The use of reliever medication in asthma: the role of negative mood and symptom reports

Exploring the complexities of illness identity and symptom management in seeking a diagnostic label of postural orthostatic tachycardia syndrome (POTS): An inductive approach

OBJECTIVES

Postural orthostatic tachycardia syndrome (POTS) is a debilitating and under-recognized condition of the autonomic nervous system. This study applied Leventhal's Common-Sense Model of Illness Representations to explore the journey to a diagnosis of POTS and to understand its relevance to poorly understood conditions which have common comorbidities.

DESIGN

An inductive qualitative approach was used to explore the processes by which patients formulate explanations and management of symptoms within the search for a diagnostic label and to investigate illness identity in the context of existing diagnoses or multimorbidity.

METHODS

Participants (n = 29) for this nested qualitative study were recruited from a larger longitudinal study of people who had been newly referred to a specialist POTS service. Semi-structured interviews were conducted via video call. Three researchers coded and analysed data using Reflexive Thematic Analysis and elements of Grounded Theory.

RESULTS

The analysis resulted in three overarching themes: 'Seeking physiological coherence and validation', 'Individual persistence', and 'Navigating the cumulative burden'. 'Accessibility and disparities of health care' was noted as a contextual factor. Receiving a POTS diagnosis was regarded by participants as providing legitimacy and increased access to treatment. Overall, delays in the diagnostic journey and the lack of a clear diagnosis impacted negatively on patients through increased uncertainty and a lack of clear guidance on how to manage symptoms. Findings also suggested there were great complexities in assigning symptoms to labels in the context of multimorbidity.

CONCLUSIONS

Participants' stories highlighted the urgent need for better recognition of POTS so that the self-regulatory process can be initiated from the early stages of symptom detection.

How do embodied experiences of asthma influence caregiver conceptual models?

RATIONALE

Many studies propose that patients', caregivers', and children's asthma management practices may diverge from biomedical recommendations because their understandings of asthma (i.e., conceptual models) are different from biomedical perspectives. However, little research in this area has examined conceptual models of asthma using embodiment theory, which suggests that caregivers' and children's experiences of the physical body shape their perspectives and consequent management strategies.

OBJECTIVE

We investigated how two embodied processes of symptom perception-detection and interpretation-may influence caregiver or patient conceptions of asthma.

METHODS

We interviewed 41 caregivers of children with asthma in Gainesville, Florida, and St. Louis, Missouri, and conducted ethnographic visits or virtual interviews with 19 children with asthma aged 6-16.

RESULTS

Four aspects of asthma's embodied experience shaped conceptual models via processes of detection and interpretation: 1) symptoms are experienced in the context of other bodily processes; 2) acute symptoms and exacerbations are more salient than their absence; 3) the embodied experience of asthma is one of integrated physiological and emotional processes; and 4) caregivers and children acquire embodied practices of perceiving symptoms that produce embodied knowledge.

CONCLUSION

Participant narratives suggest that embodied experiences of asthma shape caregivers' and children's understandings of asthma in ways that differ from the biomedical model. We argue that a focus on embodied experiences may provide important ground for mutual understanding and communication between providers and caregivers and/or patients.

Dissociating breathlessness symptoms from mood in asthma

It is poorly understood why asthma symptoms are often discordant with objective medical tests. Differences in interoception (perception of internal bodily processes) may help explain symptom discordance, which may be further influenced by mood and attention. We explored inter-relationships between interoception, mood and attention in 63 individuals with asthma and 30 controls. Questionnaires, a breathing-related interoception task, two attention tasks, and standard clinical assessments were performed. Questionnaires were analysed using exploratory factor analysis, and linear regression examined relationships between measures. K-means clustering also defined asthma subgroups. Two concordant asthma subgroups (symptoms related appropriately to pathophysiology, normal mood) and one discordant subgroup (moderate symptoms, minor pathophysiology, low mood) were found. In all participants, negative mood correlated with decreased interoceptive ability and faster reaction times in an attention task. Our findings suggest that interpreting bodily sensations relates to mood, and this effect may be heightened in subgroups of individuals with asthma.

Emergency department visits and hospitalisations for asthma, COPD and respiratory tract infections: what is the role of respiratory viruses, and return to school in September, January and March?

Background

Asthma exacerbations increase in September coinciding with children returning to school. The aim of this study was to investigate whether this occurs 1) for COPD and respiratory tract infections (RTIs); 2) after school resumes in January and March; and 3) identify which viruses may be responsible.

Methods

Emergency department (ED) visits and admissions for asthma, COPD and RTIs and the prevalence of viruses in Ontario, Canada were analysed daily between 2003 and 2013. ED visits and admissions were provided by the Canadian Institute for Health Information. Viral prevalence was obtained from the Centre for Immunisation and Respiratory Infectious Diseases.

Results

ED visits and admissions rates demonstrated a biphasic pattern. Lowest rates occurred in July and August and the highest rates in September for asthma, and after December for COPD and RTI. The increase in rates for 30 days before and after school return in September was greatest for children with asthma <15 years (2.4–2.6×). Event rates fell after school return in January for all three conditions ranging from 10–25%, and no change followed March break for asthma and COPD. Human rhinovirus was prevalent in summer with a modest relationship to asthma rates in September. The prevalence of respiratory syncytial virus, influenza A and coronavirus was associated with sustained event rates for COPD and RTIs.

Conclusions

Asthma, COPD and RTIs increase in September but do not occur after return to school in January and March. Human rhinovirus is associated with ED visits and admissions only in September.

Asthma, COPD and RTIs increase in September but do not occur after return to school in January and March. Human RV is associated with ED visits and admissions only in September.https://bit.ly/3jEy168

The role of trait mindfulness in quality of life and asthma control among adolescents with asthma

OBJECTIVE

The current study focused on the role of trait mindfulness in asthma-related quality of life (QoL) and asthma control in adolescent asthma patients. Furthermore, potential underlying mechanisms (general and asthma-specific stress) of this relationship were investigated.

