interrelationship of indices of emotional precipitants of asthma, psychological response to asthma,...
TRANSCRIPT
Journal of Asthma, 21(1), 21-28 (1984)
Interrelationship of Indices of Emotional Precipitants of Asthma, Psychological Response to Asthma, and
Symptom History in Children
Gregory S. Jurenec, Ph.D.* Clinical Psychologist
Comprehensive Mental Health Services 798 North 26th Street
New Castle, Indiana 47362
I NTRO D UCT 10 N
While considerable research has been de- voted to the role of psychological processes in asthma, it has been contended that no consistent picture of the "psychology" of asthma has emerged (1,2). Several inves- tigators, however, have suggested that it may be that psychological processes are clinically significant for only a subgroup of asthmatic children, a distinction which may be important in the consideration of psy- chologically oriented treatment procedures, such as relaxation training (1).
A number of methods or dimensions of such a subclassification have appeared in the literature. One of the first such distinc- tions was made between asthma which ap- peared to be related to allergic factors and appeared largely in children (extrinsic), and asthma of less obvious etiology often linked to infectious factors (intrinsic). However, as medical research has increasingly clarified
*Address reprint requests to: Dr. Gregory S. Jurenec, Comprehensive Mental Health Services, 798 North 16th Street, New Castle, Indiana 47362
Copyright @ 1984 by Marcel Dekker, Inc. 21
Douglas G. Ullman, Ph.D. Professor of Psychology Bowling Green State University Bowling Green, Ohio 43403
the processes underlying asthma, the ex- trinsic-intrinsic dimension has become quite ambiguous and much less useful. For exam- ple, it is now recognized that most asth- matic children do show allergic sensitivity on skin tests. However, these allergic reac- tions are frequently unrelated to the onset of asthmatic symptoms (3).
Consequently, other dimensions of the asthmatic child have been explored. Block et al. (4) proposed a negative relationship between allergy and psychopathology, sug- gesting that the symptoms of nonallergic children (i.e., children without family histo- ries of asthma, negative or weak skin tests, etc.) may be influenced by neurotic conflicts or a maladaptive mother-child relationship. This notion, however, is subject to similar problems as the "extrinsic-intrinsic" scheme. That is, since most children show allergic responsivity and have a positive family his- tory of asthma, this distinction is rarely clear cut. Nonetheless, the Block et al. proposition represents one of the earlier at- tempts at empirically deriving subgroups which show psychological differences. Tak- ing a different approach, Purcell et al. (5,6)
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22 Jurenec and Ullman
used a structured interview procedure to assess the importance of emotional, as com- pared to other precipitants (or triggers), of asthma in children. He found that children for whom emotional stimuli were important precipitants of attacks responded with a re- duction in symptoms when separated from their families. On the other hand, children for whom emotional stimuli were unimpor- tant precipitants showed no significant symptom change upon separation. Thus, an interview identifying the importance of emotional precipitants of attacks served to distinguish asthmatics in a meaningful way. A third approach to differentiating asth- matics is reflected in the work of Kinsman and his colleagues (7-10). They focused on the reaction of adolescent and adult asth- matics to their symptoms by way of an in- strument they developed named the Asthma Symptom Checklist. They reported that one of the subscales, panic-fear, served as a useful predictor of the potency of med- ication prescribed upon discharge with a group of hospitalized asthmatics (7-lo), and use of PRN medication (11). Further, a set of MMPI items chosen for their ability to pre- dict panic-fear scores (MMPI Panic-Fear Scale) has been found to be related to length of hospitalization and likelihood of rehospitalization (8,9). Interestingly, Kins- man et al. (7) report that about 42% of the asthmatics sampled reported that experi- ences belonging to the panic-fear category occurred during most or all of their attacks. Thus, these data suggest a subgroup of asthmatics who have strong psychological reactions to their symptoms as well as more potent maintenance medication, longer hos- pitalization, and a greater likelihood of re- hospitalization.
The extent to which these three sub- grouping approaches reflect independent dimensions is unclear at this point. For in- stance, are children who react to the onset of symptoms with anxiety or fearfulness also more susceptible to emotional triggers of symptoms? Similarly, is allergic history related to the importance of emotional pre- cipitants and emotional reactions, or does allergy simply reflect another precipitant?
