Psychological Defenses and Coping Styles in Patients Following a Life-Threatening Attack of Asthma: NMAD patients

It is interesting that the two questionnaire scores of “psychiatric caseness” employed in this study, the General Health Questionnaire and the Middlesex Hospital Questionnaire, both scored more highly in the psychiatrically diagnosed patients than in the nondiagnosed patients. This obviously provides validation of the clinical diagnoses. The GHQ, however, when it is used in patients who are medically ill to attempt to define “psychiatric caseness,” usually has a cut off score of 11 to 12, and if one were to use this score with the 25 NMAD patients, then only three of them would be diagnosed as having a psychiatric disorder on the GHQ. The high levels of denial and “faking good” seen in the NMAD patients, however, suggest that if this particular scale is used with these patients, it would be more appropriate to use a lower cut off point for “psychiatric caseness.” Clearly, if physicians are to employ scales such as these to detect psychiatric disorder, then certainly in the patients described in this study, cut off scores would have to be lower than usually recommended.

The Asthma Symptom Checklist Hyperventilation/ Hypocapnia scale was significantly higher in the psychiatrically diagnosed patients than in the nondiagnosed patients which is another indicator of the link between anxiety, hyperventilation, and altered medical status in patients with respiratory disease. The finding that patients who decompensate psychiatrically following the NMAD have higher levels of psychiatric illness in their family and in their past, than the patients who increase their levels of denial is understandable. It has been demonstrated that patients who develop psychiatric disorders after any disaster, and the South Australian bushfires are a good local example of this, tend to be premorbidly or constitutionally more at risk of developing such disorders.

An obvious simple way that clinicians can use to help them predict how individual patients will cope following the medical disaster of a NMAD is to take note of the patients family and past psychiatric history to see if there is an increased constitutional risk of developing psychiatric disorders. It is worth noting that the seven patients with a positive past psychiatric history had a wide range of psychiatric disorders before the NMAD but tended to decompensate following the NMAD with symptoms of anxiety. This may be a reflection of their understandable fear and anxiety, but may also be related to the fact that as they have asthma, they are therefore more at risk of developing symptoms related to the chest such as hyperventilation which is also well known to be causally connected with anxiety and panic attacks.