METHODS

In this cross-sectional study, questionnaire data of 94 adolescents with asthma that were prescribed daily asthma medication were included. Two Structural Equation Models (SEMs), a direct model and an indirect model, were tested.

RESULTS

We found that trait mindfulness was directly related to asthma-related QoL, but not to asthma control. The relationship between trait mindfulness and asthma-related QoL was explained by asthma-specific, but not by general stress. Furthermore, an indirect relation from mindfulness to asthma control via asthma-specific stress was found.

CONCLUSIONS

Cross-sectional evidence for a relation between mindfulness and asthma-related QoL is found. These findings may point to the possibility that an intervention aimed at increasing mindfulness could be a promising tool to improve asthma-related QoL in adolescents via a decrease in asthma-specific stress.

Attentional bias to respiratory- and anxiety-related threat in children with asthma

This study investigated attentional biases in children with asthma. The study aimed at testing whether children with asthma are vigilant to asthma and/or anxiety cues. Thirty-six children (18 with asthma and 18 healthy controls) aged 9-12 completed a computerised dot probe task designed to measure attentional bias to three different categories of words: asthma, anxiety symptom and general negative emotion. Main caregiver anxiety was also assessed, as was frequency of inhaler use for those with asthma. Children with asthma showed an attentional bias towards asthma words but not anxiety or general negative emotion words. Children without asthma showed no significant attentional biases to any word categories. Caregiver anxiety was correlated with asthma word attentional bias in the asthma group. The findings indicate that attentional bias is present in children with asthma. Further research is required to ascertain if this exacerbates or maintains health-related problems.

Effect of anticipation triggered by a prior dyspnea experience on brain activity

[Purpose] Oxygenated hemoglobin (oxy-Hb) concentrations in the prefrontal cortex are closely associated with dyspnea. Dyspnea is influenced not only by physical activity, but also by visual stimuli, and several studies suggest that oxy-Hb concentrations change in response to certain external stimuli. However, the effects of internal psychological states on dyspnea have not been reported. This study explored the influence of anticipation triggered by previous episodes of dyspnea on brain activity. [Subjects] The subjects were 15 healthy volunteers with a mean age of 25.0 ± 3.0 years. [Methods] The subjects were shown a variety of photographs and instructed to expect breathing resistance matched to the affective nature of the particular photograph. After viewing the images, varying intensities of breathing resistance that were identical to, easier than, or harder than those shown in the images were randomly administered to the subjects; in fact, the image and resistance were identical 33% of the time and discordant 66% of the time. [Results] The concentrations of oxy-Hb in the right medial prefrontal cortex (rMPFC) increased significantly with an inspiratory pressure that was 30% of the maximum intensity in the subjects shown a pleasant image compared to the concentrations in subjects shown an unpleasant image. Moreover, rMPFC activity was significantly correlated with the magnitude of the dyspnea experienced. [Conclusion] These results suggest that a correlation exists between increased oxy-Hb in the rMPFC and the effects of expectations on dyspnea.

The relationship between asthma and suicidal behaviours: a systematic literature review

Asthma is a highly prevalent chronic condition worldwide, and is particularly common in younger people compared to other chronic conditions. Asthma can result in a number of symptoms that are detrimental to the quality of life of sufferers. The aim of the present systematic literature review was to analyse the existing literature on the relationship between asthma and fatal and nonfatal suicidal behaviours. Articles were retrieved from Scopus, PubMed, ProQuest and Web of Knowledge. We searched for the terms (suicid* OR self-harm) AND (asthma* OR "bronchial hyperreactivity") published in English-language peer-reviewed journals between 1990 and December 2014. Original research papers providing empirical evidence about the potential link between asthma and suicidal behaviours were included. The initial search identified 746 articles. Specific limiting criteria reduced the number of articles to the 19 articles that were finally included in the systematic review. The review found a potential link between asthma and suicide mortality, ideation and attempts across the age groups. Limitations of the review include the restriction to English-language papers published within the chosen time period, the limited number of papers involving suicide mortality, and the fact that the majority of papers originated from the USA.

Subjective ratings of prolonged inspiratory resistive loaded breathing in males and females

Dyspnea and fear of suffocation are burdensome to patients with respiratory disease. Inspiratory resistive loads offer an experimental respiratory stimulus to quantify the discriminative domain of respiratory perception. Resistive (R) load magnitude estimation (ME) and subjective ratings were measured over sustained multiple breaths in healthy subjects. There was no significant group difference between the ME for Breath 1 and 20 for small R loads, but a significant gender difference for large R loads. Subjective responses of fear, fear of suffocation, displeasure, chest pressure, faintness, dizziness, fear of losing control, trembling, and tingling were significantly greater for females. These results demonstrate that ME of large resistive sustained loads elicits nonsignificant increases in ME in females, but a significant decrease in ME for males. The maintenance of ME in females co-occurs with increased aversive processing relative to males.

Perceived triggers of asthma: key to symptom perception and management

Adequate asthma management depends on an accurate identification of asthma triggers. A review of the literature on trigger perception in asthma shows that individuals vary in their perception of asthma triggers and that the correlation between self-reported asthma triggers and allergy tests is only modest. In this article, we provide an overview of psychological mechanisms involved in the process of asthma triggers identification. We identify sources of errors in trigger identification and targets for behavioural interventions that aim to improve the accuracy of asthma trigger identification and thereby enhance asthma control.

