Panic-fear in asthma: Requests for as-needed medications in relation to pulmonary function measurements

Nancy Wray Dahlem, Ph.D., Robert A. Kinsman, Ph.D., and Douglas J. Horton, M.D. Denver, Co/o.

Requests for as-needed medications and treatments (PRNs) by asthmatic patients scoring high, moderate, or low on the Asthma Symptom Checklist panic-fear category were studied for days when patients were matched at normal, intermediate, and subnormal levels of pulmonary

,function. Low panic-fear patients were the least likely to request PRNs regardless of the pulmonary ,function level. In contrast, high panic-fear patients often requested PRNs at each level of pulmonary,function. Only moderate panicyear patients made progressively more PRN requests on days when pulmonary functions were lower. These observations and others concerning the adverse influence of extreme panic:fear coping styles upon the treatment of asthma were discussed.

Asthmatic patients are heterogenous in regard to the role of psychological factors in their illness. A number of investigators have examined aspects of this diversity among intrinsic and extrinsic asthmatic pa- tients,’ among steroid-dependent and rapidly remit- ting patier~ts,2 and with suggestion and changes in airway resistance. 3, 4 A recent review describes the role of psychological factors in asthma in relation to known medical, immunological, and physiological characteristics of the illness.5 However, the need re- mains to specify ways that psychological factors af- fect the course of treatment and how remedial proce- dures can be integrated into medical treatment plans.

One approach to this problem has involved the identification of response styles related to the subjec- tive symptomatology of asthma. Of the symptoms experienced during asthmatic attacks, panic-fear symptoms-worried, frightened, scared, panicky, and afraid of dying-are reported to occur with high frequency and can be documented by the Asthma

From the Departments of Behavioral Sciences and Medicine, Na- tional Jewish Hospital and Research Center, and the Depart- ments of Psychiatry and Medicine, University of Colorado School of Medicine.

Supported in part by National Institutes of Health Grants MH- 28532 and AI- 10398.

Received for publication Feb. 14, 1977. Accepted for publication July 25, 1977. Reprint requests to: Dr. Nancy Wray Dahlem, Psychophysiology

Research Laboratories, Department of Behavioral Sciences, Na- tional Jeuish Hospital and Research Center, 3800 East Colfax Ave., Denver, Colo. 80206.

Symptom Checklist (ASC).6-g Response styles asso- ciated with these panic-fear symptoms have been more fully characterized by identification of a related personality dimension. lo This dimension was iden- tified by a new scale derived from the Minnesota Multiphasic Personality Inventory (MMPI) and called the MMPI panic-fear scale due to its consistently ob- served relationship with ASC panic-fear symptoms. High MMPI panic-fear patients describe themselves as fearful, highly emotional individuals who have their feelings hurt more easily than others, as feeling helpless and inclined to give up easily in the face of difficulty. At the opposite extreme, Low MMPI panic-fear patients describe themselves as experienc- ing very little discomfort or anxiety, and as being unusually calm, stable, and self-controlled.

Differences in panic-fear response styles, deter- mined either at the level of symptomatology or per- sonality, have practical implications for treatment. For MMPI panic-fear, patients have also been studied in relation to length of hospitalization and rates of rehospitalization after discharge from long-term treatment. High panic-fear patients are hospitalized longer than others, while both the extreme high and low panic-fear patients are rehospitalized with nearly twice the frequency of others after discharge. l2 All of these differences occur despite similarity with other patients in pulmonary function measurements ob- tained longitudinally throughout treatment. In brief, extreme high and low panic-fear patients present spe- cial difficulties in the treatment for their asthma.

