Journal
of Psychosomatic
Research,
IS ASTHMA A RETROSPECTIVE
Vol.
21, pp. 463 to 469.
Pergamon
Press,
A PSYCHOSOMATIC STUDY OF MENTAL ADJUSTMENT*
1977. Printed
in Great
Britain
ILLNESS?-I. ILLNESS
AND
SOCIAL
SIDNEY BENJAMIN?
(Received 14 June 1977) Abstract-A group of 53 asthmatics and 50 matched controls together with their first-degree relatives has been followed up retrospectively after an interval of 15 years. There was no evidence that the mental illness experienced by the asthma group differed significantly from that of controls during the follow up period either in period prevalence or diagnosis. The presence of mental illness amongst asthmatics was not related to the prognosis for asthma, nor to the age of onset, family history of asthma or other atopic conditions. The asthma group showed only slightly greater impairment in social adjustment than controls. These findings are discussed in the light of traditional views of asthma as a psychosomatic illness. INTRODUCTION IN SPITE of changing psychosomatic concepts there is still a tendency to regard particular conditions as psychosomatic illnesses. Amongst these the syndrome of asthma is prominent [ 11. This appears to be based on a number of traditional views including specificity of predisposing personality [2], conflicts, emotions and defence mechanisms. The claim that asthma is an ‘organ neurosis’ places asthma firmly within the spectrum of neurotic illness. Implicit in these views is the suggestion that there may be an excess of neurotic illness in those suffering from asthma either currently or in the past. It might also be argued that asthma can serve as an alternative to other neurotic illness which might therefore be less common in asthmatics. Similarly, it has been suggested that asthma is uncommon in those with psychotic illness, may act as a defence against psychosis, and may actually alternate with schizophrenia. The evidence for these claims has been extensively reviewed [3] and is based on surveys amongst both asthmatics and those with psychotic illness. The interpretation of available studies is confounded by possible sources of bias, particularly in the criteria for selection of subjects and for ascertainment of both asthma and mental illness. Deviating from these well-trodden paths is the alternative formulation of asthma as primarily a syndrome of physical illness with the inevitable repercussions of all chronic or recurrent physical illness on psychological and social health. The concept of the individual reacting to external and internal stressors with his own characteristic total response which involves physical, psychological and social change is perhaps more comprehensive. Few epidemiological studies of asthmatics in the community have included an assessment of mental health. Graham and his co-workers 143 have found an excess of disturbed behaviour in asthmatic children similar to that shown by other children in
*This investigation was partly carried out whilst working at the Institute of Psychiatry, University of London and was supported by a Bethlem Research Fund Grant. TDepartment of Psychiatry, University of Manchester, Swinton Grove, Manchester Ml3 OEU, England. 463
464
SIDNEY BENJAMIN
their survey who suffered from other chronic physical disorders. A more recent study [5] found that behaviour disturbances were commoner than in non-asthmatic controls only in those children with severe and unremitting asthma. The assessment of behaviour was not made primarily by psychiatrists in either of these studies. The only other survey of mental health in asthmatics in the community has been reported by Leigh and Marley [6] and this alone includes adult asthmatics. During childhood, the adult asthmatics had suffered mental illness more frequently and more severely than non-asthmatic controls. This assessment was retrospective and semi-standardised but the findings are similar to those of the community surveys of asthmatic children cited above. However, during adult life the asthmatics suffered rather less from mental illness than the control group. By contrast, the first-degree relatives of asthmatics reported significantly more mental illness than the first-degree relatives of controls. Although information about the mental health of asthmatics appears to be fundamental for the management of asthma and for the concept of psychosomatic illness, available data is both limited and controversial. On the basis of available evidence it is postulated that asthmatics do not differ from non-asthmatics in their experience of mental illness and that any excess of such illness that may be found will be related to the degree of physical and social incapacity suffered. The present study is designed to test this hypothesis by providing data for the physical, mental and social health of asthmatics during a 15-year period. METHOD The investigation by Leigh and Marley [6] took place between 1955 and 1958. This has now been extended into a longitudinal study by following up the same