Understanding dyspnea as a complex individual experience

Dyspnea is the highly threatening experience of breathlessness experienced by patients with diverse pathologies, including respiratory, cardiovascular, and neuromuscular diseases, cancer and panic disorder. This debilitating symptom is especially prominent in the elderly and the obese, two growing populations in the Western world. It has further been found that women suffer more strongly from dyspnea than men. Despite optimization of disease-specific treatments, dyspnea is often inadequately treated. The immense burden faced by patients, families and the healthcare system makes improving management of chronic dyspnea a priority. Dyspnea is a multidimensional sensation that encompasses an array of unpleasant respiratory sensations that vary according to underlying cause and patient characteristics. Biopsychological factors beyond disease pathology exacerbate the perception of dyspnea, increase symptom severity and reduce quality of life. Psychological state (especially comorbid anxiety and depression), hormone status, gender, body weight (obesity) and general fitness level are particularly important. Neuroimaging has started to uncover the neural mechanisms involved in the processing of sensory and affective components of dyspnea. Awareness of biopsychological factors beyond pathology is essential for diagnosis and treatment of dyspnea. Increasing understanding the interactions between biopsychological factors and dyspnea perception will enhance the development of symptomatic treatments that specifically address each patient's most pressing needs at a specific stage in life. Future neuroimaging research can provide objective markers to fully understand the role of biopsychological factors in the perception of dyspnea in the hope of uncovering target areas for pharmacologic and non-pharmacologic therapy.

Emotions and neural processing of respiratory sensations investigated with respiratory-related evoked potentials

OBJECTIVE

Patients with respiratory diseases such as asthma and chronic obstructive pulmonary disease frequently experience respiratory sensations, which are often perceived as unpleasant or threatening. However, the accurate perception of respiratory sensations is important for the management and treatment of these diseases. Emotions can substantially influence the perception of respiratory sensations and might affect the course of respiratory diseases, but the underlying neural mechanisms are poorly understood. The respiratory-related evoked potential (RREP) recorded from the electroencephalogram is a noninvasive technique that allowed first studies to examine the impact of emotions on the neural processing of respiratory sensations.

METHODS

In this review, we will briefly introduce the importance of the perception of respiratory sensations and the influence of emotions on respiratory perception. We then provide an overview on the technique of RREP and present a systematic review on recent findings using this technique in the context of emotions.

RESULTS AND CONCLUSIONS

The evidence currently available from studies in healthy individuals suggests that short-lasting emotional states and anxiety affect the later RREP components (N1, P2, P3) related to higher-order neural processing of respiratory sensations, but not the earlier RREP components (Nf, P1) related to first-order sensory processing. We conclude with a discussion of the implications of this work for future research that needs to focus on respiratory patient groups and the associated clinical outcomes.

The impact of emotion on the perception of graded magnitudes of respiratory resistive loads

Emotional state can modulate the perception of respiratory loads but the range of respiratory load magnitudes affected by emotional state is unknown. We hypothesized that viewing pleasant, neutral and unpleasant affective pictures would modulate the perception of respiratory loads of different load magnitudes. Twenty-four healthy adults participated in the study. Five inspiratory resistive loads of increasing magnitude (5, 10, 15, 20, 45 cm H(2)O/L/s) were repeatedly presented for one inspiration while participants viewed pleasant, neutral and unpleasant affective picture series. Participants rated how difficult it was to breathe against the load immediately after each presentation. Only at the lowest load, magnitude estimation ratings were greater when subjects viewed the unpleasant series compared to the neutral and pleasant series. These results suggest that negative emotional state increases the sense of respiratory effort for single presentations of a low magnitude resistive load but high magnitude loads are not further modulated by emotional state.

Self-reported health bias: the role of daily affective valence and arousal

OBJECTIVE

The present study addresses gaps in the literature on affect-biased health perceptions by (a) investigating health bias while considering both valence and arousal components of affect; (b) establishing the presence of, and variability in, affective health bias at the daily level; and (c) exploring daily health bias in a non-clinical, community sample of adults.

DESIGN

Participants were 477 adults (aged 33-80 years) who reported daily health events, health satisfaction and affect for up to 56 days. Health bias was present when the effect of a given day's health events on that day's health satisfaction was significantly moderated by that day's affect. Multilevel modelling was used to investigate fixed and random within-day effects.

MAIN OUTCOME MEASURE

Daily health satisfaction.

RESULTS

Significant interaction effects indicated the presence of health bias on the daily level: positively valenced affect buffered the negative impact of health events on health satisfaction, whereas negatively valenced affect exacerbated this association; additionally, valence emerged as the most salient characteristic of positive affect, whereas arousal was a differentiating factor for negative affect.

CONCLUSION

The results provide evidence that both valence and arousal components of affect are important to consider when investigating day-level health bias, and that these effects can be detected using a general population of adults.

The impact of emotions on symptom perception in patients with asthma and healthy controls

Accurate perception of respiratory symptoms is highly important for course and treatment of asthma. Recent findings suggest that emotions can greatly impact respiratory symptom perception. This study compared the impact of emotions on respiratory symptom perception between patients with asthma and matched healthy controls. Pleasant and unpleasant emotional states were elicited by viewing emotional picture series while symptom reports and respiratory parameters were measured. Greater symptom report was observed for the unpleasant compared to the pleasant emotional state that was not related to respiratory parameters. Notably, this effect was comparable between patients with asthma and healthy controls. The present results suggest that the impact of emotions on respiratory symptom perception is a rather general phenomenon and not dependent upon previous experiences with asthma symptoms.

Looking at allergens increases symptom report in patients with allergic asthma

OBJECTIVE

Accurate symptom perception is highly important for self-management and clinical treatment of asthma. Recent findings suggest that psychological factors can greatly impact asthma symptom perception. This study examined whether looking at allergens would lead to changes in perceived asthma symptoms.

METHODS

Allergic asthma patients and healthy controls viewed picture series containing either allergens or neutral material. Symptom reports and respiratory parameters were measured.

RESULTS

The present results demonstrate that looking at pictures with allergens increases subjective symptom reports in patients with allergic asthma in the absence of changes in objective respiratory parameters, but not in healthy controls.

CONCLUSIONS

The results are suggestive of preceding learning processes during which patients have learned the association between visual representations of allergens and symptom-inducing effects of real contact with these allergens. This impacts asthma symptom perception without changes in respiratory status and might influence treatment decisions.

