Psychosocial aspects of asthma in adults.

In 1903 Osler wrote: “All writers agree that there is, in a majority of cases of bronchial asthma, a strong neurotic element. Many regard it as a neurosis”. In 1966 the authors of a popular general medical textbook included the following statement: “Psychological influences play some part in nearly every asthmatic and quite often they appear to be mainly responsible, if not in starting the asthma, at least in maintaining it. Anxieties of various kinds, a sense of frustration, or frequently discord and an atmosphere of tension in the home, often underlie the tension in the bronchi. Treatment is not likely to be satisfactory unless these influences are appreciated and the patient handled with sympathetic understanding, tact and firmness, and the diYculties eased as much as possible”. In 1972 inhaled steroids became available and this ushered in the modern era of asthma management with the emphasis on antiinflammatory treatment for what is essentially an inflammatory disease of the bronchi and bronchioles. The introduction of much more eVective treatment for asthma has been associated with diminished interest in psychological or psychosocial aspects of asthma, to the extent that they are now often ignored or patients, doctors, and nurses pay no more than lip service to them. In the recent edition of the major British book on respiratory medicine 190 pages are devoted to asthma and there are references to psychological or psychosocial aspects in children and adults on only five. In an 860 page international manual on asthma there were references to psychological or psychosocial factors on only 11 pages. In a recent excellent publication for nurses on asthma management with over 100 contributors there is no chapter on the importance of adverse psychological or social factors. However, there are striking similarities between patients recognised as being noncompliant with their asthma management, patients with brittle asthma, patients with near fatal asthma, and patients who die from asthma. Indeed, there is so much overlap in the psychosocial features associated with these four groups of patients that they can be regarded as a spectrum ranging from non-compliance at one end to death at the other. This review attempts to summarise the evidence for this and looks at strategies that have been employed to recognise such patients and address the problems they face.