A prospective study of the relationship of mood and stress to pulmonary function among patients with asthma

Lung physiology and controlled exposure study design

Controlled human inhalation exposure ( CHIE) studies provide a unique opportunity to conduct formal experiments to examine the human health effects of airborne pollutants. Lung function, easily measured using spirometry, is a common physiological variable often utilized in these studies. By design, CHIE studies only induce mild and reversible acute effects, which may or may not predict adverse effects that may develop under chronic exposure conditions. There is substantial inter- and intra-individual variability in functional capacity and symptoms such as chest tightness and dyspnea, which are complex variables that are affected by individual perception, physiological lung impairment, and other variables (e.g., concomitant health conditions, and level of conditioning/fitness). Thus, the design of the CHIE study and physiological and environmental factors of study participants can affect each CHIE study's results. Researchers can address many of these critical issues in the problem formulation phase of CHIE studies, utilizing existing information on the expected effects of the substance of interest and possible modes of action. Thoughtful design and interpretation of CHIE studies will increase their utility for evaluating and setting environmental health policy.

Is there a relationship between anxiety and depression with respiratory functions in patients with relapsing-remitting multiple sclerosis?

BACKGROUND

Psychiatric symptoms are common in multiple sclerosis. The relationship of emotional state with respiratory function is unclear in these patients. We aimed to evaluate the relationship between the clinical characteristics, anxiety and depression status, and respiratory functions of patients with relapsing-remitting multiple sclerosis (RRMS).

METHOD

The research was planned as a prospective case-control study. Ninety RRMS patients and 50 healthy controls were included in the study. The MS diagnosis was confirmed according to the revised 2017 McDonald's criteria. Disability was divided into two subgroups according to the Expanded Disability Status Scale (EDSS) (under 3.5 and 3.5-5.5). Beck anxiety and Beck depression inventories evaluated. A pulmonary function test was performed with a computerized spirometry device. Forced expiratory volume-1st second (FEV1), forced vital capacity (FVC), FEV/FVC, peak expiratory flow (PEF), maximal expiratory flow (MEF), peak inspiratory flow (PIF), and maximal inspiratory flow (MIF) values were obtained.

RESULTS

There were 90 RRMS patients with a mean age of 38.68±10.95 years, and 58 (64.40%) were female in the study. The anxiety and depression scores of the patients were significantly higher than the control group (p=0.02, 0.002). FVC and FEV1 values were lower in patients with higher Beck depression scores (p=0.012, 0.007). FVC, FEV1, MEF50, and PIF values were lower in patients with higher Beck anxiety scores (p=0.002, 0.002, 0.030, 0.027). When EDSS and number of attacks were fixed, there was a low to moderate correlation between anxiety and FEV1-FVC (p=0.001, r=-367, -0.360 respectively), and a low negative correlation between depression and FEV1 (p=0.045, r=-0.214).

CONCLUSION

Anxiety and depression scores are higher in patients with RRMS. Depression and anxiety are particularly associated with low FVC and FEV1 in patients.

Use of biologics to treat acute exacerbations and manage disease in asthma, COPD and IPF

A common feature of chronic respiratory disease is the progressive decline in lung function. The decline can be indolent, or it can be accelerated by acute exacerbations, whereby the patient experiences a pronounced worsening of disease symptoms. Moreover, acute exacerbations may also be a marker of insufficient disease management. The underlying cause of an acute exacerbation can be due to insults such as pathogens or environmental pollutants, or the cause can be unknown. For each acute exacerbation, the patient may require medical intervention such as rescue medication, or in more severe cases, hospitalization and ventilation and have an increased risk of death. Biologics, such as monoclonal antibodies, are being developed for chronic respiratory diseases including asthma, COPD and IPF. This therapeutic approach is particularly well suited for chronic use based on the route and frequency of delivery and importantly, the potential for disease modification. In recent clinical trials, the frequency of acute exacerbation has often been included as an endpoint, to help determine whether the investigational agent is impacting disease. Therefore the significance of acute exacerbations in driving disease, and their potential as a marker of disease activity and progression, has recently received much attention. There is also now a need to standardize the definition of an acute exacerbation in specific disease settings, particularly as this endpoint is increasingly used in clinical trials to also assess therapeutic efficacy. Moreover, specifically targeting exacerbations may offer a new therapeutic approach for several chronic respiratory diseases.

