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
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
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.
7 psychosomatic diseases
etiology: specific psychological conflicts or personality types
Old Psychosomatic Medicine:
New Psychosomatic Medicine:
TREATING AND STUDYING CHILDREN IS KEY
Early treatment is most effective
Children are more malleable than adults
Lifelong patterns are established in childhood
Children are not short adults
Developmental perspective is essential
Physiological development, especial puberty
Social roles, influence of family evolve
10% are hospitalized at least once yearly
2%-6% miss more than 30 days of school
Death rate up 40%
(CDC data, 1995)
Plus: Genetic predisposition
Family Moves to Hotel
10/25 had significant positive PFT
response to separation
Purcell et al., 1969
35.6% “responded” to suggestion
20% is conservative estimate
Isenberg et al., 1992
STRESS AND ASTHMA: CLINICAL MANAGEMENT
1. Differentiate the 20% for whom stress is an important trigger from the 80% for whom it isn’t.
-Direct questions about precipitants
-Anxious response to symptoms
2. Psychological intervention often helpful to this 20%.
-Family involvement in stress management
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)
Recognition of clinical symptoms
Initiation of timely self-management
Reduced functional morbidity
Fritz et al. JAACAP. 35:1033-41, 1996
AM-2 programmable, hand-held spirometer
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
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%)
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?
* 12/29 studies had to be excluded
* No global reduction in:
~ school absenteeism
~ asthma attacks
~ hospital delays
~ emergency visits
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.
One year follow-up of 82 families