Search

Daily inhaled bronchodilator medication usage was recorded using an electronic device and airway obstruction by daily peak flow measurement. The demographic, clinical, and psychological characteristics of the subjects were noted. Subjects were allocated to as-needed (prn) medication usage groups according to the mean number of inhaler activations on days with zero, moderate, and severe airway obstruction. Segregation into arbitrary and nonarbitrary use, and into overuse, appropriate use, and underuse resulted in six usage groups. Appropriate use was observed in only 10 of 39 subjects. The major psychological variable to differ among groups was the MMPI variable Pt, representing general anxiety. Arbitrary users had a significantly higher mean score than nonarbitrary users. The variable Specific Internal Awareness, representing a perceived difficulty in recognizing the premonitory symptoms of an asthma attack, also differed among the usage groups, with arbitrary users having the lowest scores. These findings raise the possibility that reliance on an objective measurement of airway obstruction rather than on subjective symptomatology might enhance compliance with prn medication in some patients.

The present study explores the complex interplay of objective indices of illness-severity and personal characteristics of patients and physicians as they influence judged illness-severity and medical decisions concerning length of hospitalization and intensity of prescribed oral corticosteroids in a chronic asthmatic population. The results indicate that, depending on the physician's personal characteristics, he may: a) confuse his patient's psychological physical distress, resulting in medical judgment and decisions being influenced by patient personality; b) accurately distinguish between psychological physical distress but treat a psychological problem as though it were a medical problem; c) judge and treat the patient's illness objectively, regardless of the patient's personality. These findings stress the importance of expanding the present biomedical model of medicine to include a better appreciation of how social, psychological, and behavioral factors influence the medical decisions about treatment and the resulting outcome.

In a sample of intractable adult asthmatics, the prevalence of Bender-Gestalt signs suggestive of neuropsychological problems was documented. Sixty-five per cent of the sample was found to have equivocal or definite Bender-Gestalt signs suggestive of cerebral dysfunction. A clear majority of the asthmatics manifested definite signs of memory impairment when they were asked to recall the Bender designs. The study provides the first documentation of the neuropsychological sequelae of asthma in adults.

An understanding of the existence and action of depression is essential to the medical management of patients with chronic illness. This study found thirteen unique patterns of depression in depressed persons being treated for chronic medical conditions. Of the 132 persons sampled, 96.2% fell clearly into one of these groups. The fact that these people manifested their clinical depression in such a variety of ways argues against a unilateral approach to the treatment of affective distress among those with a chronic medical illness. While patients manifest their affective distress in a variety of ways, self-esteem issues are significantly involved in almost half of the identified patterns.

In an attempt to assess patient and physician behavior patterns which interfere with effective medical treatment, 100 chronic adult and adolescent asthmatics were asked about the frequency and the nature of their medication non-compliance. The nature of the patient's medication abuse was also related to underlying personality characteristics, as measured by the MMPI Panic-Fear scale. Finally eleven physicians were asked about the frequency with which they asked their patients about over abuse and under abuse of prescribed medications. The results are impressive, showing that 54.0% of the patients reported some type of medication abuse, and that the nature of the abuse may be predicted from the patient's MMPI Panic-Fear score. Perhaps the most important finding was that while over 50% of the patients reported medication non-compliance (under abuse, over abuse, or cyclical abuse), only 27.3% of the physicians said that they routinely inquired about medication abuse. Such a discrepancy suggests one area in which patient and physician characteristics may have a bearing on the effective delivery of medical treatment. The findings underscore the need for physicians to include in their diagnostic procedure a routine inquiry into the patient's patterns of medication non-compliance.

