• 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 second (FEV₁) on bronchial challenge than non-anxious subjects; they hypothesised that anxiety might produce greater vigilance. On the other hand, greater accuracy of perception of variability in asthma might lead to greater anxiety.

Delay and denial have frequently been identified in qualitative studies of the attitudes of asthma patients to self-management. In one study¹² in which 30 general practice patients with a diagnosis of asthma prescribed regular inhaled steroids were interviewed, about half the patients accepted their asthma and used regular daily inhaled steroids or had a pragmatic approach to asthma control using inhaled steroids intermittently but reporting that this strategy was successful. The other 50% of interviewees did not accept that they had asthma and were classified as “deniers”. Their self-definition commonly was that they had a “bad chest” which resulted in intermittent illness but was not a permanent condition. None of the “deniers” used their prescribed inhaled steroid. Denial was related to seeing asthma as a stigmatised illness and also to seeing themselves as people who could “cope”. To these subjects, acceptance of a self-definition of having asthma and using a preventer regularly would mean that they were “not coping”.

Janson and Becker¹³ prospectively followed 95 patients with asthma and assessed the reasons for the type of action taken when acute episodes occurred. They found that a delay in seeking help was common due to attitudes ranging from fear of steroids to the need to “tough it out”; however, they also found that a small but significant minority identified a pivotal episode in their dealing with acute asthma which changed their attitude to self-management.

The post hoc studies described at the beginning of this article present us with a believable association between denial, psychological morbidity, and a high risk of adverse outcome but they have the limitation of working backwards from a non-representative group. The qualitative studies support the belief that denial and delay are linked to patient willingness to cooperate actively in asthma self-management, but leave unanswered the question of the objective risk of acute episodes associated with different psychological patterns and attitudes to management. Among patients with moderate asthma, are “deniers” more at risk of acute episodes than patients who accept their asthma? In Janson's study was there any evidence that the patients who described themselves as having a pivotal experience that changed their attitudes to their asthma actually did demonstrate more successful asthma control?

Few studies have looked at the prospective consequences of psychological attitudes. In the 1980s Kaptein¹⁴ showed that patients admitted with asthma who had high anxiety scores were more likely to be re-admitted within 6 months. One recent study by Adams et al¹⁵ in hospital outpatients has shown that the prospective risk of admission was related to greater use of strategies such as “hoping for a miracle” to cure asthma.

In this issue of Thorax the paper by Greaves et al¹⁶ complements the findings by Adams et al and presents new data on how the effect of psychological factors on the risk of asthma episodes may depend on a complex relationship between psychological factors and the experience of a recent attack. We might expect patients who have had recent attacks to have low confidence, a high fear of attack, and a high risk of future attacks. Conversely, we would expect patients who have successfully controlled asthma for more than a year to have low anxiety/fear, high confidence, and a low risk of future attacks. Greaves et al show that the story is not so simple. Past attack experience does not completely explain patient differences in panic fear and confidence, and high confidence in a patient has different implications for the risk of an acute attack depending on whether the patient has a history of well controlled or poorly controlled asthma. They conclude that fear of attack is undesirable in patients with good asthma control but is good in patients with poor control. Similarly, confidence in control is good if asthma is well controlled, but too much confidence is bad if asthma is poorly controlled. Dirks et al¹⁷ found more than 20 years ago that hospitalisation was more common in both patients with very high and very low levels of anxiety. The persistence of this pattern is striking as medical management of asthma has changed dramatically since the 1980s.

“Recent attack experience is an important mediator of patient behaviour and attitudes to asthma management”

The study by Greaves et al¹⁶ suggests that there may “good” and “bad” denial of asthma symptoms. It is good for patients with well controlled asthma to be confident in their control and not to be fearful about their asthma, and this may be a form of “positive denial”. Equally, lack of confidence in patients with stable asthma is not a good sign. Lack of confidence may be associated with depression and poor quality of life. In our own study in general practice patients with mild to moderate asthma¹⁸ we found that poor quality of life was a prospective predictor of GP contact for asthma independent of asthma symptoms. Conversely, patients with high asthma confidence scores but who have poorly controlled asthma are expressing a belief in their ability to control episodes which is not warranted by their attack history. This is a denial of the need to change their self-management. This overconfidence is likely to be associated with poor compliance and delay in taking action during episodes. Chambers et al¹⁹ found that the most frequent reason patients gave for non-use or intermittent use of inhaled corticosteroids was a belief that inhaled steroids were unnecessary during non-symptomatic periods. Factors associated with regular use of inhaled steroids were belief about the value of active participation with their doctor in self-care and belief that asthma was a serious health problem.

It would be of value to carry out further studies to determine whether the high confidence/high risk group in the study by Greaves et al is less compliant than the other groups described in the study .

Greaves et al suggest that the period immediately after a serious asthma episode may be a particularly important time for educating and negotiating with patients to change their self-management attitudes and behaviour. This is likely to be of critical importance for overconfident asthma patients who may comprise a significant minority of patients in general practice.

In conclusion, the study by Greaves et al makes clear that recent attack experience is an important mediator of patient behaviour and attitudes to asthma management. Future studies should be mindful of this.