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Man can do without food for weeks, without water for a few days. A few minutes without air, however, means death. Experiencing shortness of breath is associated with strong feelings of anxiety and panic. In this research paper, the three most prevalent respiratory disorders will be discussed, from a behavioral and social science perspective.
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1. Asthma, Chronic Bronchitis, Pulmonary Emphysema
In order to understand the relevance of the contribution of behavioral and social sciences to the study of patients with respiratory disorders, in this paragraph deﬁnitions of asthma, chronic bronchitis, and emphysema, and risk factors, epidemiology, and medical management will be discussed brieﬂy ﬁrst.
Asthma is derived from Greek, meaning ‘panting or distressed breathing.’ A universally accepted deﬁnition of asthma is not available, reﬂecting changing views over time in the area of pulmonology and gaps in the knowledge about the precise nature of asthma. Learned societies in the US, the UK, and in other countries proposed various deﬁnitions in an attempt to standardize epidemiological studies and diagnostic and therapeutic medical strategies. One of the most comprehensive deﬁnitions of asthma is given by the American Thoracic Society: Asthma is a clinical syndrome characterized by increased responsiveness of the tracheobronchial tree to a variety of stimuli. The major symptoms of asthma are paroxysms of dyspnea, wheezing, and cough, which may vary from mild to almost undetectable, to severe and unremitting (status asthmaticus)’ (ATS 1987, http://www.ginasthma./com). Three characteristics stand out: Asthma is deﬁned as reversible, intermittent, and variable. The episodes of airways obstruction causing dyspnea (shortness of breath) either disappear (are reversible) spontaneously or as a consequence of adequate medical, pharmacological treatment. Attacks of asthma vary in their occurrence over a certain period of time—some patients experience asthma attacks almost daily, some only once a year—and the severity of the episodes of shortness of breath varies within and between patients.
Chronic bronchitis is deﬁned in behavioral terms: ‘The presence of chronic productive cough for three months in each of two successive years in a patient in whom other causes of chronic cough have been excluded’ (ATS 1995). Patients who fulﬁll criteria for the diagnosis of chronic bronchitis cough frequently and produce sputum over extended periods of time, and may be short of breath. In contrast to asthma, chronic bronchitis is an irreversible medical condition.
Eliminating the most important risk factor—smoking tobacco—reduces the symptoms and severity of the disorder somewhat without leading to a complete reversal of the condition of the lungs and their airways. Pulmonary emphysema is deﬁned in terms of anatomic pathology as ‘abnormal permanent enlargement of the airspaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious ﬁbrosis’ (ATS 1995). In patients with emphysema continuous shortness of breath is the most important symptom, almost always associated with signiﬁcant impairments in the ability to perform activities of daily life. Here, as is the case in patients with chronic bronchitis, smoking tobacco is the major cause of the disorder.
Over the past decades, pulmonologists, epidemiologists, researchers in related medical domains, and behavioral and social scientists viewed asthma, chronic bronchitis, and emphysema as three related disorders. Despite the differences between the three disorders, the rather similar consequences (shortness of breath, coughing, producing sputum) formed the basis for this ‘lumping view.’ More recently, the advocates of a ‘splitting view’ dominate the scientiﬁc arena. Differences in the views on causation and pathophysiological bases of the disorders are responsible for this change (Vermeire and Pride 1991). This is why asthma will be discussed separately from chronic bronchitis and emphysema. These last two disorders usually are subsumed under the heading Chronic Obstructive Pulmonary Disease (COPD), deﬁned as ‘a disease state characterized by the presence of airﬂow obstruction due to chronic bronchitis or emphysema’ (ATS 1995, http://www.goldcopd.com).
2. Epidemiology And Some Medical Characteristics
The prevalence of asthma varies between different studies in different parts of the world because of differences in the deﬁnition of asthma. Large differences in data on prevalence of asthma are also attributable to differences in genetic susceptibility and environmental conditions. Asthma has a clear genetic basis: Chances for a child, conceived by a man and a woman who both are asthmatics themselves, of being asthmatic are about 75 percent. Environmental stimuli appear to play a role in worsening asthma symptoms. However, air pollution as such does not appear to be a factor that causes asthma. Interestingly, a recent study in Germany demonstrated that the prevalence of asthma in the more polluted Eastern part of Germany was lower than in the Western, more highly developed, and less polluted, part of the country (Nicolai and Von Mutius 1997). This has led researchers to hypothesize about the ‘hygiene effect’: Having young children growing up in a relatively unpolluted environment, with a high level of sanitation (i.e., low chance of exposure to germs causing ﬂu and colds) predisposes a child to a higher chance of being sensitive to relatively low levels of allergens and respiratory infections, increasing their chances to develop asthma.
