0.56 [0.34, 0.91]). Mental disorders (any lifetime) (OR = 0.74 [0.64, 0.85]), any anxiety disorder (OR = 0.75 [0.6, 0.92]) and any substance use disorder (OR = 0.79 [0.65, 0.94]) were significantly less likely among adults who were raised in a rural setting. Maternal psychopathology and exposure to trauma were significantly lower among those raised in a rural setting, compared with those who were not. These relations were not explained by sociodemographic differences.

CONCLUSIONS

These data provide preliminary evidence that being raised in a rural environment lowers the risk of mental and physical health problems in adulthood. Being raised in a rural community also appears to be associated with significantly lower likelihood of exposure to trauma and maternal psychopathology. Future studies that can identify potential protective factors and mechanisms underlying these pathways are needed next.

Lifelong opioidergic vulnerability through early life separation: a recent extension of the false suffocation alarm theory of panic disorder

The present paper is the edited version of our presentations at the "First World Symposium On Translational Models Of Panic Disorder", in Vitoria, E.S., Brazil, on November 16-18, 2012. We also review relevant work that appeared after the conference. Suffocation-False Alarm Theory (Klein, 1993) postulates the existence of an evolved physiologic suffocation alarm system that monitors information about potential suffocation. Panic attacks maladaptively occur when the alarm is erroneously triggered. The expanded Suffocation-False Alarm Theory (Preter and Klein, 2008) hypothesizes that endogenous opioidergic dysregulation may underlie the respiratory pathophysiology and suffocation sensitivity in panic disorder. Opioidergic dysregulation increases sensitivity to CO2, separation distress and panic attacks. That sudden loss, bereavement and childhood separation anxiety are also antecedents of "spontaneous" panic requires an integrative explanation. Our work unveiling the lifelong endogenous opioid system impairing effects of childhood parental loss (CPL) and parental separation in non-ill, normal adults opens a new experimental, investigatory area.

Prospective impact of panic disorder and panic-anxiety on asthma control, health service use, and quality of life in adult patients with asthma over a 4-year follow-up

Background Panic disorder (PD) is a common anxiety disorder among asthmatic patients with overlapping symptoms (e.g., hyperventilation). However, the longitudinal impact of PD on asthma control remains poorly understood. This study assessed the impact of PD and panic-anxiety on asthma control over a 4.3-year follow-up in 643 adult asthmatic patients. Methods Consecutive patients presenting to a tertiary asthma clinic underwent a sociodemographic, medical history, and psychiatric (Primary Care Evaluation of Mental Disorders) interview and completed questionnaires including the Anxiety Sensitivity Index (ASI) to assess panic-anxiety. At follow-up, patients completed the Asthma Control (ACQ) and Asthma Quality of Life (AQLQ) questionnaires and reported emergency department visits and hospitalizations during the follow-up. Results Baseline frequency of PD was 10% (n = 65). In fully adjusted models, analyses revealed that PD and ASI scores predicted worse follow-up ACQ total scores (β = 0.292, p = .037; β = 0.012, p = .003) but not AQLQ total scores. ASI scores also predicted greater nocturnal and waking symptoms, activity limitations, and bronchodilator use on the ACQ (β = 0.012-0.018, p < .05) as well as lower symptom (β = -0.012, p = .006) and emotional distress (β = -0.014, p = .002) subscale scores on the AQLQ. Neither PD nor ASI scores were associated with hospitalizations, although ASI scores (but not PD) were associated with an increased risk of emergency department visits (relative risk = 1.023, 95% confidence interval = 1.001-1.044). Conclusions PD and anxiety sensitivity are prospectively associated with poorer asthma control and may be important targets for treatment.

Anxiety, depression and personality traits in severe, prednisone-dependent asthma

BACKGROUND

Anxiety and depression are prevalent in patients with asthma, and associated with more exacerbations and increased health care utilization. Since psychiatric intervention might improve asthma control, we examined whether patients with severe, prednisone-dependent asthma are at higher risk of these disorders than patients with severe non-prednisone dependent asthma or mild-moderate asthma, and whether they exhibit different personality traits.

METHODS

Sixty-seven adults with severe prednisone-dependent asthma, 47 with severe non-prednisone dependent and 73 patients with mild-moderate asthma completed the HADS depression and anxiety subscale and the NEO-FFI for personality traits. In addition, asthma duration, body mass index and FEV1 were measured.

RESULTS

The prevalence of clinically significant depressive symptoms (9% vs. 0 vs. 0%; p = 0.009) and anxiety symptoms (19% vs. 6.4 vs. 5.5%; p = 0.01), was higher in patients with severe, prednisone-dependent asthma than in patients with severe non-prednisone dependent or mild-moderate asthma. Patients with prednisone-dependent asthma were respectively 3.4 (95%CI: 1.0-10.8 p = 0.04) and 3.5 (95%CI: 1.3-9.6 p = 0.01) times more likely to have significant depression symptoms and 1.6 (95%CI: 0.7-3.7, p = 0.2) and 2.5 (95%CI: 01.1-5.5, p = 0.02) times more likely to have symptoms of anxiety than patients with severe non-prednisone dependent or mild-moderate asthma. There were no differences found in personality traits between the 3 groups.

CONCLUSION

Patients with severe, prednisone-dependent asthma have more often psychological distress as compared to patients with severe non-prednisone dependent or mild-moderate asthma.