Psychiatric comorbidities in Asian adolescent asthma patients and the contributions of neuroticism and perceived stress

PURPOSE

Psychiatric comorbidity is reported to be common among adolescents with asthma, but little is known about its underlying psychological factors.

OBJECTIVE

This study explored the profile of anxiety and depressive comorbidities among adolescents with well-controlled and poorly controlled asthma and the contribution of neuroticism and perceived stress.

METHODS

The Revised Child Anxiety and Depression Scale, Neuroticism subscale of Big Five Inventory, Perceived Stress Scale, and Asthma Control Test were administered to 198 adolescents (aged 12-19 years) with well-controlled (n = 137) and poorly controlled asthma (n = 61) as well as 171 healthy neighborhood controls.

RESULTS

Adolescents with poorly controlled asthma, compared with well-controlled asthma patients and healthy controls, had higher scores of depression (p = .006), panic attacks (p = .002), total anxiety (p = .038), and total internalizing symptoms (p = .017), after adjusting for gender, age, ethnicity, smoking status, and family housing type. Adolescents with asthma had higher neuroticism (p = .025), perceived stress (p = .022), and body mass index (p = .006) and lower self-rated health (p < .001) than healthy controls. No significant differences in psychiatric comorbidity scores were observed after accounting for differences in underlying psychological and physical factors. Among asthma patients, increased asthma control was associated with decreased scores of psychiatric comorbidity (p < .01), but the association was not significant after allowing for decreased neuroticism and perceived stress.

CONCLUSIONS

The diagnosis of asthma and poor asthma control in adolescents is associated with excess psychiatric comorbidity, which is likely due to increased neuroticism and perceived stress.

Airway responsiveness to psychological processes in asthma and health

Psychosocial factors have been found to impact airway pathophysiology in respiratory disease with considerable consistency. Influences on airway mechanics have been studied particularly well. The goal of this article is to review the literature on airway responses to psychological stimulation, discuss potential pathways of influence, and present a well-established emotion-induction paradigm to study airway obstruction elicited by unpleasant stimuli. Observational studies have found systematic associations between lung function and daily mood changes. The laboratory-based paradigm of bronchoconstrictive suggestion has been used successfully to elicit airway obstruction in a substantial proportion of asthmatic individuals. Other studies have demonstrated modulation of airway responses to standard airway challenges with exercise, allergens, or pharmacological agents by psychological factors. Standardized emotion-induction techniques have consistently shown airway constriction during unpleasant stimulation, with surgery, blood, and injury stimuli being particularly powerful. Findings with various forms of stress induction have been more mixed. A number of methodological factors may account for variability across studies, such as choice of measurement technique, temporal association between stimulation and measurement, and the specific quality and intensity of the stimulus material, in particular the extent of implied action-orientation. Research has also begun to elucidate physiological processes associated with psychologically induced airway responses, with vagal excitation and ventilatory influences being the most likely candidate pathways, whereas the role of specific central nervous system pathways and inflammatory processes has been less studied. The technique of emotion-induction using films has the potential to become a standardized challenge paradigm for the further exploration of airway hyperresponsiveness mediated by central nervous system processes.

Contribution of stress to asthma worsening through mast cell activation

OBJECTIVE

To review the available evidence linking stress to asthma and to investigate whether mast cells contribute to the effect of stress through activation by corticotropin-releasing hormone (CRH).

DATA SOURCE

The PubMed database was searched for articles (1998-2011) using the keywords anxiety, asthma, exacerbation, inflammation, mast cells, socioeconomic status, stress, violence, and worsening.