The effect of anxiety on respiratory sensory gating measured by respiratory-related evoked potentials

Respiratory sensory gating is evidenced by decreased amplitudes of the respiratory-related evoked potentials (RREP) N1 peak for the second (S2) compared to the first occlusion (S1) when two paired occlusions are presented with a 500-millisecond (ms) inter-stimulus-interval during one inspiration. Because anxiety is prevalent in respiratory diseases and associated with altered respiratory perception, we tested whether anxiety can modulate individuals' respiratory neural gating mechanism. By using high-density EEG, RREPs were measured in a paired inspiratory occlusion paradigm in 11 low and 10 higher anxious individuals with normal lung function. The N1 peak gating S2/S1 ratio and the N1 S2 amplitudes were greater in higher compared to low anxious individuals (p's<0.05). In addition, higher anxiety levels were correlated with greater S2/S1 ratios (r=0.54, p<0.05) and S2 amplitudes (r=-0.49, p<0.05). The results demonstrate that anxiety is associated with reduced respiratory sensory gating which might underlie altered respiratory symptom perception in anxious individuals.

Symptoms, lung function, and perception of asthma control: an exploration into the heterogeneity of the asthma control construct

BACKGROUND

Asthma control is still surprisingly poor, which may be related to factors causing discrepancies between objective lung function measures and subjective symptom reports or discrepancies between objective indicators of asthma control and control perception. Identifying patients prone to such discrepancies may help to understand asthma control problems.

METHODS

Ninety-four persons with asthma participated in this study. We used cluster analysis to identify different subgroups of asthma control, based on a measure of lung function and self-report of daytime and nighttime symptoms, activity limitations, reliever medication use, and perception of asthma control. Subsequently, we explored between-cluster differences in clinical and psychological characteristics.

RESULTS

We identified two homogeneous clusters: a cluster of persons with poorly controlled asthma and a cluster of persons with well-controlled asthma. A third cluster included persons with an intermediate level of asthma control, an absence of nighttime symptoms, and a reduced impact of asthma symptoms on daily activities despite high levels of symptoms and reliever medication use. Members of the poorly controlled asthma cluster showed higher symptom levels, more catastrophic thinking, and activity avoidance beliefs compared with members of other clusters.

CONCLUSION

The clusters we identified crosscut current definitions of asthma severity and asthma control and indicate the importance of affective evaluation of symptoms in explaining poor asthma control.

New dimensions of abnormal illness behaviour derived from the Illness Behaviour Questionnaire

The primary aim was to explore the factor structure of the Illness Behaviour Questionnaire (IBQ) and the generalisability of the derived dimensions to both general community members and four chronic illness groups. A questionnaire was administered to 675 participants, comprising 344 from the community, 80 with asthma, 95 with diabetes, 79 with chronic pain and 77 with chronic fatigue syndrome (CFS). Illness severity was calculated for all chronic illness participants (self-rated health for community members). Three IBQ scales were derived following an exploratory factor analysis for the whole sample: Affirmation of Illness (α = 0.71 (CFS)-0.79 (asthma, diabetes)), Concern for Health (α = 0.71 (asthma)-0.78 (pain)) and General Affective State (α = 0.70 (CFS)-0.80 (asthma)). Patterns of response across the five samples, and intercorrelations among the new scales and the original seven scales, were largely in accord with expectation. Long-standing criticisms of the IBQ were addressed by using systematic statistical principles to identify meaningful and psychometrically sound IBQ dimensions. The derived structure offers a more parsimonious account of possible illness responses, with the availability of a more concise yet informative index of abnormal illness behaviour having practical utility for researchers and clinicians alike.

The impact of anxiety on the neural processing of respiratory sensations

Previous studies demonstrated that anxiety considerably impacts the reported perceptions of respiratory sensations. A novel feature of the current study is exploring the impact of anxiety on the neural processing of respiratory sensations elicited by short inspiratory occlusions during different affective contexts. Using high-density EEG, respiratory-related evoked potentials (RREP) were recorded in 23 low and 23 matched higher anxious individuals when viewing unpleasant or neutral picture series. Low anxious individuals showed the expected pattern of reduced magnitudes of later RREP components P2 and P3 during the unpleasant compared to the neutral affective context (p<0.05 and p<0.01). In contrast, higher anxious individuals showed greater magnitudes of P2 and P3 during the unpleasant compared to the neutral affective context (p's<0.05). Moreover, higher anxiety levels were correlated with greater magnitudes for P2 (r=0.44, p<0.01) and P3 (r=0.54, p<0.001) during the unpleasant relative to the neutral affective context. Earlier components of the RREP (Nf, P1, N1) were not affected by anxiety. This study demonstrates that anxiety affects the later, higher-order neural processing of respiratory sensations, but not its earlier, first-order sensory processing. These findings might represent a neural mechanism that underlies the increased perception of respiratory sensations in anxious individuals.

Dyspnea-related anxiety: The Dutch version of the Breathlessness Beliefs Questionnaire

Dyspnea-related anxiety may lead to reduced quality of life and functional disability through fearful avoidance of dyspnea-evoking activity. We describe the validation of a generic - diagnosis-independent - instrument assessing dyspnea-related anxiety. A total of 187 patients with respiratory diseases completed the Breathlessness Beliefs Questionnaire (BBQ), a 17-item questionnaire adapted from the Tampa Scale for Kinesiophobia (TSK), a measure of how harmful pain patients think painful movement is and to what extent they think activity should be avoided. Measures of negative and positive affectivity (PANAS), anxiety and depression (HADS), functional status (PFSDQ), and health-related quality of life (CRDQ) were also completed. Principal component analysis and item-total correlations suggested a reliable (reduced) 11-item BBQ (Cronbach's alpha = .85) with two factors converging with the TSK factors: a 'somatic focus' factor assessing the harmfulness of dyspnea and the underlying pathology and an 'activity avoidance' factor assessing beliefs that activity should be avoided. Correlational analyses support the construct validity of the BBQ: higher scores on the BBQ are associated with reduced health-related quality of life and functional status. Associations between 'somatic focus' and negative affectivity and anxiety and between 'activity avoidance' and positive affectivity and depression further supported the validity of the BBQ and its subscales. The BBQ is a valid, short, and useful instrument to assess respiratory patients' beliefs about the harmfulness of their disease and physical activities. Further research is needed to document to what extent BBQ scores are related to daily life activities and symptoms.