Psychomaintenance in chronic illness refers to the perpetuation of chronicity or the defeat of medical management because of psychological, as opposed to strictly physical, reasons. The Battery of Asthma Illness Behavior (BAIB) has been developed to assess psychomaintenace potentials among chronic asthmatics. In this study of 57 adult asthmatic patients, the clinical utility of the BAIB was assessed by having two psychologists predict the likelihood of rehospitalization within six months following intensive medical treatment. Independent, blind predictions using the BAIB, but in the absence of any demographic or medical information, enabled hit rates of 70% and 84% by te psychologists. Moreover, the predictions were independent of the objective severity of the patients' asthma, indicating that the clinical judgments were not merely readings of the patients' asthma severity on the basis of the BAIB scores. The need for rapid, clinical assessment of psychological factors maintaining chronic illness was discussed.

Coping styles in asthma indexed by a Panic-Fear personality measure are known to influence physicians' medical decisions and long-term treatment outcome. Unusually High or Low Panic-Fear personality styles are maladaptive, the former characterized by anxious, helpless dependency and the latter by an extreme counterphobic independence. In this study (N = 90), the psychological experiences among Panic-Fear personality groups (LOW, Moderate, and High) of asthma patients are described at three levels of assessment: (1) general personality characteristics; (2) attitudes toward asthma and its treatment; and (3) the subjective symptoms reported during breathing difficulties. Comparisons among the groups delineated the linkages between Panic-Fear personality and more illness-specific attitudes, symptoms, and experiences in asthma. Discussion centered upon how general personality and illness-specific characteristics associated with extreme High and Low Panic-Fear personality may contribute to the psychomaintenance of asthma.

In a sample of 150 people drawn from a population of asthma, tuberculosis, and chronic pain patients, a key cluster analysis revealed five different clusters of items in the Taylor Manifest Anxiety Scale: Restlessness, Embarrassment, Sensitivity, Physiological Anxiety, and Self-Confidence. These clusters are consistent and four of them appear moderately related, whereas Embarrassment is fairly independent of the others.

Certain patient styles perpetuate chronic physical illness, defeat medical treatment, and increase the utilization of medical services. Two such extreme styles among asthmatic patients are indexed by the MMPI panic-fear scale, reflecting either (a) helpless dependency and anxiety, or (b) excessive inappropriate independence. The present findings indicate that both of these patient styles are related to excessively high hospitalization rates during the two 1-year periods after discharge from intensive treatment, even among patient groups having asthma of similar objective severity. The discussion centres upon the increased demand for medical services, and the need for early identification of patients whose personal styles contribute to the maintenance of illness.

Research is reviewed relating to two aspects of response styles among asthmatic patients, neither of which is a mere derivative of the patient's medical condition. One aspect, indexed by panic-fear symptomatology, appears to be associated with the level of attention directed at breathing difficulties, ranging from symptom disregard (low panic-fear symptomatology) to symptom vigilance (high panic-fear symptomatology). A second aspect, indexed by a derived personality dimension, appears to be associated with the quality of the patient's reactions to acknowledged breathing difficulties, ranging from extreme independence (low panic-fear personality) to helpless and ineffective dependency (high panic-fear personality). Simply, these aspects of patient response styles refer both to the attention directed toward breathing difficulties and to the quality of the patient's reactions in response to acknowledged breathing difficulties. Their importance derives from 1) their interaction with the severity of asthma to influence medical decisions about the intensity of prescribed medications and length of hospitalization during medical treatment and 2) their effect on long-term medical outcome. Awareness of these two aspects of patient response styles should enable differential approaches to be adopted by physicians seeking to counteract psychological contributions to chronicity in asthma.

Bronchial asthma is an illness particularly susceptible to psychological and behavioral exacerbation and perpetuation. The Battery of Asthma Illness Behavior has demonstrated a remarkable ability to identify such psychomaintenance potentials in chronic asthmatic patients. The present study advances previous research by showing that BAIB scores are independent of degree of airways hyperreactivity. This finding strengthens the assertion that the BAIB assesses psychomaintenance potentials independent from the objective medical parameters of the illness.