Indeed, there is little empirical data ad- dressing the degree to which psychological and various historical symptom variables (e.g., age of onset, family history, severity, etc.) ”fall together.”
Consequently, this report represents a pi- lot project intended as a first step toward the identification of meaningful subgroups of asthmatics. This was attempted by seek- ing to evaluate the relationship between the three dimensions reviewed above: panic- fear, the importance of emotional precipi- tants of attacks, and the role of allergic fac- tors in asthmatic children attending a summer camp. In addition, relationships between these dimensions and other demo- graphic and historical variables were evalu- ated, including symptom histories.
METHOD
Subjects
Twenty-nine asthmatic children (16 boys, 13 girls) between the ages of 7% and 12 at- tending Camp Superkids were studied. This camp is a 6-day overnight camp for asth- matic children which took place in North- western Ohio, sponsored by the South Shore Lung Association, a chapter of the Ohio Lung Association.
Materials and Procedure
Each child was interviewed individually to obtain symptom information and to as- sess the importance of emotional precipi- tants of asthma, using the structured interview procedure described by Purcell et al. (5). Subjects were asked to list all of the precipitants of asthma which came to mind, after which they were given a list of com- mon precipitants from which they could add to their list, if applicable. They were then asked to rank the importance of these precipitants, ranking as 1 the precipitant that was responsible for the greatest num- ber of symptoms. If the child identified no emotional precipitants (EPs), helshe was given a rating of “1.” If EPs were ranked
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Indices of Asthma
among the three most frequent precipitants, the child was given an EP rating of “3,” while a rating of ”2” was given for those who identified EPs which, however, were not ranked among the three most important precipitants. During the same interview, three subscales of the Asthma Symptom Checklist (7) (ASC) were administered: pan- ic-fear, irritability, and fatigue. The latter two scales were included in order to pro- vide items in which to “nest” the panic-fear items as well as to assess other potentially relevant reactions to symptoms.
Symptom histories were obtained through parental questionnaires and a re- view of the camp medical records. These sources provided data such as age of onset, allergic history, precipitants of asthma, fam- ily history of asthmalallergy, the child’s re- action to symptoms, history of illnesses, and hospitalizations. In the questionnaire, parents were also asked to list precipitants of their child’s asthma, with emotional pre- cipitants (e.g., anger) given as an example (see Table 1 for list of variables used.) Changes in symptom frequency, medica- tion, and attitudes toward asthma were evaluated with 1-, 2-, and 3-month post- camp questionnaires.
RESULTS AND DISCUSSION
A correlation matrix was computed for the 40 variables identified. While the prob- lems associated with the computation of such a large number of correlations based upon a relatively small number of subjects were appreciated, such a procedure was felt to be justifiable given the exploratory nature of this pilot work. Nonetheless, these re- sults are taken to be merely suggestive and will serve to provide leads to additional, more refined research.
Of major interest were relationships be- tween indices of the child’s reaction to symptoms (i.e., the scales of the ASC) and several indices of the importance of emo- tional precipitants of attacks. The latter vari- able was assessed in several ways in order to facilitate future use of this dimension. In
23
Table 1. List of Major Variables Studied and Abbreviations Used -
SEX AGE PF
I
FAT
NPAREP
PC PA R E P
EPRAT
NEP
NPRE
PCEP
FEAR
ANGER
ONSET FamHxAs FamHxAll Pt HxAl I Resl HOSP ER
SCH
SX F R E RAT
MEDRAT
Panic-fear scale of Asthma Symptom Checklist Irritability scale of Asthma Symptom Checklist Fatigue scale of Asthma Symptom Checklist Number of emotional precipitants listed by parents in questionnaire Percent of precipitants listed by parents which were emotional Emotional precipitant rating from child interview The number of emotional precipitants listed by the child The number of precipitants listed by child Percentage of precipitants listed by child which were emotional Degree to which parents describe the child‘s reaction to symptoms as fearful Degree to which parents describe the child‘s reaction to symptoms as angry Age of onset Family history of asthma Family history of allergy Patient history of allergy Number of respiratory infections Number of hospitalizations for asthma Number of emergency room visits for asthma in past year Number of school days missed in past year due to asthma Symptom frequency rating for past month Medication rating for past month
MEDCH1, 2, 3 Medication changes at the first, second, and third follow-ups
SXCH1, 2, 3 Changes in symptom frequency at each of the three follow-ups
addition to the ranking procedure described earlier, the number of emotional precipi- tants, the total number of precipitants listed, and the percentage of precipitants which were emotional were considered in the analyses. A similar approach was taken with the precipitants identified by parents on questionnaires, i.e., the number of emo- tional precipitants and the percentage of precipitants which were emotional were both considered.