Complementary and alternative medicine use and psychosocial outcomes among urban adolescents with asthma

Objective. Many adolescents with asthma use complementary and alternative medicine (CAM) for asthma symptom management. The purpose of this study was to investigate cross-sectional and longitudinal differences in psychosocial health outcomes between high and low CAM users among urban adolescents with asthma. Methods. Adolescents (Time 1: N = 151, Time 2: N = 131) completed self-report measures regarding the use of 10 CAM modalities, mental health, and health-related quality of life (HRQoL) following two clinic visits 1 year apart as part of a larger observational study. Multivariable regression analyses using backward elimination examined relationships between CAM use at Time 1 and outcomes at Time 1 and Time 2, controlling for key covariates and, in longitudinal analyses, Time 1 functioning. Results. Participants (M(age) = 15.8, SD = 1.85) were primarily African-American (n = 129 [85%]) and female (n = 91 [60%]) adolescents with asthma. High and low CAM users differed significantly in terms of several psychosocial health outcomes, both cross-sectionally and longitudinally. In cross-sectional multivariable analyses, greater frequency of praying was associated with better psychosocial HRQoL (R(2) = 0.22). No longitudinal relationships remained significant in multivariable analyses. Conclusions. Specific CAM techniques are differentially associated with psychosocial outcomes, indicating the importance of examining CAM modalities individually. Greater frequency of praying was cross-sectionally associated with better psychosocial HRQoL. When controlling for key covariates, CAM use was not associated with psychosocial outcomes over time. Further research should examine the effects of CAM use in controlled research settings.

Anxiety and depression in asthma

PURPOSE OF REVIEW

there is growing awareness of the correlation between psychological factors, the course of asthma, and the outcomes of asthma treatment. However, the implications of this correlation are still poorly understood. Here, we review the role of anxiety and depression in asthma with a focus on recent literature.

RECENT FINDINGS

recent studies suggest an interaction between behavioral, neural, endocrine, and immune processes and suggest that psychological factors play an active role in the genesis of asthma. Notably, the role of chronic stress has been investigated, including the parental psychological state during pregnancy. There is evidence that in patients with asthma, such stress may induce hyporesponsiveness of the hypothalamus-pituitary-adrenal axis, resulting in reduced cortisol secretion.

SUMMARY

even though it is generally accepted that anxiety and depression are more common in asthmatic patients and that there is a close correlation between psychological disorders and asthma outcomes, such as poorer control of asthma symptoms, the implications and practical consequences of this link remain weak. New studies are introducing an intriguing model of the links between emotional stress, brain centers, the immune system, and the hypothalamus-pituitary-adrenal axis that is far removed from the original concept of 'asthma nervosa'.

Anxiety is associated with diminished exercise performance and quality of life in severe emphysema: a cross-sectional study

BACKGROUND

Anxiety in patients with chronic obstructive pulmonary disease (COPD) is associated with self-reported disability. The purpose of this study is to determine whether there is an association between anxiety and functional measures, quality of life and dyspnea.

METHODS

Data from 1828 patients with moderate to severe emphysema enrolled in the National Emphysema Treatment Trial (NETT), collected prior to rehabilitation and randomization, were used in linear regression models to test the association between anxiety symptoms, measured by the Spielberger State Trait Anxiety Inventory (STAI) and: (a) six-minute walk distance test (6 MWD), (b) cycle ergometry peak workload, (c) St. Georges Respiratory Questionnaire (SRGQ), and (d) UCSD Shortness of Breath Questionnaire (SOBQ), after controlling for potential confounders including age, gender, FEV1 (% predicted), DLCO (% predicted), and the Beck Depression Inventory (BDI).

RESULTS

Anxiety was significantly associated with worse functional capacity [6 MWD (B = -0.944, p < .001), ergometry peak workload (B = -.087, p = .04)], quality of life (B = .172, p < .001) and shortness of breath (B = .180, p < .001). Regression coefficients show that a 10 point increase in anxiety score is associated with a mean decrease in 6 MWD of 9 meters, a 1 Watt decrease in peak exercise workload, and an increase of almost 2 points on both the SGRQ and SOBQ.

CONCLUSION

In clinically stable patients with moderate to severe emphysema, anxiety is associated with worse exercise performance, quality of life and shortness of breath, after accounting for the influence of demographic and physiologic factors known to affect these outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00000606.

Psychological and self-management factors in near-fatal asthma

BACKGROUND

Several studies that have analyzed differences in psychological and self-management variables between patients with a near-fatal asthma (NFA) attack and asthmatics without a NFA attack (non-NFA) have shown conflicting results, probably due to the heterogeneity of the events studied and the selection of comparison groups.

OBJECTIVE

To determine whether NFA patients, in stable situation, have greater psychological morbidity and worse self-management behavior than non-NFA patients with similar sociodemographic and clinical characteristics.

METHODS

A sample of 44 NFA patients (mean=5.65 years after the NFA episode) and 44 non-NFA patients matched for age, sex, and asthma severity was assessed. All patients were in clinical stable situation. Information about sociodemographic, clinical, functional, and morbidity variables was collected for each patient, and the Cognitive Depression Inventory, the Trait-Anxiety Scale, the Toronto Alexithymia Scale, the Practical Knowledge of Self-management questionnaire, and the Medication Adherence scale were administered.

RESULTS

In comparison with non-NFA patients, NFA patients showed higher levels of trait-anxiety (23.84 vs. 16.86; P=.001) and more difficulties describing and communicating feelings (11.36 vs. 8.90; P=.002). NFA and non-NFA patients did not differ in self-management variables. After adjustment in multivariate logistic regression analysis for age, sex, and asthma severity, significant differences were observed between NFA and control group patients in marital status [odds ratio (OR)=0.26; P=.017; 95% confidence interval (CI)=0.09-0.78], prescribed dose of inhaled corticoids (OR=4.48; P=.006;95% CI=1.53-13.09), and trait-anxiety (OR=1.071;P=.025;95%CI=1.01-1.14).

CONCLUSIONS

NFA patients show higher psychological morbidity than non-NFA, even years after the NFA episode.

Psychologic distress and maladaptive coping styles in patients with severe vs moderate asthma

BACKGROUND

Though several biologic factors have been suggested to play a role in the development and persistence of severe asthma, those associated with psychologic factors remain poorly understood. This study assessed levels of psychologic distress and a range of disease-relevant emotional and behavioral coping styles in patients with severe vs moderate asthma.

