Psychobiological Aspects of Asthma and the Consequent Research Implications: THE INTERACTION OF MEDICAL part 3

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.

Individuals with asthma have varying levels of ability to perceive both their degree of airways obstruc­tion and narrowing as well as variable levels of response to this event. It has been well demonstrated that in an individual asthmatic subject there is a consistent relationship between the degree of breath- lessness and the FEVb but that between subjects there is a wide individual variation in the magnitude of sensation for any given FEVp Apart from issues related to temporal adaptation and increased bronchial responsiveness, as postulated by Burdon et al, indi­vidual personality styles, past experiences of a medi­cal, psychologic, developmental, familial, and social nature, and the present individual and social situation all play important roles in the way that patients adapt to, and react toward, the threat of worsening airways symptoms. Clearly psychologic defenses such as denial and projection, which have been commonly described in asthmatics can, if they are used excessively by an individual, adversely affect their response to worsen­ing asthma status. A recent study postulated that very high levels of denial should be considered a risk factor for death from asthma and found that asthmatic patients tend to respond following a life-threatening attack of asthma by either demonstrating extremely high levels of denial or by psychiatrically decompen­sating. The same is true of patients who become inappropriately anxious in response to the threat of worsened asthma and who somatize their symptoms of distress. These patients often present with symptoms of chest discomfort, pain, or tightness as well as with overt hyperventilation and dyspnea, and it is logical to suppose that these somatic chest symptoms have appeared as a learned unconscious adaptive response over time. In patients such as these the production of somatic symptoms related to the chest is as good an expression of anxiety as if the patient were to tell his physician that he felt anxious, and in view of their respiratory history one would predict that asthmatic patients would tend to present with chest-related somatic symptoms rather than with, for instance, cardiac or neurologic symptoms. female viagra online

As well as the individual biologic and psychologic issues that affect the type and prevalence of psychiatric disorder seen in patients with asthma, there are also important factors within the family and wider social and cultural system that may have an adverse effect.