CHAPTER 5
Asthma
KAREN B. SCHMALING, PAUL M. LEHRER, JONATHAN M. FELDMAN, AND NICHOLAS D. GIARDINO
99EPIDEMIOLOGY AND HEALTH CARE COSTS
RELATED TO ASTHMA 100
EVIDENCE BASIS FOR PSYCHOLOGICAL
THEORIES APPLIED TO MECHANISMS
INVOLVED IN ASTHMA 100
Classical and Operant Conditioning 100
Cognitive and Perceptual Processes 101
Psychoanalytic Theory 102
Family Systems Theory 103
PSYCHOLOGICAL FACTORS ASSOCIATED
WITH ASTHMA 104
Effects of Stress and Emotions on Asthma 104
Comorbid Psychiatric Disorders: Prevalence
and Effects 106
Autonomic Nervous System and Inflammatory Processes in
Stress and Asthma: Possible Connections 108
MEDICAL TREATMENTS FOR ASTHMA 108
ADHERENCE 108
PSYCHOSOCIAL FACTORS ASSOCIATED WITH MEDICAL
TREATMENTS AND OUTCOMES 109
Psychiatric Disorders 109
Other Psychological Variables and Their Associations with
Self-Care and Medical Utilization 110
PSYCHOLOGICAL INTERVENTIONS FOR ASTHMA 111
Asthma Education 111
Psychotherapy 111
Written Emotional Expression Exercises 112
Other Psychosocial Interventions 112
Direct Effects of Psychological Treatments on the
Pathophysiology of Asthma 112
Biofeedback Techniques 113
Other Self-Regulation Methods 113
Discussion 114
CONCLUSIONS, UNANSWERED QUESTIONS, AND
FUTURE DIRECTIONS 114
REFERENCES 114This chapter reviews the application of psychological theo-
ries to the understanding of asthma; the effects of stress and
mood states on asthma; and the prevalence of psychiatric
disorders among persons with asthma and the effects of co-
occurring psychiatric disorders and asthma on patient mor-
bidity. We also provide an overview of medical treatments for
asthma and the challenge of adherence with those treatments,
with an examination of the role of psychological variables
in adherence. The research on psychological variables asso-
ciated with outcomes, such as medical utilization, also are
summarized. Behavioral and other psychological interven-
tions are reviewed that directly or indirectly affect asthma.
We conclude with suggestions for future research needs and
directions.
Asthma is a common condition characterized by re-
versible airway obstruction, airway in”ammation, and in-
creased bronchial responsiveness to a variety of stimuli,
ranging from allergens and other irritants to strong emotions
(National Heart Lung and Blood Institute, 1997). In particu-
lar, the role of in”ammation in asthma has been recognized as
crucial and has received increasing attention in the past
decade. The central role of in”ammation has implications for
treatment, and for pathways by which psychosocial factors
may affect asthma. Symptoms of cough, wheezing, and
shortness of breath are commonly associated with an asthma
exacerbation. An asthma attack may be characterized by hy-
percapnia (excessive carbon dioxide) and hypoxia (lack of
oxygen), which may partially account for the high prevalence
of anxiety disorders among persons with asthma. We will ex-
amine these issues later in this chapter.
Asthma and allergies co-occur frequently; allergies are a
common trigger for an asthma exacerbation. About 60% of
persons with asthma are allergic (Ford, 1983); the develop-
ment of asthma and allergies may occur early in childhood
as a common outcome of immune system development
(see Wright, Rodriguez, & Cohen, 1998, for a review). Some
genetic predisposition is probably necessary to develop
asthma, but not all persons who are predisposed will develop
asthma; family stress seems to be implicated in its develop-
ment in childhood (Mrazek, Klinnert, Mrazek, & Macey,
1991; Wright, Weiss, & Cohen, 1996). Asthma is a condition
worthy of the attention and efforts of behavioral scientists: