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

doi:10.1378/chest.95.6.1298

Chest

Volume 95, Issue 6, June 1989, Pages 1298-1303

https://doi.org/10.1378/chest.95.6.1298 Get rights and content

Twenty-five patients who have suffered a near miss asthma death (NMAD) have undergone a comprehensive psychiatric evaluation on average 13 months following this event. Forty percent of the patients were judged to have psychiatric disorders at the time of assessment. All patients had very high levels of denial and following the NMAD, patients appeared to either decompensate psychiatrically, usually exhibiting symptoms of anxiety disorders, or further increase their levels of denial. Those patients who had psychiatric illnesses at the time of the study were more constitutionally vulnerable towards developing these disorders and had a reduced perception of their quality of life compared with the patients who increased their levels of denial following the NMAD. The effects of the NMAD on patients and their families ranged from mutual anger and anxiety, although the anger was often repressed, to mutual overinvolvement and overdependence. The presence of high levels of denial of asthma and a history of psychiatric illness in the patient appear to be factors that may increase the likelihood of death from asthma.

Section snippets

PATIENTS AND METHODS

Flinders Medical Center is a 500-bed teaching hospital in Adelaide, South Australia. For the purposes of this study, asthma was defined by a history of variable cough, wheeze, and dyspnea, with measured increased bronchial responsiveness to inhaled histamine, or a 20 percent increase in forced expiratory volume in one second spontaneously or in response to inhaled bronchodilator agents. The Respiratory Unit is following those patients who have suffered a near miss asthma death. The NMAD has

RESULTS

The 25 patients were comprised of 19 women and six men. Their mean age was 35.7 years (range 18 to 68, standard deviation 13.3). The mean age of the men was 39.5 years (range 18 to 68, standard deviation 18.8) and the women was 34.4 years (range 19 to 57, standard deviation 11.1). Seven patients were single and 18 were married or in de facto relationships. The study interviews took place in the outpatient setting on average 13 months following the NMAD (range 1 to 58 months), and all patients

DISCUSSION

The major finding of this study is that the psychiatric and psychological profiles of the group of patients who have suffered a NMAD are most unusual. The prediction that they would not have particularly high levels of denial because of the consequences of their NMAD has not been upheld. Instead, what has been found is that while the patients as a whole have very high levels of denial anyway, they seem to respond psychologically to the NMAD by either decompensating psychiatrically and

ACKNOWLEDGMENTS

Professor Ross Kalucy and Dr. John Alpers gave advice and assistance, Mr. Nicholas Potts and Miss Susan Haynes helped with interviewing, Miss Joylene Eden rendered statistical assistance, and Miss Gwyn Jones gave secretarial expertise.

