Behavior therapy for asthma: A review

BEHAVIOR

THERAPY

FOR

ASTHMA:

A REVIEW

TERRY J. KNAPP Department of

Psychology.

Untversity

of Nevada.

Las Vegas. NV Y9l54.

L’.S.t\

and LIXDA A. WELLS Department

of Psychology. (Recerrrtf

West Virginia

University

2 rlugrtsr 1977)

Summary--The paper reviews 24 case studies and experiments which assess behavior therapy for asthma or some collateral behavior management problem. The reports are examined in terms of treatment population, design. dependent variable. technique. outcome. and follow-up. Methodological and rnstrumentation suggestions are made for future research.

Behavior therapy techniques have found increasing acceptance both as direct treatment procedures for somatic disorders (Katz and Zlutnick, 1974; Knapp and Peterson, 1976). and as adjunctive methods to traditional medical and preventive practices (Pomerleau, Bass and Crown, 1975). Recently, researchers utilizing these methods have devoted considerable attention to the respiratory system and to asthma in particular. This paper reviews twenty-four studies which have either behaviorally treated some aspect of the asthmatic response (N = 17) or some collateral behavior management problem associated with asthmatic patients (N = 7).t The review is partitioned by the preceding two general categories, and in the former case by an examination of treatment population, design, dependent variable, technique, outcome and follow-up. Both sections follow a general discussion of asthma as a disorder. rtsrhma and asthma like responding

Bronchial asthma has a prevalence of about 30 per 1,000 persons in the United States (Vital, 1973). Mathison (1975) has described the presenting symptoms: “To the patient. asthma means labored breathing accompanied by wheezing, a sense of chest constriction, and frequently coughing, gasping, and apprehension. To the physician, asthma should mean reversible obstruction of the bronchial airways caused by smooth muscle constriction, mucosal edema, and the retention of secretions. with resultant symptoms and signs of respiratory insufficiency” (p. 524). Kinsman has elaborated on the subjective symptoms. He and his coworkers in a series of studies (Kinsman, Luparello, O’Banion and Spector, 1973; Kinsman. O’Banion, Resnikoff, Luparello and Spector, 1974; Kinsman, Spector, Shycard and Luparello, 1974) isolated five categories of symptoms which were reported by patients as characterizing an asthmatic attack. In order of decreasing frequency these were bronchoconstriction. fatigue, panic-fear, irritability and hyperventilation-hypocapnia. In addition, the categorization of asthmatic patients along a severity dimension has produced several groupings. Eggleston (1976) has suggested four (sporadic attacks. continuous mild asthma, frequent episodes, and chronic severe asthma), while in a review of 1070 cases Freedman and Pelletier (1970) employed three categories (mild, persistent or severe, and explosive asthma). A further distinction is usually made between intrinsic asthma associated with respiratory infection, and extrinsic asthma produced by the patient’s allergic reaction to environmental agents such as dust or animal danders. * Requests for reprints should be sent to Terry J. Knapp. Department of Psychology. University of Nevada. Las Vegas, NV 89 154. U.S.A. t Foreign language articles (Sichel. Chevauche-Baldauf. and Baldauf. 1973) and reports of treatment with 1964) were excluded even though the latter is hypnosis (e.g. Aronoff. Aronoff and Peck. 1975; Edwards. occasionally regarded as a behavior therapy technique. 103