The relationship observed between the
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24 Jurenec and Ullman
importance of emotional precipitants and panic-fear is somewhat unclear (see Table 2). While the correlation found between emotional precipitant ratings (EPRAT) and panic-fear were nonsignificant (r = 0.33, p > 0.10), a significant correlation was found between panic-fear and the number of emotional precipitants (NEP) the child identified ( r = 0.43, p < 0.05).
While these results would seem to make it difficult to argue that the assessment of the importance of emotional precipitants and panic-fear are entirely independent di- mensions, the magnitude of the correlations found does not suggest a particularly strong relationship. Further, it appears that child and parent perceptions of emotional pre- cipitants are dissimilar, as reflected by the nonsignificant, negative correlation between EP indices for parents and their children. For example, the correlation between the number of precipitants reported by parents and children was -0.21 (p > 0.10). This might suggest that ratings of the impor- tance of emotional precipitants may be in- fluenced by the source of information, i.e., parent or child.
An examination of the relationships be- tween the remaining ASC scales, namely, irritability and fatigue, and indices of emo- tional precipitants reveal several significant correlations. For example, the correlation found between the emotional precipitant rating and irritability was 0.51 (p < 0.01), and 0.53 between the number of emotional precipitants and fatigue ( 1’ < 0.01). These
findings, along with relationships noted above between panic-fear and EP indices may suggest a dimension of general emo- tional reactivity, whether the stimulus is the asthma, or other external stimuli (which in turn may trigger the asthma).
As opposed to the discussion of ”psycho- logical” variables, the assessment of rela- tionships between psychological variables and symptomidemographic variables failed to reveal any consistent patterns, although several significant correlations were found (see Table 3). Age of onset and emotional precipitant rating were found to be posi- tively related (r = 0.42, p < 0.05), implying that the later the child’s asthma begins, the more likely heishe will be to attribute greater importance to emotional triggers. The percent of parent reported precipitants which were emotional (PCPAREP) was sig- nificantly related to both family history of allergy and the number of school days missed ( r = -0.55, p < 0.01; r = 0.47, to p < 0.05). To some extent, these values may simply reflect the fact that each of the vari- ables are derived from parental reports. However, it would not be unreasonable to speculate that a family with no history of allergy might be less prone to seek allergic explanations for the asthma and thus be more open to the consideration of psycho- logical triggers.
The evaluation of the interrelationship among demographicisymptom variables re- vealed one notable pattern (refer to Table 4). Children who showed variability in
Table 2. Correlation Matrix for Psychological Variables
PF I FAT NPAREP PCPAREP EPRAT N EP NPRE PCEP FEAR ANGER
PF I
FAT
NPAREP
PCPAREP
EPRAT
NEP
NPRE
PCEP
FEAR
0.53’ 0.36 -0.19 -0.23 0.33 0.43b 0.35 0.29 0.42 0.45b 0.23 0.24 0.51a 0.50a 0.64’ 0.25 0.27
0.73a -0.30 -0.21 -0.39 -0.23 0.06 -0.16 0.03 -0.30 -0.05 0.24
0.56a 0.83’ 0.16 0.21 0.24
-0.07 0.05 0.35 0.53’ 0.40 0.20 0.46b
0.81’ 0.58a 0.79‘ -0.05
-0.04
-0.26 0.03
-0.13 0.19 0.41b
-0.30 -0.19 -0.45b -0.20 -0.22
”p 5 0.01. ’p 5 0.05.