METHODS

Eighty-four patients (50% women, mean [M] age 46 years) with severe (n = 42) and moderate (n = 42) asthma were recruited. Severe asthma was defined according to American Thoracic Society criteria. Patients underwent demographic and medical history interviews and pulmonary function and allergy testing. Patients also completed questionnaires measuring asthma symptoms and the Millon Behavioral Medicine Diagnostic Inventory, which assesses psychologic distress and emotional/behavioral coping factors that influence disease progression and treatment.

RESULTS

After adjustment for covariates and applying a correction factor that reduced the significant P level to < .01, patients with severe vs moderate asthma reported experiencing more psychologic distress, including worse cognitive dysfunction (F = 6.72, P < .01) and marginally worse anxiety-tension (F = 4.02, P < .05). They also reported worse emotional coping (higher illness apprehension [F = 9.57, P < .01], pain sensitivity [F = 10.65, P < .01], future pessimism [F= 8.53, P < .01], and interventional fragility [F = 7.18, P < .01]), and marginally worse behavioral coping (more functional deficits [F = 5.48, P < .05] and problematic compliance [F = 4.32, P < .05]).

CONCLUSIONS

Patients with severe asthma have more psychologic distress and difficulty coping with their disease, both emotionally and behaviorally, relative to patients with moderate asthma. Future treatment studies should focus on helping patients with severe asthma manage distress and cope more effectively with their illness, which may improve outcomes in these high-risk patients.

Modeling of longitudinal polytomous outcome from complex survey data--application to investigate an association between mental distress and non-malignant respiratory diseases

BACKGROUND

The data from longitudinal complex surveys based on multi-stage sampling designs contain cross-sectional dependencies among units due to clustered nature of the data and within-subject dependencies due to repeated measurements. Special statistical methods are required to analyze longitudinal complex survey data.

METHODS

Statistics Canada's longitudinal National Population Health Survey (NPHS) dataset from the first five cycles (1994/1995 to 2002/2003) was used to investigate the effects of demographic, social, life-style, and health-related factors on the longitudinal changes of mental distress scores among the NPHS participants who self-reported physician diagnosed respiratory diseases, specifically asthma and chronic bronchitis. The NPHS longitudinal sample includes 17,276 persons of all ages. In this report, participants 15 years and older (n = 14,713) were considered for statistical analysis. Mental distress, an ordinal outcome variable (categories: no/low, moderate, and high) was examined. Ordered logistic regression models based on the weighted generalized estimating equations approach were fitted to investigate the association between respiratory diseases and mental distress adjusting for other covariates of interest. Variance estimates of regression coefficients were computed by using bootstrap methods. The final model was used to predict the probabilities of prevalence of no/low, moderate or high mental distress scores.

RESULTS

Accounting for design effects does not vary the significance of the coefficients of the model. Participants suffering with chronic bronchitis were significantly at a higher risk (ORadj = 1.37; 95% CI: 1.12-1.66) of reporting high levels of mental distress compared to those who did not self-report chronic bronchitis. There was no significant association between asthma and mental distress. There was a significant interaction between sex and self-perceived general health status indicating a dose-response relationship. Among females, the risk of mental distress increases with increasing deteriorating (from excellent to very poor) self-perceived general health.

CONCLUSIONS

A positive association was observed between the physician diagnosed self-reported chronic bronchitis and an increased prevalence of mental distress when adjusted for important covariates. Variance estimates of regression coefficients obtained from the sandwich estimator (i.e. not accounting for design effects) were similar to bootstrap variance estimates (i.e. accounting for design effects). Even though these two sets of variance estimates are similar, it is more appropriate to use bootstrap variance estimates.

Self-management plans for asthma control and predictors of patient compliance

OBJECTIVE

To evaluate the impact of peak flow or symptom-based self-management plans on asthma control and patients' quality of life and to determine the main psychosocial factors that affect compliance with these plans.

METHODS

The study sample consisted of 63 patients with persistent asthma outpatients. Data collection included demographics, pulmonary functions, symptom scores, and asthma control parameters recorded over the previous 2 consecutive years. A standard asthma self-management education program including personal action plans was given to the patients who were randomly divided into peak flow meter (PFM) (n = 31) or symptom-based (n = 32) action plan groups. Patients were then assessed prospectively for various study outcomes including symptoms, drug compliance, psychiatric co-morbidities, quality of life, and asthma control over the next 12 months. Psychiatric co-morbidities were assessed using Rotter's Internal and External Locus of Control Scale (RIELCS), Beck Depression Inventory (BDI), Structured Clinical Interview for DSM-IV (SCID-I), Spielberger State-Trait-Anxiety Inventory (STAI), and Short Form-36 (SF-36).

RESULTS

Of the 63 patients (79% female; mean age 43), 85% of them had moderately or severely persistent asthma. Baseline demographics, clinical parameters, psychiatric diagnosis, and quality of life were not different between groups. Personal asthma plans increased optimal asthma control significantly. Emergency visits, antibiotic treatments, systemic corticosteroid treatments, and unscheduled visits were fewer than the previous year. Control parameters were better in the PFM group. After the self-management education, the quality of life dimensions, i.e., vitality, total mental and general scores of both groups increased. Frequency of psychiatric co-morbidities decreased from 61.9% to 49.2%. However, state anxiety levels were increased in both groups. These increases were statistically significant in the PFM group. Compliance with the action plans was better in the PFM group. Higher BDI scores were associated with worse compliance. No statistically significant association was found between demographic parameters and the compliance. Although the compliance had decreased in both groups after 6 months, this decrease was greater in the symptom group. Higher RIELCS and mental health scores were associated with better compliance.

