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Asthma: Social and Psychological Factors and Psychosomatic Syndromes; Advances in Psychosomatic Medicine, Volume 24 FREE TO VIEW

Gabriel Laszlo, MD
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Bristol, United Kingdom

Chest. 2004;125(6):2372. doi:10.1378/chest.125.6.2372
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By E. S. Brown, ed. Basel, Switzerland: Karger, 2003; 171 pp; $137.50

As a medical student in the United Kingdom in 1960, I learned that 50% of asthmatics had positive intradermal test results, and were deemed “allergic”; the remainder were given labels such as nervous, constitutional, intrinsic, or psychosomatic according to the physician’s model of the disease. Our allergist sent his patients to boarding schools in Switzerland to reduce their antigen exposure. Our pediatrician sent his patients to the same schools to “amputate the parents” because their understandable anxiety appeared to cause or exacerbate attacks of “bronchospasm.” House dust mite allergen and IgE were isolated in 1968, and the concept of asthma as an inflammatory disorder was rehabilitated. Nevertheless, physicians continued to recognize the influence of psychological factors in asthma with only anecdotal evidence to support any link.

Asthma: Social and Psychological Factors and Psychosomatic Syndromes is a timely and well-documented attempt to summarize current research into the behavioral aspects of asthma. No expert knowledge is assumed. Current guidelines and standard pharmacologic interventions are taken for granted. The book opens with a chapter on epidemiologic trends pointing out the difficulty of defining asthma, and the influence of changing definitions on its apparent prevalence. We are cautioned about premature acceptance of seductive hypotheses (hygiene, obesity) and advised that severe asthma and expensive treatment of comorbid conditions account for half of the costs of treatment nationally. The reader is given a rather brief introduction to quality of life.

The next chapter ingeniously tabulates the history of ideas about psychosomatic philosophies of medicine, which are presented in parallel with the medical history of asthma. Gregerson demonstrates that over the years current models (“zeitgeist”) have hampered progress in understanding asthma because it actually has many causes and mechanisms, and quotes the opinion that undue emphasis on psychological factors discredited the psychosomatic field. She discusses systems that could be helpful for planning research. This thoughtful presentation, which is somewhat obscured by philosophical jargon, deserves careful attention. It would have been interesting to learn her views, and those of some of the other authors, on how molecular biology and genetics might illuminate this topic.

The next chapters deal authoritatively with the interaction between depression, anxiety, panic disorder, and asthma. These concentrate on epidemiology rather than treatment, and point out some consequences of psychiatric comorbidity. A chapter entitled “Psychiatric Syndromes That Mimic Asthma” gives an account of vocal cord dysfunction and psychogenic cough. Dysfunctional breathing is considered in two essays entitled “Sighing Dyspnea” and “Hyperventilation Syndrome”; these plausible, but vague diagnoses are presented as differential diagnoses of asthma, but there is little advice about how to manage the overlap between disordered breathing and asthma, and the European literature is largely ignored.

Tousman and Zetz describe a model for changing behavior by education, which places the daily work of nurses and respiratory therapists into a helpful theoretical framework. Next is a useful chapter on adherence by physicians to guidelines, and by patients to agreed treatment schedules, including valuable reviews of research methods for assessing the use of medication by diaries and electronic devices. Rietveld describes the causes and consequences of overperception of symptoms and its relationship to somatization, but avoids the unsolved problem of underperception and whether this contributes to poor control or fatalities.

The nub of this book is a detailed account by Miller and Wood of their own and other psychophysical experimental studies on how emotional states might influence airway caliber and inflammation. Physicians have been speculating for centuries on the basis of their clinical experience, on how stress and ill health influence respiratory and other sensations, and how they appear to alter immunity. Here these models start to take shape. They outline experimental studies showing how the autonomic system can be stimulated by emotional influences in the short term, and discuss the long-term modulation of both autonomic and immune pathways via the hypothalamus. However, experimental approaches like these may be difficult to develop because most asthmatics are well controlled, and rapid changes of lung function are damped. The volume then concludes with a discussion of the psychiatric complications of corticosteroids.

The editor has largely achieved his stated aim, which is to inform clinicians, general practitioners, allergists, pulmonologists, and mental health professionals about the relation between psychology, psychiatry, and bronchial asthma. The chapters are mostly well written in plain English, mainly without confusing abbreviations and psychologists’ code words, (they crop up occasionally), and almost entirely without printing errors (I found only one). There is no serious overlap between the chapters, and the ratio of evidence-based statements to speculation is admirably high.




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