Vol. 60, No. 5, pp. 295-300

296 Dahlem, Kinsman, and Horton J. ALLERGY CLIN. IMMUNOL.

NOVEMBER 1977

The effect of the panic-fear response styles upon asthma and its treatment is likely to be mediated by the patient’s behavior. Previous observations suggest that high panic-fear patients react to the stress of asthma by emphasizing their discomfort, and by panic and helplessness. In contrast, low panic-fear patients would be expected to minimize distress associated with airway obstruction. s-l2 The object of the present study was to investigate the influence of panic-fear on ways asthmatic patients behave during treatment. One behavior which can be monitored during treatment is requests for as-needed medications and treatments (PRNs). Asthmatic patients in long-term treatment are generally prescribed a routinely scheduled medi- cation regimen to control their asthma. However, supplemental PRNs are available and taken at the pa- tient’s own discretion to relieve the distress of airway obstruction. These PRN requests were selected as the focal behavior since they are both patient-initiated, and therefore likely to reflect differences in response styles, and have been recommended as a useful clini- cal index of the effectiveness of current therapy.13* l4 Requests for PRNs were expected to increase as air- way obstruction increased, but also to differ in pre- dictable ways for asthmatic patients among panic-fear categories.

METHODS Subjects

Eighty-eight asthmatic patients, 27 males (mean age, 36.1 + 17.4 yr) and 61 females (mean age, 40.0 2 15.2 yr), in long-term intensive treatment at National Jewish Hospital and Research Center (NJHRC) during the period from March, 1975, to June, 1976, were involved in the study. They were a heJerogeneous group of perennial asth- matic patients, and most had a long history of intractable asthma with frequent severe attacks, often requiring re- peated hospitalization. Recent studies of patients at NJHRC have shown that 80% were hospitalized during the year preceding admission to NJHRC, often on repeated occa- sions, and some for as many as 180 days.‘* Eighty-six per- cent were judged to have asthma aggravated by infection. Allergic (i.e., reaginic) factors, identified by skin testing and antigen inhalation challenge, were involved in the asthma of 37% of the patients.i5 All developed airway obstruction after inhalation of small, measured amounts of either methacholine or histamine, or both.i6 Seventy-two percent had been prescribed maintenance oral corticoste- roids at discharge.

Measures employed

Panic-fear. Panic-fear was measured by the Asthma Symptom Checklist (ASC), which has been described elsewhere.6-g The ASC was administered to patients within 3 wk following admission to treatment. Briefly, the ASC is a 77-item checklist measuring the reported frequency of

occurrence of five symptom categories during asthmatic attacks: panic-fear, irritability, fatigue, hyperventilation- hypocapnia, and airway obstruction. The panic-fear symp- tom category includes 7 connotatively similar items: scared, panicky, worried, frightened, worried about myself, wor- ried about the attack, and afraid of dying. The patient indi- cated on a 5point scale (1 = never; 5 = always) next to each item, the frequency with which he typically experi- enced the symptom during asthmatic attacks. Panic-fear scores were obtained by adding the scale values for the seven items and were converted to z scores based on norma- tive data, providing a distribution with a mean of 50 and a standard deviation (SD) of 10. Complete details of the item composition of the ASC and scoring procedure are provided in an earlier report.6 Finally, patients were separated into categories according to their panic-fear scores: low (one- half SD below the mean; N = 18), high (one-half SD above the mean; N = 17), and moderate (between the two ex- tremes; N = 53).

Pulmonary functions. Each day during treatment, pa- tients were asked to perform morning (8 :00 A.M.) spiromet- ric pulmonary function measures (Vertek 5000 VF lung function analyzer [Hewlett-Packard, Boston, Mass.] cali- brated weekly with a 1.5liter syringe. The highest daily value from at least two forced expiratory maneuvers at max- imal effort was used. These provided daily measures of the first-second forced expiratory volume (FEV i), forced vital capacity (FVC), and peak expiratory flow rate (PEFR). From these measures, FEVi expressed as a percentage of FVC (FEV,/FVC%) was derived. Predicted FVC, derived from an algorithm based on age, height, and sex, was also available. i7

As-needed medications and treatments (PRNs). All PRNs taken within 24 hr after the 8:00 A.M. pulmonary functions were recorded for all patients. To derive a PRN index score reflecting both amount and intensity of PRNs, inhaled steam or mist was scored 1, inhaled or orally admin- istered bronchodilators were scored 2, and injected medica- tions were scored 3 on each occasion. This scoring system was established on an a priori basis before collection of any data. The physicians prescribing PRNs had no knowledge of their patient’s panic-fear scores.

