Depression and panic are important asthma triggers
Depression and panic are important asthma triggers
Screen for emotional conditions as well as environmental factors
Thirty years ago, most clinicians believed asthma attacks were psychologically induced. Then opinion changed, as studies showed environmental factors are important asthma triggers.
It seems now both assessments have merit and should be combined. Researchers are finding proof that psychological factors do have a strong bearing on asthma exacerbations and on how well patients manage their disease.
"Our attitudes toward asthma today are a combination of the old and the new," says Arlene Plansky, RNC, MSN, nurse practitioner at Boston Medical Center’s Pulmonary, Asthma and Allergy Center.
"Where 10 years ago we used anti-constrictives, we now use anti-inflammatories, but we’re also very aware of the role of emotions in asthma," she says.
A recent Canadian study confirms that the risk of death from an acute asthma exacerbation increases significantly among patients who are depressed, excited, or under stress.
Emotions can trigger fatality
As many as 10% of the general population with asthma is considered to be at risk of death from asthma attacks triggered by emotional factors, according to the study published in the Journal of Asthma in December.
While lead author Suzanne Tough, MD, admits her data cannot be considered a predictor of death from asthma, she says the research gives clinicians a heads up that emotional indicators "suggest greater risk of death." Tough is a researcher at the Calgary Regional Health Authority Division of Pediatrics and a professor of medicine at Alberta Asthma Center at the University of Alberta in Edmonton, Alberta, Canada.
Tough surveyed the families of 38 patients, ages 15 to 50, who had died of acute asthma exacerbations to discover their triggers.
She found:
• 56.3% of the patients had been under stress;
• 46.9% had been excited;
• 32.3% had seemed depressed.
A group of asthma patients who survived recent attacks also said their exacerbations were triggered by the same emotional states — stress, 35.1%; excitement, 20.6%; and depression, 13.4%.
"Clearly, depression has been found a risk factor for asthma death, but we don’t know why," says Fred Wamboldt, MD, head of the division of psychosocial medicine at National Jewish Medical and Research Center in Denver.
Wamboldt says there are theories that depression causes a set of neurochemical events in the brain that make the lungs hyperresponsive, triggering asthma events.
He also notes that depression causes a vicious cycle because "when someone is depressed, health-promoting behaviors tend to fall by the wayside and, in the case of asthma, that can mean a worsening condition."
Stress is another chicken and egg behavioral pattern, Wamboldt says, that affects behavior and worsens adherence to asthma treatment.
"How compliant can stressed out people be?" asks Plansky.
"We serve the community with the highest incidence of asthma per zip code in Mass-achusetts," she says. This is an inner city neighborhood with a high minority population, a high incidence of poverty, and high stress that comes from city life.
Plansky says the overwhelming amount of stress in the lives of many of her patients contributes to the high incidence of panic attacks she sees.
"Is it panic or asthma? Sometimes it’s very hard to determine, because it can start out as a panic attack and turn into an asthma exacerbation and vice versa. You must treat both of them," Plansky says.
She cites studies that show the incidence of panic attacks is five times higher in adult asthmatics than in the general population and she says her clinic sees more than average.
"I’d say half of them have a panic component in their asthma," she says. (See list of symptoms of panic, p. 51.)
Wamboldt says studies have shown that patients vulnerable to panic attacks have brain stem area disorders that are connected to breathing mechanisms.
"These deficits leave them with a faulty suffocation alarm that tells them when and how to breathe. That alarm can be set off by anxiety," he says.
Wamboldt says there is an apparent genetic link between asthma and panic disorder, so taking a family history can be helpful in diagnosis. "Patients with either one are more likely to have relatives with a history of respiratory illness," he says.
"A patient with asthma and a lot of anxiety should be evaluated for panic disorder," Wamboldt says.
"It’s a very real thing, it’s not all in the head," says Plansky.
Triggers and treatments
Panic attacks are triggered by what the patient perceives as a threat to breathing, like riding in an airplane, swimming, or being in a risky environment, which describes the day-to-day lives of many inner city residents, Wamboldt says.
He adds that asthmatic patients with panic disorders "tend to be very sensitive to odors and can be set off by perfume or smoke."
Plansky remembers a patient who came in with a full-blown panic attack the day after her car had been towed. "It probably wasn’t just that the car had been towed, but that was the final stressor in a life in the inner city where there is little security."
"People do not die of panic attacks. They are very treatable," says Wamboldt, who offers three treatment options:
• Breathing retraining therapy: This technique teaches patients to slow down and do deep diaphragmatic breathing to prevent hyperventilation.
• Cognitive behavioral therapy: The goal of this treatment for panic disorders is to help patients figure out ways they safely test whether their acute condition is asthma- or panic-induced. Wamboldt suggests placing an oximeter on a patient’s finger, asking him to slow down, letting him see the results.
• Pharmacologic therapy: Older tricyclic antidepressants and serotonin reuptake blockers work on the part of the brain stem responsible for panic attacks and can be helpful for some patients. (But watch for contraindications, such as patients with cardiac comorbidities.)
Plansky offers another method: "Sit them down and give them a little attention, talk quietly and get them to a place where they feel safe and comfortable."
She continues, "If you can allay their fears and calm them down, many times they won’t need medication."
[Arlene Plansky can be reached at (617) 414-6955, Fred Wamboldt at (303) 398-1827, and Suzanne Tough at (403) 270-8003.]
Panic Attack Symptoms*
racing heartchest pain
difficulty breathing
numbness or tingling
nausea
a feeling of unreality
terror
fear of going crazy
fear of dying
The presence of four of these symptoms is a positive diagnosis for panic.
* Cognitive behavioral therapy and/or pharmacologic therapy are recommended for patients suffering from depression and panic.
Source: Compiled from interviews with Arlene Plansky, RNC, MSN, Boston, and Fred Wamboldt, MD, Denver.
Questions to Determine if a Patient is Depressed
The following questions are standard guidelines for diagnosing depression and are known by the acronym SIGECAPS.
Patients answering yes to three or four SIGECAPS questions have a positive diagnosis for depression.
Sleep — Has your amount of sleep increased or decreased?
Interest — Have you noticed a decrease in your enjoyment of things that once interested you?
Guilt — Do you think everything is your fault? Specifically, do you think your asthma is your fault?
Energy — Has your energy level decreased or increased recently?
Concentration — Are you able to follow conversations, the television, the newspaper easily?
Appetite — Has your appetite increased or decreased? Have you gained or lost weight?
Psychomotor functions — Are you slowing down mentally or physically?
Suicide — Have you thought about taking your own life? Have you made plans to commit suicide?
Source: Interview with Arlene Plansky, RNC, MSN, Boston.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.