CONCLUSION

Introduction of self-management plans improved illness control and quality of life in asthma patients. Use of the PFM and the presence of higher RIELCS and lower BDI scores can be used to predict compliance with the action plans.

The role of panic-fear in comorbid asthma and panic disorder

We examined mediational models of panic-fear, panic disorder (PD), and asthma outcomes among adult asthma patients. PD was assessed by the Anxiety Disorders Interview Schedule. Twenty-one asthma-PD patients and 27 asthma-only patients completed spirometry and questionnaires. Asthma-PD patients reported greater illness-specific and generalized panic-fear than asthma-only patients, despite no differences in asthma severity or physical symptoms during asthma attacks. Illness-specific panic-fear mediated the relationship between PD and poorer health-related quality of life, including emotional disturbance due to asthma. Illness-specific panic-fear was associated with more primary care office visits for asthma. Asthma-PD patients reported greater irritability during asthma attacks than asthma-only patients. Generalized panic-fear was directly associated with restriction of activities due to asthma and use of rescue medication for asthma. Neither measure of panic-fear was associated with asthma severity. Panic-fear experienced during asthma attacks may be an important area to target for improving health-related quality of life among asthma-PD patients.

COPD as a lung disease with systemic consequences--clinical impact, mechanisms, and potential for early intervention

The natural course of chronic obstructive pulmonary disease (COPD) is complicated by the development of systemic consequences and co-morbidities. These may be major features in the clinical presentation of COPD, prompting increasing interest. Systemic consequences may be defined as non-pulmonary manifestations of COPD with an immediate cause-and-effect relationship, whereas co-morbidities are diseases associated with COPD. The major systemic consequences/co-morbidities now recognized are: deconditioning, exercise intolerance, skeletal muscle dysfunction, osteoporosis, metabolic impact, anxiety and depression, cardiovascular disease, and mortality. The mechanisms by which these develop are unclear. Probably many factors are involved. Two appear of paramount importance: systemic inflammation, which presents in some patients with stable disease and virtually all patients during exacerbations, and inactivity, which may be a key link to most COPD-related co-morbidities. Further studies are required to determine the role of inflammatory cells/mediators involved in systemic inflammatory processes in causing co-morbidities; the link between activity and co-morbidities; and how COPD therapy may affect activity. Both key mechanisms appear to be influenced significantly by COPD exacerbations. Importantly, although the prevalence of systemic consequences increases with increasing severity of airflow obstruction, both systemic consequences and co-morbidities are already present in the Global Initiative for Chronic Obstructive Lung Disease Stage II. This supports the concept of early intervention in chronic obstructive pulmonary disease. Although at present early intervention studies in COPD are lacking, circumstantial evidence suggests that current treatments may influence events leading to the systemic consequences and co-morbidities, and thus may affect the clinical manifestations of the disease.

Psychological and somatic symptoms in screening for depression in asthma patients

Correctly identifying asthma patients who need treatment for depression is part of comprehensive care. The objective of this study was to compare the prevalence of depressive symptoms measured by the short-form Center for Epidemiologic Studies Depression Scale (CESD-SF), which measures somatic and psychological symptoms, with the original and short-form Geriatric Depression Scale (GDS and GDS-SF), which measure only psychological symptoms. In total, 257 asthma patients (mean age 42 years, 75% women) completed the GDS (score range 0-30, positive screen > or = 11) and the CESD-SF (score range 0-30, positive screen > or = 10). The performance of each scale was compared to clinical diagnoses of depressive disorders reported by physicians using a skill score analysis. Twenty percent of patients had GDS scores > or = 11 and 32% had CESD-SF scores > or = 10. The somatic symptom of restless sleep was the most common CESD-SF symptom and the symptom that contributed most to the total score. The GDS had a skill score of +.16 (+1 = maximum possible, 0 = best guess) and the CESD-SF had a skill score of -.02 compared to physician-reported depressive disorders. Similar results were found for the GDS-SF. Thus, more patients had a positive CESD-SF screen, which was attributable mostly to a somatic sleep symptom that overlaps with asthma symptoms, and the GDS was more consistent with physicians' reports of depressive disorders.

Psychological treatment of comorbid asthma and panic disorder: a pilot study

We evaluated two protocols for treating adults with comorbid asthma and panic disorder. The protocols included elements of Barlow's panic control therapy and elements of Barlow's "panic control therapy" and several asthma education programs, as well as modules designed to teach participants how to differentiate asthma and panic symptoms, and how to apply specific home management strategies for each. Fifty percent of subjects dropped out of a 14-session protocol by the eighth session; however, 83% of patients were retained in an eight-session protocol. Clinical results were mostly equivalent: significant decreases of >50% in panic symptoms, clinically significant decreases in asthma symptoms, improvement in asthma quality of life, and maintenance of clinical stability in asthma. Albuterol use decreased significantly in the 14-session protocol and at a borderline level I the 8-session protocol, while pulmonary function was maintained. A controlled evaluation of this procedure is warranted.

Panic, suffocation false alarms, separation anxiety and endogenous opioids

This review paper presents an amplification of the suffocation false alarm theory (SFA) of spontaneous panic [Klein DF (1993). False suffocation alarms, spontaneous panics, and related conditions. An integrative hypothesis. Arch Gen Psychiatry; 50:306-17.]. SFA postulates the existence of an evolved physiologic suffocation alarm system that monitors information about potential suffocation. Panic attacks maladaptively occur when the alarm is erroneously triggered. That panic is distinct from Cannon's emergency fear response and Selye's General Alarm Syndrome is shown by the prominence of intense air hunger during these attacks. Further, panic sufferers have chronic sighing abnormalities outside of the acute attack. Another basic physiologic distinction between fear and panic is the counter-intuitive lack of hypothalamic-pituitary-adrenal (HPA) activation in panic. Understanding panic as provoked by indicators of potential suffocation, such as fluctuations in pCO(2) and brain lactate, as well as environmental circumstances fits the observed respiratory abnormalities. However, that sudden loss, bereavement and childhood separation anxiety are also antecedents of "spontaneous" panic requires an integrative explanation. Because of the opioid system's central regulatory role in both disordered breathing and separation distress, we detail the role of opioidergic dysfunction in decreasing the suffocation alarm threshold. We present results from our laboratory where the naloxone-lactate challenge in normals produces supportive evidence for the endorphinergic defect hypothesis in the form of a distress episode of specific tidal volume hyperventilation paralleling challenge-produced and clinical panic.

