Asthma and Stress

Historical Perspective

Early references to the importance of emotional and psychological processes were put forth in a treatise on asthma by Maimonides, an influential medieval rabbi, philosopher, and physician. Sir William Osler referred to asthma as “a neurotic affection” in his medical textbook, which served as a cornerstone of medical teaching in the latter part of the 19th century. Indeed, before we understood the inflammatory basis of asthma, it was among the disorders believed to be “purely” psychogenic in origin and was commonly referred to as asthma nervosa.

Early research in this area was strongly dominated by psychoanalytic theory, an extension of the Freudian idea that symptoms were a symbolic expression of unconscious conflicts and repressed desires. The so-called specific emotion theory was developed in large part by Alexander and colleagues at the Chicago Institute of Psychoanalysis beginning in the 1930s. Concurrently, learning theorists argued that particular emotional experiences may have reinforced pulmonary physiologic responses, thus increasing the likelihood of their recurring in the same context. Eventually, purely psychoanalytic and behavioral formulations gave way to physiological studies providing more objective support for the idea that emotions play an important role in asthma. Stress and psychological factors have been associated with asthma symptomatology and with bronchoconstriction and reduction in pulmonary flow rates.

To explore potential mechanisms linking stress and asthma, it is helpful first to consider how stressors may influence disease in general and second to frame these hypotheses within the current asthma paradigm.

Life Stress Model

When faced with environmental demands, individuals appraise whether the event is threatening or potentially overwhelming to their existing coping resources. If environmental demands are found to be taxing or threatening, and coping resources are viewed to be inadequate, we perceive ourselves as being under stress. This perception is presumed to result in negative emotional states including fear, anger, anxiety, and depression. Changes in behavioral and emotional states that accompany the perception of, and adaptation to, environmental circumstances are accompanied by complex patterns of neuroendocrine and immunologic changes.

Current Asthma Paradigm

Asthma and allergic disease are understood to be chronic inflammatory processes regulated through[Page 78] immune phenomena in which many cells (i.e., mast cells, eosinophils, and T lymphocytes) and associated cytokines play a role. Evidence supports the role of complex neural mechanisms and alterations of autonomic nervous system control in the pathophysiology and symptomatology of asthma. Hormones and neuropeptides released into the circulation when individuals experience stress are also thought to be involved in regulating both inflammatory and airway responses. Furthermore, self-management of disease is a cornerstone of current asthma guidelines. Poor self-management has been linked to poor asthma outcomes. Factors important to adherence include asthma knowledge, skills, and management behavior. In addition, these variables are known to be affected by mental health, social support, and personal health beliefs and behaviors.

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