Psychologic Distress and Maladaptive Coping Styles in Patients With Severe vs Moderate Asthma

doi:10.1378/chest.09-1979

Chest

Volume 137, Issue 6, June 2010, Pages 1324-1331

https://doi.org/10.1378/chest.09-1979 Get rights and content

Background

Though several biologic factors have been suggested to play a role in the development and persistence of severe asthma, those associated with psychologic factors remain poorly understood. This study assessed levels of psychologic distress and a range of disease-relevant emotional and behavioral coping styles in patients with severe vs moderate asthma.

Methods

Eighty-four patients (50% women, mean [M] age 46 years) with severe (n = 42) and moderate (n = 42) asthma were recruited. Severe asthma was defined according to American Thoracic Society criteria. Patients underwent demographic and medical history interviews and pulmonary function and allergy testing. Patients also completed questionnaires measuring asthma symptoms and the Millon Behavioral Medicine Diagnostic Inventory, which assesses psychologic distress and emotional/behavioral coping factors that influence disease progression and treatment.

Results

After adjustment for covariates and applying a correction factor that reduced the significant P level to < .01, patients with severe vs moderate asthma reported experiencing more psychologic distress, including worse cognitive dysfunction (F = 6.72, P < .01) and marginally worse anxiety-tension (F = 4.02, P < .05). They also reported worse emotional coping (higher illness apprehension [F = 9.57, P < .01], pain sensitivity [F = 10.65, P < .01], future pessimism [F= 8.53, P < .01], and interventional fragility [F = 7.18, P < .01]), and marginally worse behavioral coping (more functional deficits [F = 5.48, P < .05] and problematic compliance [F = 4.32, P < .05]).

Conclusions

Patients with severe asthma have more psychologic distress and difficulty coping with their disease, both emotionally and behaviorally, relative to patients with moderate asthma. Future treatment studies should focus on helping patients with severe asthma manage distress and cope more effectively with their illness, which may improve outcomes in these high-risk patients.

Section snippets

Study Participants

In total, 84 patients with documented, persistent, severe (n = 42) or moderate (n = 42) asthma were recruited through physician referrals from two tertiary care outpatient asthma clinics. Severe asthma was defined based on having received adequate therapy and verified treatment adherence, with patients meeting American Thoracic Society¹⁹ major and minor criteria for severe asthma.

A comparison group of patients with moderate asthma was recruited from the same centers, and the groups were matched

Sociodemographic, Clinical, and Asthma Characteristics

Comparisons of sociodemographic and clinical characteristics across the two groups are shown in Table 1. Not unexpectedly, patients in the severe asthma group had worse FEV₁ (percent predicted) than patients in the moderate group. There were no other significant differences. As seen in Table 2, patients with severe asthma had higher levels of eosinophils (%) than patients with moderate asthma, but not neutrophils and lymphocytes. Patients with severe vs moderate asthma had greater health

Discussion

Results of the attitudinal/emotional coping subscale analyses reveal that patients with severe vs moderate asthma are more likely to negatively anticipate symptoms and medical interventions (illness apprehension, future pessimism) and are more likely to be hypersensitive to disease-related interventions or procedures (interventional fragility). We are not aware of any studies of patients with asthma assessing these particular coping styles. However, these results are in line with those of

Acknowledgments

Author contributions: Dr Lavoie: contributed to analyzing the data and writing the manuscript.

Dr Bouthillier: contributed to overseeing the administration and scoring of the Millon Behavioral Medicine Diagnostic Inventory, for analyzing the data, and for manuscript editing.

Dr Bacon: contributed to analyzing the data and manuscript editing.

Dr Lemière: contributed to the study design, patient recruitment, and manuscript editing.