subjects after an interval of 15 years. Details of the original selection of subjects, the matching of controls and criteria for ascertainment are provided by Leigh and Marley. For the purpose of the present study it is important to note that the probands were a random sample of 55 asthmatics (25 males, 30 females) registered with two general practices and represented a cross-section of asthmatics, unbiased by hospital or psychiatric referral. They covered a broad spectrum of severity of illness and the age of onset ranged from the first year to 42 years. They were well matched for age and sex with a random selection of 55 non-asthmatic controls from the same general practices. Both first- and second-degree relatives of probands and controls were included in this earlier study but for the purpose of the present investigation seconddegree relatiwzs have been omitted. The potential subjects for the present study therefore consisted of the 55 probands and 55 controls and those of their first-degree relatives known to be aiive at the time of the first study, numbering 561 in total. Of these subjects 94 % were traced and to these were added 81 relatives born during the followup period, resulting in a total of 607. It was possible to collect detailed information about health during the follow-up period for virtually all these subjects. Sources of information included standardised interviews of the subjects and/or another informant, postal questionnaires, general practitioners’ and hospital records, death certificates and post-mortem reports. Standardised criteria were used for the ascertainment of respiratory disease and mental illness, the latter being classified according to the International Classification of Disease (8th revision). Further details of methods and results are provided elsewhere [3]. RESULTS During the follow-up period the number of subjects experiencing mental illness was somewhat greater for the asthma probands than controls but after correction for the period at risk this difference is minimal and not statistically significant (Table 1). A few subjects had more than one episode of mental illness during the follow up but the period prevalence for episodes also failed to show any significant difference between groups. There was insufficient evidence to make a definitive diagnosis for each of the 30 subjects with mental illness, but 23 had had an affective neurosis with predominant anxiety or depression. There was no episode of psychotic illness. The asthmatics and controls did not differ in this respect. Details of physical health are provided elsewhere [3]. With regard to asthma the progress was very
Is asthma a psychosomatic
465
illness?-1
TABLEI.-PERIODPREVALENCEOFMENTALILLNESSPROBANDS Asthma
Control
53 17 717 23.17
50 13 645 20.16
N Subjects with mental illness Subject years at risk Prevalence /lOOO subiect years at risk Z=O.44, not significant.
good, 47 of the 53 subjects being either ‘cured’ (the criterion being at least three years totally free from asthma) or else were substantially improved. For the first-degree relatives the period prevalence of mental illness was also similar for the two groups and differences did not approach statistically significant levels (Table 2). TABLE 2.-PERIOD
PREVALENCEOF MENTALILLNESS-RELATIVES
Adult (13 +) Asthma Control N 251 196 Subjects with mental illness 32 28 Subject years at risk 3263 2362 Prevalence /lo00 subject years at risk 9.81 11.85
Children (12 -) Asthma Control 91 7s 7 3 617 610 11.34 4.92
Z=O.72 (adults); 1.25 (children), not significant. It is notable however that the child relatives of asthmatics were reported to suffer mental illness more than twice as often as the child relative of controls. Diagnoses of these illnesses were again predominantly the affective neuroses but two relatives in each group suffered episodes of functional psychoses (schizophrenic or depressive). As expected, more of the asthma group relatives than control relatives suffered from asthma at some stage (42/306 asthma group, 131245 control group; x2=9*82, degrees of freedom=], p ~0.01). The majority of these cases was either ‘cured’ or showed some degree of improvement in the follow-up period. In all, there were 112 subjects who had a history of asthma, their allocation to groups being shown in Table 3. TABLE 3.-ALL
SUBJECTS WITH ASTHMAFOLLOWEDUP
Asthma Probands Relatives Total
group
53 42 95
Control group
Total
4 13 17
57 55 112
This larger group of asthmatics was investigated for factors possibly related to prognosis for asthma. A comparison of those who were either ‘cured’ or improved with those who failed to improve shows that the occurrence of mental illness previously described is found to be equally distributed regardless of the outcome of their physical symptoms (Table 4). TABLE 4.-MENTAL
ILLNESSAND PROGRESS OF ASTHMA
Asthma improved N* Mental illness No mental illness x2=0. *No information
79 22 57
Not improved 31 8 23
Total 110 30 80
for mental illness for 1 subject from each group.