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Citation Excerpt :
Finally, psychosocial stress could be the consequence of chronic severe asthma itself. The experience of frequent asthma attacks and/or chronic impairment in social functioning might obviously result in anxiety and depression [42]. However, our results show an association with prednisone dependent asthma and not with severe non-prednisone dependent asthma.
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.
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.
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.
Patients with severe, prednisone-dependent asthma have more often psychological distress as compared to patients with severe non-prednisone dependent or mild-moderate asthma.
Understanding dyspnea as a complex individual experience
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If negatively cued stimuli cannot be avoided, learnt anticipation of dyspnea in response to a stimulus might increase the negative perception of respiratory stimuli [33], so patients are more likely to feel out-of breath because they know they are climbing the stairs and they expect to feel breathless. The fear of future dyspnea and resulting avoidance of activities that might induce dyspnea generate a positive feedback loop that drives the spiral of decline and leads to increased perception of disability at comparable pulmonary function [34]. On the neuronal level, brain activation during anticipation of dyspnea was found to correlate with brain activation during the perception of dyspnea [35].
Dyspnea is the highly threatening experience of breathlessness experienced by patients with diverse pathologies, including respiratory, cardiovascular, and neuromuscular diseases, cancer and panic disorder. This debilitating symptom is especially prominent in the elderly and the obese, two growing populations in the Western world. It has further been found that women suffer more strongly from dyspnea than men. Despite optimization of disease-specific treatments, dyspnea is often inadequately treated. The immense burden faced by patients, families and the healthcare system makes improving management of chronic dyspnea a priority.
Dyspnea is a multidimensional sensation that encompasses an array of unpleasant respiratory sensations that vary according to underlying cause and patient characteristics. Biopsychological factors beyond disease pathology exacerbate the perception of dyspnea, increase symptom severity and reduce quality of life. Psychological state (especially comorbid anxiety and depression), hormone status, gender, body weight (obesity) and general fitness level are particularly important. Neuroimaging has started to uncover the neural mechanisms involved in the processing of sensory and affective components of dyspnea.
Awareness of biopsychological factors beyond pathology is essential for diagnosis and treatment of dyspnea. Increasing understanding the interactions between biopsychological factors and dyspnea perception will enhance the development of symptomatic treatments that specifically address each patient's most pressing needs at a specific stage in life. Future neuroimaging research can provide objective markers to fully understand the role of biopsychological factors in the perception of dyspnea in the hope of uncovering target areas for pharmacologic and non-pharmacologic therapy.
Onset and risk factors for anxiety and depression during the first 2 years after lung transplantation
2012, General Hospital Psychiatry
Citation Excerpt :
This is an important omission since — as demonstrated in other forms of organ transplantation — clinically significant psychiatric morbidity is prevalent [17,26–29] and can predict negative longer-term health outcomes [27–30]. Anxiety disorders, and panic disorder in particular, appear to be uniquely associated with chronic lung disease, based on evidence from (nontransplanted) samples [31–35]. Given lung recipients' own history of lung disease plus their enduring physical symptoms and functional impairments posttransplant, they may be at heightened risk for anxiety disorders posttransplant, relative to risk in other transplant populations.
Anxiety disorders are prominent in chronic lung disease; lung transplant recipients may therefore also be at high risk for these disorders. We sought to provide the first prospective data on rates and risk factors for anxiety disorders as well as depressive disorders during the first 2 years after transplantation.
A total of 178 lung recipients and a comparison group (126 heart recipients) received psychosocial and Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition assessments at 2, 7, 12, 18 and 24 months posttransplant. Survival analysis determined onset rates and risk factors.
The panic disorder rate was higher (P<.05) in lung than heart recipients (18% vs. 8%). Lung and heart recipients did not differ on rates of transplant-related posttraumatic stress disorder (15% vs. 14%), generalized anxiety disorder (4% vs. 3%) or major depression (30% vs. 26%). Risk factors for disorders included pretransplant psychiatric history, female gender, longer wait for transplant, and early posttransplant health problems and psychosocial characteristics (e.g., poorer caregiver support and use of avoidant coping).
Heightened vigilance for panic disorder in lung recipients and major depression in all cardiothoracic recipients is warranted. Strategies to prevent psychiatric disorder should target recipients based not only on pretransplant characteristics but on early posttransplant characteristics as well.
