NEW DEVELOPMENTS IN THE PSYCHOBIOLOGY OF ASTHMA

Gregory K. Fritz, M.D.Professor and Director of Child & Adolescent Psychiatry

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

Director of Psychiatry, Hasbro Children’s Hospital

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.

• 7 psychosomatic diseases• etiology: specific psychological

conflicts or personality types

• mind-body interactions in disease• all illnesses may be psychosomatic• interest in psychophysiologic mechanisms

Old Psychosomatic Medicine:

New Psychosomatic Medicine:

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

•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

• 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 Mortality1982 - 1992

Death rate up 40%to 18.8/1,000,000

(CDC data, 1995)

3154

5106

1982 1992

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

• Infectious• Allergic• Mechanical• Psychosocial

Plus: Genetic predisposition

Psychological Factors Can Impact Pediatric Asthma At Multiple Points

Vulnerability to Disease/Prevention Perinatal stress, psychoimmunology, parenting

Precipitant or TriggerSuggestion, strong emotions, stress

Recognition/Perception of SymptomsAccurate symptom perception, panic-fear response, denial

Acute Episode InterventionsAsthma knowledge, biofeedback/relaxation, family response

Chronic Disease ManagementMedication adherence, depression, medication side effects

Adaptation to Illness/Functional MorbidityFamily adaptation, management responsibility, self image,psychological interventions, factitious symptoms

Psychological Factors Can Impact Pediatric Asthma At Multiple Points

Vulnerability to Disease/PreventionPerinatal stress, psychoimmunology, parenting

Precipitant or TriggerSuggestion, strong emotions, stress

Recognition/Perception of SymptomsAccurate symptom perception, panic-fear response, denial

Acute Episode InterventionsAsthma knowledge, biofeedback/relaxation, family response

Chronic Disease ManagementMedication adherence, depression, medication side effects

Adaptation to Illness/Functional MorbidityFamily adaptation, management responsibility, self image,psychological interventions, factitious symptoms

Experimental Separation of Children with Asthma from their Families

BaselinePFT’s 4x/day2 weeks

Family Moves to HotelPFT’s 4x/day2 weeks

ReunionPFT’s 4x/day2 weeks

10/25 had significant positive PFTresponse to separation

Purcell et al., 1969

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 suggestion20% is conservative estimate

Isenberg et al., 1992

Stress and Asthma Methods

• 5 minute baseline

• 5 minute stressful task

• Measures: Airway resistance Heart rate Galvanic skin response (GSR) Skin temperature

• 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 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

Changes in Airway Resistance in Response to Stress

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 Points

Vulnerability to Disease/Prevention Perinatal stress, psychoimmunology, parenting

Precipitant or TriggerSuggestion, strong emotions, stress

Recognition/Perception of SymptomsAccurate symptom perception, panic-fear response, denial

Acute Episode InterventionsAsthma knowledge, biofeedback/relaxation, family response

Chronic Disease ManagementMedication adherence, depression, medication side effects

Adaptation to Illness/Functional MorbidityFamily adaptation, management responsibility, self image,psychological interventions, factitious symptoms

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

Recognition of clinical symptoms

Initiation of timely self-management

Reduced functional morbidity

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

• 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

• 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

Assessments Per ChildMean = 53 (20-117)

Child’s Percentage in Accurate ZoneMean = 54% (2-100%)

Child’s Percentage in Danger ZoneMean = 12% (0-51%)

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

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 Points

Vulnerability to Disease/Prevention Perinatal stress, psychoimmunology, parenting

Precipitant or TriggerSuggestion, strong emotions, stress

Recognition/Perception of SymptomsAccurate symptom perception, panic-fear response, denial

Acute Episode InterventionsAsthma knowledge, biofeedback/relaxation, family response

Chronic Disease ManagementMedication adherence, depression, medication side effects

Adaptation to Illness/Functional MorbidityFamily adaptation, management responsibility, self image,psychological interventions, factitious symptoms

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 Points

Vulnerability to Disease/Prevention Perinatal stress, psychoimmunology, parenting

Precipitant or TriggerSuggestion, strong emotions, stress

Recognition/Perception of SymptomsAccurate symptom perception, panic-fear response, denial

Acute Episode InterventionsAsthma knowledge, biofeedback/relaxation, family response

Chronic Disease ManagementMedication adherence, depression, medication side effects

Adaptation to Illness/Functional MorbidityFamily adaptation, management responsibility, self image,psychological interventions, factitious symptoms

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?

• 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

Children's adherence to preventive asthma medications

range = 0-102%

range = 52-59%

range = 0-96%range = 5-129%

range = 0-94%

0

10

20

30

40

50

60

70

80

90

100

Beclomethasone(Vanceril,Beclovent)

Auticasone(Flovent)

Cromolyn (Intal) Neocromil(Tilade) N=2

Salometrol(Serevent)

Medications

% o

f pre

scrib

ed d

oses

take

n

Ideal % adherence

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 Points

Vulnerability to Disease/Prevention Perinatal stress, psychoimmunology, parenting

Precipitant or TriggerSuggestion, strong emotions, stress

Recognition/Perception of SymptomsAccurate symptom perception, panic-fear response, denial

Acute Episode InterventionsAsthma knowledge, biofeedback/relaxation, family response

Chronic Disease ManagementMedication adherence, depression, medication side effects

Adaptation to Illness/Functional MorbidityFamily adaptation, management responsibility, self image,psychological interventions, factitious symptoms

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 AgeParent and Child Report

r = .29, p < .001 (child)r = .38, p < .001 (parent)

1

2

3

4

6 7 8 9 10 11 12 13 14

Child Age

Res

pons

ibili

ty

Parent Child

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

• 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