A young boy awoke one night from a bad asthma attack. As he staggered toward his parents' room, he stumbled, fell and hit his head on their bedroom door. His parents, startled at the noise, found him lying in the hallway and called an ambulance.
Even years later, the boy remembers the ambulance lights going back and forth as he lapsed in and out of consciousness. The mere thought of asthma symptoms waking him at night causes his breath to shorten and his body to tense.
Asthma and anxiety could be the terrible twosome of the airways. They share many of the same symptoms - difficult breathing, sweating, fear and feelings of palpitations - and patients' inability to discriminate between the two can complicate treatment.
Only 40% of asthma patients with an anxiety disorder are diagnosed by the medical system, while parents catch an additional 10%, said Wayne Katon, MD, professor and vice chair of the department of psychiatry and behavioral sciences at University of Washington School of Medicine, Seattle.
"It is very important to screen kids with asthma for anxiety and depressive disorders," Katon said. "If they are not effectively treated, it leads to more of a symptom burden on kids and their families."
When children have both disorders, they perceive a higher symptom burden, have less hope for treatment, are more functionally impaired and are more likely to begin smoking. Ultimately, they cost the medical system about 50% more than anxiety-free patients.1
Linking the Disorders
Little is known about the physiology underpinning the connection between asthma and anxiety. But asthma experts recognize that stress can be an asthma trigger in certain patients. When their stress response system kicks into overdrive, their airway muscles tighten and constrict, worsening wheezing and coughing.
A study led by researchers from the University of Wisconsin-Madison identified certain spots in the brain that link emotions and asthma.
Using functional magnetic resonance imaging, they traced brain activity of six participants with mild allergic asthma during three inhalation challenges.
The researchers asked participants to read words that were neutral, negative or words associated with an asthmatic episode. Asthma-related words caused increased inflammation and activity in participants' brain regions that govern emotions.
These findings "represent a previously undescribed approach to understanding the functional link between emotion processing circuits in the brain and peripheral physiologic process relevant to disease progression," the authors wrote.2 While such preliminary research is intriguing, researchers have yet to establish causality between asthma and anxiety. Katon hypothesizes that an underlying third variable, perhaps genetic, predisposes people to both disorders.
"We know that with certain medical disorders, there are clear high levels of comorbidity, and family members are often affected more commonly with all of these disorders," Katon said.
For now, health care providers must work toward recognition and assessment of patients with both disorders.
Certain anxiety disorders, most notably agoraphobia, panic disorder and general anxiety disorder, have been observed in higher numbers among people with asthma, but specific and social phobias are found less frequently than in the general population, said Eric B. Weiser, PhD, associate professor of psychology at Curry College in Milton, Ma.
Employing either the Anxiety Sensitivity Index or the Mood and Feelings Questionnaire can identify about 80% of asthma patients with comorbid anxiety, according to research from the University of Washington School of Medicine.3
The 16-item Anxiety Sensitivity Index typically is used to assess posttraumatic stress disorder, anxiety, panic and substance abuse. It evaluates patients' fear of anxiety symptoms such as rapid heartbeat, nervousness and shortness of breath.
The slightly shorter Mood and Feelings Questionnaire asks patients to determine how frequently they feel or act in ways described in 12 to 13 passages. Each questionnaire takes only about 5 minutes to administer.
"There are effective instruments out there, they are just not being used much," Katon said.
But when you have effective treatments, he added, people become more interested in picking up disorders.
Cognitive Behavioral Therapy
Psychologists have long endorsed cognitive behavioral therapy to help patients deal with their conditions.
"One reason why there is such a high comorbidity between panic and asthma is that the symptoms of panic disorder may represent conditioned responses to subtle autonomic changes that resemble symptoms of asthma attacks that perhaps occurred at a much younger age," said Weiser.
In other words, patients experience anxiety when confronted with stimuli they associate with a previous asthma attack. The stimulus varies from person to person depending on their anxiety disorder and personal experiences.
Psychologist Thomas L. Creer, PhD, now retired, worked with young patients to identify their traumatic experiences with asthma, and then he coached them to relax while thinking of these memories or during physical exposure to the stimuli. At the end of their therapy, patients could visualize their most serious attack and stay calm, Creer said.
He developed and tested these techniques combined with asthma education nearly 30 years ago through Living with Asthma, a self-management program at the National Asthma Center in Denver, Colo., now the National Jewish Medical and Research Center.
A more recent study paired similar methods to control patients' fears with asthma education and modules designed to teach patients to differentiate between asthma and anxiety4 The researchers taught subjects to tolerate anxiety symptoms by exposing them to similar sensations, said Paul Lehrer, PhD, professor of psychiatry at the University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School in Piscataway.
For example, researchers mimicked hyperventilation by having subjects breathe through a straw. This demonstrated that the sensations were uncomfortable, not dangerous, thereby helping reduce the subject's fear of the anxiety symptoms.
"When you fear them less, then you experience less anxiety and have fewer panic attacks, like the opposite of a vicious spiral," Lehrer said.
Just as importantly, the researchers showed subjects how to differentiate between those avertable anxiety attacks and asthma attacks by using a peak flow meter.
Subjects collected daily readings to determine their typical peak flow meter levels. They used these criteria during attacks to determine if they were having a true asthma attack and whether to take bronchodilators, call their health care provider, or go to the emergency room.
These practices resulted in a 50% decrease in patient's albuterol use and zero trips to the emergency room, Lehrer said. This study, however, did not contain a control group, so the researchers cannot determine whether the improvements resulted from their treatment plan or simply the passage of time.
A larger study that collected data comparing subjects' improvements in medical symptom burden and physical impairment with levels before treatment could yield better options, he said.
As interest in the interaction between stress, anxiety and asthma grows, it is likely that providers will begin to pay more attention to patients' psychological state, particularly for those with more severe symptoms or symptoms that interrupt their daily functioning.
"Anxiety and depression lead to amplification of physical symptoms so that people complain of more minor physical symptoms as if they are major symptoms than people without anxiety or depression," Katon said.
Just as health care providers teach patients to identify and cope with cigarette smoke and pet dander, stress reduction techniques can be an important component of asthma control along with the appropriate use of medication.
"The more you know and perform self-management skills, the better you are able to control any trigger whether it is emotional or otherwise," Creer said.
Kristen Ziegler is assistant editor of ADVANCE for Managers in Respiratory Care. Reach her at firstname.lastname@example.org.
1. Katon W, Lozano P, Russo J et al: The prevalence of DSM-4 anxiety and depressive disorders in youth with asthma compared to controls. J Adolescent Health. 2007;41:455-463.
2. Rosenkranz MA, Busse WW, Johnstone T, Swenson CA, Crisafi GM, Jackson MM, et al. Neural circuitry underlying the interaction between emotion and asthma symptom exacerbation. Proc Natl Acad Sci USA. 2005;102(37):13319-24.
3. Seelig MD, Katon W. Gaps in depression care: why primary care physicians should hone their depression screening, diagnosis, and management skills. J Occup Environ Med. 2008;50(4):451-8.
4. Lehrer PM, Karavidas MK, Lu SE, Feldman J, Kranitz L, Abraham S, et al. Psychological treatment of comorbid asthma and panic disorder: A pilot study. J Anxiety Disord. 2008;22(4):671-83.