By contrast, when the age of onset of asthma is divided into lo-yr epochs it is found that the prognosis for early onset asthma is better than for later onset asthma, the difference being significant at the 1 % level (Table 5). This finding in a community study is in keeping with the observations of prognosis based on more selected samples of hospital or clinic attenders. Tt is of interest in the present
466
SIDNEY
BENJAMIN
study as it helps to validate the criteria used for assessment predominate. TABLE5.-PROGKESS OF ASTHMAAND
in a study in which negative findings
AGE
OF ONSET
Asthma improved Not improved Total Age of onset N=78 N=30 N= log* ~~~___~~~ ~___ ~~___. o-9 48 9 57 IO-19 9 4 13 20-29 15 7 22 3016 10 16 x*=13.937, degrees of freedom=3,p ~001. *No information for age of onset for 2 subjects from each group. As the prognosis differs for early and late onset asthma there might also be differences in the mental illness experienced by these sub-groups. However, the frequency of mental illness in asthmatics divided by age of onset (Table 6) shows no significant difference. In other words mental illness is as common in the early onset asthmatic as those with later onset. TABLE6.-MENTAL ILLNESSAND AGE Ar ONSET OF ASTHMA Mental illness No mental illness Total N=30 N=76* Age at onset N=106 _____. _ o-9 20 37 57 .-IO-19 2 10 12t 20-29 6 15 21130+ 2 14 16 x2=4.071, degrees of freedom=3, not significant. *Age of onset unknown for 4 subjects. iHistory of mental illness unknown for 1 subject. Other constitutional factors related to asthma that might be expected to influence mental illness during the follow-up period have been considered. Neither the presence of the ‘atopic syndrome’ (asthma, hay fever or rhinitis and eczema) (Table 7) nor a family history of asthma (Table 8) appears to influence the occurrence of mental illness. TABLEI.-MENTAL ILLNESSAND Mental illness 11 7 4
‘ATOPIC SYNDROME'
No mental illness Total _._-.._____ 50 39 22 29 17 21*
N ‘Atopic syndrome’ No atopic illness (exceot asthma) x~=O@Ol, degree of freedom=l, not significant. *No information for mental illness for 1 subject in this group. TABLE&--MENTAL ILLNESSANDFAMILYHISTORYOF ASTHMA Mental illness No mental illness Total 30 80 N 110 -~ 55 74* Family history 19 No family history 11 25 36” x*=0.096, degree of freedom = 1, not significant. *No information for mental illness for 1 subject from each group. Although this investigation has been concerned primarily with the mental health of asthmatics, a limited assessment of social function was included. This assessment is limited to the asthma and control probands who could be interviewed personally, and is based on standardised interviews with these subjects and other informants. Three aspects of social function were each rated on a 4-point scale. Time lost from work per year during follow up for any reason is shown in Table 9. The employment
Is asthma a psychosomatic
46-l
illness?-1
TABLE9.-TIME LOSTFROMWORKANNUALLY Control Asthma N il month 1-6 months S} ‘E a> :; Mainly unemployed Entirely unemployed x2=0.144, degree of freedom=l, not significant.
‘I)
Total
;i
TABLEIO.-LIMITATION OF LEISUREACTIVITKS Asthma N 47 Nil 24 Mild 14 Moderate 9 x* =4*770, degrees of freedom =2. p 10.10.
Control 43 32 9 2
Total 90 56 23 11
TABLE1 I.--SATISFACTIONIN FAMILYRELATIONSHIPS Asthma Control _.________ _ N 46* 43 Entirely satisfactory 20 15 Mild dissatisfaction 19 23 Moderate dissatisfaction 7 l’ Severe dissatisfaction 0> 7 ;’ 5 1> x2=1.331, degrees of freedom=2, not significant. *Information lacking for 1 informant.
Total 89 35 42 12
record of most asthmatics appears to be good and does not differ significantly from that of controls. Although all three subjects described as totally unemployed belong to the asthma group, in only one case was this attributable to respiratory disease (the others being due to cardiovascular disease and agoraphobia). The limitation in range of leisure activities (Table 10) was assessed by asking subjects about physical activities they would like to have pursued but from which they had to abstain due to ill health. Impairment of mild and moderate degree was shown by more of the asthma group, the difference approaching statistical significance. It seemed likely that asthmatics limited their evident impairment in employment and leisure by selecting activites which were within their capacity. Relationships with key figures in the family (Table 11) ranged from ‘entirely satisfactory’ to ‘severe dissatisfaction’ (defined as ‘frequent arguments, possibly including physical violence, or no contact on account of disagreement’). Considerable dissatisfaction with family relationships was expressed but is similar in the two groups. DISCUSSION
The present study fails to show any significant difference between the period prevalence of mental illness experienced by the asthma group or by their first-degree relatives compared with the control group. Nor was there any difference in the diagnostic categories. Moreover, the progress of asthma did not appear to be related to the occurrence of mental illness. Neurotic illness was common in both asthma and control groups. There was no instance in which a ‘recovered’ asthmatic lapsed into psychosis. There is no evidence that mental illness was less common in so-called ‘atopic’ asthma (as defined by a history of other atopic illness, family history or early onset), than in other cases of asthma. These findings fail to support the concepts of asthma as an ‘organ neurosis’ or as a defence against psychosis and also fail to validate the tradi-
