Psychobiological Aspects of Asthma and the Consequent Research Implications: THE INTERACTION OF MEDICAL part 4
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 alconducted 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.
They prescribed accordingly. High-sensitivity physicians could also distinguish between physical and psychologic distress in their patients and could accurately interpret the degree of their patients illness from their pulmonary function tests. However, the actual medical decisions of high-sensitivity physicians deviated from this realistic appraisal and their prescription, for instance, of oral steroids was influenced by patient personality variables. Dirks et al commented that these physicians tried to treat a psychologic problem as a medical problem and in so doing tended to prescribe steroids inappropriately. An interesting finding was that the physicians denoted as having moderate sensitivity to their patients tended to treat them better along medical lines than the other two groups of physicians. With one exception we have found no other reviews in the literature concerning the relationship between the chronic respiratory patient and his physician and no comments on transference and counter-transference issues. This is somewhat surprising in view of the nature of the psychologic defenses used by patients and the long duration of the physician- patient relationship, and may in part reflect similar defenses being used by the treating physicians and investigators, specifically denial, intellectualization, and rationalization.
The family issues in asthma have received wide attention, particularly with respect to asthmatic children where abnormal family functioning has been described as a possible risk factor for death due to asthma. Abnormal family functioning has been noted in families of asthmatics who have survived a life- threatening episode of acute asthma where mutual anger and distrust, as well as mutual overinvolvement, has been described. There are also issues of primary and secondary gain for the patient and his family to deal with, and the extensive psychiatric literature on the importance of an individuals level of perceived social support as a protective factor limiting the development of minor psychiatric disorder suggests that this may be an influential factor in determining levels of individual morbidity in asthmatic patients.
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The wider social and cultural issues have, despite some notable exceptions, seldom been extensively addressed in the literature. It can be argued that asthma is a stigmatized illness that is often thought within the community to be self-induced or “emotional.” Because of increasingly effective symptomatic treatment there is now a generation of asthmatic subjects, many of whom do not know what it is like to be ill or physically disabled by their asthma. They have little experience of how to cope with severe attacks and may therefore use inappropriate measures when these occur. Asthmatics are taught to lead “normal” lives, but this normality may lead to adverse effects, particularly when they are in a crisis situation, made worse because community attitudes have hardened against the need for medication in recent years. Yellowlees and Ruffin have described how asthmatics commonly use high levels of denial as a primary psychologic defense mechanism, and how this may at one level be an adaptive response, but this type of psychologic defense, if used excessively, may be particularly dangerous in a social setting that negates the recognition of being ill and the need to take medication, and is likely to be a factor in the increasing numbers of patients dying of asthma. Denial is a normal coping mechanism in response to adversity and is often adaptive. Increased levels of denial are likely to be helpful in allowing patients to cope with a chronic illness like asthma yet retain a normal social presentation and, in our culture where abnormal physical appearance or function is heavily stigmatized, an increased amount of denial is probably essential to allow patients with asthma to cope and feel relatively normal. Denial is also often increased in situations of constant loss, and asthma is associated with losses particularly in health and self-esteem, and it is also commonly used as a defense against fear, anxiety, and depression. The interaction of individual and community denial in response to an illness like asthma, and the potential adverse effects that these attitudes may have, merit attention.