104 Asthma
face of relationship distress may preclude problem solving
about the source of the disagreement, and the subsequent
possibility of improvement in relationship satisfaction with
problem resolution. The authors suggest that parental recruit-
ment of child input among families with a child with asthma
could indicate compensatory attempts to involve an ill child
in family activities. The family systems model, on the other
hand, would posit that the focus on the child de”ects attention
from the parents• marital distress: Parental solicitousness to-
ward the child functions to avoid con”ict in the marital dyad
so the child•s illness is •protectiveŽ and maintains homeosta-
sis in the family.
There are several questionnaires such as the Family Envi-
ronment Scale (Moos & Moos, 1986), the Family Adaptabil-
ity and Cohesion Scale (Olson, Portner, & Laree, 1985), and
the Family Assessment Device (Epstein, Baldwin, & Bishop,
1983) that are scored to re”ect systemic constructs of rigidity,
cohesion, con”ict, and so forth. These questionnaires have
been used to characterize the environment and dynamics
of the families of children with asthma on a limited basis
(e.g., Bender, Milgrom, Rand, & Ackerson, 1998). As yet,
however, research informed by family systems theory that
focuses on adults with asthma is lacking.
PSYCHOLOGICAL FACTORS ASSOCIATED
WITH ASTHMA
Effects of Stress and Emotions on Asthma
Patients with asthma often believe that stress and emotions
can trigger or exacerbate asthma (e.g., Rumbak, Kelso,
Arheart, & Self, 1993). The association between emotions and
air”ow has been examined empirically through laboratory-
based experiments and studies of the covariation of air”ow
and emotions in naturalistic conditions.
Laboratory Studies
Isenberg et al. (1992a), in addition to reviewing response to
suggestion, also reviewed studies that examined individuals•
responses to emotional provocation. Across the seven studies
reviewed that involved the induction of emotions in the lab-
oratory, 31 of 77 (40%) participants showed signi“cant air-
way constriction in response to emotion. In addition, a trend
toward greater likelihood of reacting to emotions among
adult versus child participants was found. Isenberg et al.
(1992) note that the proportion of participants who respond
to suggestion and to emotion are similar, but studies have
not tested directly if participants who respond to suggestion
also are likely to respond to emotion. It also is possible that
bronchoconstrictive responses to emotion may occur via the
effects of expectation and suggestion, that is, if patients be-
lieve that emotions trigger their asthma, then they also are
likely to believe that participating in a study on the effects of
emotional arousal on asthma will indeed trigger their asthma.
Since the Isenberg et al. (1992a) review, a number of other
laboratory studies have been conducted to examine the effects
of emotion induction on symptom perception (e.g., breath-
lessness) and objective measures of pulmonary function.
Emotional imagery during asthma attacks diminished accu-
rate symptom perception and enhanced sensations of breath-
lessness among adolescents with asthma (Rietveld, Everaerd,
& van Beest, 2000), but breathlessness was not associated
with objective measures of lung function. The induction of
negative emotions followed by exercise increased subjective
asthma symptom report (e.g., breathlessness), which was not
associated with objective measures of pulmonary function
(Rietveld & Prins, 1998). Similarly, the induction of stress
and negative emotions resulted in increased breathlessness,
but not airways obstruction, among adolescents with asthma;
the sensations of breathlessness were stronger during the
stress induction paradigm than during the induction of actual
airway obstruction through a bronchial provocation proce-
dure (Rietveld, van Beest, & Everaerd, 1999).
This series of studies by Rietveld and colleagues provide
important information about the role of stress and negative
emotions in subjective and objective asthma symptoms. These
studies utilize adolescents, and as such, the generalizability of
the results to adults warrants examination in future studies.
For example, to the extent that emotion regulation and chronic
illness self-management are both processes that tend to im-
prove with experience, maturity, and so forth, the results of
these studies may overestimate the extent to which emotion
induction results in subjective reports of asthma reports in
adults. Physiologically, to the extent that hormonal responses
to stress differ in adolescents versus adults, the relative
activation of the HPA axis may result in cortisol release or
attenuation, and anti- versus pro-in”ammatory effects, with
consequences for air”ow.
Other laboratory studies have found more support for an
association between stress and emotional arousal, and objec-
tive changes in pulmonary function. Ritz, Steptoe, DeWilde,
and Costa (2000) asked adults with and without asthma to
view seven “lm clips designed to elicit speci“c emotional
states, to engage in mental arithmetic (designed to elicit active
coping), and to view graphic medical photographs (designed
to elicit passive coping). The emotion induction procedure re-
sulted in signi“cant increases in respiratory resistance among
the participants with asthma for all emotional conditions com-
pared to the neutral condition, but this effect did not occur