468
SIDNEY BENJAMIN
tional dichotomy of ‘atopic’ and ‘nervous’ asthma. They also fail to support more recent suggestions of alexithymia as a process involving excessive filtration between limbic and neocortical functions and therefore the obverse of a postulated schizophrenic process [7]. Sources of bias which may well have influenced findings in other studies cannot be totally excluded from the present investigation. Retrospective investigations are frought with potential hazards. The number of illness episodes and their diagnostic categories could not be determined with certainty in every case. Inevitably some episodes are liable to have been forgotten and the prevalence data are therefore likely to be underestimated. One may speculate that the asthma group may be more health conscious than the controls who may tend to under-report illness of all kinds. This may account for the tendency for fewer mental illnesses to be reported in the child relatives of controls. Rating scales have classified data into a few broad categories in order to avoid ambiguity and are inevitably crude so that valid distinctions may have been lost. A supplementary study of the current mental and respiratory state of the asthma and control probands at the time of follow-up has been carried out to avoid these possible sources of error [8], but the retrospective investigation has the advantage of studying health over an extended period. Bias has been limited as far as possible by standardisation of criteria for diagnosis and ascertainment. The extent to which the asthma group is representative of all asthmatics is open to question but it includes approximately equal numbers of both sexes and shows a range of age, age of onset, social class and severity of asthma. There is ample evidence that as a group they showed considerable physiological impairment [8]. Although the control members are non-asthmatic and therefore suitable to act as a control for asthma, it is conceivable that they might have suffered an excess of other ‘psychosomatic’ disorders which could have balanced the effect of asthma in the asthma group. In fact, the frequency of such disorders in both groups was found to be similar at the inception of the study [6]. The present investigation has not considered aspects of psychological function other than overt mental illness and, to a lesser extent, social adjustment. It might be argued that processes of aetiological significance for asthma may require more sensitive methods of detection. Claims for specificity of predisposing personality have been justlycriticised [9] on the grounds that there is no evidence of apathognomonic personality structure and that in any case the commonly reported traits may simply reflect the effects of prolonged incapacitating illness. Although relapses are sometimes associated with stressful circumstances, it does not follow that an abnormality of personality caused the patient to be predisposed to asthma. The observation of mood swings during attacks of asthma in adults and behaviour disorders in children is in keeping with findings in those who have other physical illness and need not have aetiological connotations. Such associations are commonly observed in many physical illnesses and may equally be formulated as different aspects of the constitutionally predisposed individual’s total response. The present study indicates that the long-term prognosis for mental health in the asthmatic is as good as for the non-asthmatic and that the level of social function need not be greatly impaired. Asthma may best be considered in the context of other chronic and life-threatening illnesses and the factors which determine the individual’s level of function in these conditions.
Is asthma a psychosomatic
illness?-1
469
REFERENCES 1. GROENJ. J. Present status of the psychosomatic approach to bronchial asthma. In Modern Trends in Psvchosomatic Medicine-III (Edited bv HILL 0. W.). Butterworths. London (1976). 2. ALEXANDERF., FRENCH T. H. and POLL& G. Psychosomatic Spec&ity. Chicago ‘University Press, Chicago (1968). 3. BENJAMINS. Asthma and mental illness: a longitudinal community study. M.D. thesis, University of London (1976). 4. GRAHAMP. J., WILLIAMSH. E., ALLANJ. and MCANDREWI. Childhood asthma: a psychosomatic disorder? Some epidemiological considerations. Br. J. Prev. Sot. Med. 21,78 (1967). 5. MCNICHOL K. N., RUTTERM. L., YULE W. and PLESSI. B. Spectrum of asthma in children-III. Psychological and social components. Br. Med. J. 4, 16 (1973). 6. LEIGHD. and MARLEYE. Bronchial Asthma. A Genetic Population andpsychiatric Study. Pergamon, London (1967). 7. NEMIAHJ. C. Denial revisited: reflections on psychosomatic theory. Psychother, Psychosom. 26, 140 (1975). 8. BENJAMINS. Is asthma a psychosomatic illness?-II. A correlative study of respiratory impairment and mental state. J. Psychosom. Res. 21,471. 9. LIPOWSKIZ. J. Psychosomatic medicine: an overview. In Modern Trends in Psychosomatic Medicine -111 (Edited by HILL 0. W.). Butterworths, London (1976).
of Psychosomatic
Research,
IS ASTHMA A RETROSPECTIVE
Vol.
