Behavioral factors in asthma.

Abstract

Asthma is a chronic airway disorder of increasing interest to behavioral psychologists in past decades. Despite treatment advances, increases in asthma morbidity and mortality, particularly among Hispanic and African American persons, continue to be a major public health concern. Several behavioral factors have been identified as having an impact on the development, presentation, management, and treatment of asthma. Our review summarizes the state of knowledge in several of these areas, including social-operant processes, treatment adherence, environmental control, symptom perception, self-monitoring, physician behavior, and the effects of comorbid psychopathology. We also discuss cultural and other contextual factors that may influence asthma-related outcomes. ********** Asthma is a chronic airway disorder that affects over 15 million people in the United States alone. The major characteristics of asthma include airflow obstruction, bronchial hyperresponsivity, and airway inflammation. Despite continuing advances in the understanding of asthma pathophysiology and the development of new and better treatments, the prevalence, morbidity and mortality from asthma have risen steadily in industrialized countries over the past decades. In the United States, the prevalence rate for self-reported asthma increased nearly 60% between 1982 and 1996 and 123% between 1982 and 1996 for persons aged 18-44 years (Centers for Disease Control and Prevention (CDCP), 1992; 1995; 1998). Age-adjusted rates of death by asthma have more than doubled over the past 25 years, to over 5,000 per year (CDCP, 1998; Kussin & Fulkerson, 1995). Numerous factors have been proposed to explain increases in asthma, including worsening air quality, changes in diet, allergen exposure, immunizations, decreased exposure to childhood diseases, and other lifestyle changes such as increased sedentary indoor activities. In addition to the increased prevalence of asthma over the last quarter century, treatment outcomes for asthma continue to fall short of nationally established guidelines. For example, over 2 million emergency room visits and over 500,000 hospitalizations are made in the United States every year for asthma problems (CDC, 1998). Recent national surveys of adults and parents of children with asthma estimate that over 25% of persons with asthma made three or more unscheduled visits to their doctor, went to the emergency room, or were hospitalized for their asthma during the year (American Lung Association, 1998; Glaxo Wellcome, 1998). The National Heart, Lung, and Blood Institute (NHLBI) Expert Panel guidelines (National Heart Lung and Blood Institute, 1997) list having minimal or no need for urgent care visits or hospitalization as a goal for asthma management. Furthermore, while another NHLBI panel goal is for persons with asthma to be able to maintain normal activities levels, about onethird of asthma patients report limitations in lifestyle and daily activities from their asthma (American Lung Association, 1998; Glaxo Wellcome, 1998). It is likely that many factors are responsible for the divergence between desired and actual outcomes in asthma. Behavioral issues, including lack of treatment adherence by patients, physician failure to adhere to treatment guidelines, and poor doctor-patient communication skills, have been shown to contribute to the current state. We will review these and other behavioral factors that affect the development, presentation, management, and treatment of asthma. Pavlovian Conditioning As early as Sherrington's classic experiments (1900), changes in respiratory activity elicited by the conditional pairing of stimuli with agents that produce respiratory effects have recently been the focus of an increasing number of studies (see Ley, 1999, for an excellent review). However, a growing body of research suggests that Pavlovian conditioning could play a role in asthma symptoms. …