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The Curious 2000-Year Case of Asthma

From The Family Therapy Institute of Alexandria, Alexandria, Virginia.

Address reprint requests to: Dr. M. Banks Gregerson, The Family Therapy Institute of Alexandria, 220 S. Washington St., Alexandria, VA 22314-2215. Email: oltowne{at}aol.com

	ABSTRACT

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Millions worldwide have asthma, with the numbers succumbing increasing sharply in the past two decades. After 2000 years of scientific study, who succumbs to asthma when is as puzzling as who regains health when and how. The discipline of psychosomatic medicine and science investigates and treats diseases like asthma that typically confound general medicine. Still psychosomatic medicine, like general medicine, only manages but does not remedy asthma, which can currently only be in remission but not cured. This historical review reveals the progress and missteps that have been made in the study and treatment of asthma by comparing the general medicine approach with the major research findings on asthma published over 60 years in Psychosomatic Medicine. Research has identified antecedent, collateral, and subsequent factors to scientifically describe and control this disease in terms of diagnosis, management, and treatment. Paradoxically and regrettably, the prognosis for those with asthma is worse than ever. Curious also that a noninfectious disease should spread so rapidly and mostly for specific groups identified by variables like age, gender, ethnicity, and socioeconomic status. Furthermore, partial, not full, family concordance indicates merely genetic influence, not determination. General medicine now focuses on enumerating the range of environmental and situational triggers, or stimuli, producing asthma and describing the pathophysiology of bronchial inflammation. With a more comprehensive multifactorial approach, psychosomatic medicine seems well suited to investigate further the physiological, psychological, social, and environmental factors implicated in this medical conundrum. A future challenge for psychosomatic medicine is to stem the tide of rising prevalence and cure the disease of asthma.

Key Words: asthma • psychosomatic medicine • review of literature, • multifactorial model, • theory • method.

Abbreviations: APS = American Psychosomatic Society; SES = socioeconomic status.

	INTRODUCTION

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The discipline of psychosomatic medicine and science (1–3) investigates and treats diseases like asthma that typically confound general medicine. For more than two millennia medicine has recognized, although not always accurately comprehended, asthmatic symptoms. Curious, after all this time, that neither cause nor cure is known, although asthma management has become increasingly effective (4–7). Psychosomatic science pursuing a cure for asthma has investigated asthma treatment, etiologies and development, mechanism, and management (8–22). After 2000 years of psychosomatic study, our best efforts only manage but do not remedy asthma nor pinpoint its causes (23, 24). To better navigate toward a future solution, this historical review of the asthma literature recounts progress and missteps during the 60 years the APS has published their flagship journal, Psychosomatic Medicine.

Found at all ages and in all races, asthma refers to episodic breathing difficulties that sometimes result in dysfunction, severe disability, and even death (25). Around 200 BC the Greek physician Aretaeus described the symptom of panting or grasping paroxysms by coining the term from which the word "asthma" is derived (26).

Who succumbs to asthma when is as puzzling as who regains health when and how. Today asthma undermines the quality of life for millions and literally stifles countless lives worldwide (27–29). Asthma epidemiology in the United States raises many more questions than provides answers (7, 27–51) (see Table 1). Epidemiological shifts worldwide echo these US patterns (49).

Moreover, personal characteristics like ethnicity and age evidence inconsistent asthma patterns. Some ethnic groups (ie, Native Americans) have lower incidence rates, whereas others (ie, African-American and Hispanic) have higher rates (24, 27–29, 31–33, 35, 36, 39, 42–51). Most frequently females older than 45 and males aged 16 to 44 years have asthma remissions (42). Yet children, too, can be in remission. It is difficult to set a criterion for "cure" if we do not know definitively what causes asthma. Researchers need to carefully partial out the relative influences of age, gender, ethnicity, geographic region, and SES to move forward the asthma discussion from description to mechanisms (52, 53).

By now researchers can describe associations, effects, and influences without attempting to definitively explain mechanisms. For instance, having parents with asthma is the most potent predictor that a child will become asthmatic (42, 54, 55). Genetics is a popular, convenient explanation for this familial transmission (39, 56). Yet only partial, not full, family concordance indicates merely genetic influence, not complete causation.