21, pp. 463 to 469.
Pergamon
Press,
A PSYCHOSOMATIC STUDY OF MENTAL ADJUSTMENT*
1977. Printed
in Great
Britain
ILLNESS?-I. ILLNESS
AND
SOCIAL
SIDNEY BENJAMIN?
(Received 14 June 1977) Abstract-A group of 53 asthmatics and 50 matched controls together with their first-degree relatives has been followed up retrospectively after an interval of 15 years. There was no evidence that the mental illness experienced by the asthma group differed significantly from that of controls during the follow up period either in period prevalence or diagnosis. The presence of mental illness amongst asthmatics was not related to the prognosis for asthma, nor to the age of onset, family history of asthma or other atopic conditions. The asthma group showed only slightly greater impairment in social adjustment than controls. These findings are discussed in the light of traditional views of asthma as a psychosomatic illness. INTRODUCTION IN SPITE of changing psychosomatic concepts there is still a tendency to regard particular conditions as psychosomatic illnesses. Amongst these the syndrome of asthma is prominent [ 11. This appears to be based on a number of traditional views including specificity of predisposing personality [2], conflicts, emotions and defence mechanisms. The claim that asthma is an ‘organ neurosis’ places asthma firmly within the spectrum of neurotic illness. Implicit in these views is the suggestion that there may be an excess of neurotic illness in those suffering from asthma either currently or in the past. It might also be argued that asthma can serve as an alternative to other neurotic illness which might therefore be less common in asthmatics. Similarly, it has been suggested that asthma is uncommon in those with psychotic illness, may act as a defence against psychosis, and may actually alternate with schizophrenia. The evidence for these claims has been extensively reviewed [3] and is based on surveys amongst both asthmatics and those with psychotic illness. The interpretation of available studies is confounded by possible sources of bias, particularly in the criteria for selection of subjects and for ascertainment of both asthma and mental illness. Deviating from these well-trodden paths is the alternative formulation of asthma as primarily a syndrome of physical illness with the inevitable repercussions of all chronic or recurrent physical illness on psychological and social health. The concept of the individual reacting to external and internal stressors with his own characteristic total response which involves physical, psychological and social change is perhaps more comprehensive. Few epidemiological studies of asthmatics in the community have included an assessment of mental health. Graham and his co-workers 143 have found an excess of disturbed behaviour in asthmatic children similar to that shown by other children in
*This investigation was partly carried out whilst working at the Institute of Psychiatry, University of London and was supported by a Bethlem Research Fund Grant. TDepartment of Psychiatry, University of Manchester, Swinton Grove, Manchester Ml3 OEU, England. 463
464
SIDNEY BENJAMIN
their survey who suffered from other chronic physical disorders. A more recent study [5] found that behaviour disturbances were commoner than in non-asthmatic controls only in those children with severe and unremitting asthma. The assessment of behaviour was not made primarily by psychiatrists in either of these studies. The only other survey of mental health in asthmatics in the community has been reported by Leigh and Marley [6] and this alone includes adult asthmatics. During childhood, the adult asthmatics had suffered mental illness more frequently and more severely than non-asthmatic controls. This assessment was retrospective and semi-standardised but the findings are similar to those of the community surveys of asthmatic children cited above. However, during adult life the asthmatics suffered rather less from mental illness than the control group. By contrast, the first-degree relatives of asthmatics reported significantly more mental illness than the first-degree relatives of controls. Although information about the mental health of asthmatics appears to be fundamental for the management of asthma and for the concept of psychosomatic illness, available data is both limited and controversial. On the basis of available evidence it is postulated that asthmatics do not differ from non-asthmatics in their experience of mental illness and that any excess of such illness that may be found will be related to the degree of physical and social incapacity suffered. The present study is designed to test this hypothesis by providing data for the physical, mental and social health of asthmatics during a 15-year period. METHOD The investigation by Leigh and Marley [6] took place between 1955 and 1958. This has now been extended into a longitudinal study by following up the same subjects after an interval of 15 