Patient-reported and physician-reported depressive conditions in relation to asthma severity and control

BACKGROUND

Depressive conditions in asthma patients have been described mostly from patient reports and less often from physician reports. While patient reports can encompass multiple symptoms, physician assessments can attribute symptoms to a mental health etiology. Our objectives were to identify associations between patient- and physician-reported depressive conditions and asthma severity and control.

METHODS

Patient-reported depressive symptoms were obtained using the Geriatric Depression Scale (GDS) [possible score 0 to 30; higher score indicates more depressive symptoms]. Patients were categorized as having a physician-reported depressive disorder if they had the following: a diagnosis of depression, depressive symptoms described in medical charts, or were prescribed antidepressants at doses used to treat depression. Patients also completed the Severity of Asthma Scale (SOA) [possible score 0 to 28; higher score indicates more severe] and the Asthma Control Questionnaire (ACQ) [possible score 0 to 6; higher score indicates worse control].

RESULTS

Two hundred fifty-seven patients were included in this analysis (mean age, 42 years; 75% women). Mean SOA and ACQ (+/- SD) scores were 5.9 +/- 4.2 and 1.4 +/- 1.2, respectively; and mean GDS score was 6.3 +/- 6.4. After adjusting for age, sex, race, Latino ethnicity, education, medication adherence, body mass index, and smoking status, patient-reported depressive symptoms were associated with asthma severity (p = 0.007) and with asthma control (p = 0.0007). In contrast, physician-reported depressive disorders were associated with asthma severity (p = 0.04) but not with asthma control (p = 0.22) after adjusting for covariates.

CONCLUSIONS

Physician- and patient-reported depressive conditions were associated with asthma severity. In contrast, patient-reported depressive symptoms were more closely associated with asthma control than were physician-reported depressive disorders. Identifying associations between depressive conditions and asthma severity and control is necessary to concurrently treat these conditions in this population.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT00195117.

Chronic obstructive lung diseases and prevalence of mood, anxiety, and substance-use disorders in a large population sample

Only a few population-based studies have examined prevalence of mental disorder in people with chronic respiratory conditions. Clinical studies have yielded mixed results. In this analysis, data from the 2002 Canadian Community Health Survey (CCHS) were used. This was a national health survey that included administration of the World Mental Health Composite International Diagnostic Interview to a sample of 36,984 subjects. Participants were asked about chronic medical conditions that had been diagnosed by a health professional. Chronic respiratory conditions were associated with major depressive disorder, bipolar disorder, panic disorder (including agoraphobia), social phobia, and substance dependence. Although the observed associations were statistically highly significant, the prevalence estimates were lower than previous reports from studies using clinical samples, suggesting that selection bias may have influenced some estimates.

Specific psychiatric morbidity among a sample of asthmatics in south western Nigeria

OBJECTIVE

This study was to identify specific psychiatric morbidity among asthma patients and to compare their rates to controls.

METHOD

Hundred consecutive asthmatics were screened using the General Health Questionnaire (GHQ-30), and the Present State Examination (PSE). The same instruments were also administered to 75 healthy individuals, and 75 orthopaedic patients.

RESULTS

Patients with asthma had a higher occurrence of psychopathology. The specific psychiatric diagnoses among asthmatics were generalized anxiety disorder (23%), depressive disorder (11%), while 2% had panic disorder.

CONCLUSION

Psychiatric morbidity is more common among asthmatics, than the general population and other patient group.

Mental disorders among adults with asthma: results from the World Mental Health Survey

OBJECTIVE

Our objectives were (a) to determine which common mental disorders are associated with asthma in the general population after controlling for age and sex, and (b) to assess whether the associations of mental disorders with asthma are consistent across diverse countries.

METHOD

Eighteen population surveys of household-residing adults were carried out in 17 countries (N=85,088). Mental disorders were assessed with the Composite International Diagnostic Interview 3.0, a fully structured diagnostic interview. The disorders considered here are 12-month anxiety disorders (generalized anxiety disorder, panic disorder/agoraphobia, posttraumatic stress disorder and social phobia), depressive disorders (dysthymia and major depressive disorder) and alcohol use disorders (abuse and dependence). Asthma was ascertained by self-reports of lifetime diagnosis among a subsample (n=42,697).

RESULTS

Pooled estimates of age-adjusted and sex-adjusted odds of mental disorders among persons with asthma relative to those without asthma were 1.6 [95% confidence interval (95% CI)=1.4, 1.8] for depressive disorders, 1.5 (95% CI=1.4, 1.7) for anxiety disorders and 1.7 (95% CI=1.4, 2.1) for alcohol use disorders.

CONCLUSION

This first cross-national study of the relationship between asthma and mental disorders confirms that a range of common mental disorders occurs with greater frequency among persons with asthma. These results attest to the importance of clinicians in diverse settings being alert to the co-occurrence of these conditions.

