THE JOURNAL OF
ALLERGY AND
ImmY
CLIntCAL VOLUME 60
NUMBER 5
Editorial Psychology, of asthma
behavior, and the treatment
David T. Graham, M.D. Madison,
Wk.
It is gratifying that interest in asthma as a psychosomatic disease continues to survive, even though it plays a fairly small part in the thinking of most clinicians about the disease. Two papers in this issue are concerned with what are often referred to as “behavioral” or “psychological” aspects of asthma. While for some purposes it may be convenient to think of them as belonging in the same category, it is also important to recognize that their topics are conceptually quite different. It is first of all important to make clear the distinction between events that precipitate attacks of asthma and the psychological response to asthma. Miklich and co-workers (page 285) used a behavioral method of treatment that requires knowledge of the stimulus conditions leading to attacks. Dahlem, Kinsman, and Horton (page 295) do not concern themselves with that question, but rather are asking about fears that develop during, and presumably because of, an attack. It must be mentioned, however, that it is not necessarily true that the fear arises because of the asthma. The available data do not rule out the possibility that the fear and the asthma are parallel responses to the same external stimulus, and that neither is the cause of the other. The message of the work of Dahlem, Kinsman, and Horton as far as therapy is concerned is that there is a __Reprint requests to: Dr. David T. Graham, Chairman, Department of Medicine, University of Wisconsin, Madison, Wk. 53706.
set of symptoms in asthma which is relatively independent of the degree of airway obstruction. The same group has reported essentially zero correlations between scores on their Panic-Fear symptom scale and measures of pulmonary function.’ Furthermore, as their present paper shows, requests for medication for asthma are a very poor guide to the state of a patient’s airways, since they are so much a function of the Panic-Fear symptoms that are present. The report of Miklich and co-workers describes the use of only one form of what is now likely to be referred to as behavior therapy. These authors employed Wolpe’s technique, called Systematic Desensitization by Reciprocal Inhibition (SDRI). When it is applied to the treatment of asthma, the therapist must know what events in the patient’s life have been sources of stimuli that in some way disturbed him. There are variations in the technique. Although presumably one would be most interested in events that are known to have precipitated asthma, desensitization may be undertaken by considering “anxiety” or some other state of the patient different from asthma. Miklich and co-workers say: “SDRI teaches patients to associate relaxation with imagined anxiety-provoking situations. The expectation is that this learned association will inhibit anxiety in the real-life situations.” In fact, however, their procedures seem to have included chiefly, if not exclusively, situations associated with asthma, which is certainly not exactly the same thing as anxiety. Vol. 60, No. 5, pp. 273-275
274
Editorial
The patient is asked to imagine disturbing situations, progressing from the least to the most disturbing (in what is called a “hierarchy”), as he is gradually able to imagine them without feeling disturbed. This process is intended to desensitize him so that the situations no longer make him sick. The results of Miklich’s study are disappointing and, as the authors remark, at variance with earlier reports of successful use of similar techniques. Moore,2 for instance, was able to reduce the number of reported attacks of asthma and to increase the maximum peak flow rate (MPFR) by the use of simple relaxation training, of relaxation with suggestions that improvement would occur, and of relaxation with SDRI. The last produced the most benefit. The relaxation training produced “a suggestible relaxed state, merging with light hypnosis.” Miklich also induced relaxation; perhaps it differed from that induced by Moore. Although Miklich and co-workers are correct in pointing out differences in frequency of data collection and in length of follow-up, there is still enough comparability to make it surprising that their patients did not improve as Moore’s did. It is becoming increasingly evident that is it difficult to sort out the significant elements in the various forms of treatment that are called “behavioral,” and that what the investigator may have thought was the crucial element in his treatment may not have been. It has, for instance, been found that meditation and relaxation are perhaps as effective in lowering blood pressure as is the more complicated “biofeedback” method.3 Very careful controls are necessary to identify the relevant variables. It is important to distinguish biofeedback from SDRI. In the former, information about some physiological variable is given (“fed back”) to the patient. This feedback, in ways unknown, sometimes enables the patient to control the processes involved. In its simplest, and usual, form, the method does not include manipulation of stimuli intended to produce the physiological changes of interest, and therefore does not require knowing what events in the patient’s life have precipitated attacks of illness. The physiological changes, e.g., in blood pressure, are allowed to occur SDRI, of course, does require “spontaneously.” knowledge of stimuli, and, furthermore, manipulation of pathogenic stimuli (i.e., instructions to imagine disturbing events) is part of the therapeutic technique. There has been at least one encouraging report of reduction in airway resistance by biofeedback,4 but Khan” recently reported an equivocal outcome when he used it to treat asthmatic children. The treated children improved, but one of his control groups improved just as much.