years. Details of the original selection of subjects, the matching of controls and criteria for ascertainment are provided by Leigh and Marley. For the purpose of the present study it is important to note that the probands were a random sample of 55 asthmatics (25 males, 30 females) registered with two general practices and represented a cross-section of asthmatics, unbiased by hospital or psychiatric referral. They covered a broad spectrum of severity of illness and the age of onset ranged from the first year to 42 years. They were well matched for age and sex with a random selection of 55 non-asthmatic controls from the same general practices. Both first- and second-degree relatives of probands and controls were included in this earlier study but for the purpose of the present investigation seconddegree relatiwzs have been omitted. The potential subjects for the present study therefore consisted of the 55 probands and 55 controls and those of their first-degree relatives known to be aiive at the time of the first study, numbering 561 in total. Of these subjects 94 % were traced and to these were added 81 relatives born during the followup period, resulting in a total of 607. It was possible to collect detailed information about health during the follow-up period for virtually all these subjects. Sources of information included standardised interviews of the subjects and/or another informant, postal questionnaires, general practitioners’ and hospital records, death certificates and post-mortem reports. Standardised criteria were used for the ascertainment of respiratory disease and mental illness, the latter being classified according to the International Classification of Disease (8th revision). Further details of methods and results are provided elsewhere [3]. RESULTS During the follow-up period the number of subjects experiencing mental illness was somewhat greater for the asthma probands than controls but after correction for the period at risk this difference is minimal and not statistically significant (Table 1). A few subjects had more than one episode of mental illness during the follow up but the period prevalence for episodes also failed to show any significant difference between groups. There was insufficient evidence to make a definitive diagnosis for each of the 30 subjects with mental illness, but 23 had had an affective neurosis with predominant anxiety or depression. There was no episode of psychotic illness. The asthmatics and controls did not differ in this respect. Details of physical health are provided elsewhere [3]. With regard to asthma the progress was very
Is asthma a psychosomatic
465
illness?-1
TABLEI.-PERIODPREVALENCEOFMENTALILLNESSPROBANDS Asthma
Control
53 17 717 23.17
50 13 645 20.16
N Subjects with mental illness Subject years at risk Prevalence /lOOO subiect years at risk Z=O.44, not significant.
good, 47 of the 53 subjects being either ‘cured’ (the criterion being at least three years totally free from asthma) or else were substantially improved. For the first-degree relatives the period prevalence of mental illness was also similar for the two groups and differences did not approach statistically significant levels (Table 2). TABLE 2.-PERIOD
PREVALENCEOF MENTALILLNESS-RELATIVES
Adult (13 +) Asthma Control N 251 196 Subjects with mental illness 32 28 Subject years at risk 3263 2362 Prevalence /lo00 subject years at risk 9.81 11.85
Children (12 -) Asthma Control 91 7s 7 3 617 610 11.34 4.92
Z=O.72 (adults); 1.25 (children), not significant. It is notable however that the child relatives of asthmatics were reported to suffer mental illness more than twice as often as the child relative of controls. Diagnoses of these illnesses were again predominantly the affective neuroses but two relatives in each group suffered episodes of functional psychoses (schizophrenic or depressive). As expected, more of the asthma group relatives than control relatives suffered from asthma at some stage (42/306 asthma group, 131245 control group; x2=9*82, degrees of freedom=], p ~0.01). The majority of these cases was either ‘cured’ or showed some degree of improvement in the follow-up period. In all, there were 112 subjects who had a history of asthma, their allocation to groups being shown in Table 3. TABLE 3.-ALL
SUBJECTS WITH ASTHMAFOLLOWEDUP
Asthma Probands Relatives Total
group
53 42 95
Control group
Total
4 13 17
57 55 112
This larger group of asthmatics was investigated for factors possibly related to prognosis for asthma. A comparison of those who were either ‘cured’ or improved with those who failed to improve shows that the occurrence of mental illness previously described is found to be equally distributed regardless of the outcome of their physical symptoms (Table 4). TABLE 4.-MENTAL
ILLNESSAND PROGRESS OF ASTHMA
Asthma improved N* Mental illness No mental illness x2=0. *No information
79 22 57
Not improved 31 8 23
Total 110 30 80
for mental illness for 1 subject from each group.