Previous research has demonstrated that the Battery of Asthma Illness Behavior is related to a wide variety of medical outcome variables in bronchial asthma. It has been maintained that BAIB scores reflect the degree to which psychological and behavioral factors can adversely affect medical management and prognosis. The present study advances previous research by investigating the relationship between BAIB scores and average longitudinal spirometry.

In most, if not all, chronic illnesses, the patient is a participant in medical management. Attitudes and behaviors during treatment can influence medical outcome in important ways that are becoming increasingly understood. This case history illustrates how a personal style may have contributed to the worst possible outcome, death, in an illness that is usually not fatal. There is a need to unravel the complex interplay between the psychological and medical factors contributing to such extremes in medical treatment failure in order to permit timely and appropriate intervention.

Anxiety reduction procedures as adjuncts to medical treatment have almost invariably been reported to benefit asthmatic patients in individual case studies. However, the results of more systematically controlled studied are clearly inconsistent. This discrepancy is understandable in view of what is now known about anxiety in asthma. Four catches, each based on what has been reported about the roles and forms of anxiety in asthma, are presented. Each catch argues against general, across-the-board application of anxiety reduction procedures in asthma. Careful evaluation leading to more problem-oriented treatment is needed in view of the different roles of anxiety in asthma.

MMPI alexithymia scores and MMPI panic-fear personality scores were calculated for 202 adult asthmatic patients. Both sets of scores were shown to be related to the number of days rehospitalized. In addition, patients who scored high on both the alexithymia and panic-fear personality scales were judged by their attending physicians as being more severely ill than other patients. Both of these relationships were independent of the objective severity of the patient's asthma as indexed by longitudinal pulmonary functions. The study highlights the fact that alexithymia and panic-fear are two dimensions which may contribute to medical intractability in chronic asthma.

Recent research with the MMPI panic-fear scale has identified personality traits implicated in the psychological maintenance of the medical intractability of asthma. Intensity of prescribed medication, length of hospitalization, and rates of rehospitalization have been found to relate to MMPI panic-fear scores independent of the objective medical severity of the illness as indexed by longitudinal pulmonary functions. In the present study, MMPI panic-fear scores are related to separation and protection conflicts arising in childhood. While the nuclear conflict theory of asthma maintains that such conflicts occur in nearly all asthmatics and form a genetic component of the asthma, the present study finds that childhood separation and protection conflicts occur in a minority of patients, but may be instrumental in maintaining the medical intractability of the illness.

Clinical observations and studies of asthmatic patients have often concluded that therre is a strong relationship between the degree of the patient's anxiety and the medical intractability of his illness. However, psychotherapeutic interventions designed to alleviate patient anxiety have been noticeably inconsistent in achieving meaningful alleviation of the patient's asthma. The present paper addresses this apparent paradox by positing the existence of two types of anxiety: a) asthma-specific anxiety, as indexed by Panic-Fear symptomatology scores of the Asthma Symptom Checklist; and b) characterological and pervasive anxiety, as indexed by Panic-Fear personality scores of the Minnesota Multiphasic Personality Inventory. In this study, long term medical outcome was found to be influenced by the combination of these types of anxiety. Wehn high asthma-specific anxiety coexisted with high characterological anxiety, medical outcome following intensive long term medical treatment was exceptionally poor. In contrast, when high asthma-specific anxiety coexisted with average levels of characterological anxiety, medical outcome was exceptionally good. These results are discussed relative to the theoretical distinctions between signal anxiety and anxiety concomitant with a lack of basic ego resources.

Previous studies have found that both ASC and MMPI Panic-Fear scale scores are related to the maintenance of the medical intractability of asthma. Despite the large overlap of these two scales, they measure somewhat different aspects of "Panic-Fear". The ASC measures a situational response (state variable) to breathing difficulties, while the MMPI measures a more stable, diffuse, and global personality characteristic (trait variable). The present study analyzes the relationship between these state and trait variables as they relate to the intensity of prescribed discharge medication. The results indicate that it is the trait variable which is more important in the maintenance of the medical intractability of asthma. The state variable is implicated in maintaining the illness only to the extent that it is a specific manifestation of the trait variable.