Research on causal mechanism of asthma symptoms currently centers on the role of inflammation (57, 58). Yet even this approach simply describes the course of asthma or may simply be histamine priming antecedent to the initial asthma attack (59, 60). Furthermore, general medicine has developed an ever-burgeoning typology (8, 57) (see Table 2) based mostly on what triggers, or produces, asthma. On the other hand, research in psychosomatic medicine has focused on the phenomenology, personality, and interpersonal antecedents to and effects of an asthmatic attack. Today we need to put together comprehensively the social and physical environmental triggers, the basic genetic material producing vulnerability to asthma, and the psychological findings.

A historical view shows us best where not to go. We have no need for historical red herrings to reappear. For example, physicians like Oliver Wendell Holmes and William Osler at the turn of the last century termed asthma a symptom of health (57, 61, 62). Asthma was thought to indicate that a patient would recover from rather than expire from a fevered infection. Osler termed asthma "all in the mind" (61) and "a slight ailment that promotes longevity" (57). Then, one crucial scientific study shifted the medical zeitgeist by demonstrating 21 fatal cases of asthmatic lung disease (63). This dramatic reversal demonstrated the fundamental corrective role of science for medicine.

What scientific description of asthma has withstood the historical test of time? History, or the erosion over time of anomalous data, provides another type of epistemological proof for testing scientific findings for truth. The continued scientific pursuit of answers for the case of asthma receives strong support from the productive, if mostly descriptive, body of research published in Psychosomatic Medicine. So, this selective rather than exhaustive review on asthma research summarizes Psychosomatic Medicine findings from original empirical articles and literature reviews as well as conference abstracts and reviews of books and articles published elsewhere. Enduring developments in both concepts and methods relevant to asthma are highlighted.

	CONCEPTS AND METHODS IN ASTHMA RESEARCH FROM GENERAL AND PSYCHOSOMATIC MEDICINE

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Concepts
On one hand, some medical experts question whether asthma is psychosomatic. On the other hand, others find asthma anomalous to a definitive biological explanation. Such medical anomalies are precisely the province of psychosomatic medicine. The psychosomatic conceptual framework for asthma has changed.

Psychosomatic conceptual models of asthma have evolved from the relatively unsatisfying and untenable single solutions to a more comprehensive and inclusive multifactorial framework. In asthma research during the initial years of Psychosomatic Medicine, a psychological approach (9, 10, 20, 64–98) (see Table 3) predominated over a biological one. The specific psychological theory investigated was psychodynamic and psychoanalytic. Researchers searched for both the effects of and internal conflicts that purportedly cause asthma. A single root cause was hypothesized.

Oftentimes today etiologies other than allergies take precedence (27, 111), although none have been proven. Throughout the history of Psychosomatic Medicine, researchers in asthma investigated self-perceptions of symptoms (9, 77, 112–118) and then family factors (85, 119–122). Recently the focus shifted from cause to cure by examining treatment outcomes for individuals with asthma (8, 10–22, 102, 123). When many treatment outcome studies produced mixed results, researchers began questioning whether unidentified subgroups of asthmatic patients obscured any apparent benefits some asthmatic patients demonstrated (124).

Little agreement or acceptance exists, though, for a "gold standard" typology (see Table 2 for two current typologies). For instance, since 1940 (25), general medicine textbooks have defined extrinsic and intrinsic types of asthma. Except for brief mention in a few well-conceived studies (66, 117), psychosomatic research omits this extrinsic/intrinsic dimension while emphasizing psychological aspects. If the psychosomatic reader familiar with psychosomatic asthma research must ask what the "extrinsic/intrinsic" distinction is, then the point about lack of agreement for any one typology makes itself clear. In extrinsic asthma a trigger external to the person can be identified, whereas intrinsic asthma has no identifiable external trigger.

Yet the typology effort, whether biological or psychological, may be based on a "straw man" supposition. Many different initial stimuli could act through the same basic mechanism to produce an asthma attack. In function-oriented systems parlance, what the component is is not as important as what the component does. A focus on initial stimuli adds unnecessary complexity where parsimony would be preferred. All these triggers are just that, triggers tripping off an asthma attack. It is of use to list the range of triggers but not to base entire categories on them.

