Asthma & Psychological Link

Introduction

Asthma is a chronic and episodic illness causing obstruction of air passages making it difficult for a person to breathe normally. For a normal individual breathing is a natural effortless exercise done involuntarily. But for an asthma patient, normal breathing is itself a laborious effort, reducing the quality of life. What is the cause of asthma? Is it a pathological condition or a psychosomatic illness? This is being debated for a long time.

Prevalence of asthma is between 5-10%.Certain Indian cities like Delhi and Jaipur reported a higher prevalence ranging between 24-38% among school children. Asthma usually starts in childhood. It is widely believed that 50% of asthmatic develops their first symptom before the age of 6 years. There is genetic predisposition; even though a single gene responsible for asthma is not so far identified. Probably it is multifactorial, genetic        susceptibility and environmental factors contribute to asthma.

Mechanism

As per the present scientific knowledge asthma is a medical condition. The main inciting cause is environmental allergens leading on to a cascade of cellular activity resulting in narrowing of airways. The pathology in asthma sets off in the following manner.

• The muscles of the airways constrict.
• Mucus membrane lining the airways swells.
• Mucus collects in the airways further blocking the air flow.

These subsequently lead to breathlessness, wheezing and coughing. Some of the main triggers are house dust, pollen, fungi, insects, animal danders, food, sudden change in climate and certain chemicals.

However, according to traditional viewpoint, asthma is primarily a somatoform disease with psychological variables. The widely supported belief is that powerful emotions like anger, worry and fear trigger asthmatic attacks. This is not surprising since we all experience a change in breathing pattern whenever we are under a high state of excitement and stress. The other significant reasons believed to trigger asthma are anxiety and depression disorders.

Asthma was one of the “Holy Seven” illnesses thought to be psychosomatic. Research suggests that psychiatric forces may affect the clinical expression of asthma in several ways: altered awareness of airway resistance, suggestibility of airway constriction, comorbidity with panic disorder and depression.

The true picture may be somewhere in between purely physiological causes and psychological triggers. Inputs provided by the sufferer to the health care provider will play a vital role in identifying the true cause. Even though asthma itself is an organic disease there are a few variants where the clinical picture is asthma mimic. For example anxiety is a psychological problem and in its extreme it increases the respiratory rate to an extent that it resembles asthma. Co existing anxiety or panic disorder probably worsens the course of asthma. As much as 30% of persons with asthma meet criteria for panic disorder or anxiety hyperventilation. Panic disorder appears to be underestimated by doctors and its symptoms may be misunderstood as that of asthma worsening. An extremely high level of anxiety predicts increased rates of hospitalization and asthma associated deaths. It can go to an extreme of hysterical reaction again mimicking asthma.

Depression has a meaningful and negative effect on the course of asthma. Depression can lead on to breathlessness, but at the same time being chronic illness asthma itself can precipitate depression. Depressed patients tend to manage their asthma poorly.

 Another variant noticed among young female patients is the vocal cord dysfunction (VCD) where the patient present with asthma and wheezing. It is not due to bronchospasm but due to functional closure of vocal cord during inspiration. The abnormal laryngeal sound resembles wheezing or stridor. This has strong psychological association. Some VCD patient may have a comorbid psychiatric illness and traumatic childhood history that contribute to the symptoms and interfere with their care.

Conclusion:

Asthma is a chronic disease affecting 5-10% of population all over the world. This is an organic disease with definite patho-physiological changes in the body. However it can be precipitated or worsened by many psychological factors that the individual is facing even to an extent that asthma sometimes is considered as a psychosomatic illness. More over there are psychological conditions or situations where the respiration is affected and many a time this situation resembles asthma (Asthma mimics).So it is important that psychological triggers may be properly identified and corrected and at the same time asthma mimics should be segregated and considered as purely psychological illnesses and managed accordingly. Until such time medical advances throw more light on the causes of asthma, management focus will be on psychological intervention, behavioral treatment and conventional medication.