Bronchial Asthma is a chronic condition whose worldwide incidence continues to rise unabated, both in richer countries and those with emerging economies [1
]. Its pathophysiology is better understood than ever before and current treatments are more effective than ever. However, the costs incurred by the disease continue to increase and young people continue to die from it. One area of aetiology that is often neglected in the Western World is the psychological element of asthma; by neglecting this area, potential treatments are also neglected [2
]. Early in the twentieth century many prominent thinkers had overemphasized the psychological basis of disease; such work is often considered discredited nowadays, but we should not forget how important psychosocial factors are in all diseases. Indeed in 1965 Michael Hirt edited a book [5
] with the aim "to stimulate research on the psychosocial implications of asthma, which will meet the vigorous methodological conditions possible in the laboratory setting". A review in JAMA at the time stated "It is extremely doubtful that this publication will achieve such a goal". This second prophecy has proven correct; we can find little such good quality research and no data at all about the beliefs and practices of doctors in this area. This contrasts with other treatment modalities, for example Vollmer et al's paper in 1997 [6
] which compared allergy specialists and general physicians pharmacological treatments of asthma.
Doctors in the English speaking world are particularly reticent about psychosomatic medicine (such as chronic fatigue or irritable bowel syndrome [[7
] and [8
]]). There are many reasons for this, but perhaps a dominant one is the culture of political correctness; doctors fear offending their patients by implying their illness is "all in the mind"; we may mistakenly think that our patients themselves are convinced their illnesses are entirely physical, whereas many studies have shown that patients actually do incorporate psychological explanations into their health belief models [9
]. We worry they will think we are saying it is their fault, that they should just pull themselves together. Other countries do not feel this reticence; for example, in Germany there are institutes of psychosomatic medicine to which people can be referred by their GP. How would this be perceived in Britain? In America, psychosomatic medicine does have a more respectable profile as illustrated in a review article by Weiner [10
]; however it is still somewhat neglected there as emphasised in a JAMA editorial 1999 by Spiegel [3
] who writes about how social factors are strongly linked to physical disease outcomes, although their influence is often ignored.
In 1950 Alexander published a work that described seven conditions thought particularly to have a psychosomatic aspect [11
]. These were reverently referred to as the "Holy Seven" in the following years [12
]. They were: gastric ulceration, ulcerative colitis, bronchial asthma, essential hypertension, eczema, hyperthyroidism and rheumatoid arthritis (see Figure in results). Modern doctors recognise a psychological element to all illness and hence Alexander's choice of these seven diseases is now considered outmoded [13
]. In these days of holistic medicine it is wise to consider the psychosocial domain in most medical conditions, although the degree to which this affects disease expression varies. Indeed, there is much evidence that psychosomatic factors are particularly important in asthma.
Percentage of GPs who see psychological factors as pre-dominant in the development of the following. A graph of GPs beliefs about the psychological influence on a number of common diseases.
In an otherwise very thorough review of asthma control in the BMJ in 2006 John Rees [14
] only mentions psychological factors twice:
"Factors that are difficult or impossible to alter: Psychological problems"
as well as:
"In the future it is likely that appropriate interventions such as cognitive behavioural therapy will be available to target adherence in particular patients, although as yet evidence is lacking to support any particular intervention."
However, the evidence deserves more than this. He does not mention at all the wealth of research that shows positive outcomes for children if the psychosocial domain is influenced. As long ago as 1993 Bryan Lask [4
] was lamenting the lack of attention given in British Thoracic Society (BTS) guidelines to the psychological causes and management of asthma; for example, parental counseling [15
], and family therapy [16
] have proven benefits but are not mentioned. In adults cognitive behavioural therapy [17
] has been shown to have beneficial effects. This situation has not changed in the most recent BTS guidelines [18
], where the only mention of anything psychological was the following, found under 'complementary and alternative medicines':
"In difficult childhood asthma, there may be a role for family therapy as an adjunct to pharmacotherapy".
The situation is slightly better with the German asthma guidelines [19
]: there is a section for "Non-medical Measures" (Nichtmedikamentöse Maßnahmen) in which it is emphasized that family relationships are important to success in treating children, and that psychosocial problems in all age-groups are common. Moreover it is mentioned that psychosocial factors will play a role in the development and maintenance of asthma and support should be tailored accordingly. However there is no advice about who to refer, when, or to what specific psychosocial therapeutic intervention.
