• asthma
• attack context
• psychological factors

In a series of Australian studies Yellowlees,¹ Ruffin,² and Campbell³ have found high rates of anxiety and panic disorder among patients who have suffered near fatal asthma episodes. In the UK Ayres and coworkers have found a high lifetime prevalence of psychiatric symptoms and psychiatric morbidity in patients with brittle asthma.^4,5 Both the Australian studies and that by Ayres et al report a consistent pattern of high levels of denial of asthma and delay in seeking help in acute attacks. The confidential enquiries into asthma deaths^6–8 suggest that psychological factors including denial and delay contribute to some deaths. Patients who had died from asthma were more likely to be those who found it difficult to cooperate with medical management.

However, these studies only refer to a small minority of asthma patients, are post hoc, and may be relevant only to a special group of asthmatic subjects. It is not easy to translate these findings for very severe high risk subjects to moderate asthmatics in general practice.

Anxiety is not always found to be higher among patients with poorly controlled asthma. Barboni et al⁹ compared patients with near fatal asthma with a group of matched controls and found no difference in psychiatric anxiety scores between the two groups. Boseley et al¹⁰ found no significant difference in anxiety between adherent and non-adherent patients. Some anxiety may be useful in self-management. Spinhoven et al¹¹ found that anxious subjects were more accurate in detecting a fault in forced expiratory volume in 1 …