J. ALLERGY
CLIN. IMMUNOL. NOVEMBER 1977
What exactly is fed back is, or at least ought to be, important. Some of Miklich’s subjects were given information about contraction of their frontalis muscles, as a measure of degree of relaxation. We do not know, however, whether there is really an association between frontalis tension and airway resistance. Khan fed back information about airway resistance, which is clearly more closely related to the asthmatic process. In general, there has been some lack of precision in defining the emotional state in asthma. The word “anxiety” is often used, but probably not carefully enough. Why should an asthmatic get worse when he is anxious, if anxiety is associated with increased release of epinephrine? (This association, incidentally, is not as firmly established as one might think.) The entire question of the relations of particular emotional states to various illnesses remains difficult because of the rather loose way in which names of emotions are often used, and of the lack of generally employed criteria for using any of them. Presumably, the Panic-Fear dimension of Dahlem, Kinsman, and Horton measures approximately what is generally meant The lack of correlation between the by “anxiety.” Panic-Fear dimension and severity of pulmonary function impairment suggests that there is something the matter with a simple assumption that reducing anxiety is the key to the psychosomatic or behavioral approach to the treatment of asthma. This point would be stronger, however, if one knew the relation between changes in Panic-Fear and in airway resistance in individual patients followed for a period of time. In any case, this question is significant in connection with the use of anxiety-provoking situations in desensitization therapy. It is worth emphasizing, whatever the correct answer may be to the question about names of emotions, that many authors agree that asthmatics, much more than patients with other psychosomatic diseases, are very directly concerned with dependence on and separation from their mothers or other persons whose love they want. One welcomes contributions of the kind embodied in the two papers under discussion in the present issue of this JOURNAL. It seems to the present writer that the relative indifference often shown to psychosomatic understanding of many diseases, including asthma, is based as much on the clinician’s belief that such understanding has no practical therapeutic application as it is on skepticism about its validity. Work of the kind here represented should help to establish the place of psychological concepts and methods in the approach of the practical physician to asthma.
VOLUME NUMBER
60 5
REFERENCES I. Kinsman, Ii. A., Dahlem. N. W., Spector, S., and Staudenmaqer, H.: Observations on subjective symptomatology coping behavior and medical decisions in asthma, Psychosom. Med. 39:i102, 1977. 2. Moore, N. Behavior therapy in bronchial asthma. A controlled study, J. Psychosom. Res. 9:257, 196.5. 3. Shapiro, A. P.. Schwartz, G. E., Ferguson, D. C. E., Red-
Editorial
275
mond, D. P., and Weiss, S. M.: Behaviorial methods in the treatment of hypertension. A review of their clinical status, Ann. Intern. Med. 86:626, 1977. 4. Vachon, L.: Visceral learning of respiratory resistance, Psychosom. Med. 24:471, 1971. 5. Khan, A. V.: Effectiveness of biofeedback and counterconditioning in the treatment of bronchial asthma, J. Psychosom. Res. 21:97, 1977.
ALLERGY AND
ImmY
CLIntCAL VOLUME 60
NUMBER 5
Editorial Psychology, of asthma
behavior, and the treatment
David T. Graham, M.D. Madison,
Wk.
It is gratifying that interest in asthma as a psychosomatic disease continues to survive, even though it plays a fairly small part in the thinking of most clinicians about the disease. Two papers in this issue are concerned with what are often referred to as “behavioral” or “psychological” aspects of asthma. While for some purposes it may be convenient to think of them as belonging in the same category, it is also important to recognize that their topics are conceptually quite different. It is first of all important to make clear the distinction between events that precipitate attacks of asthma and the psychological response to asthma. Miklich and co-workers (page 285) used a behavioral method of treatment that requires knowledge of the stimulus conditions leading to attacks. Dahlem, Kinsman, and Horton (page 295) do not concern themselves with that question, but rather are asking about fears that develop during, and presumably because of, an attack. It must be mentioned, however, that it is not necessarily true that the fear arises because of the asthma. The available data do not rule out the possibility that the fear and the asthma are parallel responses to the same external stimulus, and that neither is the cause of the other. The message of the work of Dahlem, Kinsman, and Horton as far as therapy is concerned is that there is a __Reprint requests to: Dr. David T. Graham, Chairman, Department of Medicine, University of Wisconsin, Madison, Wk. 53706.
