Exposing the Role of Psychosocial Stress on Asthma

Aaron B. Holley, MD


February 28, 2020

If you've practiced pulmonary medicine, you've probably encountered patients with asthma who can't stay out of the emergency room. They have repeated exacerbations and are continually placed on steroids. Your efforts at control seem fruitless. You rule out comorbid contributors and consider bronchial thermoplasty or biologics as the cycle continues and patients get worse.

Admittedly, there are multiple possible explanations for this type of asthma behavior. You might be treating the wrong phenotype or failing to recognize comorbid disease that affects control. Patients may be noncompliant with medications (data say they probably are), using inhalers incorrectly, or neglecting to reduce exposure to triggers. For some patients, though, control proves elusive due to ongoing psychological stress.

The perception of dyspnea has a complex relationship with behavioral health and neurocognitive activation. Please indulge me while I oversimplify. After feedback from muscles, stretch receptors, and chemoreceptors is passed to the brainstem, it's relayed to various areas of the cortical-limbic system where additional processing occurs. For a given perturbation in respiratory mechanics or gas exchange, interpretation by the cortex can vary significantly by the patient's current emotional state. Signals can even be misinterpreted entirely.

The resulting reality? For the poorly controlled patients with asthma, stress levels and behavioral health need to be assessed.

Landeo-Gutierrez and colleagues recently published a review on asthma and exposure to violence and psychosocial stress in the American Journal of Respiratory and Critical Care Medicine (AJRCCM). It summarizes the literature on the topic, which is largely observational, and serves as a call to action for prospective studies. While the findings aren't novel and similar reviews have been published before, the relationship between psychosocial stress and asthma needs all the exposure it can get.

Although the guidelines on severe asthma published by the Global Initiative for Asthma, the National Heart, Lung, and Blood Institute, and the European Respiratory Society/American Thoracic Society all acknowledge the relevance of behavioral health, it's my experience that clinicians give short shrift to stress and anxiety when asthma control is poor.

There are several reasons why this may be the case.

First, there's no validated method for quantifying the percentage of dyspnea that's related to exaggerated perception secondary to cortical-limbic processing.

Second, once a diagnosis of asthma is made, clinicians are reluctant to withhold asthma therapies from a distressed patient. This is expected and understandable, and is particularly true in the emergency and acute care settings, where an established physician-patient relationship does not exist.

Finally, with the advent of so many new therapies for asthma, there's always something else to try. Taking into consideration stress and anxiety equates to prolonged appointment times to obtain patient histories, more frequent follow-up care, and less assurance of improved outcomes. Why go into all of that if you can prescribe a biologic or refer for bronchial thermoplasty?

So, while the AJRCCM review concludes that more research is needed, I'll conclude with a call for more attention to the role of behavioral health in the clinical practice of asthma.

Aaron B. Holley, MD, is an associate professor of medicine at Uniformed Services University and program director of pulmonary and critical care medicine at Walter Reed National Military Medical Center. He covers a wide range of topics in pulmonary, critical care, and sleep medicine.

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