The prevalence of asthma is about 7 percent in the US, about 15 percent in the UK, about 1 percent among Inuits, and about 30 percent among inhabitants of Tristan da Cunha, an island in the southern part of the Atlantic ocean between South America and Africa (Gergen and Mitchell 2001). The prevalence of asthma is increasing, especially in industrialized countries. The reasons for this are largely unknown. The increased attention by physicians for a possible diagnosis of asthma in a patient with respiratory problems probably is a contributing factor in the increase of asthma prevalence: Asthma used to be underdiagnosed and undertreated (Kaptein et al. 1987). In young children, boys outnumber girls in prevalence of asthma in a ratio of about 2:1. In adult patients, hardly any sex ratio differences are observable in the prevalence of asthma. Contrary to popular beliefs, one hardly ever outgrows one’s asthma, ‘one only outgrows one’s pediatrician.’
2.2 Chronic Obstructive Pulmonary Disease (COPD)
The prevalence of COPD is about 5 percent (ATS 1995). Recent studies predict considerable increases in the prevalence of COPD (Murray and Lopez 1997), with COPD becoming the third leading cause of death in the future. Despite reductions in the number of smokers of tobacco in industrialized countries, the post-World War II generation with their smoking habits of decades, will fall victim to becoming patients with COPD. Also, as the number of women who smoke cigarettes increased substantially after World War II, COPD will no longer be an illness for men only.
Chronic bronchitis has 50 years of age as the average age of onset, emphysema sets in at around 60 years of age. COPD has a SES-gradient, with a lower socio- economic class dominance. COPD can be labeled as a blue-collar worker disorder due to the fact that poor housing and working conditions contribute to developing COPD.
The great majority, about 80 percent, of patients with respiratory disorders are seen by the general practitioner (or primary care physician, family physician). Based on critical views and evidence on the quality of care provided by these physicians to patients with asthma in particular, considerable effort has been devoted to improving this quality. In many countries, societies of general practitioners developed guidelines on the optimal management of patients with asthma. In these guidelines early diagnosis, aggressive medical treatment, and a great emphasis on teaching patients self-management skills are the cornerstones of modern management of asthma. Similar guidelines have been developed for the management of patients with COPD in a primary care setting, with an emphasis on stopping smoking techniques.
The remaining 20 percent of patients with respiratory disorders are seen by medical specialists: pulmonary physicians, allergologists, pediatricians. Only a very small percentage of patients is being managed on an in-patient basis—for status asthmaticus in patients with asthma, for severe respiratory problems in patients with COPD. In various countries in the world, specialized long-stay respiratory clinics provide care for those patients with asthma and/or COPD in whom the intractability combines with severe psychological and social problems.
3. Asthma And Psychology
Looking back over some 100 years of behavioral and social science research on patients with asthma, one cannot help but be impressed by the gains that have been made, gauged in terms of behavioral outcomes for these patients. Three periods in this line of research and clinical care can be discerned.
3.1 Psychosomatic Views On Asthma
Between World War I and World War II, psychosomatic views on various psychosomatic disorders and illnesses represented an inﬂuential line of research of clinical care. Given the unknown etiology of a number of major diseases (e.g., hypertension, diabetes mellitus, and asthma), theories were developed in which it was postulated that psychological factors played a substantial role in causing a number of speciﬁc illnesses. With regard to asthma, a combination of three factors was supposed to be a necessary and sufficient condition: (a) a ‘weak spot’ in the body of the patient, (b) a characteristic psychological proﬁle of the patient, and (c) a situation eliciting the illness.
Patients with asthma were supposed to have a respiratory system which was sensitive to disruptions. In addition, due to faulty mother–child interaction in the early years of life, a speciﬁc personality proﬁle was assumed to be established in the patient: A combination of excessive love of the mother for the child (‘smothering with kisses’) and an unconscious wish of the mother to reject her child, was supposed to render the child sensitive to asthma. In the event of a stressful life event (e.g., being separated from the mother, experiencing social conﬂicts), an asthma attack would happen.
Empirical evidence for these psychosomatic views is lacking. No study identiﬁed the supposed mother– child psychopathology put forward by the theory. Psychosomatic therapy (i.e., psychodynamic interventions) failed to demonstrate any positive effect. It is safe to state that the highly selected sample of patients with asthma seen by the theorists (psychiatrists and specialists in internal medicine) represented patients who exhibited psychosocial problems as a consequence of having to cope with the adaptive tasks of having severe, brittle asthma.
3.2 Psychological Consequences Of Asthma
The second theoretical and empirical approach to asthma from a behavioral and social science perspective focused on the consequences of asthma on the daily lives of afflicted patients: their quality of life. Using disease-speciﬁc questionnaires with adequate psychometric properties, limitations in functional, psychological, and social domains were identiﬁed. Asthma patients experience excessive absenteeism from school and work, heightened levels of anxiety and depression, and feelings of social isolation (Maille et al. 1996).
