102 Asthma
cognitive-emotional pathway to the airways was identi“ed,
cognitive-behavioral interventions to optimize patient func-
tioning could be developed.
Perceived versus Objective Pulmonary Function
Good self-management is crucial to optimal asthma care;
self-management skills include adherence with medications,
which typically involves using as-needed medications based
on perceptions of need by self-monitoring or awareness of
possible exposure to triggers (e.g., pretreatment before exer-
cise). From this perspective, it is clear that patients• percep-
tions are the foundations for optimal asthma control. But,
how ably can patients with asthma accurately perceive their
respiratory status?
The process of detection, perception, and response to ob-
jectively demonstrable changes in air”ow seems subject to a
good deal of personal variation, perhaps akin to the experi-
ence of and response to pain. In terms of patients• abilities to
perceive changes in air”ow, many studies have shown a poor
correspondence between symptoms and air”ow among the
majority of individuals. One study reported that only a
quarter of patients demonstrated a statistically signi“cant as-
sociation between PEFR and symptoms (Apter et al., 1997),
and these correlations, while statistically signi“cant, were of
questionable clinical signi“cance (e.g., coef“cients ranged
from.25 to.39, leaving at least 80% of the variability in
PEFR unaccounted for by symptom report). Similarly,
Kendrick, Higgs, Whit“eld, and Laszlo (1993) found statisti-
cally signi“cant correlations between PEFR and symptoms in
only 40% of patients. A series of studies by Reitveld and col-
leagues (reviewed next) showed poor correspondence be-
tween subjective symptom report and objective pulmonary
function; they suggest that symptom perception is largely
attributable to mood. However, other studies have reported
much stronger associations between perceived breathlessness
and lung function (e.g.,r0.88 by Burdon, Juniper, Killian,
Hargreave, & Campbell, 1982). While correlations re”ect the
relative association of two variables, they do not re”ect other
important information for asthma management (e.g., how
frequently can a patient detect when his/her air”ow has
diminished signi“cantly), to the point at which medications
should be used? Finally, behavioral follow-through„actually
using medications when the need to do so is identi“ed„is yet
another independent step in appropriate self-management.
There are alarming reports of signi“cant delays in seeking
treatment, despite patients• reported awareness of decreased
respiratory function in the 24 to 48 hours prior to obtaining
treatment (e.g., Mol“no, Nannini, Martelli, & Slutsky, 1991).
In a subset of persons with severe asthma, the inability to
perceive changes in air”ow may be life threatening or fatal.
For example, a comparison of patients who had near fatal
asthma attacks, patients with asthma without near-fatal
attacks, and a group of participants without asthma revealed
that patients who had a near fatal attack had a blunted respira-
tory response to hypoxia generated by rebreathing (breathing
within a con“ned space, resulting in gradually increasing car-
bon dioxide as the available air is recycled), and their percep-
tion of dyspnea was lower than participants without asthma
(Kikuchi et al., 1994). Inaccurate perception of respiratory
status has been associated with repressive-defensive coping
(see also next section) (Isenberg, Lehrer, & Hochron, 1997;
Steiner, Higgs, & Fritz, 1987).
Timely and accurate perception of your respiratory status is
central to appropriate asthma self-management, but research
suggests a good deal of variability among patients• perceptual
abilities that may have life-threatening consequences.Psychoanalytic TheoryFrom the psychoanalytic perspective, asthma has been
posited to develop in response to repressed emotions and
emotional expression, such as repressed crying (Alexander,
1955). This perspective views asthma as a psychosomatic
illness, suggesting direct causal links between psychologi-
cal factors and disease. The psychoanalytically-informed
literature related to asthma is largely limited to case studies
and other clinical materials (e.g., Levitan, 1985). Two areas
of empirical research, however, may have been in”uenced
by these early psychoanalytic formulations, namely, re-
search on alexithymia and the repressive-defensive coping
style.AlexithymiaDif“culty in labeling and expressing emotions has been
termedalexithymia(Nemiah, 1996). Several decades ago, a
group of researchers developed a measure of alexithymia as a
subscale of the MMPI (Kleiger & Kinsman, 1980) and used it
in a series of studies of patients with asthma. They found that
alexithymic patients were more likely to be rehospitalized and
had longer lengths of stay than did non-alexithymic patients
(Dirks, Robinson, & Dirks, 1981); these differences were
not attributable to underlying asthma severity. More recently,
it has been shown that dif“culty distinguishing between
feelings and bodily sensations, as measured by the Toronto
Alexithymia Scale, is related to greater report of asthma
symptomatology, but not objective measures of pulmonary