TERRY J. KNAPP

IOI

and

LINDA A. WELLS

it is worth noting that not all incidences of bronchospasm. wheezing. or intermittent airway obstruction are properly regarded as asthmatic responding (Frazer and Pare, 1970). A differential diagnosis requires ruling-out bronchitis. obstructive emphysema, and congestive heart failure (Krupp and Chatton, 1976). Current somatic treatment for outpatients is pharmacological in the form of inhalation or oral bronchodilators with cromolyn sodium and:or corticosteroids in less responsive cases (Richerson. 1976). Acute severe attacks with status asthmaticus (failure to respond to emergency intravenous aminophylline and subcutaneous ephinerphrine treatment) require intensive inpatient care. Learning accounts of asthma as a psychophysiological disorder are wideiy available in both primary (Turnball, 1962: Yorkston, 1975) and secondary sources (Lachman, 1972; Ullman and Krasner, 1975). These are supported by a substantial number of animal studies (e.g. Dekker and Groen. 1956; Ottenberg. Stein, Lewis and Hamilton. 19%). as well as by human analog investigations (e.g. Dekker. Pelser and Groen, 1957; Herxheimer, 1951). The specific application of behavior modification to the treatment of chiIdhood asthma has been discussed by Wohl (1971). Learning approaches generally emphasize one of two analyses: (1) antecedent stimuli through respondent conditioning have come to elicit asthmatic attacks, (2) reinforcing stimuli serve in an operant fashion to maintain or exacerbate attacks. However, therapeutic approaches need not adhere to either position to hold that relaxation training is a useful adjunction to medical treatment, or to argue that respiratory functioning might be improved by operant conditioning. While many of the investigations reviewed here contend that emotional stimuli precipitate asthmatic attacks, the issue may be properly regarded as apart and perhaps irrelevent with respect to the effectiveness of behavior therapy as a treatment modality for selected cases of asthma. Treafnrent

population

In contrast to much of the behavior therapy literature (Rosen, 1975), asthma studies are marked by their use of clinical patients rather than analogue subjects. All but one of the reviewed studies concerned patients (Rathus, 1973) with a differential diagnosis of asthma. Subjects for the most part have been children ranging in age from 5 years to 16 years and selected from among the resident population of asthmatic hospitals or summer camps. A few studies have employed both child and adults (Moore, 1965; Phillipp, Wilde and Day, 1972) or adult patients exclusively (Vachon and Rich, 1976; 1974) however, only Moore (1965) Yorkston, McHugh, Brady, Serber and Sargeant, and Davis, Saunders, Creer and Chai (1973) have assessed for differential effects of the age variable and found no differences. Similarly, both sexes are well represented in the studies reviewed, but no differences between them reported. The subjects’ severity of asthma has ranged from mild to severe, with a substantial number of studies reporting Davis et al. was the only investigation patients with a history of status asthmaticus. to examine severity of symptoms as an independent variable and they found interactive effects. These are discussed in the outcome section. Finally, one study (Phillipp et al., 1972) has compared intrinsic vs extrinsic subjects and reported differential effects which are discussed later. Design

With only one exception (Neisworth and Moore, 1972), the case studies have been either anecdotal reports (Cooper, 1964; Rathus, 1973; Sergeant and Yorkston, 1969; Walton, 1960) which do not altow for the drawing of definitive condusions, or singlesubject designs without reversals (Sirota and Mahoney, 1974) making identification of the effective treatment component difficuh. The controlled experiments with two exceptions (Danker, Mikiich, Pratt and Creer, 1975; Yorkston et al.. 1974) have provided, where appropriate, a no-treatment control group for comparison purposes. Typically this took the form of asking control subjects

Beha\ior

Table Technique

thsrapy

105

for asrhma

t. Case stud& Outoome

16 *months only

bur

attacks

5 jeair

conplrrrly

ircc or asrhma

Ralhun 1973

Sirota

and

Makoncy. 19T.l

to sit quietly for a period of time equal to that of the subjects undergoing the experimental treatment. None of the controlled experiments employed a placebo comparison group. This defect is particularly crucial given the psychogenic components of the disorder Lachman, 1972), the susceptibility of particular response measures to effort and demand influences (Luparelio, Lyons, Bleecker and McFadden, 1968) and the inability to identify the specific therapeutic ingredient in systematic desensitization (Kazdin and Wilcoxon, 1975).

The case studies and controhed experiments reviewed have employed a variety of dependent measures. These may be classified as physiological indices of respiratory functioning and measures of collateral behavior such as duration of coughing or self-report of attack frequency. Physiological measures. Most studies (7 out of the 10 controlled experiments) have used Peak Forced Expiratory Flow Rate (PEFR) as the principle or sole physiological measure. Others (Phillipp et al., 1972; Yorkston et al., 1974) have utilized Forced Expiratory Volume, one second (FEV,). Both measures require an apparatus (flow meter) into which the subject exhales with as much force as possible following an inspiration to maximum capacity. The PEFR is the rate of air out flow at the peak of the expiration curve, while FEV, is the volume of air expired during the first second. Another set of measures simply expresses PEFR or FEV, as a percentage of predicted (expected values based on normal population parameters). The latter measure has the advantage of data normalization, thus providing in addition to a change measure a general indication of severity. Respiratory function measures have a validity which may be lacking in mere self reports and avoid the problem of requiring a reliability check. They are not, however,

106

TERRY

J.