The ﬁrst studies on the effects of psychological interventions in order to reduce the limitations caused by asthma adopted a learning theory perspective: relaxation training, biofeedback, and systematic desensitization. In these studies, pulmonary function was the major outcome measure. The effects of behavioral interventions turned out to be limited, however (Lehrer 1998).
The research performed by a group of psychologists in Denver, Colorado, USA, in the 1970s and 1980s set the scene for the third phase in psychological research on patients with asthma. Kinsman et al. (1982) demonstrated how the affective and cognitive responses of asthma patients to their illness and symptoms predicted important outcome measures such as length of hospitalization and rehospitalization, irrespective of the medical severity of the respiratory condition.
3.3 Self-Management Training
A logical next step, given the evidence for the impact of the psychological response (coping behavior) of patients to their asthma, pertains to teaching asthma patients to optimize their handling, or self-management, of the disorder. Creer (1979) represents the ﬁrst psychologist who studied the effects of this type of intervention in children and adults. In self-management training, patients with asthma are taught skills to perceive the ﬁrst signs of periods of shortness of breath, take appropriate action to prevent or control episodes of shortness of breath, and manage bouts of asthma if they occur. Reviews of the effects of self-management training report reductions in symptom frequency and severity, use of medical resources, and fewer disruptions of daily life (e.g., absenteeism from school or work, levels of anxiety) (Clark and Gong 2000).
Current research on asthma by psychologists focuses on reﬁning self-management training, symptom perception, and the effects of emotional expression on pulmonary function (Smyth et al. 1999).
4. COPD And Psychology
In contrast to the considerable amount of research performed by psychologists and social scientists on patients with asthma, patients with COPD have been the subject of research from this perspective only relatively recently. There are at least two reasons for this. The impact of smoking tobacco, the major cause of COPD, has become clear only after World War II; psychologists and social scientists joined medical professionals in their therapeutic pessimism for decades. The ﬁrst empirical study on the psychological consequences of COPD was published only in 1961.
No psychosomatic theories were developed on patients with COPD. Studies on the neuropsychological consequences demonstrated that severe grades of COPD negatively affect cognitive functioning of patients. Depression, fatigue, and feelings of social isolation are the dominant psychological and social consequences of COPD. Restrictions in daily activities, absenteeism from work, early retirement, and invalidity are major functional consequences of COPD. The quality of life, therefore, of patients with COPD is signiﬁcantly lower than in healthy persons (Kaptein and Dekker 2000).
Psychologists contribute to the care for patients with COPD in two areas: pulmonary rehabilitation programs and self-management training. Pulmonary rehabilitation pertains to ‘an art of medical practice wherein an individually tailored multidisciplinary program is formulated which through accurate diagnosis, therapy, emotional support, and education stabilizes or reverses both the physio-and psychopathology of pulmonary diseases and attempts to return the patient to the highest possible functional capacity allowed by his pulmonary handicap and overall life situation’ (Ries 1997). Physical therapy, breathing exercises and training, smoking cessation techniques, graded exercise aimed at improving ambulation, and coping skills training usually are parts of pulmonary rehabilitation programs. Reviews and meta-analyses of the effects of these programs indicate that use of health services, limitations in daily activities, and psychological problems tend to be reduced to some degree (Kaplan and Ries 2001). High dropout percentages, however, are the rule. Identifying the separate contributions of the various components in pulmonary rehabilitation programs to various outcome measures is not feasible, however.
The current emphasis in health psychology research in COPD focuses on teaching patients self-management skills. Cognitive behavior modiﬁcation techniques are used to alter nonadaptive cognitions and behavior. In a study of patients’ pessimistic self-statements (‘I can’t walk very far without getting short of breath, so what’s the use?’) were addressed and altered into more active ones (‘This walking is uncomfortable, but I can handle it. Soon I will be able to walk farther.’). Results showed that levels of exercise tolerance and quality of life increased in comparison to various control conditions (Atkins et al. 1984).
Increasingly, guidelines on the medical management of patients with COPD include results of psychological research on self-management (ATS 1995). This development is positive: it reﬂects how pulmonary physicians acknowledge the relevance of topics such as compliance or adherence, and incorporating self-management into clinical care. Patient empowerment is instrumental for the wellbeing of patients with this chronic respiratory disorder.
Future research efforts will strengthen the position of patients with COPD. Health psychologists who work in the area of COPD face many challenges. Smoking cessation is a primary subject for health psychologists and other social scientists, given the psychological and societal determinants of smoking tobacco in particular. Simplifying self-management skills and incorporating the teaching and uptake of these skills into medical care are additional challenges. COPD is an under-funded medical disorder (Gross et al. 1999). Future research both from a medical and a psychological perspective will help in preventing COPD to develop, and in improving quality of life in patients with COPD.
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