New developments in the psychobiology of asthma
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NEW DEVELOPMENTS IN THE PSYCHOBIOLOGY OF ASTHMA. Gregory K. Fritz, M.D. Professor and Director of Child & Adolescent Psychiatry Brown Medical School Medical Director, E.P. Bradley Children’s Psychiatric Hospital Director of Psychiatry, Hasbro Children’s Hospital.

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NEW DEVELOPMENTS IN THE PSYCHOBIOLOGY OF ASTHMA

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New developments in the psychobiology of asthma

NEW DEVELOPMENTS IN THE PSYCHOBIOLOGY OF ASTHMA

Gregory K. Fritz, M.D.

Professor and Director of Child & Adolescent Psychiatry

Brown Medical School

Medical Director, E.P. Bradley Children’s Psychiatric Hospital

Director of Psychiatry, Hasbro Children’s Hospital


Childhood asthma research project collaborators

Childhood Asthma Research ProjectCOLLABORATORS

Brown University School of Medicine:

Gregory K. Fritz, M.D.Elizabeth McQuaid, Ph.D.

Robert Klein, M.D.Jack Nassau, Ph.D.

Anthony Mansell, M.D.Susan Penza-Clyve, Ph.D.

Natalie Walders, Ph.D.Jonathan Feldman, Ph.D.

Sheryl Kopel, M.S.

University of Texas Health Center at Tyler:

Rick Carter, Ph.D., M.B.A.

National Jewish Center:

Marianne Wamboldt, M.D.Mary Klinnert, Ph.D.

University of Puerto Rico:

Glorisa Canino, Ph.D.Jose Rodriguez-Santana, M.D.


New developments in the psychobiology of asthma

7 psychosomatic diseases

etiology: specific psychological conflicts or personality types

Old Psychosomatic Medicine:

New Psychosomatic Medicine:

  • mind-body interactions in disease

  • all illnesses may be psychosomatic

  • interest in psychophysiologic mechanisms


Psychological factors affect disease at multiple points

Psychological Factors Affect Disease At Multiple Points

  • Vulnerability to Disease/Prevention

  • Precipitant or Trigger

  • Recognition/Perception of Symptoms

  • Acute Episode Interventions

  • Chronic Disease Management

  • Adaptation to Illness/Functional Morbidity


Treating and studying children is key

TREATING AND STUDYING CHILDREN IS KEY

Early treatment is most effective

Children are more malleable than adults

Lifelong patterns are established in childhood

PROVISOS:

Children are not short adults

Developmental perspective is essential

Cognitive development

Physiological development, especial puberty

Social roles, influence of family evolve


Pediatric asthma

Pediatric Asthma

  • Asthma is the most common chronic illness of childhood

  • Asthma is associated with significant pediatric morbidity

     10% are hospitalized at least once yearly

     2%-6% miss more than 30 days of school


Asthma mortality 1982 1992

5106

3154

1982

1992

Asthma Mortality1982 - 1992

Death rate up 40%

to 18.8/1,000,000

(CDC data, 1995)