Illness perceptions: impact on self-management and control in asthma

PURPOSE OF REVIEW

Outcome in asthma is determined not only by pulmonary function or other biomedical characteristics. An important determinant of asthma outcome is illness perceptions: patients' subjective beliefs and emotional responses to their illness. Illness perceptions influence patients' coping and self-management behavior, and thereby outcome.

RECENT FINDINGS

We review recent studies on associations between illness perceptions and outcome in patients with asthma, with a range of respondents and caregivers, with varying degree of asthma severity, and in different settings of medical care. Most studies pertain to substantial numbers of patients, and have been performed in different countries, adding to the external validity of the findings. All studies report substantial effects of illness perceptions on various categories of outcome: illness perceptions reflecting personal control over the illness are associated with a positive outcome, that is, asthma control. Findings point at the importance and clinical relevance of addressing patients' illness perceptions, and suggest that this may improve outcome in asthma care. Well conducted intervention studies on this topic are called for in order to improve outcomes and quality of life in asthma patients.

SUMMARY

Illness perceptions influence the way in which patients with asthma cope and their self-management of the illness. Illness perceptions can be assessed quite easily and directly, they inform healthcare providers about the psychosocial responses of patients towards their asthma, they are responsive to change in the clinical encounter or via self-management intervention training. Exploring patient's illness perceptions, therefore, is a crucial component of good clinical care.

The impact of emotion on respiratory-related evoked potentials

Emotion influences the perception of respiratory sensations, although the specific mechanism underlying this modulation is not yet clear. We examined the impact of viewing pleasant, neutral, and unpleasant affective pictures on the respiratory-related evoked potential (RREP) elicited by a short inspiratory occlusion in healthy volunteers. Reduced P3 amplitude of the RREP was found for respiratory probes presented when viewing pleasant or unpleasant series, when compared to those presented during the neutral series. Earlier RREP components, such as Nf, P1, N1, and P2, showed no modulation by emotion. The results suggest that emotion impacts the perception of respiratory sensations by reducing the attentional resources available for processing afferent respiratory sensory signals.

Asthma symptom perception and obesity in children

This study examined the relationship between obesity and asthma symptom perception in 200 youth with asthma. Repeated subjective and objective peak flow measurements were summarized using the Asthma Risk Grid (Klein et al., 2004), resulting in Accurate, Symptom Magnification and Danger Zone scores. Analyses were stratified by age and included ethnicity. For younger children, obesity was not significantly related to perception scores. For older children, a significant obesity-by-ethnicity interaction for Accurate Symptom Perception scores indicated that obese white children had lower accuracy than white nonobese children, while there was no difference for obese versus nonobese minority children. Obesity was also related to higher Symptom Magnification scores regardless of ethnicity for older children. These findings suggest that obesity may complicate asthma management by interfering with the ability to accurately perceive symptoms for some patients. More remains to be learned about the role of sociodemographic factors underlying this relationship.

Repeated breathlessness experiences induced by hypercapnia: differential effects on intensity and unpleasantness

BACKGROUND

The present study investigated the effect of repeated hypercapnic challenges on the sensory (intensity [I]) and affective (unpleasantness [U]) dimensions of breathlessness.

METHODS

Three subsequent rebreathing trials (Read, 1968) were administered to healthy men and women (n = 39). The I and U of breathlessness were rated every 20 s during the baseline, rebreathing, and recovery phases. Breathing behavior (fractional end-tidal CO(2) [Fetco(2)] and minute ventilation [Ve]) was monitored continuously. Intraindividual linear regression slopes for Fetco(2) and Ve] were calculated and standardized, separately for both rating dimensions.

RESULTS

Both the absolute magnitude and the slope of the I of breathlessness were higher compared to U (p < 0.05). Across-trial habituation of the peak I and U of breathlessness occurred in both genders (p < 0.001), but habituation was larger for the U than for the I (p = 0.05).

CONCLUSIONS

The findings show that the sensory and affective dimensions of breathlessness can meaningfully be distinguished during hypercapnic challenges and that repeated exposures have different effects on both dimensions.

Inaccurate perception of asthma symptoms: a cognitive-affective framework and implications for asthma treatment

Inaccurate perception of respiratory symptoms is often found in asthma patients. Typically, patients who inaccurately perceive asthma symptoms are divided into underperceivers and overperceivers. In this paper we point out that this division is problematic. We argue that little evidence exists for a trait-like stability of under- and overperception and that accuracy of respiratory symptom perception is highly variable within persons and strongly influenced by contextual information. Particularly, expectancy and affective cues appear to have a powerful influence on symptom accuracy. Based on these findings and incorporating recent work on associative learning, attention and mental representations in anxiety and symptom perception, we propose a cognitive-affective model of symptom perception in asthma. The model can act as a framework to understand both normal perception as well as under- and overperception of asthma symptoms and can guide the development of affect-related interventions to improve perceptual accuracy, asthma control and quality of life in asthma patients.

Illness perceptions about asthma are determinants of outcome

This article reviews an emerging area of research on patients with asthma: namely, illness perceptions and their relationships with various aspects of outcome. The article briefly introduces the Common Sense Model, outlining the relevance of how "lay" patients conceptualize symptoms, illness, and treatment. On the basis of a comprehensive literature search, nine empirical studies illustrating the relationships between illness perceptions and outcomes are discussed. It is concluded that further research should focus on assessing asthma-specific illness and treatment beliefs. Also, given the effects of intervention studies in illness perceptions in other patient categories, it is recommended that serious consideration be given to intervention studies focusing on eliciting and changing illness perceptions in asthma patients, especially in those whose self-management seems to be inadequate.

