108 Asthma
than patients with asthma but without depression or anxiety
(Afari et al., 2001).
Autonomic Nervous System and Inflammatory Processes
in Stress and Asthma: Possible Connections
As noted, a reasonable conclusion regarding the effects of
stress and emotions on asthma is thatsomepersons with
asthma demonstrate stress- or emotion-linked changes in
pulmonary function. Given that stress results in sympathetic
activation and the release of sympathomimetics (cortisol,
epinephrine), which are known to relax airway smooth mus-
cles, one would expect stress to be associated with broncho-
dilation. What physiological mechanisms might explain the
seemingly paradoxical association of stress with bronchocon-
striction, including the contemporary emphasis on the role
of in”ammation in asthma? Here we summarize brie”y the
common elements of several thoughtful review articles
that suggest potential pathways by which stress and emo-
tions may affect pulmonary function (Lehrer, Isenberg, &
Hochron, 1993; Rietveld, Everaerd, & Creer, 2000; Wright
et al., 1998).
The immune, endocrine, and autonomic nervous system
may contribute to airway variability and interact in complex
ways to help explain stress-related changes in airway func-
tion. Stress increases vulnerability to infection; upper res-
piratory infections are frequently associated with asthma
exacerbations. Stress affects immune function, changes in
immune function may include in”ammatory responses, in-
cluding airway in”ammation, and individual dif ferences in
changes in immune function in response to stress may par-
tially explain idiographic variability in the response to stress.
Bronchoconstriction may result from vagal reactivity in re-
sponse to stress, re”ecting contributions of the autonomic
nervous system to airway control. It is important to consider
the baseline level of stress in a given individual, and the re-
sults of possible interactions of different levels of acute and
chronic stress. Chronic stress may result in a hyporesponsive
HPA axis with attenuated cortisol secretion under added
acute stress (perhaps compounded by chronic daily use of
beta-agonist medications), suggesting a partial explanation of
the seemingly paradoxical response of bronchoconstriction
when stressed among some patients with asthma. Other con-
tributing factors include immune system down-regulation
and the increased risk of infection when stressed (Cohen,
Tyrrell, & Smith, 1991); infections in turn cause in”amma-
tion and increase susceptibility to asthma exacerbations. The
effects of chronic and acute stress on immune-mediated
changes in pulmonary function await investigation in future
research.
MEDICAL TREATMENTS FOR ASTHMAThe 1997 expert panel recommendations (National Heart
Lung and Blood Institute, 1997) are considered the gold
standard of current practice guidelines. These recommenda-
tions de“ne four levels of asthma severity (mild-intermittent,
mild-persistent, moderate-persistent, and severe-persistent)
de“ned by a combination of factors of lung function, noctur-
nal symptom frequency, and daytime symptom frequency.
Treatment recommendations are matched to the level of
severity, resulting in a stepped-care model wherein treatment
guidelines are yoked to severity step.
Medications to treat asthma typically fall into two cate-
gories:controllerandrelievermedications. Consistent with
the emphasis on the in”ammatory processes involved in
asthma, controller medications exert anti-in”ammatory ef-
fects, and include long-term inhaled (e.g., ”unisolide) or oral
(e.g., prednisone) forms. Reliever medications reverse acute
bronchoconstriction through relaxing the smooth muscles; ex-
amples include short-acting beta-2 agonists (e.g., albuterol).
Mild-intermittent asthma may be controlled through the as-
needed use of reliever medications. Severe-persistent asthma
requires the consistent use of reliever medications and both
oral and inhaled controller medications. Common side effects
of reliever medications include nervousness, rapid heartbeat,
trembling, and headaches. More common side effects of in-
haled controller medications include hoarseness and sore or
dry mouth and throat, whereas oral controller medications
(corticosteroids) are most commonly associated with in-
creased appetite, and nervousness or restlessness. Patients
may confuse corticosteroids prescribed for their asthma with
anabolic steroids (often used illegally to enhance muscle mass
with signi“cant iatrogenic effects). Although the chronic use
of oral corticosteroids for asthma control can be associated
with signi“cant side effects, patients may need to be reassured
that their asthma medications are of a different class of med-
ications that anabolic steroids. Erroneous and dysfunctional
beliefs about asthma and asthma medications may impede ad-
herence with asthma self-care recommendations. Adherence
with recommended medication regimens for asthma is a
knotty issue, as we discuss in the next section.
The Expert Panel Report emphasizes the role of patient
self-management in optimal asthma care. We review compo-
nents of asthma self-management next.ADHERENCEThe lack of adherence to prescribed medication regimens
is thought to explain signi“cant proportions of morbidity,