Inaccurate perception of asthma symptoms: A cognitive–affective framework and implications for asthma treatment

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Abstract

Inaccurate perception of respiratory symptoms is often found in asthma patients. Typically, patients who inaccurately perceive asthma symptoms are divided into underperceivers and overperceivers. In this paper we point out that this division is problematic. We argue that little evidence exists for a trait-like stability of under- and overperception and that accuracy of respiratory symptom perception is highly variable within persons and strongly influenced by contextual information. Particularly, expectancy and affective cues appear to have a powerful influence on symptom accuracy. Based on these findings and incorporating recent work on associative learning, attention and mental representations in anxiety and symptom perception, we propose a cognitive–affective model of symptom perception in asthma. The model can act as a framework to understand both normal perception as well as under- and overperception of asthma symptoms and can guide the development of affect-related interventions to improve perceptual accuracy, asthma control and quality of life in asthma patients.

Introduction

Since the 1970s, a low congruence between symptom reports and pulmonary function measures has been reported in asthma patients using a variety of methods (Boulet et al., 1994, Kendrick et al., 1993, Magadle et al., 2002, Rubinfeld and Pain, 1976, Teeter and Bleecker, 1998). Poor symptom perception is considered an important factor in asthma morbidity, but the estimated prevalence varies widely, ranging from 15 to 60% of asthma patients, depending on the measurement used (Kendrick et al., 1993, Magadle et al., 2002, Rubinfeld and Pain, 1976, Teeter and Bleecker, 1998). The group of poor perceivers is further divided into two distinct subtypes, namely under- and overperceivers (Ciccone et al., 2007, Magadle et al., 2002, Teeter and Bleecker, 1998, Yoos et al., 2003). An implicit assumption underlying this distinction is that under- and overperception of asthma is a stable, one-dimensional trait-like characteristic, analogous to near- and farsightedness in visual perception. We will challenge this assumption and advance evidence to claim that (a) apart from a small group of patients with a perceptual deficit, asthma patients with poor symptom perception are not consistent in their under- or overperception, (b) poor symptom perception is largely influenced by expectation and emotional factors, interacting with personality and situational context, and (c) interventions changing affect-related variables can play an important role in the treatment of a substantial subset of asthma patients.

Since there is no standard method of assessing symptom perception, we will first briefly discuss the various methods that can be used to assess accuracy of symptom perception in asthma.

Section snippets

Assessment of accuracy of symptom perception in asthma

A first group of methods assessing the accuracy of symptom perception is based upon a comparison of an objective index for obstructed breathing with self-reported symptoms. This may be naturally occurring bronchoconstriction, or may be induced, for example, in a provocation test or by breathing against an external respiratory resistance. Comparing symptoms and lung function has yielded both categorical approaches to poor perception, classifying patients not responding with symptoms to induced

Is over- or underperception of asthma symptoms a dispositional variable?

Obviously, a small group of asthma patients are stable underperceivers. Using respiratory related evoked potentials (RREP), Davenport, Cruz, Stecenko, and Kifle (2000) identified patients with a stable perceptual deficit in a sample of children with a history of life-threatening asthma (LTA). A specific P1 peak was only observed in about half of the patients with LTA in reaction to inspiratory occlusion, whereas almost all control subjects showed a P1 peak. Because the P1 peak is thought to

Which variables modulate symptom perception accuracy?

A wide variety of psychological variables that influence symptom perception in general (Pennebaker, 1982), and respiratory symptom perception in particular (De Peuter et al., 2004, Von Leupoldt and Dahme, 2007) have been listed. However, inaccurate perception of asthma symptoms can be conceived as dependent on two major groups of overarching psychological variables: expectancy-related and affective variables.

Explaining the influence of affect and expectancy on symptom perception in asthma

In the following, we first review the processes that may be involved in the perception of asthma symptoms and, second, integrate these processes as building blocks into a working model of symptom perception in asthma.

With our working model of symptom perception in asthma, we aim to explain how information from different sources is processed and perceived as an asthma symptom. Models of symptom perception or specific models about the perception of asthma symptoms all state that the perception of

Improvement of inaccurate perception: from theory to therapy

In addition to predicting when inaccurate perception of asthma symptoms will occur, the working model may be used to make specific predictions on how the perception of asthma symptoms may be improved. Because of the various factors influencing symptom perception in asthma, there are many possibilities for interventions targeting symptom perception. Based on the components of our model, we list interventions that can be used to target these components and thereby improve symptom perception in

Empirical validation of the model

We presented a working model of symptom perception in asthma to explain findings concerning the influences of contextual and affective factors in the perception of asthma symptoms, in which we proposed that threat-level evaluations and illness representations are essential in explaining these influences.

A next step to validating the model will consist of a further clarification of the effects of asthma representations on inaccurate perception of asthma symptoms. There are several strategies to

General conclusion

Although patients who inaccurately perceive asthma symptoms are typically divided into underperceivers and overperceivers, we pointed out that little evidence exists for a trait-like stability of under- and overperception and that accuracy of respiratory symptom perception is highly variable within persons and is strongly influenced by contextual information. Current methods to assess inaccurate symptom perception do not take into account this within-person variation.

We proposed a

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