Psychological adjustment to chronic disease

This Review discusses physiological, emotional, behavioural, and cognitive aspects of psychological adjustment to chronic illness. Reviewing the reports of the past decade, we identify four innovative and promising themes that are relevant for understanding and explaining psychological adjustment. In particular, the emphasis on the reasons why people fail to achieve a healthy adjustment has shifted to the identification of factors that help patients make that adjustment. To promote psychological adjustment, patients should remain as active as is reasonably possible, acknowledge and express their emotions in a way that allows them to take control of their lives, engage in self-management, and try to focus on potential positive outcomes of their illness. Patients who can use these strategies have the best chance of successfully adjusting to the challenges posed by a chronic illness.

Mental disorders in chronic obstructive pulmonary disease (COPD)

Recent research using questionnaire measures has demonstrated high prevalence rates of mental disorders in chronic obstructive pulmonary disease (COPD). However, clinical interviews and clinical rather than healthy control groups have rarely been employed. The aim of the present study was to assess mental disorders in patients with COPD with advanced methodology, to identify moderating factors explaining mental co-morbidities and to compare results with a clinical control group without COPD. A standardized clinical interview (F-DIPS) and a range of questionnaires were used to assess mental disorders, perceived physical symptoms and cognitions in 20 hospitalized patients with mild-to-moderate COPD (mean FEV(1)/VC (%)=61.3). Results were compared with a hospitalized clinical control group without pulmonary dysfunction (CCG; N=20). Results showed that 55% of patients with COPD received a diagnosis of a mental disorder compared to 30% of CCG patients. All principal mental diagnoses in the COPD group were anxiety disorders (especially Panic Disorder with Agoraphobia), while CCG patients received a wider range of diagnoses (anxiety, pain, alcohol abuse). There was no systematic association between anxiety levels and respiratory function in the whole COPD group, but a positive correlation between anxiety levels and perceived physical symptoms (p<0.001) as well as negative cognitions (p<0.001 and p<0.05, respectively) for COPD patients with anxiety disorder (N=11). The present results confirm the high prevalence rate of anxiety in patients with COPD and suggest further that anxiety in COPD patients may be mediated by cognitive processes. These findings are discussed in terms of their implications for treatment.

Distractive Auditory Stimuli Reduce the Unpleasantness of Dyspnea During Exercise in Patients With COPD

BACKGROUND

Dyspnea is the primary symptom limiting exercise in patients with COPD. Recent research has demonstrated that psychological factors can substantially influence the perception of dyspnea, but little is known about the modulation of perceived intensity or unpleasantness of dyspnea by attentional distraction. Therefore, we examined the impact of distractive auditory stimuli on the perception of exercise-induced dyspnea and the affective state in patients with COPD during 6-min walking tests (6MWTs).

METHODS

Twenty patients with mild-to-severe COPD (mean FEV1, 55.9% predicted) underwent two 6MWTs. Under one exercise condition, distractive auditory stimuli were presented with headphones, while the other condition was performed without auditory distraction. Lung function (FEV1), heart rate (HR), pulse oximetric saturation (SpO2), perceived intensity of dyspnea (ie, visual analog scale for perceived intensity of dyspnea [VAS-I]), and perceived unpleasantness of dyspnea (visual analog scale for perceived unpleasantness of dyspnea [VAS-U]) were measured before and after exercise. In addition, the global level of dyspnea (Borg score), positive affectivity (PA), and negative affectivity were assessed after both conditions.

RESULTS

A similar exercise level during both conditions was confirmed by comparable results in FEV1, HR, SpO2, and distances walked. During auditory distraction, Borg scores and increases in VAS-U were smaller, while PA was higher compared to the nondistraction condition (p<0.05). VAS-I did not show differences across conditions.

CONCLUSIONS

Distractive auditory stimuli decrease the global level of exercise-induced dyspnea in patients with COPD by reducing the perceived unpleasantness of dyspnea and lead to an additional increase in PA. Auditory distraction might therefore serve as an intervention for the reduction of dyspnea during exercise in this patient group.

Contents of lay illness models dimensions for physical and mental diseases and implications for health professionals

OBJECTIVE

The main aim of this study was to establish the contents of the lay illness models on depression, cancer, hypertension, schizophrenia and influenza in healthy and ill people suffering from these diseases who have/have not coexisted with people with these health alterations.

METHODS

Dimensions of lay illness models for depression, schizophrenia, cancer, hypertension and influenza were assessed in 348 people (62.6% women) aged 13-50 (M=20.72; S.D.=5.96) with different personal experience with the studied diseases.

RESULTS

Lay illness beliefs are usually close to medical knowledge, but in some relevant cases they are very divergent from this. Experience with the disease (to have suffered from it or to have coexisted with an ill relative) seems to have a great influence in the contents of lay illness models.

CONCLUSION

People's representations on illnesses are not complete or correct at all, and this will have, as the Common Sense Model establishes, relevant repercussions on individuals' behaviors in relation to health and illness and on the outcomes of diseases.

PRACTICE IMPLICATIONS

To know the personal illness models for physical and mental health threats of healthy and ill people with different personal experience with the disease has important implications for health professionals' promotion and prevention strategies and clinical (treatment/rehabilitation) actuations.