A systematic review of the psychological risk factors associated with near fatal asthma or fatal asthma

Psychological factors such as anxiety, depressive disorders and/or personality disorders may predispose patients with asthma to near fatal asthma (NFA) or fatal asthma (FA). NFA is defined by an asthma exacerbation resulting in respiratory arrest requiring mechanical ventilation or a pCO(2) >or=45 mm Hg. Most studies have used the case-control study design. Several studies analyzing the effects of psychological factors on the risk of NFA or FA have shown conflicting results. We reviewed all of the literature found by the systematic search done of psychological factors on the risk NFA or FA. A MEDLINE search identified 423 articles between 1960 and March 2006. Seven case-controlled studies were identified following strict applications of the inclusion and exclusion criteria. Due to the significant heterogeneity in the measurement of the psychological factors, a summary statistic was not calculated. The trial characteristics were tabulated and qualitative trends were observed to explain the heterogeneity in the results of the studies. Recommendations on future studies in the field are outlined in detail. Following a systematic assessment of all published studies, we cannot conclude that psychological factors increase the risk of NFA and FA.

The relationship between the severity of asthma and comorbidites with anxiety and depressive disorders

OBJECTIVE: There is evidence that asthma is associated with increased frequency of psychiatric symptoms and mental disorders. Our aim was to assess the frequency of anxiety and depressive disorders in a sample of asthmatic outpatients and observe if there is any relationship between this comorbidity and the severity of asthma. METHOD: Sixty-two consecutive patients of two outpatient asthma clinics located in university hospitals were evaluated. Psychiatric diagnoses were assessed with the Mini-International Neuropsychiatric Interview 4.4 Version. RESULTS: Twenty-seven patients (43.5%) met criteria for at least one psychiatric diagnosis. The most frequent diagnoses were major depression (24%), generalized anxiety disorder (20.9%) and panic disorder/agoraphobia spectrum disorders (17.7%). We found no significant differences in the prevalence of anxiety disorders and depression between the groups with mild/moderate and severe asthma. Despite the high frequency of depression and anxiety disorders, only 4 (6.5%) patients were under psychiatric treatment and 13 (20.9%) patients were taking benzodiazepines. Twelve of 15 (80%) patients who reported present use of psychotropic medication were not under psychiatric treatment at the moment of the study. CONCLUSIONS: Our results support the high morbidity of anxiety and depressive disorders in asthmatic patients, independent of the severity of asthma.

Anxiety, panic and adult asthma: a cognitive-behavioral perspective

A review of previous research suggests increased probability of the prevalence of anxiety disorders, and particularly panic disorder and panic attacks in patients with asthma, as compared to a normal population. Research also indicates significant levels of co-morbidity between asthma and anxiety as measured on dimensional scales of anxiety and panic. Clinical anxiety and panic manifestations affect symptom perception and asthma management through the effects of anxiety symptoms such as hyperventilation, and indirectly through self-management behavior and physician response. However, there is limited data on the impact of anxiety co-morbidity on asthma quality of life. Some studies indicate that individuals with co-morbid asthma and anxiety or panic report worse asthma quality of life both in general and in relation to their symptomatology, being limited in their daily activities, in response to environmental stimuli and in regard to feelings of emotional distress. Cognitive-behavioral therapy (CBT) is an effective and empirically supported treatment of choice for anxiety disorders and panic attacks. However, standard CBT protocols for anxiety and panic may need to be specifically targeted at improving asthma outcomes. Also, asthma research literature is lacking in randomized controlled trials applying CBT to patients with co-morbid asthma and clinical anxiety manifestations. Trials evaluating CBT interventions in individuals with clinical anxiety manifestations and asthma may provide evidence of these interventions as an effective adjunct to improve asthma management and control.

Personality characteristics of asthma patients

INTRODUCTION

Asthma, similarly to other chronic conditions, is strongly influenced by psychological factors. Previous studies have not established the personality characteristics of adult asthma patients as compared to non-patients.

OBJECTIVES

To study the psychological characteristics of adult asthma patients in comparison to a pattern drawn up for the Portuguese population. To study the relationships between the personality and the severity and duration of the disease.

METHODS

Outpatients of the Immunallergology and Pulmonology units of the São João Hospital suffering from asthma responded to the Revised NEO Personality Inventory (NEO-PI-R). Patients with co-morbidity factors were not excluded. The doctor who attended them classified the severity of the asthma according to the Global Initiative for Asthma (GINA). Relationships between the personality and the severity/duration of the disease were analysed using the ANOVA models.

RESULTS

300 asthma patients aged between 17 and 79 were studied. Of these, 75% were female; the great majority had intermittent/light persistent asthma (71%); 17% had moderate persistent asthma and 12% had severe persistent asthma. The duration of the disease was less than 10 years in 34% and over 23 years in 35%. The asthma patients had higher Neuroticism scores (p < 0.001), with the other facets (except impulsiveness) equally high. All the remaining domains--Extroversion, Openness to Experience, Conscientiousness and Agreeableness--had lower scores than the control group (p < 0.001). Both Extroversion and Openness to Experience decrease with growth in the severity (p = 0.003; p = 0.009) and the duration of the disease (p = 0.006; p = 0.013). Neuroticism increases in tandem with the severity of the disease.

CONCLUSION

This study shows the predominance of Neurotic characteristics and lowered Extroversion, Openness to Experience, Agreeableness and Conscientiousness characteristics in asthmatics as compared to the general Portuguese population. Decreased Extroversion and Openness to Experience are observed as the severity and duration of the disease increase. Further studies are necessary to clarify the relationships between personality and the severity and duration of the disease.

Health care use and quality of life among patients with asthma and panic disorder

The purpose of this study was to assess the associations between panic disorder (PD) and health services use, health-related quality of life, and use of short-acting beta2-agonists among individuals with asthma. We studied 21 adults with comorbid asthma and panic disorder (asthma-PD) and 27 asthma patients without PD (asthma-only). Participants attended a single session at a laboratory to complete the study. A retrospective chart review was conducted to assess use of health care resources for asthma treatment during the past 12 months. Patients completed the Asthma Quality of Life Questionnaire and lung function testing. Asthma-only and asthma-PD patients displayed no differences on asthma severity, as measured by spirometry and asthma medication class. Asthma-PD patients had more visits to their primary care physicians for asthma (p < 0.01) and reported a lower quality of life related to asthma (p < 0.01) and greater use of short-acting beta2-agonists (p < 0.05) than asthma-only patients. These findings were independent of pulmonary function, asthma medication class, and sociodemographic status. These data show that coexistence of PD in asthma is associated with increased use of primary care health resources and greater perceived impairment from asthma, independent of asthma severity. These findings indicate a need to develop interventions to improve quality of life and self-management of asthma among PD patients.