Cost of asthma

Cost of Asthma

  • In 1990, cost of illness related to asthma: $6.2 Billion

  • 43% of cost is related to use of emergency services and hospitalization

  • Asthma is a major national health problem despite medical advances


Multifactorial etiology of asthma

Multifactorial Etiology of Asthma

  • Infectious

  • Allergic

  • Mechanical

  • Psychosocial

    Plus: Genetic predisposition


Psychological factors can impact pediatric asthma at multiple points

Psychological Factors Can Impact Pediatric Asthma At Multiple Points

  • Vulnerability to Disease/Prevention

    • Perinatal stress, psychoimmunology, parenting

  • Precipitant or Trigger

    • Suggestion, strong emotions, stress

  • Recognition/Perception of Symptoms

    • Accurate symptom perception, panic-fear response, denial

  • Acute Episode Interventions

    • Asthma knowledge, biofeedback/relaxation, family response

  • Chronic Disease Management

    • Medication adherence, depression, medication side effects

  • Adaptation to Illness/Functional Morbidity

    • Family adaptation, management responsibility, self image,

    • psychological interventions, factitious symptoms


Psychological factors can impact pediatric asthma at multiple points1

Psychological Factors Can Impact Pediatric Asthma At Multiple Points

  • Vulnerability to Disease/Prevention

    • Perinatal stress, psychoimmunology, parenting

  • Precipitant or Trigger

    • Suggestion, strong emotions, stress

  • Recognition/Perception of Symptoms

    • Accurate symptom perception, panic-fear response, denial

  • Acute Episode Interventions

    • Asthma knowledge, biofeedback/relaxation, family response

  • Chronic Disease Management

    • Medication adherence, depression, medication side effects

  • Adaptation to Illness/Functional Morbidity

    • Family adaptation, management responsibility, self image,

    • psychological interventions, factitious symptoms


Experimental separation of children with asthma from their families

Experimental Separation of Children with Asthma from their Families

Baseline

PFT’s 4x/day

2 weeks

Family Moves to Hotel

PFT’s 4x/day

2 weeks

Reunion

PFT’s 4x/day

2 weeks

10/25 had significant positive PFT

response to separation

Purcell et al., 1969


Suggestion can trigger acute asthma

Suggestion can Trigger Acute Asthma

  • The case of the glass rose

  • Meta-analysis of 20 studies, 427 asthmatic subjects

  • Saline suggested as bronchoconstrictor; PFT’s pre and post-suggestion

    35.6% “responded” to suggestion

    20% is conservative estimate

    Isenberg et al., 1992


Stress and asthma methods

Stress and Asthma Methods

  • 5 minute baseline

  • 5 minute stressful task

  • Measures: Airway resistance

  • Heart rate

  • Galvanic skin response (GSR)

  • Skin temperature


Changes in airway resistance in response to stress

Changes in Airway Resistance in Response to Stress

  • Controls

    • Changes in airway resistance ranged

    • from -32.0% to 65.5%

  • Children with Asthma

    • Changes in airway resistance ranged

    • from -51.8% to 219.4%


Changes in airway resistance in response to stress1

Changes in Airway Resistance in Response to Stress

  • As a group, children with asthma did not have greater increases in resistance than controls

  • Approximately 20% of children with asthma demonstrate significant increases in resistance in response to stress


Stress and asthma clinical management

STRESS AND ASTHMA: CLINICAL MANAGEMENT

1. Differentiate the 20% for whom stress is an important trigger from the 80% for whom it isn’t.

-Clinical judgement

-Direct questions about precipitants

-Anxious response to symptoms

2. Psychological intervention often helpful to this 20%.

-Relaxation techniques

-Biofeedback, hypnosis

-Family involvement in stress management


Psychological factors can impact pediatric asthma at multiple points2

Psychological Factors Can Impact Pediatric Asthma At Multiple Points

  • Vulnerability to Disease/Prevention

    • Perinatal stress, psychoimmunology, parenting

  • Precipitant or Trigger

    • Suggestion, strong emotions, stress

  • Recognition/Perception of Symptoms

    • Accurate symptom perception, panic-fear response, denial

  • Acute Episode Interventions

    • Asthma knowledge, biofeedback/relaxation, family response

  • Chronic Disease Management

    • Medication adherence, depression, medication side effects

  • Adaptation to Illness/Functional Morbidity

    • Family adaptation, management responsibility, self image,

    • psychological interventions, factitious symptoms


High risk asthmatics

HIGH RISK ASTHMATICS

Global disregard of symptoms differentiated pediatric asthma patients who died from matched, living patients.

(Strunk et al, 1985; Zach & Kainer, 1989)

Survivors of near fatal asthma episodes showed blunted response to both load perception and chemosensitivity

(Kikuchi et al, 1994)


Asthma perception

Asthma Perception

Recognition of clinical symptoms

Initiation of timely self-management

Reduced functional morbidity


Symptom perception in the clinical setting does it matter

Symptom Perception in the Clinical Setting: Does it Matter?

  • PEFR or FEF25-75 correlate with subjective estimates: r = -.54 to +.88

  • Better perceptual accuracy  less functional morbidity (school days missed, ER visits)

    Fritz et al. JAACAP. 35:1033-41, 1996


Clinical assessment of asthma symptom perception

Clinical Assessment of Asthma Symptom Perception

  • Used at home, 1-2 months: naturalistic

  • Subjective estimate “locked in” before spirometry

  • Multiple pulmonary function indices

  • Easy data storage and downloading

  • Cost: $750 for each device

AM-2 programmable, hand-held spirometer


Psychological variables

Psychological Variables

  • IQ (WISC Block Design and Vocabulary)

  • Attention

    1. Auditory (WISC Arithmetic and Digit Span)

    2. Visual (Continuous Performance Test)

    3. Parent Ratings (Connor’s Parent Rating Scale)

    Subscales: Opposition, Inattention, Hyperactivity, ADHD

  • Depression (Children’s Depression Inventory Profile)

  • Anxiety (MASC)


Perceptual accuracy

Perceptual Accuracy

Assessments Per Child

Mean = 53 (20-117)

Child’s Percentage in Accurate Zone

Mean = 54% (2-100%)

Child’s Percentage in Danger Zone

Mean = 12% (0-51%)


What factors predict perceptual accuracy in pediatric asthma

What Factors Predict Perceptual Accuracy in Pediatric Asthma?

