Panic-fear in asthma: Requests for as-needed medications in relation to pulmonary function measurements
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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 patients 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- tients 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.
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.
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 patients panic-fear scores.
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 patients 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.
VOLUME 60 NUMBER 5
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 --
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 patients 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 w...