Impact of depressive symptoms on adult asthma outcomes

BACKGROUND

Psychological disorders, including depression, are common in adults with asthma. Although depression is treatable, its impact on longitudinal asthma outcomes is not clear.

OBJECTIVE

To elucidate the impact of depressive symptoms on patient-centered outcomes and emergency health care use in adults with asthma.

METHODS

We conducted a prospective cohort study of 743 adults with asthma who were recruited after hospitalization for asthma. Depressive symptoms were defined as having a score of 16 or more on the Center for Epidemiologic Studies Depression Scale. We examined the impact of depressive symptoms on patient-centered outcomes (validated severity-of-asthma score, Marks Asthma Quality of Life Questionnaire, and 12-Item Short-Form Health Survey physical component summary score) and on future emergency health care use for asthma ascertained from computerized databases.

RESULTS

The prevalence of depressive symptoms was 18% (95% confidence interval [CI], 15%-21%) among adults with asthma. Depressive symptoms were associated with greater severity-of-asthma scores after controlling for age, sex, race/ ethnicity, educational attainment, and cigarette smoking (mean score increment, 2.6 points; 95% CI, 1.8-3.4 points). Furthermore, depressive symptoms were associated with poorer asthma-specific quality of life (mean score increment, 19.9 points; 95% CI, 17.7-22.1 points) and poorer physical health status (mean score decrement, 3.7 points; 95% CI, 1.5-5.8 points). Depressive symptoms were associated with a greater longitudinal risk of hospitalization for asthma (hazard ratio, 1.34; 95% CI, 0.98-1.84). After controlling for differences in preventive care for asthma, the relationship was stronger (hazard ratio, 1.45; 95% CI, 1.05-2.0).

CONCLUSION

Depressive symptoms are common in adults with asthma and are associated with poorer health outcomes, including greater asthma severity and risk of hospitalization for asthma.

Cognitive-behavioral treatment combined with asthma education for adults with asthma and coexisting panic disorder

This study tested the efficacy of a nurse-administered 8-week group treatment program for adults with asthma suffering from coexisting panic disorder. The program consisted of cognitive behavioral treatment (CBT) for panic disorder combined with asthma education (AE). Forty-eight women with a confirmed diagnosis of asthma and panic disorder were randomly allocated to a treatment condition (n=25) and a wait-list control condition (n=23). Twenty-five participants--15 in the treatment group and 10 in the wait-list control group--completed treatment. Repeated measures ANOVA procedures were used to compare the groups on panic and asthma outcomes at posttreatment and 6-month follow-up. The results demonstrate that the CBT-AE program is capable of producing substantial and durable antipanic and antianxiety treatment effects and led to substantial but nonsustained improvement in morning peak-flow expiratory rate and asthma-related quality of life. Implications of these findings for this clinical population are addressed.

Psychological distress in hospitalized patients with chronic obstructive pulmonary disease

OBJECTIVES

To investigate the prevalence of psychological distress in hospitalized patients with chronic obstructive pulmonary disease (COPD), and to examine possible associations between psychological distress and several sociodemographic variables.

METHODS

The Hopkins Symptom Checklist was used to gather data from 92 hospitalized COPD patients. These data were compared with 3,319 respondents aged 45 or over drawn from the 1998 Norwegian Statistics Health Survey. The latter were divided into four groups: respondents with COPD, respondents with other respiratory diseases, respondents with mixed chronic diseases, and a healthy group.

RESULTS

The prevalence of psychological distress was found to be 58.7% in the hospitalized COPD patients and 42.9% in the community-based COPD sample. After controlling for sociodemographic variables and current smoking, the results showed a higher risk of psychological distress among hospitalized COPD patients (OR = 23.69; 95% CI: 13.37-41.98) and the community-based COPD sample (OR = 18.16; 95% CI: 8.31-39.68), and with sub-samples with other respiratory diseases (OR = 5.87; 95% CI: 3.82-9.02), and mixed chronic diseases (OR = 3.51; 95% CI: 2.39-5.18).

CONCLUSIONS

COPD is associated with a high prevalence of psychological distress in both hospital and community settings. Furthermore, it appears that age, gender, education, marital status, and current smoking status do not substantially mediate the association between the severity of psychological distress and COPD status. The results provide additional evidence of the importance of screening for psychological distress symptoms in both hospitalized and community-based patients with COPD.

Depression and pulmonary function in outpatients with asthma

The purpose of this study was to examine the relation between depression, anxiety and pulmonary function in asthmatics. Thirty-eight adult asthmatic patients underwent psychometric evaluation with the DSSI/sAD questionnaire, filled in an asthma questionnaire and underwent spirometry. The majority of patients suffered from mild-persistent asthma. Twenty-six reported symptoms of anxiety and 25 reported symptoms of depression. A statistically significant reduction in FEV1 and FEV1/FVC values was observed in asthmatic patients with symptoms of depression. The mean value of FEV1 was 81.84(+/-20.83) in patients without symptoms and 63.73(+/-17.99) in patients with symptoms of depression. The mean values of FEV1/FVC were 0.85(+/-0.11) and 0.75(+/-0.10), respectively. These findings indicate a high frequency of depression and anxiety in adult asthmatic patients. A biological linkage between depression and impaired pulmonary function is proposed.