Psychologic distress and maladaptive coping styles in patients with severe vs moderate asthma
2010, Chest
Citation Excerpt :
However, given the relative paucity of research in this area, future research is needed to explore the asthma-glucocorticoid-cognitive dysfunction link in greater depth. Findings of marginally higher rates of anxiety are consistent with similar studies in patients with life-threatening9,46,47 and brittle48 asthma. Patients with moderate-to-severe vs milder forms of asthma have a high prevalence (6.5%-24%) of anxiety disorders,49–52 suggesting that anxiety may be a specific feature of more severe forms of asthma.
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.
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.
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]).
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.
National study of asthma quality of life - Application of the Asthma Quality of Life Questionnaire (AQLQ-M) by Marks in the Portuguese population
2008, Revista Portuguesa de Pneumologia
The Portuguese version of the Marks Asthma Quality of Life Questionnaire (AQLQ-M) has already proven to have good diagnostic properties, and is suitable for use with Portuguese asthma patients. The last forty years have seen a worldwide rise in the rate, morbidity, mortality and economic burden associated with asthma and the disease continues to be underdiagnosed and undertreated. In this study the AQLQ-M was administered to 826 asthmatic patients from continental Portugal (97.9% Caucasian, mean age 40.5 years, 30.2% male, 69.8% female), followedup by pulmonologists and allergologists. Patients were classified in line with the Global Initiative for Asthma (GINA) severity categories: 40.5% intermittent asthma, 26.9% mild persistent, 21.4% moderate persistent, 11.2% severe persistent. AQLQ-M scores maintained significant relationships with asthma severity, symptoms and lung function. Most of the patients were not managed and 74.6% were observed in an emergency room during last year. Women reported poorer QoL than men in all the questionnaire's subscales. Surprisingly, smokers presented better QoL than non-smokers. The results of this study evidence that the Portuguese version of the AQLQ-M is a useful instrument for measuring health-related quality of life in adults with asthma.
A versão portuguesa do Asthma Quality of Life Questionnaire de Marks (AQLQ-M) demonstrou anteriormente que apresenta boas propriedades psicométricas e é adequada para utilização em doentes portugueses com asma. Ao longo dos últimos 40 anos, tem vindo a observar-se um aumento global na prevalência, morbilidade, mortalidade e custos económicos associados à asma, continuando esta a ser uma doença subdiagnosticada e subtratada. Neste estudo, o AQLQ-M foi aplicado a 826 doentes asmáticos de Portugal continental (97,9% caucasianos; média de idades = 40,5 anos; 30,2% do sexo masculino; 69,8% do sexo feminino) seguidos em consulta de pneumologia ou imunoalergologia. Os doentes foram classificados de acordo com os níveis de gravidade do Global Initiative for Asthma (GINA). Apresentavam asma intermitente 40,5%; 26,9% asma persistente ligeira; 21,4% asma persistente moderada e 11,2% asma persistente grave. A pontuação do AQLQ-M manteve correlações estatisticamente significativas com a gravidade da asma, sintomas e função pulmonar. A maioria dos doentes não se apresentava controlada, tendo 74,6% recorrido ao serviço de urgência ao longo do último ano. Para todas as subescalas do questionário, as mulheres apresentavam pior qualidade de vida (QdV) do que os homens. Surpreendentemente, os fumadores apresentavam melhor QdV do que os indivíduos que nunca fumaram. Os resultados deste estudo revelaram que a versão portuguesa do AQLQ-M é um instrumento útil para a medição da QdV relacionada com a saúde em adultos com asma.
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View all citing articles on Scopus

Read before the Thoracic Society of Australia Annual Meeting, Sydney, Australia, May 1988. This study was supported by grants from the Flinders Medical Center Research Foundation and the Asthma Foundation of Australia.

Manuscript received July 13; revision accepted October 11.

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Chest

Clinical Investigations in Critical CarePsychological Defenses and Coping Styles in Patients Following a Life-Threatening Attack of Asthma

Section snippets

PATIENTS AND METHODS

RESULTS

DISCUSSION

ACKNOWLEDGMENTS

J Chron Dis

J Allerg Clin Immunol

Death in patients with asthma

Med J Austral

Asthma in Australia: strategies for reducing morbidity and mortality

Psycho-maintenance in asthma: hospitalization rates and financial impact

Br J Med Psychol

Patient and physician characteristics influencing medical decisions in asthma

Journal Asthma Res

Physiologic and psychological characteristics associated with deaths due to asthma in childhood: a case-controlled study

JAMA

A case-control study of deaths from asthma

Thorax

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

Med J Austral

Diagnostic and statistical manual of mental disorders

National Institute of Mental Health diagnostic interview schedule

Arch Gen Psychiatry

Clinical Investigations in Critical Care
Psychological Defenses and Coping Styles in Patients Following a Life-Threatening Attack of Asthma