110 Asthma
and •exaggerated perceivers,Ž whose perceived breathless-
ness is greater than actual air”ow limitation, were “ve and
seven times, respectively, more likely to have psychiatric
disorders than were more accurate perceivers (Rushford,
Tiller, & Pain, 1998). The mechanism by which air”ow per-
ception is affected by psychiatric disorders is unknown.
There are several possible explanations involving psycholog-
ical in”uences on symptom perception (Rietveld, 1998).
First, poor perception may be a consequence of psychiatric
disorders by creating dif“culties with concentration because
of the distracting and disabling emotional symptoms.
Second, asthma symptoms may be similar to symptoms of
certain psychiatric disorders, leading to confusion about the
source of the symptoms among patients with both types of
disorders. For example, shortness of breath is a symptom of
asthma and of panic disorder. Errors in discrimination and at-
tribution, such as taking an anxiolytic in response to a sup-
posed panic attack, would delay appropriate treatment if the
symptoms actually re”ected an exacerbation of asthma.
Third, poor perception and psychiatric disorders may re”ect
a common pathway, such as priming or kindling effects for
emotional and somatic sensations. Asthma occurring in the
context of a comorbid psychiatric disorder should cue
providers to assess patients• perceptual accuracy regarding
their pulmonary status, for example, by comparing percep-
tions of dyspnea with peak expiratory ”ow.
Other Psychological Variables and Their Associations
with Self-Care and Medical Utilization
Apart from categories of psychiatric diagnoses, certain psy-
chosocial characteristics have been reliably linked to non-
optimal self-care and medical utilization. We will examine
two characteristics in terms of their associations with self-
care and medical utilization behaviors, the tendency to re-
spond to asthma with panic-fear and social relationships.
Panic-Fear
Research on the role of panic-fear in asthma has focused
on generalized panic-fear and asthma-speci“c panic-fear.
Generalized tendencies toward panic-fear reactions have
been measured using a subscale of the MMPI, and tendencies
for panicky and fearful responses speci“cally to asthma
symptoms have been measured using a subscale of the
Asthma Symptom Checklist (Kinsman, Luparello, O•Ban-
ion, & Spector, 1973). Independent of objective asthma
severity, both high generalized and asthma-speci“c panic-
fear have been associated with more medical utilization
(Dahlem, Kinsman, & Horton, 1977; Dirks, Kinsman, et al.,
1977; Hyland, Kenyon, Taylor, & Morice, 1993; Kinsman,
Dahlem, Spector, & Staudenmayer, 1977; Nouwen, Freeston,
Labbe, & Boulet, 1999). However, generalized panic-fear
may be a better predictor of asthma-related morbidity than
asthma-speci“c panic-fear (Dirks, Fross, & Evans, 1977).
Greater generalized panic-fear has been associated with
higher rehospitalization rates (Dirks, Kinsman, Horton,
Fross, & Jones, 1978) whereas greater illness-speci“c panic-
fear has been associated withlowerrehospitalization rates
(Staudenmeyer, Kinsman, Dirks, Spector, & Wangaard,
1979). High asthma-speci“c panic-fear is accompanied by
more catastrophic cognitions (Carr, Lehrer, & Hochron,
1995), particularly among patients who also meet criteria for
panic disorder (Carr et al., 1994), suggesting that cognitive
interventions are indicated for patients with co-morbid
asthma and panic disorder. Persons with high generalized
panic-fear may not be able to determine the seriousness of a
threat, and determine onset and offset of those threats, lead-
ing to a generally heightened reactivity. Moderate levels of
asthma-speci“c panic-fear is optimal, signaling the need for
vigilance and action (e.g., increased self-monitoring, taking
appropriate medications) by the patient. By contrast, patients
with low asthma-speci“c panic-fear may ignore early symp-
toms that signal the need for more medication, possibly
leading to the need for (potentially avertable) high-intensity
intervention to reverse the air”ow obstruction. Taken to-
gether, some asthma-speci“c panic-fear is adaptive but high
levels of generalized panic-fear is maladaptive for optimal
self-management of asthma.Social RelationshipsSocial relationships can decrease or buffer the effects of
stress on illness, or be another source of stress. An early study
showed that patients with asthma who were high in psy-
chosocial assets (a construct that included familial and inter-
personal relationships) required a lower average steroid dose
than those who were low in psychosocial assets (De Araujo,
van Arsdel, Holmes, & Dudley, 1973). More intimate rela-
tionship satisfaction was associated with more medication
use, after accounting for the effects of disease severity, sug-
gesting that patients in more satis“ed relationships may be
more adherent (Schmaling, Afari, Barnhart, & Buchwald,
1997). Patients with intimate relationships were 1.5 times
more likely to evidence satisfactory adherence with their
medications than single patients (Rand, Nides, Cowles, Wise,
& Connett, 1995). Although this study was conducted with a
large sample of patients with chronic obstructive pulmonary