Panic disorder: from respiration to the homeostatic brain

There is some experimental evidence to support the existence of a connection between panic and respiration. However, only recent studies investigating the complexity of respiratory physiology have revealed consistent irregularities in respiratory pattern, suggesting that these abnormalities might be a vulnerability factor to panic attacks. The source of the high irregularity observed, together with unpleasant respiratory sensations in patients with panic disorder (PD), is still unclear and different underlying mechanisms might be hypothesized. It could be the result of compensatory responses to abnormal respiratory inputs or an intrinsic deranged activity in the brainstem network shaping the respiratory rhythm. Moreover, since basic physiological functions in the organism are strictly interrelated, with reciprocal modulations and abnormalities in cardiac and balance system function having been described in PD, the respiratory findings might arise from perturbations of these other basic systems or a more general dysfunction of the homeostatic brain. Phylogenetically ancient brain circuits process physiological perceptions/sensations linked to homeostatic functions, such as respiration, and the parabrachial nucleus might filter and integrate interoceptive information from the basic homeostatic functions. These physiological processes take place continuously and subconsciously and only occasionally do they pervade the conscious awareness as 'primal emotions'. Panic attacks could be the expression of primal emotion arising from an abnormal modulation of the respiratory/homeostatic functions.

A prospective study of the relationship of mood and stress to pulmonary function among patients with asthma

The purpose of this study was to examine the association of psychosocial and other variables to pulmonary function over four months. Thirty-two patients with asthma kept daily records of pulmonary function and psychosocial variables for an average of 140 days. Data on other potential covariates of pulmonary function, as assessed by peak flow meters, were also collected (e.g., allergen exposure). Sixteen subjects (50%) had significant associations between pulmonary function and psychosocial variables. Between-subjects analyses showed small but significant associations between pulmonary function and other variables. These results confirmed previous reports of individual variability in the association of psychosocial variables with pulmonary function.

Relationship between separation anxiety disorder, parental panic disorder, and atopic disorders in children: a controlled high-risk study

OBJECTIVE

To test the hypotheses that rates of atopic disorders are elevated in offspring of parents with panic disorder (PD) and in children with separation anxiety disorder (SAD).

METHOD

Rates of atopic disorders were assessed in 343 offspring (aged 6-17 years) of parents with PD, nonpanic psychiatric disorders, and no psychiatric disorder. Lifetime history of atopic disorders was determined by parental responses to a clinician-administered questionnaire assessing medical treatment for asthma and allergies. Logistic regression analyses assessed the association between atopic disorders and parental PD, and between atopic disorders and probable or definite childhood SAD. Analyses controlled for age, sex, socioeconomic status, and treatment for other medical illnesses.

RESULTS

Increased rates of atopic disorders were found in offspring of parents with PD (odds ratio [OR] = 2.56, 95% confidence interval [CI] = 1.27-5.16, p = .009) and in children with SAD (OR = 2.71, 95% Cl = 1.22-6.03, p = .015). Associations remained significant when both parental PD and SAD were included in the model, suggesting that each contributed independently to increased rates of atopy. The interaction of parental PD and child SAD was not significant.

CONCLUSIONS

Atopic disorders in children are associated with parental PD and with childhood SAD. Results do not appear to support that having both childhood SAD and a parent with PD confers increased risk for atopic disorders above and beyond either condition alone.

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.

Psychiatric disorders in asthmatic outpatients

It has been reported that the lifetime prevalence of panic disorder in patients with pulmonary disease is higher than epidemiologic estimates of population prevalence. We evaluated the frequency of anxiety disorders in 86 subjects from the Outpatient Asthma Clinic. Psychiatric diagnoses were assessed with the Mini-International Neuropsychiatric Interview 4.4 Version (MINI). Forty-five asthmatic patients (52.3%) reported at least one current anxiety disorder. The frequency of panic disorder with or without agoraphobia was 13.9% (n=12) and that of agoraphobia without panic disorder was 26.8% (n=23). Social anxiety and generalized anxiety disorders occurred in 9.3% (n=8) and 24.4% (n=21) of the sample, respectively. Twenty-nine patients (33.7%) reported a major depressive episode. The psychiatric morbidity of the sample was 61.6% (n=53). Our results tend to support the high morbidity of anxiety disorders, particularly panic/agoraphobic spectrum disorders, in asthmatic outpatients.

Natural rubber latex allergy in the occupational setting

Over the last decade, the prevalence of natural rubber latex (NRL) allergy has reached epidemic proportions among workers who use or who are exposed to powdered latex products. NRL-associated occupational asthma is confined largely to those exposed to powdered latex glove use or other latex aerosols. The most frequent presenting symptom of NRL allergy is contact urticaria; inhalation may cause symptoms of allergic rhinitis and asthma. Skin prick testing is the most accurate tool for diagnosis of NRL allergy. The cornerstone of management is cessation of exposure; substitution with non-NRL or nonpowdered NRL gloves results in predictable rapid disappearance of latex aeroallergen.

Screening and assessing adult asthmatics for anxiety disorders

The purpose of this study was to evaluate a strategy designed to permit early detection of anxiety disorders in asthmatics. Ninety-one adult asthmatics were screened for anxiety disorders using the Sheehan Patient Rated Anxiety Scale (SPRAS) and the Anxiety Sensitivity Index (ASI) and then individually evaluated by a nurse trained in the administration of the Anxiety Disorders Interview Schedule-IV (ADIS-IV. Thirty-five (38%) of the participants met the diagnostic criteria for one or more anxiety disorders. Comparison of the SPRAS and ASI findings revealed that the SPRAS was more effective in detecting asthmatics likely to be suffering from coexisting anxiety disorders. Comparison of the nurses diagnostic formulations with those of an expert revealed that trained nurses using the ADIS-IV can diagnose anxiety disorders in the asthmatic population with a high degree of accuracy. These results have implications for resolving the problem of unrecognized and untreated anxiety disorders in the asthmatic population.