Symptom perception and functional morbidity across a 1-year follow-up in pediatric asthma

The purpose of this study was to examine the association between asthma symptom perception measured during a 5-6 week baseline and functional morbidity measured prospectively across a 1-year follow-up. Symptom perception was measured by comparing subjective ratings with peak expiratory flow rate (PEFR) and forced expiratory volume in one second (FEV(1)). We hypothesized that accurate symptom perception (ASP) would be associated with less functional morbidity. Participants consisted of 198 children with asthma ages 7-17 recruited from three sites. The children used a programmable electronic spirometer in the home setting to guess their PEFR prior to exhalation. Each "subjective" guess was classified as being in an ASP, dangerous symptom perception (DSP; underestimation of symptoms), or symptom magnification (SM; overestimation) zone based upon the corresponding measurement of PEFR or FEV(1). An index of functional morbidity was collected by parent report at baseline and across 1-year follow-up. A greater proportion of ASP blows and a lower proportion of DSP blows based on PEFR predicted less functional morbidity reported at baseline, independent of asthma severity and race/ethnicity. A greater proportion of ASP blows (using PEFR and FEV(1)) and a lower proportion of SM blows (using FEV(1)) predicted less functional morbidity across 1-year follow-up. Symptom perception was not associated with emergency department visits for asthma at baseline or across follow-up. In comparison to PEFR, FEV(1) more frequently detected a decline in pulmonary function that children did not report. Symptom perception measured in naturalistic settings was associated with functional morbidity at baseline and prospectively across 1-year follow-up. Support was found for including multiple measures of pulmonary function in the assessment of asthma symptom perception.

The influence of corticosteroids on the perception of dyspnea in asthma

Corticosteroids are effective anti-inflammatory medications that are recommended for the control of persistent asthma. Little, however, is known about their influence on the perception of dyspnea, which, in turn, is important to the successful self-management of asthma. This paper provides a synopsis of available studies examining the impact of corticosteroids on the sensitivity to perceive dyspnea and presents possible mechanisms underlying this relationship. The results of these investigations are conflicting with some studies showing improved perception and other studies showing worsened perception of dyspnea after corticosteroid treatment. Thus, firm conclusions cannot be derived from the currently available data. Implications for future research, which is required to increase our understanding of potential influences of corticosteroids on the perception of dyspnea, are provided.

Sensory and Affective Aspects of Dyspnea Contribute Differentially to the Borg Scale’s Measurement of Dyspnea

BACKGROUND

Recent research has shown that distinct dimensions in the perception of dyspnea can be differentiated; however, most studies to date have only used a global rating scale for the measurement of this sensation.

OBJECTIVES

This study examined the different influence of sensory and affective aspects of perceived dyspnea on the commonly used Borg scale, which measures the global perception of dyspnea.

METHODS

Dyspnea was induced in 16 healthy volunteers (mean age 26.2 +/- 6.3 years) by breathing through an inspiratory resistive load (3.57 kPa/l/s) in two experimental conditions (attention and distraction). After each of the two conditions the experienced intensity (i.e., sensory dimension) and unpleasantness (i.e., affective dimension) of dyspnea were rated on separate visual analog scales (VAS), followed by a global rating of dyspnea on the Borg scale. Hierarchical multiple linear regression models were calculated to analyze the predictive validity of VAS ratings of intensity and unpleasantness on the Borg scale ratings.

RESULTS

When subjects attended to their breathing, only VAS intensity scores showed a significant influence on Borg scale ratings (p < 0.05). In contrast, only the VAS unpleasantness scores showed a significant influence on Borg scale ratings (p < 0.05) when subjects were distracted.

CONCLUSIONS

These findings show that sensory and affective aspects of perceived dyspnea differentially influence the global measure of dyspnea as determined by the Borg scale. A differentiation between these aspects in future studies through the use of separate rating scales could yield more detailed information on the perception and report of dyspnea.

Psychological aspects in the perception of dyspnea in obstructive pulmonary diseases

Dyspnea is an impairing symptom in obstructive pulmonary diseases. Besides multiple physiological pathways contributing to this sensation recent research has demonstrated an important role of psychological factors in the perception of dyspnea. The present review article synthesizes the research literature with regard to psychological aspects of the perception of dyspnea as well as other dyspnea-related issues such as course of disease, neuropsychological correlates and interventions that focus on psychological or behavioural changes. The available data show that inaccurate perception of dyspnea is related to poorer treatment outcome in obstructive pulmonary diseases and is impacted upon by emotional, attentional and learning processes. Neuropsychological deficits might further contribute to this association. Different psychological and behavioural interventions might reduce comorbid psychological disorders and thus improve the perception of dyspnea. However, future research is clearly required to substantiate current findings.

The impact of emotions on the sensory and affective dimension of perceived dyspnea

Dyspnea is an impairing symptom in various diseases. Recent research has shown that the perception of dyspnea, like pain, consists of a sensory (intensity) and an affective (unpleasantness) dimension, but little is known about the specific impact of different emotions on these distinct dimensions. We therefore examined the impact of viewing affective picture series of positive, neutral, and negative valence on perceived dyspnea during resistive load breathing in healthy volunteers. Inspiratory time (Ti), breathing frequency (f), and oscillatory resistance (Ros) remained unchanged across conditions. Ratings for unpleasantness of dyspnea increased from positive to neutral to negative series, but ratings for intensity of dyspnea showed no changes. The results suggest that the affective dimension of the perception of dyspnea is particularly vulnerable to emotional influences, irrespective of objective lung function.

Psychiatric disorders and asthma outcomes among high-risk inner-city patients

OBJECTIVE

The purpose of this study was to examine the rate of psychiatric disorders among patients attending an ethnically diverse, inner-city asthma clinic for an initial visit and assess the association between psychiatric disorders and asthma morbidity.

METHODS

A semistructured psychological interview was conducted to assess for psychiatric diagnoses. A pulmonary physician, who was blind to psychiatric disorder, established diagnosis of asthma based on national guidelines.