  • Better perceivers are older and have higher SES

  • Intelligence and attentional factors are related to perceptual accuracy

  • Depression and anxiety symptoms are not related to perceptual accuracy


Asthma symptom perception clinical management

ASTHMA SYMPTOM PERCEPTION: CLINICAL MANAGEMENT

1. Identify the children with poor perception (not easy).

2. Insist that they use peak flow monitoring for management decisions.

3. Training in symptom perception skills?


Psychological factors can impact pediatric asthma at multiple points3

Psychological Factors Can Impact Pediatric Asthma At Multiple Points

  • Vulnerability to Disease/Prevention

    • Perinatal stress, psychoimmunology, parenting

  • Precipitant or Trigger

    • Suggestion, strong emotions, stress

  • Recognition/Perception of Symptoms

    • Accurate symptom perception, panic-fear response, denial

  • Acute Episode Interventions

    • Asthma knowledge, biofeedback/relaxation, family response

  • Chronic Disease Management

    • Medication adherence, depression, medication side effects

  • Adaptation to Illness/Functional Morbidity

    • Family adaptation, management responsibility, self image,

    • psychological interventions, factitious symptoms


Asthma education programs are not a panacea

Asthma Education Programs Are Not a Panacea

  • Logic behind asthma education is indisputable

  • Meta-analysis of 29 clinical trials

    * 12/29 studies had to be excluded

    * No global reduction in:

    ~ school absenteeism

    ~ asthma attacks

    ~ hospitalizations

    ~ hospital delays

    ~ emergency visits


Psychological factors can impact pediatric asthma at multiple points4

Psychological Factors Can Impact Pediatric Asthma At Multiple Points

  • Vulnerability to Disease/Prevention

    • Perinatal stress, psychoimmunology, parenting

  • Precipitant or Trigger

    • Suggestion, strong emotions, stress

  • Recognition/Perception of Symptoms

    • Accurate symptom perception, panic-fear response, denial

  • Acute Episode Interventions

    • Asthma knowledge, biofeedback/relaxation, family response

  • Chronic Disease Management

    • Medication adherence, depression, medication side effects

  • Adaptation to Illness/Functional Morbidity

    • Family adaptation, management responsibility, self image,

    • psychological interventions, factitious symptoms


Asthma medication adherence

Asthma Medication Adherence

  • Children, and adolescents in particular, have demonstrated poor adherence to complicated disease regimens

  • The standard of care in asthma treatment proposes that children and teens take medications that have no immediate effect on their symptoms multiple times a day

  • STUDY: 81 children monitored with medihaler (MDI-Logs) 1+ months


Results what are kids doing with those inhalers anyway

Results: What are kids doing with those inhalers, anyway?

  • Children were taking less than half of their prescribed daily medications (mean daily adherence = .48, median = .45)

  • For all medications, the total of missed days ranged from 0-28; mean across medications ranged from 11-15

  • Nine children “dumped” medication, 4 of these on last day of study


Medication adherence clinical management

MEDICATION ADHERENCE: CLINICAL MANAGEMENT

1. Adequate knowledge from a solid asthma education program does not guarantee adequate adherence.

2. Assume a significant degree of non adherence even when parent and child assures otherwise.

3. When a reasonable regimen does not lead to a good control, the child is probably not getting the medicine.

4. There are many paths to non adherence.


Psychological factors can impact pediatric asthma at multiple points5

Psychological Factors Can Impact Pediatric Asthma At Multiple Points

  • Vulnerability to Disease/Prevention

    • Perinatal stress, psychoimmunology, parenting

  • Precipitant or Trigger

    • Suggestion, strong emotions, stress

  • Recognition/Perception of Symptoms

    • Accurate symptom perception, panic-fear response, denial

  • Acute Episode Interventions

    • Asthma knowledge, biofeedback/relaxation, family response

  • Chronic Disease Management

    • Medication adherence, depression, medication side effects

  • Adaptation to Illness/Functional Morbidity

    • Family adaptation, management responsibility, self image,

    • psychological interventions, factitious symptoms


Development of children s asthma responsibility sample

Development of Children’s Asthma Responsibility: Sample

  • 209 children enrolled in a summer camp for children with asthma and their mothers

     One year follow-up of 82 families

  • Ages 6-14 years (mean age = 9.9)

  • 43% female

  • Asthma severity ratings:

     42% mild

     27% moderate

     31% severe


Increase in responsibility with age parent and child report

Increase in Responsibility with AgeParent and Child Report


Children s responsibility for asthma management

Children’s Responsibility for Asthma Management

  • Increased with child age, by both parent report (r = .60, p < .001) and by child report (r = .47, p < .001)

  • By age 13, children are taking primary responsibility for a majority of asthma tasks


Asthma management responsibility

Asthma Management Responsibility

  • Children with asthma take increasing responsibility for self-management with age

  • Parent and child reports of who performs management behaviors can be discrepant, particularly for preventive tasks

  • Adherence is a complex set of behaviors occurring within the family context. Assessments of adherence must identify family roles for the multiple components of disease management


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