Inaccurate perception of asthma symptoms: A cognitive–affective framework and implications for asthma treatment
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
References (131)
- et al.
Medication, chronic illness and identity: The perspective of people with asthma
Social Science & Medicine
(1997) - et al.
The catastrophic misinterpretation model of panic disorder
Behaviour Research and Therapy
(2001) - et al.
How does interoceptive exposure for Panic Disorder work? An uncontrolled case study
Journal of Anxiety Disorders
(1997) - et al.
Perception of respiratory sensation assessed by means of histamine challenge and threshold loading tests
Chest
(2000) - et al.
Accuracy of respiratory symptom perception in different affective contexts
Journal of Psychosomatic Research
(2005) - et al.
Perception scoring of induced bronchoconstriction as an index of awareness of asthma symptoms
Chest
(1994) Panic disorder and asthma: Causes, effects and research implications
Journal of Psychosomatic Research
(1998)- et al.
Differentiation between the sensory and affective aspects of histamine-induced bronchoconstriction in asthma
Respiratory Medicine
(2007) - et al.
Dyspnea: The role of psychological processes
Clinical Psychology Review
(2004) - et al.
Anxiety, panic and adult asthma: A cognitive–behavioral perspective
Respiratory Medicine
(2007)
Symptom perception in pediatric asthma: Resistive loading and in vivo assessment compared
Chest
Distraction from chronic pain during a pain-inducing activity is associated with greater post-activity pain
Pain
Cognitive processes during fear acquisition and extinction in animals and humans: Implications for exposure therapy of anxiety disorders
Clinical Psychology Review
The effects of suggestion on airways of asthmatic subjects breathing room air as a suggested bronchoconstrictor and bronchodilator
Journal of Psychosomatic Research
Perceived control of asthma and quality of life among adults with asthma
Annals of Allergy, Asthma and Immunology
Psychological treatment of comorbid asthma and panic disorder: A pilot study
Journal of Anxiety Disorders
Heart rate variability biofeedback: Effects of age on heart rate variability, baroreflex gain, and asthma
Chest
Biofeedback treatment for asthma
Chest
Effects of long-acting bronchodilators and placebo on histamine-induced asthma symptoms and mild bronchusobstruction
Respiratory Medicine
The risk of hospitalization and near-fatal and fatal asthma in relation to the perception of dyspnea
Chest
Conscious and unconscious perception: An approach to the relations between phenomenal experience and perceptual processes
Cognitive Psychology
A cognitive-motivational analysis of anxiety
Behaviour Research and Therapy
Perceived symptoms and discomfort during induced bronchospasm: The role of temporal adaptation and anxiety
Behaviour Research and Therapy
ARIA update: I—Systematic review of complementary and alternative medicine for rhinitis and asthma
Journal of Allergy and Clinical Immunology
Negative affectivity and the influence of suggestion on asthma symptoms
Journal of Psychosomatic Research
Breathing retraining for asthma
Respiratory Medicine
Cognitions associated with initial medical consultations concerning recurrent breathing difficulties: A community-based study
Psychology & Health
Mood states associated with transitory changes in asthma symptoms and peak expiratory flow
Psychosomatic Medicine
Heart rate variability as an index of regulated emotional responding
Review of General Psychology
Symptom perception and respiratory sensation in asthma
American Journal of Respiratory and Critical Care Medicine
Dyspnea and pain: Similaritiesand contrasts between two very unpleasant sensations
American Pain Society Bulletin
Perception of bronchoconstriction in asthma patients measured during histamine challenge test
European Respiratory Journal
Psychological mechanisms of medically unexplained symptoms: An integrative conceptual model
Psychological Bulletin
Trait anxiety, symptom perceptions, and illness-related responses among women with breast cancer in remission during a tamoxifen clinical trial
Health Psychology
Psychiatric and medical features of near fatal asthma
Thorax
A test of the symptom amplification hypothesis in patients with asthma
Journal of Nervous & Mental Disease
Beyond attentional strategies: A cognitive–perceptual model of somatic interpretation
Psychological Bulletin
Lung function, adherence and denial in asthma patients who exhibit a repressive coping style
Psychology, Health & Medicine
Interoception: The sense of the physiological condition of the body
Current Opinion in Neurobiology
Mastery of your anxiety and panic: Therapist guide
Interoceptive exposure versus breathing retraining within cognitive–behavioural therapy for panic disorder with agoraphobia
British Journal of Clinical Psychology
Neuroanatomical basis for first- and second-order representations of bodily states
Nature Neuroscience
Neural systems supporting interoceptive awareness
Nature Neuroscience
Respiratory-related evoked potentials in children with life-threatening asthma
American Journal of Respiratory and Critical Care Medicine
Preparedness and phobias: Specific evolved associations or a generalized expectancy bias
Behavioral and Brain Sciences
The Implicit Association Test as a tool for studying dysfunctional associations in psychopathology: Strengths and limitations
Journal of Behavior Therapy and Experimental Psychiatry
Illness-specific catastrophic thinking and overperception in asthma
Health Psychology
Selective attention for asthma-related stimuli in asthma: Evidence from the visual dot-probe task
Context-evoked overperception in asthma
Psychology & Health
Cited by (115)
Systemic Inflammation in Asthma: What Are the Risks and Impacts Outside the Airway?
2024, Journal of Allergy and Clinical Immunology: In PracticeUnder-perception of airflow limitation, self-efficacy, and beliefs in older adults with asthma
2023, Journal of Psychosomatic ResearchFrom fear of falling to choking under pressure: A predictive processing perspective of disrupted motor control under anxiety
2023, Neuroscience and Biobehavioral ReviewsEffects of emotional contexts on respiratory attention task performance
2023, Respiratory Physiology and NeurobiologyRelationships among pulmonary function, anxiety and depression in mild asthma: An exploratory study
2022, Biological Psychology