STUDY SELECTION

Articles were selected based on their relevance to the topic, with emphasis on clinical or epidemiologic data linking stress to asthma and studies that offered possible explanations for how stress may affect asthma.

RESULTS

Many articles point to an association between stress (socioeconomic status, interpersonal conflicts, emotional distress, terrorism) and asthma exacerbations but without any distinct pathogenetic mechanism. A few articles have reported reduced circulating cortisol and/or sensitivity to corticosteroids. We propose that mast cells, known to be involved in the pathophysiology of asthma, can be activated by CRH, which is secreted under stress in the lungs, leading to selective release of proinflammatory mediators. This effect may be augmented by neuropeptides or cytokines. CRH also reduces T-regulatory cell production of interleukin 10, which in known to inhibit allergic mast cell activation.

CONCLUSION

More studies are required to investigate lung levels of CRH and selective mast cell mediators. Reducing stress and using CRH receptor antagonists and/or mast cell blockers may serve as possible new therapeutic approaches for asthma.

Asthma exacerbations: origin, effect, and prevention

Asthma is the most common chronic respiratory disease, affecting up to 10% of adults and 30% of children in the Western world. Despite advances in asthma management, acute exacerbations continue to occur and impose considerable morbidity on patients and constitute a major burden on health care resources. Respiratory tract viruses have emerged as the most frequent triggers for exacerbations in both children and adults; however, the mechanisms underlying these remain poorly understood. More recently, it has become increasingly clear that interactions might exist between viruses and other triggers, increasing the likelihood of an exacerbation. In this article we begin with an overview of the health, economic, and social burden that exacerbations of asthma carry with them. This is followed by a review of the pathogenesis of asthma exacerbations, highlighting the various triggers responsible and multiple interactions that exist between them. The final section first addresses what preventative measures are currently available for asthma exacerbations and subsequently examines which of the new treatments in development might lessen the burden of exacerbations in the future.

Daily mood, shortness of breath, and lung function in asthma: concurrent and prospective associations

OBJECTIVE

Previous asthma diary studies have yielded equivocal findings on concurrent associations between lung function and mood, and prospective associations have rarely been explored. We therefore examined concurrent and prospective associations between daily mood, shortness of breath, and lung function, and studied between-individual variability and stability of concurrent associations across different times of the day.

METHOD

Twenty asthma patients and 20 healthy controls recorded their positive and negative mood, shortness of breath, physical activity, peak expiratory flow (PEF) and forced expiratory volume in the first second (FEV(1)) using an electronic pocket spirometer with diary functions three times per day for about 21 days.

RESULTS

For both groups, PEF showed positive concurrent associations with ratings of various mood states, whereas FEV(1) was only associated with positive mood. Both indices correlated negatively with shortness of breath. Within-individual concurrent associations varied significantly in both groups and their stability varied across time of the day, with overall higher stability for associations with shortness of breath in asthma and PEF for both groups. Prospectively, higher shortness of breath consistently predicted lower lung function later during the day and on the subsequent day.

CONCLUSION

The relationship between normal mood variations and lung function is highly variable across individuals and times of the day, limiting the predictive value of average group associations. Shortness of breath is predictive of future lung function decline in asthma. Future longitudinal research should focus on extreme emotional states, effort-independent measures of lung function, and additional indicators of asthma control.

Perspectives on complementary and alternative therapies in asthma

Asthma is a chronic disease that affects millions of individuals living in the USA. Proper asthma management is essential for controlling asthma symptoms and exacerbations. In recent years, however, there has been increased recognition of individuals using complementary and alternative medicine (CAM) to treat asthma. This article reviews the status of the current literature on various cultural factors that influence CAM use. In addition, current research of two widely used forms of CAM, herbal remedies and relaxation techniques, is presented. Future directions and recommendations to increase the methodological rigor of CAM research are discussed, particularly as they pertain to herbal remedies and relaxation strategies. The importance of well-designed research studies, including observational studies and randomized controlled trials, is highlighted.