set of symptoms in asthma which is relatively independent of the degree of airway obstruction. The same group has reported essentially zero correlations between scores on their Panic-Fear symptom scale and measures of pulmonary function.’ Furthermore, as their present paper shows, requests for medication for asthma are a very poor guide to the state of a patient’s airways, since they are so much a function of the Panic-Fear symptoms that are present. The report of Miklich and co-workers describes the use of only one form of what is now likely to be referred to as behavior therapy. These authors employed Wolpe’s technique, called Systematic Desensitization by Reciprocal Inhibition (SDRI). When it is applied to the treatment of asthma, the therapist must know what events in the patient’s life have been sources of stimuli that in some way disturbed him. There are variations in the technique. Although presumably one would be most interested in events that are known to have precipitated asthma, desensitization may be undertaken by considering “anxiety” or some other state of the patient different from asthma. Miklich and co-workers say: “SDRI teaches patients to associate relaxation with imagined anxiety-provoking situations. The expectation is that this learned association will inhibit anxiety in the real-life situations.” In fact, however, their procedures seem to have included chiefly, if not exclusively, situations associated with asthma, which is certainly not exactly the same thing as anxiety. Vol. 60, No. 5, pp. 273-275
274
Editorial
The patient is asked to imagine disturbing situations, progressing from the least to the most disturbing (in what is called a “hierarchy”), as he is gradually able to imagine them without feeling disturbed. This process is intended to desensitize him so that the situations no longer make him sick. The results of Miklich’s study are disappointing and, as the authors remark, at variance with earlier reports of successful use of similar techniques. Moore,2 for instance, was able to reduce the number of reported attacks of asthma and to increase the maximum peak flow rate (MPFR) by the use of simple relaxation training, of relaxation with suggestions that improvement would occur, and of relaxation with SDRI. The last produced the most benefit. The relaxation training produced “a suggestible relaxed state, merging with light hypnosis.” Miklich also induced relaxation; perhaps it differed from that induced by Moore. Although Miklich and co-workers are correct in pointing out differences in frequency of data collection and in length of follow-up, there is still enough comparability to make it surprising that their patients did not improve as Moore’s did. It is becoming increasingly evident that is it difficult to sort out the significant elements in the various forms of treatment that are called “behavioral,” and that what the investigator may have thought was the crucial element in his treatment may not have been. It has, for instance, been found that meditation and relaxation are perhaps as effective in lowering blood pressure as is the more complicated “biofeedback” method.3 Very careful controls are necessary to identify the relevant variables. It is important to distinguish biofeedback from SDRI. In the former, information about some physiological variable is given (“fed back”) to the patient. This feedback, in ways unknown, sometimes enables the patient to control the processes involved. In its simplest, and usual, form, the method does not include manipulation of stimuli intended to produce the physiological changes of interest, and therefore does not require knowing what events in the patient’s life have precipitated attacks of illness. The physiological changes, e.g., in blood pressure, are allowed to occur SDRI, of course, does require “spontaneously.” knowledge of stimuli, and, furthermore, manipulation of pathogenic stimuli (i.e., instructions to imagine disturbing events) is part of the therapeutic technique. There has been at least one encouraging report of reduction in airway resistance by biofeedback,4 but Khan” recently reported an equivocal outcome when he used it to treat asthmatic children. The treated children improved, but one of his control groups improved just as much.
J. ALLERGY
CLIN. IMMUNOL. NOVEMBER 1977
What exactly is fed back is, or at least ought to be, important. Some of Miklich’s subjects were given information about contraction of their frontalis muscles, as a measure of degree of relaxation. We do not know, however, whether there is really an association between frontalis tension and airway resistance. Khan fed back information about airway resistance, which is clearly more closely related to the asthmatic process. In general, there has been some lack of precision in defining the emotional state in asthma. The word “anxiety” is often used, but probably not carefully enough. Why should an asthmatic get worse when he is anxious, if anxiety is associated with increased release of epinephrine? (This association, incidentally, is not as firmly established as one might think.) The entire question of the relations of particular emotional states to various illnesses remains difficult because of the rather loose way in which names of emotions are often used, and of the lack of generally employed criteria for using any of them. Presumably, the Panic-Fear dimension of Dahlem, Kinsman, and Horton measures approximately what is generally meant The lack of correlation between the by “anxiety.” Panic-Fear dimension and severity of pulmonary function impairment suggests that there is something the matter with a simple assumption that reducing anxiety is the key to the psychosomatic or behavioral approach to the treatment of asthma. This point would be stronger, however, if one knew the relation between changes in Panic-Fear and in airway resistance in individual patients followed for a period of time. In any case, this question is significant in connection with the use of anxiety-provoking situations in desensitization therapy. It is worth emphasizing, whatever the correct answer may be to the question about names of emotions, that many authors agree that asthmatics, much more than patients with other psychosomatic diseases, are very directly concerned with dependence on and separation from their mothers or other persons whose love they want. One welcomes contributions of the kind embodied in the two papers under discussion in the present issue of this JOURNAL. It seems to the present writer that the relative indifference often shown to psychosomatic understanding of many diseases, including asthma, is based as much on the clinician’s belief that such understanding has no practical therapeutic application as it is on skepticism about its validity. Work of the kind here represented should help to establish the place of psychological concepts and methods in the approach of the practical physician to asthma.
VOLUME NUMBER
60 5
REFERENCES I. Kinsman, Ii. A., Dahlem. N. W., Spector, S., and Staudenmaqer, H.: Observations on subjective symptomatology coping behavior and medical decisions in asthma, Psychosom. Med. 39:i102, 1977. 2. Moore, N. Behavior therapy in bronchial asthma. A controlled study, J. Psychosom. Res. 9:257, 196.5. 3. Shapiro, A. P.. Schwartz, G. E., Ferguson, D. C. E., Red-
Editorial
275
mond, D. P., and Weiss, S. M.: Behaviorial methods in the treatment of hypertension. A review of their clinical status, Ann. Intern. Med. 86:626, 1977. 4. Vachon, L.: Visceral learning of respiratory resistance, Psychosom. Med. 24:471, 1971. 5. Khan, A. V.: Effectiveness of biofeedback and counterconditioning in the treatment of bronchial asthma, J. Psychosom. Res. 21:97, 1977.