RESULTS

Sixty-four percent of 85 participants received at least 1 psychiatric diagnosis. The pulmonary physician rated patients with a psychiatric disorder as achieving fewer goals (M = 2.3 +/- 1.3) for asthma control than patients without a psychiatric disorder (M = 3.6 +/- 1.5, p = .0002). Patients with a psychiatric diagnosis more frequently reported an emergency room visit for asthma during the past 6 months (OR = 4.89; 95% CI, 1.76-13.39) and greater use of short-acting beta2-agonist medication (M = 1.5 +/- 0.9 canisters per month) than patients without a psychiatric diagnosis (M = 0.9 +/- 0.8, p = .003). These findings were independent of demographics, health insurance, and asthma severity. No differences emerged between patients with and without a mental disorder on percent predicted FEV1. Patients with a psychiatric disorder reported a higher severity level for asthma symptoms than the severity level indicated by their pulmonary function in comparison to patients without a psychiatric diagnosis (OR = 3.52; 95% CI, 1.23-10.10). Health insurance appeared to be a confounding factor in this relationship.

CONCLUSION

A high rate of psychiatric disorders was found among inner-city asthma patients. Psychiatric diagnoses were associated with greater perceived impairment from asthma but not objective measurement of pulmonary function.

Asthma and depression: a pragmatic review of the literature and recommendations for future research

BACKGROUND

Although the association between asthma and psychosocial factors has long been recognised, it is only in the last decade that the impact of coexisting asthma and depression has become the focus of considerable research interest. However, the findings so far have been confusing and often contradictory. This paper sets out a methodical review and appraisal of the literature to date, including suggestions for future research.

METHOD

PubMed and PsycINFO databases were used to search for English-language articles relating to asthma and depression research. The resulting articles were then reviewed and summarised, creating a report that was used to develop research recommendations.

RESULTS

The main findings from this review included: (a) results are mixed as to whether persons with asthma are more likely to be depressed than those without asthma; (b) asthma and depression may have an 'additive' adverse effect on the normal asthma-related quality of life reductions; (c) subjective measures of asthma severity may be more strongly related to depression than objective measures; (d) specific asthma symptoms appear to be linked to depression; (e) sadness and depression can produce respiratory effects consistent with asthma exacerbations; (f) depression appears to be negatively related to asthma treatment compliance; (g) corticosteroid use in asthma treatment has been associated with depression, though it is unclear how common this problem is in real life; (h) interventions that address the physical, psychological, and social consequences of asthma are likely to lead to the most successful treatment outcomes; (i) treating the depression of individuals with asthma is likely to minimise the negative effects of the coexistence; and (j) a number of common methodological problems were observed in the literature.

RECOMMENDATIONS

There is a large amount of research yet to be undertaken to clarify issues around asthma and depression, with the overdue next step being to design integrated treatment approaches, and carry out large-scale prospective studies to determine the impact of using such approaches to treat individuals with depression and asthma. Such studies will be the only way in which some fundamental questions about the development and coexistence of these two conditions will be answered.

The language of breathlessness: do families and health care providers speak the same language when describing asthma symptoms?

INTRODUCTION

Effective communication about symptoms is a critical prerequisite to appropriate treatment. Study aims were to: (a) document the symptoms that children with asthma and their parents associate with asthma, (b) identify differences between the "professional model "of asthma symptoms and the "lay model," (c) describe the family's proposed action in response to symptoms, and (d) investigate the congruence between parental assessment of "good control" and severity obtained using National Asthma Education and Prevention Program criteria.

METHOD

Children with asthma and their parents (N = 228) were recruited from diverse clinical practice sites. Parents and children described symptoms they associated with an asthma exacerbation and their proposed action. Perceived asthma control was compared with a structured assessment of severity.

RESULTS

One hundred and thirty-six unique symptoms were reported. While 78% of parents reported at least one standard asthma symptom, 48% also reported nonstandard asthma symptoms. Sixty-five percent of parents whose children's symptoms were consistent with severe asthma reported "good control."

DISCUSSION

Improved communication about symptoms would improve asthma care. Proposed strategies include standardized screening questionnaires to assess symptoms, more frequent routine visits for children with persistent asthma, and wide dissemination of realistic goals for symptom control.

Advancing the science of perceptual accuracy in pediatric asthma and diabetes

OBJECTIVES

To review research on perceptual accuracy in pediatric asthma and diabetes and to provide recommendations for future research efforts and clinical applications of the construct in these populations.

METHODS

A literature search was conducted using Medline and PsychInfo databases as well as the bibliographies of relevant articles.

RESULTS

Children and adolescents with asthma or diabetes evidence considerable variability in perceptual accuracy and frequently make clinically relevant errors that have the potential to affect self-management behavior.

CONCLUSIONS

Recommendations for future research include studying distinct types of perceptual errors, empirically supporting the relationship between perceptual accuracy and relevant outcomes, identifying factors related to perceptual inaccuracy, and conducting longitudinal research and intervention studies. Recommendations for applying the construct in clinical practice include adopting an individualized approach to symptoms to guide patient education and management, identifying patients prone to making clinically relevant errors, and developing and implementing interventions to improve accuracy.

Categorizing asthma severity: an overview of national guidelines

Asthma is an inflammatory disease of the airways associated with intermittent episodes of bronchospasm. Corticosteroids are the most effective anti-inflammatory class of medication currently available for the treatment of asthma. However, as higher doses of inhaled corticosteroids are used the risks of systemic exposure and side effects will correspondingly increase. Justification of the benefits from higher doses of inhaled corticosteroids can only be made if patients with more severe asthma can be identified. Methods to categorize asthma severity have been introduced in various national asthma management guidelines. Unfortunately, there are substantial conceptual and practical differences among these recommended approaches to asthma severity categorization. Furthermore, these recommended approaches suffer from a focus on features of asthma control, such as symptoms, short-acting beta-agonist use, and lung function rather than actual measures of asthma severity that would encompass markers of airway inflammation. Without the endpoints necessary to assess airway inflammation, current recommendations for asthma severity categorization may lead to systematic under dosing of appropriate anti-inflammatory therapy with subsequent perpetuation of the asthma exacerbation cycle.