Change in airflow among patients with asthma discussing relationship problems with their partners

This study examined the covariation of negative emotions with airflow among 48 persons with asthma and their partners as they discussed relationship problems. Measures included self-reported questionnaires, airflow and behavior coded from videotaped discussions. Significantly increased self-reported hostility and statistically but not clinically significant declines in airflow were found post- versus pre-discussion. Self-reported responses to asthma symptoms of more anger and less loneliness predicted lower post-discussion airflow after accounting for pre-discussion airflow. The use of effort-independent measures of airflow and autonomic nervous system monitoring may inform future research regarding the physiological mechanisms through which mood and behavior affect airflow.

A bidirectional relationship between psychosocial factors and atopic disorders: a systematic review and meta-analysis

OBJECTIVE

There is growing epidemiological literature focusing on the bidirectional association between psychosocial factors and atopic disorders, but no efforts to quantify the relationship systematically have been published.

METHODS

We searched Medline, PsycINFO, Web of Science, and PubMed up to June 2007. The studies included were prospective cohort studies investigating the influence of psychosocial factors on atopic disorders and the effect of atopic disorders on mental health. Two investigators independently extracted data and determined study quality.

RESULTS

There were 43 studies (in 22 articles), of which 34 evaluated the effect of psychosocial factors on atopic disorders and 9 evaluated the effect of atopic disorders on mental health. The major atopic disease assessed in these studies was asthma (90.7%) with allergic rhinitis, 4.7%; atopic dermatitis, 2.3%; and food allergies, 2.3%. The overall meta-analysis exhibited a positive association between psychosocial factors and future atopic disorder (correlation coefficient (r) as combined size effect .024; 95% confidence interval, 0.014-0.035; p < .001) as well as between atopic disorders and future poor mental health (r = .044, 95% confidence interval, 0.021-0.067, p < .001). More notably, the subgroup meta-analysis on the healthy and atopic disorder populations showed psychosocial factors had both an etiological and prognostic effect on atopic disorders.

CONCLUSIONS

The current review revealed a robust relationship between psychosocial factors and atopic disorders. This supports the use of psychological in addition to conventional physical and pharmacological interventions, in the successful prevention and management of atopic disorders.

Human umbilical cord blood-derived mast cells: a unique model for the study of neuro-immuno-endocrine interactions

Findings obtained using animal models have often failed to reflect the processes involved in human disease. Moreover, human cultured cells do not necessarily function as their actual tissue counterparts. Therefore, there is great demand for sources of human progenitor cells that may be directed to acquire specific tissue characteristics and be available in sufficient quantities to carry out functional and pharmacological studies. Acase in point is the mast cell, well known for its involvement in allergic reactions, but also implicated in inflammatory diseases. Mast cells can be activated by allergens, anaphylatoxins, immunoglobulin-free light chains, superantigens, neuropeptides, and cytokines, leading to selective release of mediators. These could be involved in many inflammatory diseases, such as asthma and atopic dermatitis, which worsen by stress, through activation by local release of corticotropin-releasing hormone or related peptides. Umbilical cord blood and cord matrix-derived mast cell progenitors can be separated magnetically and grown in the presence of stem cell factor, interleukin-6, interleukin-4, and other cytokines to yield distinct mast cell populations. The recent use of live cell array, with its ability to study such interactions rapidly at the single-cell level, provides unique new opportunities for fast output screening of mast cell triggers and inhibitors.

The critical role of mast cells in allergy and inflammation

Mast cells are well known for their involvement in allergic and anaphylactic reactions, but recent findings implicate them in a variety of inflammatory diseases affecting different organs, including the heart, joints, lungs, and skin. In these cases, mast cells appear to be activated by triggers other than aggregation of their IgE receptors (FcepsilonRI), such as anaphylatoxins, immunoglobulin-free light chains, superantigens, neuropeptides, and cytokines leading to selective release of mediators without degranulation. These findings could explain inflammatory diseases, such as asthma, atopic dermatitis, coronary inflammation, and inflammatory arthritis, all of which worsen by stress. It is proposed that the pathogenesis of these diseases involve mast cell activation by local release of corticotropin-releasing hormone (CRH) or related peptides. Combination of CRH receptor antagonists and mast cell inhibitors may present novel therapeutic interventions.