Dr Martin: contributed to the study design, patient recruitment, and

References (60)

LP Boulet et al.
Near-fatal asthma: clinical and physiologic features, perception of bronchoconstriction, and psychologic profile
J Allergy Clin Immunol
(1991)
VA Nejtek et al.
Prevalence of mood disorders and relationship to asthma severity in patients at an inner-city asthma clinic
Ann Allergy Asthma Immunol
(2001)
S Dhuper et al.
Profile of near-fatal asthma in an inner-city hospital
Chest
(2003)
TP Miller et al.
The diagnosis of potentially fatal asthma in hospitalized adults. Patient characteristics and increased severity of asthma
Chest
(1992)
C Lemière et al.
Comparison of cellular composition of induced sputum analyzed with Wright staining and immunocytochemistry
J Allergy Clin Immunol
(2001)
J Kolbe et al.
Differential influences on asthma self-management knowledge and self-management behavior in acute severe asthma
Chest
(1996)
A ten Brinke et al.
Similar psychological characteristics in mild and severe asthma
J Psychosom Res
(2001)
PM Yellowlees et al.
Psychological defenses and coping styles in patients following a life-threatening attack of asthma
Chest
(1989)
KL Lavoie et al.
Are psychiatric disorders associated with worse asthma control and quality of life in asthma patients?
Respir Med
(2005)
KL Lavoie et al.
What is worse for asthma control and quality of life: depressive disorders, anxiety disorders, or both?
Chest
(2006)

RE Carr et al.

Anxiety sensitivity and panic attacks in an asthmatic population

Behav Res Ther

(1994)

S Amsberg et al.

A cognitive behavior therapy-based intervention among poorly controlled adult type 1 diabetes patients—a randomized controlled trial

Patient Educ Couns

(2009)

S Wenzel

Severe asthma in adults

Am J Respir Crit Care Med

(2005)

L Antonicelli et al.

Asthma severity and medical resource utilisation

Eur Respir J

(2004)

PJ Barnes et al.

Difficult asthma

Eur Respir J

(1998)

SE Wenzel et al.

Bronchoscopic evaluation of severe asthma. Persistent inflammation associated with high dose glucocorticoids

Am J Respir Crit Care Med

(1997)

MA Berry et al.

Evidence of a role of tumor necrosis factor alpha in refractory asthma

N Engl J Med

(2006)

L Benayoun et al.

Airway structural alterations selectively associated with severe asthma

Am J Respir Crit Care Med

(2003)

A ten Brinke et al.

Psychopathology in patients with severe asthma is associated with increased health care utilization

Am J Respir Crit Care Med

(2001)

DA Campbell et al.

Psychiatric and medical features of near fatal asthma

Thorax

(1995)

J Kolbe et al.

Case-control study of severe life threatening asthma (SLTA) in adults: psychological factors

Thorax

(2002)

DA Campbell et al.

A comparison of asthma deaths and near-fatal asthma attacks in South Australia

Eur Respir J

(1994)

PL Rocco et al.

Psychiatric symptoms and psychological profile of patients with near fatal asthma: absence of positive findings

Psychother Psychosom

(1998)

JR Smith et al.

Clinician-assessed poor compliance identifies adults with severe asthma who are at risk of adverse outcomes

J Asthma

(2005)

HH Rea et al.

A case-control study of deaths from asthma

Thorax

(1986)

NJ Innes et al.

Psychosocial risk factors in near-fatal asthma and in asthma deaths

J R Coll Physicians Lond

(1998)

SE Wenzel et al.

Proceedings of the ATS Workshop on Refractory Asthma: current understanding, recommendations and unanswered questions

Am J Respir Crit Care Med

(2000)

National Heart Lung and Blood Institute

Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. National Asthma Education and Prevention Program

(1997)

M Mintz

Asthma update: part I. Diagnosis, monitoring, and prevention of disease progression

Am Fam Physician

(2004)

T Millon et al.