By contrast, when the age of onset of asthma is divided into lo-yr epochs it is found that the prognosis for early onset asthma is better than for later onset asthma, the difference being significant at the 1 % level (Table 5). This finding in a community study is in keeping with the observations of prognosis based on more selected samples of hospital or clinic attenders. Tt is of interest in the present
466
SIDNEY
BENJAMIN
study as it helps to validate the criteria used for assessment predominate. TABLE5.-PROGKESS OF ASTHMAAND
in a study in which negative findings
AGE
OF ONSET
Asthma improved Not improved Total Age of onset N=78 N=30 N= log* ~~~___~~~ ~___ ~~___. o-9 48 9 57 IO-19 9 4 13 20-29 15 7 22 3016 10 16 x*=13.937, degrees of freedom=3,p ~001. *No information for age of onset for 2 subjects from each group. As the prognosis differs for early and late onset asthma there might also be differences in the mental illness experienced by these sub-groups. However, the frequency of mental illness in asthmatics divided by age of onset (Table 6) shows no significant difference. In other words mental illness is as common in the early onset asthmatic as those with later onset. TABLE6.-MENTAL ILLNESSAND AGE Ar ONSET OF ASTHMA Mental illness No mental illness Total N=30 N=76* Age at onset N=106 _____. _ o-9 20 37 57 .-IO-19 2 10 12t 20-29 6 15 21130+ 2 14 16 x2=4.071, degrees of freedom=3, not significant. *Age of onset unknown for 4 subjects. iHistory of mental illness unknown for 1 subject. Other constitutional factors related to asthma that might be expected to influence mental illness during the follow-up period have been considered. Neither the presence of the ‘atopic syndrome’ (asthma, hay fever or rhinitis and eczema) (Table 7) nor a family history of asthma (Table 8) appears to influence the occurrence of mental illness. TABLEI.-MENTAL ILLNESSAND Mental illness 11 7 4
‘ATOPIC SYNDROME'
No mental illness Total _._-.._____ 50 39 22 29 17 21*
N ‘Atopic syndrome’ No atopic illness (exceot asthma) x~=O@Ol, degree of freedom=l, not significant. *No information for mental illness for 1 subject in this group. TABLE&--MENTAL ILLNESSANDFAMILYHISTORYOF ASTHMA Mental illness No mental illness Total 30 80 N 110 -~ 55 74* Family history 19 No family history 11 25 36” x*=0.096, degree of freedom = 1, not significant. *No information for mental illness for 1 subject from each group. Although this investigation has been concerned primarily with the mental health of asthmatics, a limited assessment of social function was included. This assessment is limited to the asthma and control probands who could be interviewed personally, and is based on standardised interviews with these subjects and other informants. Three aspects of social function were each rated on a 4-point scale. Time lost from work per year during follow up for any reason is shown in Table 9. The employment
Is asthma a psychosomatic
46-l
illness?-1
TABLE9.-TIME LOSTFROMWORKANNUALLY Control Asthma N il month 1-6 months S} ‘E a> :; Mainly unemployed Entirely unemployed x2=0.144, degree of freedom=l, not significant.
‘I)
Total
;i
TABLEIO.-LIMITATION OF LEISUREACTIVITKS Asthma N 47 Nil 24 Mild 14 Moderate 9 x* =4*770, degrees of freedom =2. p 10.10.
Control 43 32 9 2
Total 90 56 23 11
TABLE1 I.--SATISFACTIONIN FAMILYRELATIONSHIPS Asthma Control _.________ _ N 46* 43 Entirely satisfactory 20 15 Mild dissatisfaction 19 23 Moderate dissatisfaction 7 l’ Severe dissatisfaction 0> 7 ;’ 5 1> x2=1.331, degrees of freedom=2, not significant. *Information lacking for 1 informant.
Total 89 35 42 12
record of most asthmatics appears to be good and does not differ significantly from that of controls. Although all three subjects described as totally unemployed belong to the asthma group, in only one case was this attributable to respiratory disease (the others being due to cardiovascular disease and agoraphobia). The limitation in range of leisure activities (Table 10) was assessed by asking subjects about physical activities they would like to have pursued but from which they had to abstain due to ill health. Impairment of mild and moderate degree was shown by more of the asthma group, the difference approaching statistical significance. It seemed likely that asthmatics limited their evident impairment in employment and leisure by selecting activites which were within their capacity. Relationships with key figures in the family (Table 11) ranged from ‘entirely satisfactory’ to ‘severe dissatisfaction’ (defined as ‘frequent arguments, possibly including physical violence, or no contact on account of disagreement’). Considerable dissatisfaction with family relationships was expressed but is similar in the two groups. DISCUSSION
The present study fails to show any significant difference between the period prevalence of mental illness experienced by the asthma group or by their first-degree relatives compared with the control group. Nor was there any difference in the diagnostic categories. Moreover, the progress of asthma did not appear to be related to the occurrence of mental illness. Neurotic illness was common in both asthma and control groups. There was no instance in which a ‘recovered’ asthmatic lapsed into psychosis. There is no evidence that mental illness was less common in so-called ‘atopic’ asthma (as defined by a history of other atopic illness, family history or early onset), than in other cases of asthma. These findings fail to support the concepts of asthma as an ‘organ neurosis’ or as a defence against psychosis and also fail to validate the tradi-
