Where Psyche Meets Soma in Asthma
By Bruce D. Miller, M.D.
January 1, 2002
Dr. Miller is associate professor of psychiatry and pediatrics and chief of the division of child and adolescent psychiatry at State University of New York at Buffalo, School of Medicine and Biomedical Sciences. He is also director of pediatric psychiatry and psychology at Children's Hospital Buffalo.
We began testing the ANS model using a laboratory-based, experimental paradigm that was designed to evoke psychophysiologic responses in children with asthma (Miller and Wood, 1994). Twenty-four children with moderate to severe asthma had their heart rate, respiration and oxygen saturation (pulmonary function) continuously monitored while watching a videotape of the movie E.T. The Extra-Terrestrial. Four movie scenes were targeted for analysis: the opening credits (emotionally neutral), an E.T. death scene (sad/hopeless), a scene where E.T. revives (happy/excited) and a separation/reunion scene where E.T. goes home (mixed sad/happy). Increased heart rate variability was found to be associated with increased emotional reactivity, decreased FEV1 (forced expiratory volume in one second) following the movie and increased airway reactivity to methacholine. Further findings demonstrated that, in the context of this movie, the sad/hopeless scene was associated with greater heart rate variability (an index of vagal activation) and pulmonary instability as compared to happy and neutral scenes, with intermediate results for the mixed happy/sad scene (Miller and Wood, 1997, 1994). These findings are in support of a cholinergic/vagal mechanism mediating the impact of emotions on airway function.
In a follow-up laboratory study of 22 children with asthma (ages 8 to 16; 11 male), we found that the child's triangulation in parent conflict, insecure parent-child relatedness and self-report of hopelessness all were associated with heightened vagal activation (Wood et al., 2000).
Current studies underway in our laboratory are exploring the emotion-HPA-immune pathway of the ANS model, along with emotion-ANS pathways.
The proposed model of psychophysiologic mechanisms and supporting empirical evidence suggest certain conclusions regarding the clinical approach to psychiatric and psychosocial management of asthma in children. Identification of children with asthma at greatest risk for morbidity and mortality is essential. We know that emotional states of hopelessness and despair, depression, chronic or intense emotional stress, separation and loss, and poor family functioning are all psychosocial risk factors in childhood asthma. These risk factors can be elicited by careful history taking, and family members and primary care providers can be alerted to be on the lookout for them as well.
Once such a child has been identified, intervention should be focused in the relevant areas of risk (Miller and Wood, 1991). Individual and family psychotherapy may be helpful in reducing stress or treating depression. Antidepressant medications may be helpful in conjunction with psychologic therapies (Miller and Wood, 1995). Although concern has been raised about the use of tricyclic antidepressants along with other medicines used to treat asthma (Wamboldt et al., 1997), I find that TCAs may have an added benefit because of their direct anticholinergic effects. However, side effects need to be carefully monitored. The selective serotonin reuptake inhibitors also may be used to treat depression and anxiety. Heavily sedating medications, however, may augment vagal effects and thereby compromise airway function and should be used with extreme caution, if at all, in treating psychiatric symptoms in asthma.
The most important consideration in treating a child or adult with asthma is to be cognizant of stressful life events and situations, quality of family relationships, and emotional status of the individual patient. In treating such patients, it is important to be prepared to coordinate biologic, psychologic and family intervention when indicated and to collaborate knowledgeably and respectfully with the treating physician.
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