Evidence Basis for Psychological Theories Applied to Mechanisms Involved in Asthma 103function (Feldman, Lehrer, Carr, & Hochron, 1998). One pos-
sible interpretation of these results is that asthma symptom
complaints may be more accessible (to the patient) and
socially acceptable ways to communicate distress than are
emotions among patients who may be characterized as alex-
ithymic. Helping such patients identify emotions, cope with
emotional arousal, and discriminate emotional reactions from
asthma symptoms could lead to more appropriate utilization
of medical resources.
Repressive-Defensive Coping Style
More recently, the repressive-defensive coping style has
received attention in relationship to persons with asthma and
other chronic medical conditions. This style is characterized
by the co-occurrence of low levels of self-reported distress,
high levels of self-reported defensiveness, and high levels of
objectively measured arousal and physiological reactivity.
In adults, repressive-defensive coping has been associated
with immune system down-regulation (Jamner, Schwartz, &
Leigh, 1988). Among persons with asthma, immune system
down-regulation could increase risk for respiratory infections,
which are known to exacerbate asthma through several possi-
ble mechanisms (Wright et al., 1998). Adults with asthma who
display the repressive-defensive coping style were found to
display a decline in pulmonary function after exposure to lab-
oratory tasks (e.g., reaction time, distressing “lms) and their
autonomic nervous system was characterized by sympathetic
hypoarousal and parasympathetic hyperarousal during these
tasks (Feldman, Lehrer, & Hochron, in press). However,
among samples of children with asthma, repressive-defensive
coping style was not characteristic of a majority of children,
was not associated with more physiological reactivity under
stress (Nassau, Fritz, & McQuaid, 2000), and was associated
with more accurate symptom perception (Fritz, McQuaid,
Spirito, & Klein, 1996), which would not be predicted by a
psychosomatic model.
Alexithymia and the repressive-defensive coping style ap-
pear to be the most well-operationalized concepts that have
roots in psychoanalytic theory and have been implicated
among persons with asthma. However, the utility of these
constructs in explaining important asthma-related processes
such as symptom onset, expression, variability, course, and
outcomes, is limited based on current research. Despite the
data on repressive-defensive coping among children with
asthma not providing robust support for predicted results, re-
search on repressive-defensive coping among adults is war-
ranted since adults• styles may be more polarized and may
exert a stronger in”uence on self-management behavior than
among children, who share self-management responsibilities
with parents and other responsible adults.Family Systems TheoryFamily systems models have been explored in relationship
to children and adolescents with asthma, and will be men-
tioned only brie”y here. The classic systemic view of family
dynamics that creates and perpetuates a •psychosomaticŽ
illness such as asthma was outlined by Minuchin, Rosman,
and Baker (1978). These dysfunctional dynamics include
rigidity, overprotectiveness, enmeshment, and lack of con-
”ict resolution. In the systemic view, the function of the ill-
ness is to diffuse con”ict and maintain homeostasis in the
family (e.g., escalating tension between the parents may
prompt an asthma attack in the child, which distracts the par-
ents from continuing con”ict). Akin to the status of support
for psychoanalytic theories related to asthma, evidence to
corroborate a systemic view is largely based on clinical anec-
dotes, although a few attempts to operationalize and assess
key family dynamics exist. Families with and without a child
with asthma engaged in a decision-making task (Di Blasio,
Molinari, Peri, & Taverna, 1990). Families with a child with
asthma were characterized by protracted decision-making
times, chaotic responses, lack of agreement, and acquies-
cence to the child•s wishes, which may re”ect an overprotec-
tive stance and dif“culties with con”ict resolution, as would
be suggested by systems theory.
Observational studies have found mothers of children
with asthma to be more critical of their children than mothers
of healthy children (Hermanns, Florin, Dietrich, Rieger, &
Hahlweg, 1989; F. Wamboldt, Wamboldt, Gavin, Roesler, &
Brugman, 1995). These communication patterns would seem
inconsistent with the hypothesized characteristic of overpro-
tectiveness in such families, although they may re”ect a ten-
dency toward lack of con”ict resolution, which would be
consistent with systemic hypotheses. An observational study
of couples and children with and without asthma (Northey,
Grif“n, & Krainz, 1998) examined base rates of speci“c be-
haviors (e.g., agree, disagree) and sequences of behavior
hypothesized to be more characteristic of psychosomatic
families based on the Minuchin et al. (1978) model, such as
recruitment or solicitation of child input after a parental posi-
tion statement. Couples with a child with asthma were less
likely to agree with one another, and were more likely to so-
licit the child•s input. Couples with a child with asthma who
were unsatis“ed with their marriage were about half as likely
to disagree with one another than were couples without a
child with asthma. Relative avoidance of disagreement in the