Procedure

Daily pulmonary functions and PRNs were obtained for the first two months after hospitalization, or for the entire stay if less than two months. Each patient’s record was individually scanned for days when patients were not receiving intravenous medications. Of these days, 4 days were randomly selected at each of three levels of airway obstruction as measured by FEVi/FVC%: normal (> 74%), intermediate (65% to 74%), and subnormal (< 65%). For patients whose pulmonary functions did not provide 4 days at each level, the available days were used. An average of 3.3, 3.9, and 3.5 days were available at normal, intermediate, and subnormal pulmonary function levels. Preliminary analyses indicated that patients with missing days were not differentially distributed among the ASC panic-fear categories.

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Panic-fear in asthma 297

TABLE I. Equivalence of pulmonary function measures (mean + SD) among panic-fear groups of asthmatic patients --

Pulmonary function Panic-fear category --

Level Measure Low Moderate High F(2,85)* --

FEV, (L) 2.3 e 0.7 2.2 2 0.7 2.0 k 0.6 0.639 Normal FVC (L) 2.8 + 0.9 2.7 r 0.9 2.6 0.7 0.436 +-

FEV, IFVC% 80.2 + 4.7 79.5 2 2.0 79.0 2 4.6 0.683 PEFR (L/set) 7.2 -r- 2.1 6.4 zt 2.2 6.3 +- 2.1 1.187

FEV, (L) 2.1 k 0.6 1.9 r 0.6 1.9 t 0.5 0.744 Intermediate WC (L) 3.0 L 0.8 2.7 ? 0.9 2.7 + 0.6 0.583

FEV, /FVC% 70.3 -+ 1.0 70.0 + 0.8 69.8 t 0.9 1.699 PEFR (L/set) 6.8 r 2.2 5.7 k 2.1 6.0 2 1.9 2.236

FEV, 04 1.7 r 0.5 1.5 k 0.6 1.5 + 0.4 1.141 Subnonnal WC (L) 2.8 + 0.8 2.5 k 1.0 2.4 r 0.6 0.787

FEV, /FVC% 61.5 k 1.9 59.5 i 3.6 60.3 & 2.1 3.068 PEFR (L/set) 5.6 t 1.9 4.5 k 1.8 4.8 k 2.2 2.325

WC predicted 3.6 k 0.8 3.4 2 0.9 3.3 It 0.7 0.529 -~ *All Fs are statistically nonsignificant.

TABLE II. PRN requests in relation to panic-fear groups and pulmonary function levels --

Panic-fear category Pulmonary function

level Low Moderate High --

Overall

Percent of days with PRN requests (means and standard deviations) Normal 21.3% k 30.1 22.6% k 28.5 Intermediate 19.4% 2 25.1 36.2% k 33.6 Subnormal 23.6% k 30.3 47.5% 2 38.1

PRN index scores (means and standard deviations) Normal 0.6 f. 0.8 1.0 2 1.8 Intermediate 0.8 k 1.7 1.4 +- 1.8 Subnormal 1.0 +- 1.7 2.2 + 2.4

--

47.1% r 39.4 27.1% k 32.3 41.2% r 34.2 33.7% A 32.9 47.5% k 33.8 42.6% + 36.8

2.0 +- 2.0 1.2 2 1.9 1.4 -c 1.4 1.3 t 1.7 2.5 k 2.7 2.0 -t 2.3

Next, each patient’s requests for PRNs were scored for each day selected. Finally, only after scoring requests for PRNs were ASC panic-fear scores obtained and patients assigned to panic-fear categories (high, moderate, and low). This procedure carefully insured that requests for PRNs were evaluated in a blind fashion with respect to panic-fear categories.

Following this procedure, requests for PRNs by patients within panic-fear categories could be evaluated for periods when pulmonary functions were equated at normal, inter- mediate, and subnormal levels. Table I demonstrates the equivalence of FEVI, FVC, FEV,/FVC%, and PEFR among panic-fear groups for days when pulmonary func- tions were at normal, intermediate, and subnormal levels. As indicated in the table, predicted FVC was also similar for patients within the three panic-fear groups.