Although general medicine has seriously considered biologically based typologies of asthma, psychosomatic medicine has developed relatively more sophistication in the psychological dimensions. The psychology in psychosomatics research, though, has only recently evidenced the multifactorial trends in general psychology science that consider both psychosocial factors and biology in addition to the physical environment. The relative emphasis on biology OR psychology seems to divide general medicine from psychosomatics in terms of asthma conceptualization.

As true and complete psychosomatic scientists, we have a responsibility to speak the language of both general medicine and psychology. Some of us do this very well. A few talented and formidable scientists managed to produce publications on asthma using both psychological and biological approaches (11, 16, 79, 82, 99, 101, 102, 112–117, 125–135) (see Table 4). Expertise in psychology and biology is the hat trick of psychosomatic medicine.

For example, in the 1950s after Hans Selye (136) published general stress theory, the number of Psychosomatic Medicine articles on asthma almost tripled. Asthma etiology, if mentioned, is uniformly presumed a diathesis-stress model of disease. The diathesis is a genetic inheritance of bronchial hypersensitivity (58–60). The stress (136) is presumed to be a desynchronization (137) of body cyclic systems due to interference from the environment (138–148). This diathesis-stress model is multivariate, being both genetically and environmentally determined (138–148).

A term like "stress" has stirred concurrent interest in medicine and psychology, creating new fields (149, 150). For examples, over 60 years the 14 subtopics under asthma in an 1897 medical text (151) modestly rose to 25 in a leading 1940 text (25). But now, 50 years after Selye’s stress theory emerged, entire texts are devoted to specific stress-based diseases such as asthma and their subtopics (eg, food allergies) (152). Psychosomatic Medicine also fielded a respectable number of articles based on stress theory (14, 16–18, 21, 74, 102, 103, 124, 129, 153–156). Contemporaneously the journal published a solid amount of research on the psychophysiological approach to understanding and improving asthma conditions (10, 12, 13, 69, 70, 88–101, 105–110, 123, 157–159). The psychosomatic view of asthma had moved from the single- to the dual-factor approach, with interest increasingly comparable in psychology and biology.

With steady interest in psychology, 50 years of Psychosomatic Medicine studies examined treatment outcomes (9–20, 22) and social influences and effects (71, 85, 119–122). Specific psychological treatments investigated include psychoanalysis (66, 69), relaxation therapy (14, 18), hypnosis (11, 12, 15), conditioning (16, 17, 21, 22), and psychotherapy (10, 19, 20). In the APS literature on asthma, interpersonal or social factors like the mother-child relationship or family function (71, 85, 119–122) have already proven significant predictors of asthma prevalence, morbidity, and mortality. Recent regrettable APS neglect of familial factors does not reflect other psychosomatic researchers’ interest in such social factors (160–163). If research loses this larger social nexus, then conceptual atrophy will occur as the psychosomatic field moves backward. The drive to better manage, to prevent, and to cure asthma may be unfulfilled until APS researchers reclaim this part of the field.

In the third and fourth decade of Psychosomatic Medicine, George Engel’s biopsychosocial model (164–168) justified and stimulated research consideration on three levels: the body (bio-), the mind (psycho-), and the societal context (social). The general medicine asthma field is moving toward an even more complex level, that is, the multifactorial approach. Besides reinvolving the social environment so that psychosomatic medicine maintains the integrity of the biopsychosocial approach, adding the physical environment completes the multifactorial asthma model (138–148, 169). Now the decade of the environment, whether social or physical, may be imminent.

No asthma article in the history of Psychosomatic Medicine has examined the physical environment even though, as stated before, a long tradition studied the social environment. Special conference workshops and other venues like curriculum development may access the burgeoning field of environmental science for APS researchers. Other asthma research outside psychosomatic medicine is now considering the physical environment in addition to other psychosocial factors.

For example, in one study (as reported in Ref. 4), the more impoverished group had the most significant relationship between asthma severity and the trigger of cockroach sensitivity. Caucasians had a lower cockroach sensitization rate than African Americans, either due to a lower rate of exposure or to differing genetics. Sensitivity to the American cockroach best predicted asthma severity with sensitivity to the German and Oriental cockroaches secondary predictors, perhaps because of cross-reactivity. Furthermore, those with a higher income level had higher exposure to dust mite Dermatophagoides farinae. Experts postulate that differences in SES may result from differences in housing structure, furnishings, and floor coverings. Yet lifestyle factors, like a busier schedule that interferes with routine, light cleaning (like dusting) but not deeper hygienic cleaning (that prevents cockroach infestation), might also account for such findings.