A systematic review of psychological interventions for children with asthma

AIM

Psychological factors may influence the symptoms and management of asthma in children in many ways. It is, therefore, suggested that psychological interventions may be appropriate for this population. This paper reports a systematic review assessing the efficacy of psychological interventions in improving health outcomes for children with asthma.

METHODOLOGY

A review of Randomized Controlled Trials (RCT) was designed. RCTs assessing the effects of a psychological intervention in child participants were included in the review. Outcome measures included healthcare utilization, lung function, asthma symptoms, and psychological health status. The search was conducted until April 2005.

RESULTS

Twelve studies, involving 588 children, were included in the review; however, study quality was poor and sample sizes were frequently small. A meta-analysis was performed on two studies, examining the effects of relaxation therapy on PEFR which favored the treatment group (SD 0.82, CI 0.41-1.24). No other meta-analysis could be performed due to the diversity of interventions and the outcomes assessed. In addition, many studies reported insufficient data.

CONCLUSIONS

This review was unable to draw firm conclusions for the role of psychological interventions for children with asthma. We recommend that valid outcome measures for evaluating the effectiveness of psychological interventions for children with asthma need to address adjustment to and coping with asthma, as well as other psychological indicators. The absence of an adequate evidence base is demonstrated, highlighting the need for well-conducted RCTs in this area.

Emotions and respiratory function in asthma: a comparison of findings in everyday life and laboratory

OBJECTIVES

The present study examined the influence of emotions on the respiratory function in asthmatic and non-asthmatic individuals in everyday life and the relationship to emotion-induced respiratory changes in the laboratory.

METHODS

Affective states were induced in 10 asthmatic and 10 non-asthmatic participants by viewing affective picture series of either a pleasant, neutral, or unpleasant valence, while airway resistance (Raw) was measured with whole body plethysmography. Following this, individuals measured their mood, forced expiratory volume in the first second (FEV1), peak expiratory flow (PEF), physical activity, and medication use for 21 days with an electronic diary, which included a respiratory self-measurement device. Strong pleasant and unpleasant mood episodes were extracted from the diaries and compared with neutral affective states.

RESULTS

Asthmatic patients showed increases of Raw after unpleasant and pleasant emotional stimulation in the laboratory, which was only found after a pleasant stimulation in non-asthmatic participants. In everyday life, no group differences were obtained. Episodes of strong unpleasant mood states were associated with decreases in PEF, whereas in contrast to the laboratory assessment, pleasant mood was associated with increases in PEF. Results for FEV1 were comparable, but non-significant. Physical activity and medication use did not vary systematically between affective episodes. PEF showed no significant relationship with Raw.

CONCLUSIONS

Unpleasant mood is associated with decreased respiratory function in asthmatic patients in everyday life and in laboratory assessments, whereas effects of pleasant mood states are inconsistent. Pulmonary responses to laboratory-induced emotional conditions are not predictive of airways reactivity during daily life.

Implications of psychosocial factors as precipitant of asthma attack among a sample of asthmatics

OBJECTIVE

To explore the relationship between psychosocial factors and asthma.

METHODS

One hundred consecutive asthmatics were screened using the 30-item version of the General Health Questionnaire (GHQ-30), Present state examination (PSE) and a socio-demographic schedule incorporating psychosocial variables. Chi-squared test, student "t" test and discriminant analysis were used in analysis.

RESULTS

Among the asthmatics studied 36% had psychopathology. Psychosocial variables significantly associated with psychopathology include worrying, crying, fighting, anger, marital tension, and menstruation. The presence of multiple psychosocial variables was significantly associated with psychopathology.