It has long been well-known that severe asthma attacks can be triggered or worsened by heavy emotions. Groen and Decker [20
] wrote in 1956 about "reproducible psychogenic asthma attacks" in a fascinating paper that would not pass submission to a modern ethical committee. Periodically such work gets revisited (in less dangerous ways) such as Ritz and Steptoe [21
] who demonstrated how laboratory induction of emotions in adults can bring about attacks. Strunk et al [22
] conducted a retrospective case control study of children who died of asthma (average age 13), following discharge from hospital in the late 1970s. They examined 57 physiological and psychological variables gathered during admission and found eight that had prognostic significance. Four were psychological in nature: concurrent depression, self-care inappropriate to age, parental conflict with medical staff and disregard of asthma symptoms by patients or parents.
There is a growing body of work examining psychosocial influences on childhood asthma. The effect of emotions was further examined in a 2009 paper by Suglia et al [23
]. They found that, all other factors being equal, children of mothers who experienced chronic intimate partner violence had over twice the risk of developing asthma. This effect was reduced in children who experienced a high level of mother-child activities and further reduced if the child had a higher number of toys (after taking into account obvious confounders such as income and smoking).
So, it is known then, that psychological factors can affect disease expression. Indeed depressive co-morbidity has been shown to be commonly associated with asthma [[2
] and [4
]]; but is this cause or effect? This hypothesis was tested by Bender et al [24
] in with respect to mild or moderate asthma in children. They were surprised to find that whilst the presence or degree of asthma affected their young lives in various ways, the psychological functioning of the children was not linked to their asthma. In fact it was the Family's Adaptation (measured by the "Impact on Family Scale") that was related to the coping skills of the children in question. Perhaps this is not such a surprise to experienced GPs who know that children cope very well with many physical problems and suffer most when there are background family difficulties. It has also been observed in a fascinating study from China [25
] that the three basic temperament types affect asthma expression differently: feisty ("difficult") children were found to have asthma three times more than average whereas flexible ("easy") children had it only half as often. Indeed the authors began their abstract by saying "Asthma is considered as a typical psychosomatic disease."
Many studies have demonstrated that adults with depression and anxiety perceive themselves as having more severe physical disease, and cope less well with their illnesses. Rimington et al [26
] showed this clearly for asthma: adult patients who are more depressed or anxious scored worse on symptom scores; it was found such symptom scores were much less strongly related to actual lung function than to the results of the Hospital and Anxiety Depression scale. Furthermore they suffer more from poor control [27
]. Indeed, Kolbe et al [28
] found a higher incidence of anxiety, depression and life events in asthmatics of all ages admitted with severe attacks.
Of equal importance is the question of whether psychological therapies can improve the outcome in physical disease? A succinct study by Smyth et al in JAMA 1999 (prompting Spiegel's editorial) demonstrated that simply writing about stressful experiences could improve lung function at 4 months follow-up in adult patients with mild to moderate asthma; there was in fact a relative improvement of nearly 20% in FEV1; P value < 0.001 [29
]; this was a randomized controlled trial, with the control group writing about neutral topics.
There is also evidence that behavioural techniques can help asthma. Colland [30
] demonstrated that a self-management program was effective in reducing asthma morbidity in children, and other centres have extended this work [[31
] and [32
]]. This has been further extended by Grover et al in 2007 [17
] who demonstrated in a randomised controlled trial that CBT was superior to self-management programs in adults with asthma. On a different theme Huntley et al [33
] reviewed all relaxation techniques and their efficacy on asthma; they concluded most studies were of poor quality but that there was some evidence that muscular relaxation improved lung function.
So then, we know that psychological factors affect development, severity, and mortality in asthma. Moreover psychological therapies can improve disease outcome. The research above demonstrates that this applies to children, adolescents and adults. However, it is one thing for doctors to be aware of aetiology and treatment; it is another matter for them to act accordingly. Hence, we decided to investigate the knowledge and behaviour of our local GP population. In order for this to be done in as simple a manner as possible we sent our GP colleagues a questionnaire looking at their health beliefs and querying their referral patterns. We hypothesised that local GPs would probably be aware of the psychosocial links but that they were often likely not to refer or treat accordingly. We examined this hypothesis in several areas of aetiology and treatment (see methods).
In the interests of space we have not included the questionnaire in this paper but we are happy to email it to any interested parties.