Statistical analyses. .$nalyses of variance (ANOVA) were used to evaluate differences in the percent of days with requests for PRNs and the average PRN index scores among panic-fear groups and among levels of pulmonary func- tions.lR Duncan Multiple Range Tests were performed after

the ANOVA to locate specific sources of differences within the main design.18

RESULTS Requests for PRNs and pulmonary functions

Table II shows that the percent of days on which PRNs were requested became increasingly higher across days with normal, intermediate, and subnor- mal pulmonary function levels: PRNs were requested on 21.1% of days when pulmonary functions were normal, 33.7% when intermediate, and 42.6% when subnormal (Fz,170 = 2.50, p < 0.08). Duncan Multiple Range Tests indicated that when pulmo- nary functions were subnormal, the percent of days with requests for PRNs exceeded that for interme- diate (p < 0.05) or normal pulmonary functions (p < 0.01). Corresponding differences between in- termediate and normal pulmonary functions were not statistically significant.

298 Dahlem, Kinsman, and Horton

M Low Panic-Fear

U Moderate Panic-Fear W High Panic-Fear

NWMI Intemmdiato Sukromul

FIG. 1. Percent of days with PRN requests according to panic-fear and pulmonary function levels.

PRN index scores, which reflect the intensity of PRNs requested, showed a pattern similar to the per- cent of days on which PRNs were requested (Table II). When functions were subnormal, index scores (mean = 2.0) exceeded those for either interme- diate (mean = 1.3) or normal pulmonary functions (mean = 1 .I; both ps < 0.01).

In sum, for all patients considered together, both percent of days on which PRNs were requested and the magnitude of PRN index scores were influenced by level of pulmonary function, with subnormal levels of pulmonary function being associated with increased PRN requests.

Requests for PRNs and panic-fear

Fig. 1 shows the influence of panic-fear on percent of days on which PRNs were requested. For moderate panic-fear patients, who represent the largest patient group, the percent of days on which PRNs were re- quested was smallest during periods when functions were normal (22.6%), highest when functions were subnormal (47.5%), and between these extremes (36.2%) when functions were intermediate. For these patients, Duncan Multiple Range Tests confirmed that the percent of days with requests was higher when functions were subnormal than when they were in- termediate (p < 0.05) and also higher when functions were intermediate than normal (p < 0.01). In con- trast, the percent of days on which PRN requests were made was always low for low panic-fear patients and high for high panic-fear patients (all ps < 0.05).

For high and moderate panic-fear patients, Duncan Multiple Range Tests indicated that the percent of days with PRN requests were similar when pulmo-

J. ALLERGY CLIN. IMMUNOL. NOVEMBER 1977

nary functions were intermediate or subnormal. In contrast, for these same pulmonary function levels, low panic-fear patients requested PRNs on fewer days than others. When pulmonary functions were normal, the percent of days with PRN requests by low and moderate panic-fear patients were similar, but less than for high panic-fear patients. Mean PRN index scores showed essentially the same results as percent of days on which PRNs were requested.

In summary, only Moderate panic-fear patients showed a progressive increase in the percent of days on which PRNs were requested and in PRN index scores as lower pulmonary functions were consid- ered. For both of these measures, low and high panic-fear patients remained at opposite extremes re- gardless of the pulmonary function levels.

DISCUSSION

Most asthmatic patients are in the moderate ASC panic-fear category. For these, the frequency and in- tensity of PRN requests to relieve distress increase systematically for days with lower pulmonary func- tion levels. However, certain patients, those in the extreme high and low panic-fear categories, do not request PRNs according to this pattern. These patients present special problems during treatment.8-11 Most importantly, the level of reported panic-fear, as mea- sured by the Asthma Symptom Checklist (ASC), does not merely reflect the measured level of airway obstruction. Instead, behavioral observations provide strong confirmation that ASC panic-fear describes different ways asthmatic patients react to their illness.

When percent of days with PRN requests were con- sidered, moderate panic-fear patients requested PRNs more frequently for periods with lower pulmonary functions. In contrast, for high and low panic-fear patients, the percent of days with PRNs remained stable despite changes in pulmonary functions. Addi- tionally, for each level of pulmonary function, high panic-fear patients always requested PRNs fre- quently, while low panic-fear patients consistently made few requests. These findings suggest that high panic-fear patients overuse PRNs when pulmonary functions are normal, while low panic-fear patients consistently take PRNs more sparingly than others. The results clearly indicate that behavior toward PRNs and symptom scores involving PRNs cannot be used as accurate indices of the effectiveness of current therapy without recognizing the characteristic panic- fear response style of the patient.