Millon Behavioral Medicine Diagnostic (MBMD)

(2001)

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Redacción y consenso del texto y de las recomendaciones. El desarrollo del trabajo de redacción se basó en un sistema de consenso piramidal: de miniconsenso multidisciplinar temático por capítulo, a un gran consenso final entre todos los redactores y revisores. Tomando como base el documento elaborado en la anterior edición y las nuevas referencias bibliográficas sobre asma aparecidas desde 2009 hasta 2015, un grupo de redactores y coordinadores formado por expertos provenientes de las sociedades científicas participantes efectuaron una nueva redacción (incluidas la clasificación de la evidencia y de las recomendaciones) del fragmento del capítulo que se les asignó. Los redactores enviaron sus textos a cada uno de los coordinadores de cada capítulo, formado por los miembros del Comité Ejecutivo de la GEMA. Tras la unificación y revisión de los textos por el coordinador del capítulo, éste remitió el borrador del mismo a todos los redactores del capítulo, para efectuar el primer consenso parcial. Tras las modificaciones se fusionaron todos los capítulos en un solo documento, que a su vez fue de nuevo enviado a todos los redactores y coordinadores para su discusión telemática (y cuando se precisó, en grupos de trabajo, presencial) y aprobación. El documento resultante se remitió a expertos en metodología de guías de práctica clínica del INPECS (Instituto para la Excelencia Clínica y Sanitaria), que efectuaron una revisión crítica de la metodología y redacción del texto y recomendaciones. Tras dichas modificaciones y mejoras, finalmente, las recomendaciones fueron revisadas y consensuadas (mediante método Delphi) por un grupo de expertos en asma provenientes de las sociedades participantes. Las recomendaciones que no alcanzaron un determinado nivel de consenso fueron eliminadas del documento final.

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Funding/Support: Funding support for this study was provided by the Fonds de la recherche en santé du Québec (Drs Lavoie and Bacon) and the Richard and Edith Strauss Canada Foundation.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).

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Chest

ORIGINAL RESEARCHASTHMAPsychologic Distress and Maladaptive Coping Styles in Patients With Severe vs Moderate Asthma

Background

Methods

Results

Conclusions

Section snippets

Study Participants

Sociodemographic, Clinical, and Asthma Characteristics

Discussion

Acknowledgments

J Allergy Clin Immunol

Ann Allergy Asthma Immunol

Chest

Chest

J Allergy Clin Immunol

Chest

J Psychosom Res

Chest

Respir Med

Chest

Behav Res Ther

Patient Educ Couns

Severe asthma in adults

Am J Respir Crit Care Med

Asthma severity and medical resource utilisation

Eur Respir J

Difficult asthma

Eur Respir J

Bronchoscopic evaluation of severe asthma. Persistent inflammation associated with high dose glucocorticoids

Am J Respir Crit Care Med

Evidence of a role of tumor necrosis factor alpha in refractory asthma

N Engl J Med

Airway structural alterations selectively associated with severe asthma

Am J Respir Crit Care Med

Psychopathology in patients with severe asthma is associated with increased health care utilization

Am J Respir Crit Care Med

Psychiatric and medical features of near fatal asthma

Thorax

Case-control study of severe life threatening asthma (SLTA) in adults: psychological factors

Thorax

A comparison of asthma deaths and near-fatal asthma attacks in South Australia

Eur Respir J

Psychiatric symptoms and psychological profile of patients with near fatal asthma: absence of positive findings

Psychother Psychosom

Clinician-assessed poor compliance identifies adults with severe asthma who are at risk of adverse outcomes

J Asthma

A case-control study of deaths from asthma

Thorax

Psychosocial risk factors in near-fatal asthma and in asthma deaths

J R Coll Physicians Lond

Proceedings of the ATS Workshop on Refractory Asthma: current understanding, recommendations and unanswered questions

Am J Respir Crit Care Med

Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. National Asthma Education and Prevention Program

Asthma update: part I. Diagnosis, monitoring, and prevention of disease progression

Am Fam Physician

Millon Behavioral Medicine Diagnostic (MBMD)

ORIGINAL RESEARCH
ASTHMA
Psychologic Distress and Maladaptive Coping Styles in Patients With Severe vs Moderate Asthma