Medical Inspection – Health Blog

Although the incidence of tetanus has steadily de­clined over the years in industrialized countries, immunity against the disease is lacking or insufficient in more than 65 percent of the elderly population. Consequently, patients over the age of 60 years rep­resent nearly 60 percent of total cases, and while optimal management in intensive care units has de­creased mortality to 10 to 15 percent with good long- term recovery, the reported case fatality rate for patients over 60 years remains at approximately 52 percent. Taking into account this last figure as well as the discomfort and potential complications of pro­longed sedation, muscle paralysis, and mechanical ventilation, one might question the wisdom of inten­sive care treatment for elderly patients. Our experi­ence, however, is somewhat different in this respect. Read More…

It can be seen how many of these factors may interact, as shown in Figure 1. This demonstrates how even a patient with a disastrous developmental back­ground, major medical problems, and a strong biologic propensity to develop both asthma and psychiatric disorders may still adapt well if he has good insight into his problems and complies appropriately with an effective therapeutic regimen organized by a physician with whom he has a good and trusting relationship. Conversely a patient with a reasonable upbringing, a relatively mild degree of asthma, and a very dependent personality with few family and social supports, being treated by a physician who does not appreciate the patients psychological needs, and who consequently gets angry and frustrated, may spend inordinate amounts of time in the hospital and be placed on a regimen of excessive dosages of corticosteroids leading to a markedly increased level of disability.

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The physician-patient relationship has been exten­sively studied by such authors as Balint, but there are certain characteristics of patients with asthma that might make one expect the relationship between patient and physician, which is likely to be a long- term one, to be particularly complex. Dirks et al conducted a study to see how patient and physician characteristics could influence medical decisions in chronic asthma. These investigators rated the physi­cians objectively as to how sensitive they were to their patients’ needs. Low-sensitivity physicians were judged to relate to their patients as examples of “pulmonary pathology” whereas high-sensitivity phy­sicians treated their patients as “whole human beings.” At the end of the patients stay in the hospital, the results were collated. The three groups of physicians (low, moderate, and high sensitivity) did not differ in actual medical decisions on, for instance, the length of hospitalization or the amount of medication neces­sary, but they did differ in their judgment of illness severity despite similarity of their patients pulmonary functions. The low-sensitivity physicians tended to be wrongly influenced more by the patients personality than by objective indices of pulmonary function. These physicians tended to interpret the personality char­acteristics of the patients as reflecting illness severity and confused psychologic and physical distress. Mod­erate-sensitivity physicians appeared to be able to distinguish between psychologic and physical distress and based their judgment of illness severity more on their patient s pulmonary function results.

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Breathing is a basic physiologic function, and acute dyspnea is one of the most frightening human experi­ences. It might be thought to be abnormal for a patient suffering an acute attack of asthma not to feel at least somewhat afraid. Asthmatic patients suffering from anxiety disorders usually hyperventilate, and many of them report phobic avoidance of certain situations, particularly where their breathing pattern is inter­rupted or their airway momentarily occluded. These situations commonly include taking a shower, shaving, going to the toilet, eating alone, going in elevators, or being outside of the home without an inhaler or a companion. This cycle of fear and avoidance is both exacerbated, and confirmed, in patients with asthma because they are explicitly, and quite reasonably, taught by their treating physicians to avoid triggers or allergens for their asthma in their daily lives. Fear, hyperventilation, and panic tend to occur commonly and these symptoms of anxiety may either exacerbate, or occasionally trigger, an asthma attack leading to confusion and uncertainty in both the patients mind and lys physicians mind as to what should be the most appropriate treatment. If the patient misperceives the major cause of his dyspnea as being anxiety and does not treat his asthma with bronchodilators, then he is at risk, and conversely, if he treats his anxiety as if the problem were mainly asthma, then the bronchodilators he takes are likely to exacerbate the anxiety. Phobic avoidance of feared situations or trigger factors, and of course fear of the latter, may be inappropriately excessive as there may be a psychologic component to the “allergic reaction” and this may frequently lead to further anxiety and the development of a worsening vicious circle of fear, hyperventilation, panic, and avoidance. This avoidant behavior may be severely disabling and it can become difficult for both the patient and his attending physician to determine if the feared objects that are being avoided for physiologic or psychologic reasons, or both. This cycle of behavior may lead to significant levels of personal handicap with social and functional restriction much greater than would be expected from the objectively measured physiologic level of impairment.

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A further biologic factor that may cause anxiety may occur if hyperventilation and panic are misconstrued as being indicative of a worsening of the patients respiratory disorder. If this happens, then dosages of asthma medications may be inappropriately increased which in the case of methylxanthines and p₂-adrener- gic agonists are likely to make patients physiologically even more agitated and anxious.

Other evidence suggesting a biologic component to the anxiety disorders seen in asthmatics is the finding, which confirms the genetic predisposition of patients with anxiety disorders, of an increased rate of past personal and family psychiatric histories in asthmatic patients diagnosed as psychiatrically ill compared with psychiatrically fit asthmatics.

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Despite considerable debate, the most accepted definition of asthma is that it is a disorder of the respiratory tract, characterized by a hyperreactive bronchial tree, producing episodes of reversible airway obstruction. Gross, in a discussion on the problems of defining asthma, quoted Permutt as stating “asthma is like love, we all know what it is but who would trust anybody else’s definition.” However asthma is defined, though, it remains a common, chronic, recurrent, disabling, and potentially fatal illness, with a multifac­torial pathogenesis. Among the most commonly ac­cepted trigger factors are allergens, infections, physi­cal irritants, chemical irritants, reflex reactions (eg, to cold temperatures), exercise, and psychogenic factors, including hyperventilation.

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