468
SIDNEY BENJAMIN
tional dichotomy of ‘atopic’ and ‘nervous’ asthma. They also fail to support more recent suggestions of alexithymia as a process involving excessive filtration between limbic and neocortical functions and therefore the obverse of a postulated schizophrenic process [7]. Sources of bias which may well have influenced findings in other studies cannot be totally excluded from the present investigation. Retrospective investigations are frought with potential hazards. The number of illness episodes and their diagnostic categories could not be determined with certainty in every case. Inevitably some episodes are liable to have been forgotten and the prevalence data are therefore likely to be underestimated. One may speculate that the asthma group may be more health conscious than the controls who may tend to under-report illness of all kinds. This may account for the tendency for fewer mental illnesses to be reported in the child relatives of controls. Rating scales have classified data into a few broad categories in order to avoid ambiguity and are inevitably crude so that valid distinctions may have been lost. A supplementary study of the current mental and respiratory state of the asthma and control probands at the time of follow-up has been carried out to avoid these possible sources of error [8], but the retrospective investigation has the advantage of studying health over an extended period. Bias has been limited as far as possible by standardisation of criteria for diagnosis and ascertainment. The extent to which the asthma group is representative of all asthmatics is open to question but it includes approximately equal numbers of both sexes and shows a range of age, age of onset, social class and severity of asthma. There is ample evidence that as a group they showed considerable physiological impairment [8]. Although the control members are non-asthmatic and therefore suitable to act as a control for asthma, it is conceivable that they might have suffered an excess of other ‘psychosomatic’ disorders which could have balanced the effect of asthma in the asthma group. In fact, the frequency of such disorders in both groups was found to be similar at the inception of the study [6]. The present investigation has not considered aspects of psychological function other than overt mental illness and, to a lesser extent, social adjustment. It might be argued that processes of aetiological significance for asthma may require more sensitive methods of detection. Claims for specificity of predisposing personality have been justlycriticised [9] on the grounds that there is no evidence of apathognomonic personality structure and that in any case the commonly reported traits may simply reflect the effects of prolonged incapacitating illness. Although relapses are sometimes associated with stressful circumstances, it does not follow that an abnormality of personality caused the patient to be predisposed to asthma. The observation of mood swings during attacks of asthma in adults and behaviour disorders in children is in keeping with findings in those who have other physical illness and need not have aetiological connotations. Such associations are commonly observed in many physical illnesses and may equally be formulated as different aspects of the constitutionally predisposed individual’s total response. The present study indicates that the long-term prognosis for mental health in the asthmatic is as good as for the non-asthmatic and that the level of social function need not be greatly impaired. Asthma may best be considered in the context of other chronic and life-threatening illnesses and the factors which determine the individual’s level of function in these conditions.
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REFERENCES 1. GROENJ. J. Present status of the psychosomatic approach to bronchial asthma. In Modern Trends in Psvchosomatic Medicine-III (Edited bv HILL 0. W.). Butterworths. London (1976). 2. ALEXANDERF., FRENCH T. H. and POLL& G. Psychosomatic Spec&ity. Chicago ‘University Press, Chicago (1968). 3. BENJAMINS. Asthma and mental illness: a longitudinal community study. M.D. thesis, University of London (1976). 4. GRAHAMP. J., WILLIAMSH. E., ALLANJ. and MCANDREWI. Childhood asthma: a psychosomatic disorder? Some epidemiological considerations. Br. J. Prev. Sot. Med. 21,78 (1967). 5. MCNICHOL K. N., RUTTERM. L., YULE W. and PLESSI. B. Spectrum of asthma in children-III. Psychological and social components. Br. Med. J. 4, 16 (1973). 6. LEIGHD. and MARLEYE. Bronchial Asthma. A Genetic Population andpsychiatric Study. Pergamon, London (1967). 7. NEMIAHJ. C. Denial revisited: reflections on psychosomatic theory. Psychother, Psychosom. 26, 140 (1975). 8. BENJAMINS. Is asthma a psychosomatic illness?-II. A correlative study of respiratory impairment and mental state. J. Psychosom. Res. 21,471. 9. LIPOWSKIZ. J. Psychosomatic medicine: an overview. In Modern Trends in Psychosomatic Medicine -111 (Edited by HILL 0. W.). Butterworths, London (1976).