]ournu/ of Asthma, 21(1), 1984
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Tabl
e 3.
C
orre
latio
n M
atri
x fo
r P
sych
olog
ical
x
Sym
ptom
Var
iabl
es
FEA
R
AN
GE
R
PF
I FAT
NP
AR
EP
PCPA
REP
EPR
AT
NE
P
NPR
E
PCEP
SEX
-0.1
2 0.
02
-0.1
4 -0
.1 1
-0
.00
-0.2
4 -0
.10
0.05
-0
.03
-0.0
4 0.
06
AG
E O
NS
ET
FA
MH
x As
FA
hlH
x A
ll
0.2
1 0.
1 1
-0.0
1 0.
2 1
0.55
“ 0.
21
0.19
0.
17
0.01
0.
00
-0.0
4
0.16
-0
.02
0.1
1 -0
.02
-0.1
2 -0
.05
-0.0
5 0.
42b
0.23
0.
21
0.35
a
0.05
-0
.14
0.1
1 -0
.09
-0.2
2 -0
.25
-0.2
7 -0
.21
-0.2
4 -0
.1 1
-0
.10
0.05
-0
.36=
0.
36’
0.02
0.
24
-0.3
6=
-0.5
5‘
0.1
3 0.
00
0.1
1 0.
10
RH
k A
ll
0.06
0.
14
0.1
5 0.
13
0.39
a 0.
05
0.01
-0
.15
-0.0
6 0.
19
-0.2
5
Res
l H
OSP
ER
SC
H
SXFR
E R
AT
ME
D
RA
T
0.09
-0
.13
-0.0
2 -0
.17
-0.0
3 0.
27
-0.0
3 -0
.13
-0.2
0 -0
.05
-0.2
2
0.0
1 -0
.09
-0.3
1 -0
.22
0.06
0.
1 1
0.17
-0
.33
-0.2
9 -0
.1 1
-0
.26
-0.0
6 0.
21
-0.1
4 0.
06
0.2
1 0.
34
0.25
0.
11
-0.0
1 0.
34
0.04
0.
37
0.03
0.
47b
0.20
0.
09
0.06
0.
17
0.10
0.
28
0.05
0.
24
-0.0
7 0.
1 7
0.14
0.
05
-0.0
1 0.
03
- 0
.03
-0.1
8 -0
.22
-0.2
9 -0
.22
0.02
0.
50b
-0.2
1 -0
.46a
-0
.30
-0
.26
-0.0
8 -0
.16
-0.2
5 -
0.40
’ -0
.04
“p <
0.1
0.
bp <
0.0
5.
cp <
0.0
1.
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x
Tabl
e 4.
C
orre
latio
n M
atri
x fo
r S
ympt
om/D
emog
raph
ic V
aria
bles
FA
MH
x F
AM
Hk
PIH
h SX
FRE
ME
D
SX
M
ED
Sk
Sx
M
ED
M
ED
SE
X A
GE
ON
SE
T A
s A
ll A
ll R
pil
HO
SP
ER
S
CH
R
AT
RA
T C
HI
CH
I C
HL
C
H?
C
H3
CH
3 _
__
SEX
AG
E
ON
SE
T
FAhl
HxA
S
FAM
HxA
LL
PIH
xALL
R?Sl
HO
SP
ER
SC
H
SXFR
ERA
T
ME
DR
AT
5xC
HI
ME
DC
Hl
VE
DC
HL
SxC
H.’
ME
DC
HJ
5kC
HI
0.24
-0
.51
-0.2
4 -0
.07
-0.0
4 0.
21
-0.1
2 -0
.23
0.19
-0
.21
0.22
0.
03
0.16
0
.16
-0.0
4
0.06
0.
48”
0.05
0.
24
0.10
-0
.08
-0.0
8 -0
.24
-0.3
3 0.
08
-0.2
5 -0
.12
0.61
a -0
.18
-0.1
7 0.
24
0.17
-0
.35
0.39
0.
15
0.08
0.
24
0.17
0.
15
0.32
0.
01
0.06
0.
08
0.21
0.