Other differences, like practitioner responses, may need to be considered, too. For instance, in one study SES determined whether the primary physician referred adolescents with asthma to a specialist or prescribed the necessary but more expensive steroid medication (38). This SES inequity proves quite harrowing because early steroid use has been associated with decreased mortality due to asthma (35). Whether steroid nonuse is a direct cause of asthma or a mediator of a third variable like SES has not been determined. What can be said, though, is that social environment, health care, and asthma outcome seem to be connected.

Research provides certainty that some factors are associated with asthma but does not provide a widely accepted causal sequence. Axiomatically causation first and foremost requires correlation. Where a correlation does not exist neither can causation unless it is indirect. Then, discovering the third variable, like SES, becomes crucial. If we are confident in our methodology, then the wisest course would be one of two courses: 1) the documented correlations, eschewing the nonassociations or "nonlinks," or 2) a multifactorial system that also considers indirect links.

Such conceptual transformations from a biopsychosocial to a multifactorial systems model indelibly influence research in a number of ways. Sometimes new concepts elicit new methodologies. For example, problems with multiple variables like those from psychosomatic medicine resulted in the development of multivariate statistics. Sometimes improvements in research technology elicited new concepts. Structural modeling has allowed more consideration of simultaneous rather than linear causal patterns. The technical infrastructure of science as shown in this 60-year-old body of Psychosomatic Medicine literature reveals both method driving theory and the reverse.

Methods
Psychosomatic Medicine publications on asthma have reflected clinical and scientific technology changes over the past six decades. After the first decade of psychosomatic literature on asthma, the field started using technological biological advances such as skin sensitivity tests (89), respiratory rate and tidal volume (97), and total respiratory resistance (74). After the trifurcation of psychosomatic theory (ie, psychodynamic, emotions, and stress; Refs. 2, 3), the method of psychosomatic scientists segmented into either those of biology, as just stated, or psychology, as noted next.

Psychological science singularly uses psychometrics (170–172) and the finely honed craft of psychological experimentation (173–176). Table 5 (11, 12, 14, 15, 17, 18, 22, 56, 85, 93, 99, 100, 101, 120, 121, 130, 132, 111–113, 115, 116, 123, 130, 132, 158, 176, 177) summarizes the wide variety of methodological skills included in this body of Psychosomatic Medicine literature. Methods for the earliest psychosomatic studies relied on psychodynamic clinical tests like the Rorschach (83, 86, 177) and later work-involved trait theory (11, 99, 102, 112–116, 133, 134) as well as behavioral observations and self-reports (117, 135). Lastly, modern systemic approaches emphasize a multifactorial model of the complex interplay of biology, psychology, and, most currently, both the social and physical environments (138–148, 168, 169, 174).

	ALLEVIATING ASTHMA

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View larger version (19K): [in this window] [in a new window]   Fig. 1. A systems analysis of the case of asthma. Octagons indicate the physical environment; ovals, the social environment; diamonds, psychology; and rectangles, physiology.

View larger version (23K): [in this window] [in a new window]   Fig. 2. A systems analysis of the case of asthma.

An easily grasped metaphor pictures the deconstruction of the multifactorial system telescoping from the "macro" to the "micro." Analysis moves from the macro physical surroundings to the interpersonal and group social environments to more immediate psychological factors to the "micro" physiological variables. This examination of each dimension precedes their resynthesis (see 139, 141, 143, 148, 168, 169) for further multifactorial systems explanations.

The Physical Environment System
In the physical environment, efforts to mitigate asthma include social engineering, hygiene practices, and a continued search for clues in our built and natural surroundings. Social engineering efforts, like smoke-free restaurants, planes, and office buildings, may allay risk factors like secondary tobacco smoke. Hygiene practices include pragmatic advice to make a child’s bedroom free of house dust mites (178). The natural environment’s ozone levels, though, are not thought to be a cause of asthma because no parallel uniform worldwide rise in asthma has occurred (41).