CONCLUSION

Psychosocial variables predict the presence of psychopathology.

Rollercoaster asthma: when positive emotional stress interferes with dyspnea perception

The current study assessed how negative and positive stress is related to dyspnea perception. The participants were 25 young women with a medical diagnosis of severe asthma, and 15 matched controls. Stress was induced during repeated rollercoaster rides. Results showed that negative emotional stress and blood pressure peaked just before, and positive emotional stress and heart beat peaked immediately after rollercoaster rides. Dyspnea in women with asthma was higher just before than immediately after rollercoaster rides, even in women with asthma with a rollercoaster-evoked reduction in lung function. These results suggest that stressed and highly aroused individuals with chronic asthma tend to perceive dyspnea in terms of acquired, familiar associations between dyspnea and positive versus negative feeling states, favoring either underperception or overperception of dyspnea, depending on the emotional valence of a situation.

Urban asthma

PURPOSE OF REVIEW

To review the possible reasons why the prevalence and morbidity of asthma are greater in those living in an urban setting.

RECENT FINDINGS

Urban asthma is associated with exposure to air pollution, urban allergens, and violence. Outdoor air pollution is a particular problem in urban areas and affects children more than adults. Asthma has been shown to be exacerbated by ozone, respirable particulates, and nitrogen dioxide. Exposure to high point sources of pollutants such as heavy traffic is of particular concern. Urban allergens include cockroach, mouse, and rat. Cockroach exposure increases the risk of asthma exacerbations and may increase the risk of developing asthma. Although mouse allergen is also found in suburban homes, the concentration is a log-fold higher in inner-city homes at levels known to elicit symptoms in workers in animal facilities. Rat allergen is found in a third of inner-city homes and is associated with asthma morbidity. A recent interventional study showed that comprehensive environmental control of cockroach allergen reduced asthma morbidity. Finally, stress elicits asthma symptoms and exposure to violence is associated with greater asthma morbidity.

SUMMARY

The increase in prevalence and morbidity of asthma associated with urban living is associated with at least three plausible causative factors each of which is amenable to intervention, raising the issue of environmental justice issues: controlling air pollution in general and exposure to point sources in particular; reducing cockroach, mice, and rat infestations; and preventing violence.

Health effects of written emotional disclosure in adolescents with asthma: a randomized, controlled trial

OBJECTIVE

To test the effects of written emotional disclosure on the health of adolescents with asthma and to examine how language in disclosures predicts outcomes.

METHODS

We randomized 50 adolescents with asthma to write for 3 days at home about stressful events (disclosure) or control topics. At baseline and 2 months after writing, we assessed symptoms, affect, disability, internalizing behavior problems, and lung function; parents independently rated internalizing behavior and disability.

RESULTS

Compared with control writing, disclosure writing led to improved positive affect and internalizing problems. Disclosure also decreased asthma symptoms and functional disability among adolescents with baseline elevations of these difficulties. Lung function was not changed. Disclosures with more negative emotion, insight, and causal words--and increased causal or insight words over days--predicted improved health.

CONCLUSIONS

Written emotional disclosure improves emotional and behavioral functioning among adolescents with asthma, particularly those whose writings suggest emotional processing and cognitive restructuring.

Critical role of mast cells in inflammatory diseases and the effect of acute stress

Mast cells are not only necessary for allergic reactions, but recent findings indicate that they are also involved in a variety of neuroinflammatory diseases, especially those worsened by stress. In these cases, mast cells appear to be activated through their Fc receptors by immunoglobulins other than IgE, as well as by anaphylatoxins, neuropeptides and cytokines to secrete mediators selectively without overt degranulation. These facts can help us better understand a variety of sterile inflammatory conditions, such as multiple sclerosis (MS), migraines, inflammatory arthritis, atopic dermatitis, coronary inflammation, interstitial cystitis and irritable bowel syndrome, in which mast cells are activated without allergic degranulation.