06
-0.1
1 -0
.25
0.21
-0
.15
-0.0
6 -0
.02
0.19
-0
.17
0.49
’ -0
.24
0.1
1 0.
05
0.05
-0
.12
0.00
0.
30
-0.1
9 -0
.17
-0.1
1
0.08
0.
03
-0.1
2 0.
00
-0.0
1 0.
00
0.39
’ 0.
39’
0.25
0.
27
0.52
’ -0
.27
-0.3
3 -0
.17
-0.0
9 0.
30
-0.0
3 0.
22
0.16
0.
38’
0.14
0.
22
0.22
0.
1 1
0.22
0.
1 1
0.21
0.
18
-0.1
4 -0
.06
-0.2
2 -0
.07
0.22
0.
43
0.07
0.
15
0.44
c 0.
49‘
0.44
b
0.42
’ -0
.04
0.36
-0
.12
-0.1
9 -0
.14
-0.3
3 -0
.33
0.17
0.
1 3
0.05
-0
.1 7
-0
.04
-0.3
6 -0
.63‘
-0
.47c
0.
43b
0.38
-0
.04
0.09
-0
.11
-0.1
8 -0
.15
0.00
0.
02
0.00
0.
28
0.00
0.
28
-0.0
5 -0
.02
0.41
0.
48‘
0.00
-0
.1 1
0.
00
-0.3
5 0.
23
-0.1
7 -0
.21
0.02
0.
23
0.38
0.
23
-0.0
2 0.
14
-0.1
5 0.
15
-0.4
6’
-0.1
8
”p 5
0.
01.
’p <
0.1
0.
‘p <
0.0
5.
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Indices of Asthma 27
symptoms (i.e., changes in symptom ratings) at the first follow-up were likely to show continued changes at future follow ups. The same was found for medication changes. Further, changes in symptom fre- quency were positively related to changes in medication use. That is, as the frequency of symptoms declined, so did medication needs, as reflected in the correlation be- tween symptom and medication change at the first follow-up (r = 0.44, p < 0.05). Thus, children who showed variability in symptom frequency or medication use, typ- ically did so for both across the three months of follow-up.
Finally, several variables were found to be related to the child’s application of the camp health related skills taught at the camp. These include: age of onset (r = -0.42, y < 0.06), the number of respiratory infections the child has had (r = 0.60, p < O.Ol), and the extent to which the child’s attitude toward hisiher asthma changed (r = 0.53, p < 0.05). The prediction of skill utilization clearly needs much more attention, as an under- standing of “who benefits most from what” will be valuable in the design of future asthma programs. Consequently, research currently under way will examine this ques- tion more closely.
Several general trends may be tentatively drawn from these results. First, indices of emotional precipitants and the scales of the Asthma Symptom Checklist employed (panic-fear, irritability, and fatigue) might possibly reflect overlapping, but not identi- cal, aspects of global emotional reactivity. The extent to which these procedures reflect common variance, however, is unclear. Thus, it would be premature at this point to substitute one procedure for the other. Sec- ond, the methods and sources used to as- sess the importance of emotional precipi- tants may produce somewhat different results, particularly when the perceptions of parents and children are compared. Hence, source factors must be considered when as- sessing the importance of emotional precipi- tants. Third, no significant correlations were found between patient history of allergy and any of the 40 variables studied. This is
notable given the reciprocal relationship Block et al. (4) proposed between the pres- ence of allergy and psychogenic asthma andlor the presence of psychopathology. Last, while significant correlations between psychological and symptom demographic indices were found, the consistent pattern hoped for failed to emerge. This may be be- cause of the crude nature of the indices used as well as the possibility that no sim- ple pattern exists. Nonetheless, indices of emotional reactivity apparently may present the greatest promise in the subclassification of asthmatic children, as opposed to the presence of allergic factors. Research is cur- rently under way in which the health and symptomatology of over 60 asthmatic chil- dren has been followed closely before and after training in behavioral methods de- signed to assist in the management of their asthma. It is hoped that these data will serve to clarify some of the questions raised in this pilot project, in particular, the rela- tionship between variables studied here and symptomatic responsivity to behavioral treatment.
1.
2.
3.
4.
5 .
6.
7.
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re.c
om b
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