Many unknown influences on asthma from the physical environment still remain undiscovered. Application of current and future advances in experimentation technology and understanding of environmental sciences could benefit the field of asthma research and care.

The Social Environment System
Telescoping to the social environment, though, has already proved fruitful to pinpoint psychosomatic discoveries describing differences among asthma sufferers. Evidently, as noted earlier, ethnicity and SES predict asthma prevalence, morbidity, and mortality. More immediate social relationships, like those between siblings and between parents and children, somehow contribute to asthma. One new research challenge is to establish the efficacious use of this information to alleviate asthma. Are these factors caused or causal?

The Psychological System
The psychological dimension also has ample evidence that supports continuing such asthma research. Psychodynamic considerations have proved less useful than emotion and stress factors. For example, panic is a hallmark of asthma phenomenology, both as prodromal and antecedent to an attack. Techniques that have effectively controlled panic have been successfully transferred into controlling asthma (14, 18). As enumerated earlier, clinical research has documented effective therapy programs for individuals to control asthma symptoms, adhere to therapeutic regimens, and improve quality of life. Success of the diverse psychological treatments investigated thus far strongly encouraged further refinement. Psychology systems have important roles in precipitating and in responding to asthma. Their role in primary prevention is less well understood.

The Physiological System
Physiologically, modern Western treatments effectively manage and may even avert asthma mortality. The one universally accepted aspect of asthma is its biological underpinnings, with bronchial inflammation currently the most popular causal dimension being studied. The fact that asthmatic attacks can be precipitated by nonbiological stimuli, such as simply recalling a recent attack, implicates more than just the biological system in asthma (168).

Early steroid treatment for children predicts symptom-free adult years (35). Treatments include bronchodilators with ß-adrenergic agents or theophylline, antiinflammatory agents like systemic corticosteroids or inhaled corticosteroids as well as other anti-inflammatory drugs, receptor antagonists of antihistamines, anticholinergics, or other receptor antagonists or mediator synthesis inhibitors (57, 179).

Concomitant with these biological advances in treatments, the discerning eye of research has also improved basic diagnostic criteria in the case of asthma. Mathison (8) provides easy access to the standard diagnostic interview, an approach to asthma history-taking, and a severity-level schematic. Children, in particular, require specialized diagnostic and treatment considerations (179).

So, psychosomatic and general medicine research has provided much data showing connections between various lifestyle dimensions and asthma. Much more has yet to be established as we move into the next millennium. The multifactorial systems model can prove a useful guide for future empirical research designs (148), as can research reviews (168) like the current treatise.

	SOLVING THE 2000-YEAR-OLD CASE OF ASTHMA

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The tide of asthma mortality seems to stem from more and better diagnosis and management techniques. Furthermore, the apparent gaps in psychosomatic research should guide future research. Investigations should continue to move beyond description into intervention and then beyond management into etiology and cure.

As the psychosomatic knowledge on asthma systematically mounts, asthma may be found to permeate every system in a person’s life. Because effects can reverberate on all levels, causes could be on any one level, simultaneously on some levels, or perhaps on all of them systematically (138, 141, 143, 148). If the latter is the case, then asthma would be better termed a syndrome than a disease (57). Do we need to know the cause to cure asthma?

Perhaps what research has investigated in the past was only the obvious and may seem so only in hindsight. By looking at "what’s missing," the gaps in our scientific factual base as well as anomalous data, researchers may see for the first time patterns hitherto obscured by the obvious (180). Yet success with past psychosomatic research winnowed superfluous variables from the asthma picture. Bolstered and encouraged with this knowledge, movement toward solving to this 2000-year-old puzzle in the year 2000 is highly plausible.

Forty percent of Americans (27) have an atopic disease, of which asthma is one. More will exhibit asthma tomorrow. These individuals rely on the success of psychosomatic research to identify a cause and to create a cure for their asthma. This future goal challenges the APS just as the achieved objectives of description and control (7) have over the past 60 years of productive research. The reward for meeting this future challenge will be easy: comfortable breathing for all. Nothing is more essential for life itself than that.

Received for publication February 9, 1999.

	REFERENCES

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