The Battery of Asthma Illness Behavior was developed to assess the potential for psychomaintenance in chronic bronchial asthma. The present study demonstrates that the BAIB's success in predicting the perpetuation, exacerbation, and maintenance of asthma cannot be attributed to its merely reflecting one objective parameter of illness, i.e., age of asthma onset.

Mislabeling of symptoms was studied in a group of 587 chronic asthmatic patients. Results indicated a wide variation in both the frequency and type of mislabeling, with over 26 per cent of the patients mislabeling one or more nonairways obstruction symptom clusters as being an asthma attack. Several demographic and personality factors were found to correlate with mislabeling. Finally, mislabeling was associated with medical outcome, with mislabelers being 40 per cent more likely than nonmislabelers to be rehospitalized for their asthma within six months of discharge.

The panic-fear personality scale related to rehospitalization rates of asthmatics during two successive 6-month periods following intensive long-term treatment. High and Low Panic-Fear patients were nearly twice as likely as Moderates to be rehospitalized. Neither longitudinal pulmonary function measurements, physicians' judgments about the medical severity of the asthma during treatment, nor the presence or absence of maintenance oral corticosteroids at discharge were related to rehospitalization. The available information suggests that High Panic-Fear patients react to asthma with symptom exaggeration and helplessness, while Low Panic-Fear patients employ an equally maladaptive strategy best characterized as symptom minimization and denial. It is possible that both of these extreme response styles may affect adherence to prescribed medical regimens and are equally detrimental as indicated by rehospitalization following intensive long-term treatment.

A 15-item MMPI scale has been developed that relates to the reported frequency of panic-fear symptoms on the Asthma Symptom Checklist (ASC). High scale scores describe fearful, emotionally labile individuals who profess to be more sensitive than others and unable or disinclined to persist in the face of difficulty. The relationship between the MMPI panic-fear scale and the ASC panic-fear symptoms is highly replicable and related to a crucial aspect of chronicity in asthma. High scoring asthmatic patients were prescribed more intensive discharge steroid regimens upon completion of residential treatment. This relationship was not mediated by available objective pulmonary function measurements used to index medical condition. Development of the MMPI panic-fear scale should enable further investigation of personality and behavioral aspects related to the perceived severity and intractability of other medical conditions and disabilities.

Hypotheses about medical outcome in asthma, indexed by rates of rehospitalization within 6 months after discharge from long-term intensive care, were evaluated. Predictions for rehospitalization were based on the levels of airways hyperreactivity, indexed by inhalation challenges with histamine or methacholine, and levels of anxiety focused upon and concurrent with periods of asthmatic distress, indexed by Panic-Fear symptomatology. Results indicated that, although some prediction could be made on the basis of levels of anxiety and airways hyperreactivity alone, the best predictions resulted from the combined effects of these factors. Almost half of the patients who had highly hyperreactive airways and a tendency to disregard symptoms of breathing difficulty were rehospitalized. By comparison, none of the patients who had less hyperreactive airways and a tendency to be vigilant about their symptoms were rehospitalized. The hypotheses and results are discussed with respect to symptom-focused and general, illness-dependent types of anxiety which have different effects upon medical outcome in chronic asthma. The results have implications for the application of anxiety-reducing forms of intervention in asthma.

Numerous earlier studies have demonstrated the close relationship between MMPI Panic-Fear categories and various medical outcome measures in asthma. The present study relates MMPI Panic-Fear categories to psychosexual development. Specifically, High Panic-Fear patients demonstrate oral preoccupations, Low Panic-Fear patients demonstrate anal preoccupations, while Moderate Panic-Fear patients do not demonstrate pre-Oedipal preoccupations. Thus, MMPI Panic-Fear categories, useful in predicting medical outcome measures, have now been related to developmental levels, with the explanatory power of developmental concepts as well as their implications for psychological treatment.