Previous findings based on the MMPI panic-fear scale have indicated that high panic-fear patients are hospitalized longer and are discharged from long- term treatment on more intensive oral corticoster-

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oid regimens than low panic-fear patients despite similarities in medical condition.*-” Patients with both of these extreme panic-fear response styles are rehospitalized following long-term treatment more often than patients with moderate levels of panic- fear. ‘* The present study suggests that behaviors dur- ing treatment associated with panic-fear response styles may be responsible for these differences. Since high panic-fear patients request frequent PRN med- ications at all pulmonary function levels, these requests and related behaviors may contribute to a picture of persistent discomfort during long-term treatment and after discharge. During long-term treat- ment, ther,e behaviors may influence medical deci- sions leading to extended hospitalization and more intense medication regimens upon discharge. Follow- ing discharge, similar behaviors may result in more frequent rehospitalization. Within any treatment con- text, high panic-fear patients may also overuse sym- pathomimetic aerosols with potentially serious conse- quences.‘”

Low panic-fear patients, identified by the MMPI panic-fear scale, appear to have a general reluctance to communicate their discomfort to others.” These patients, by presenting an outwardly serene picture of well-being, both verbally and behaviorally, may influence medical decisions leading to early hospital discharges and prescription of less intensive medica- tion regimens. After discharge, their tendency to dis- regard their symptoms may lead to deterioration of the asthma to the point that treatment short of rehos- pitalization is ineffective.

Attention early in the course of treatment to the ways patients respond to their illness could permit special efforts to be directed toward those with un- usually high or low anxiety during treatment. In doing so, it should be understood that any observed anxiety or panic may reflect either personality characteristics of the patient or a focused concern about his asthma. Panic-fear symptom reports measured by the Asthma Symptom Checklist describe a kind of focused anxi- ety directed specifically at the illness. Such a focused anxiety may often be adaptive for patients who are otherwise well-adjusted. In fact, studies now in prog- ress indicate that for these patients an absence of such focused anxiety is associated with more frequent hos- pitalization, possibly as a result of their tendency to disregard or minimize their symptoms. Many sudden and unexpected deaths among asthmatic patients are thought to be due to widespread airway obstruction that was not appreciated by either the patient or the physician. *O Symptom minimization or denial, asso- ciated with low panic-,fear patients, may play an im- portant role in these deaths.

Panic-fear in asthma 299

Both high and low panic-fear patients need infor- mation about their illness and about appropriate ways to respond when in distress. For low panic-fear pa- tients, these efforts need to be directed at encouraging them to adhere to scheduled medication regimens, and to attend to their asthmatic distress in appropriate ways. For high panic-fear patients, those medications that can be easily overused, such as sympathomimetic aerosols, should be prescribed with special care. In addition, any diffuse, undirected panic and helpless- ness experienced by patients during asthmatic attacks may be reduced by physician counseling about appro- priate ways to increase the patient’s own perceived control over asthma. Such counseling may serve as an alternative to frequent hospitalization.

SUMMARY

Requests for PRNs by patients high, moderate, and low on the Asthma Symptom Checklist (ASC) panic- fear scale were studied when pulmonary functions were at normal, intermediate, and subnormal levels.

When the percentage of days with PRN requests was considered, only moderate panic-fear patients showed progressive increases when pulmonary func- tions were lower. In contrast, the percent of days with PRN requests for high and low panic-fear patients remained essentially unchanged, but consistently high for high panic-fear patients and consistently low for low panic-fear patients.

PRN index scores showed similar patterns. It was suggested that behavior toward PRNs is one impor- tant factor characterizing the panic-fear response styles known to influence treatment response in asthma.

The authors wish to thank Dr. Sheldon Spector for his technical advice concerning various aspects of this study, Melissa Dunning and Don Sherman for their assistance in assembling the data, and Sharon Robinson for her construc- tive criticism during the preparation of the manuscript.

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