KMPP

and

LIED*

A.

WELLS

without their own difficulties. among them (If their effort dependent nature (Alexander. Miklich and Hershoff. 1972). (2) excessive exertion on repeated trials may actually be harmful to the patient (Danker et 111..1975) and (3) the extensive co-operation required of the patient. Although frequently criticized in the behavior therapy literature, it is only recently that alternative methods to PEFR and FEV, have evolved. The most promising is total respiratory resistance (?-RR) determined by the forced oscillation technique (FOT). The procedure was developed by DuBois, Brody. Lewis and Burgess (1956). evaluated by Fischer, DuBois and Hyde (1968). simplified by Goldman, Knudson. Mead. Peterson, Shwaker and Wohl (1970) and automated by Levenson (1974). The details of the technique are beyond the scope of this review but may be found in abbreviated form in Feldman (1976). Vachon and Rich (1976) reported high and significant correlations between the forced oscillation measures of resistance and whole body plethksmography during both baseline (r = 0.81) and bronchodiiator tria.ls (r = 0.93). The measurement of TRR by the FOT may have the greatest utility in future research since it is not effort dependent, and does not require maximum exertion. In addition, the measure is amenable to immediate analysis. can be feedback in a variety of forms (visual. auditory) and requires only a minimum of co-operation from the patient. ~~l~~ir~~~~~lrrspws. Behavioral measures indicative of an asthmatic condition or severity of ~~sthrn~lt~c responding have included duration of bedtime coughing (Neis~vorth nnd Moore. 1977). number of attacks {Kahn. Stacrk and Bonk, 1974: Moore. 1965). amount of medication (Danker e[ al.. 1975: Kahn tar nl., 1974) and frequency of bronkomtter usage (Sirota and Mahoney, 1974). Other researchers have employed the less reliable. but nonetheless relevant measures of clinical ratings (Scheer, Crawford. Sergeant and Scheer. 1975: Yorkston et LII.. 1972) and a self evaluative mood questionnaire (Scheer er al., 1975). The measurement of such collateral responses may not be useful in determining the immediate outcome of behavior therapy, particularly in the case of conditioning strategies. but it may be highly beneficial in evaluating long term follow-up as well as assessing asthmatic responding occurring in the natural environment. Many of the measures would be improved by the addition of a second observer to determine the re~iabiIity of the data or by the use of eIectro-mechanical devices, e.g. a tape recorder to measure duration of coughing. The potential reactivity of the self-report measures must not be neglected. For example Moore (1965) found a lack of correlation between self-report of attacks and respiratory measures of PEFR and percentage efficiency.

Treatrmxt

technique

The most frequently employed technique for the behaviora treatment of asthma has been some variant of relaxation training intended either to lessen anxiety levels or reduce sensitivity (systematic desensitization) to stimuli which appear to elicit asthmatic responding. More recent therapeutic approaches have utilized an operant conditioning procedure designed to increase the patient’s respiratory functioning. Rehxation Procedures. A number of investigators have taught subjects progressive muscle relaxation and compared the outcome with a non-treatment control group (Alexander. 1972: Alexander et al.. 1973; Davis rr al.. 1973; Philiipp rt al., 1972). Others have added suggestion or systematic desensitization to relaxation (Moore, 1965; Yorkston rt al., 1974) or assisted relaxation with EMG feedback (Davis ec al., 1973; Scheer et al., 1975). The relaxation instructions have as a rule foltowed the recommendations of either Jacobson (1938) or Schulz and Luthe (1959). The number of sessions for an individual patient has ranged from a low of three (Alexander, 1972) to a high of ten (Scherr t’f ni.. 1975). IMore generally, the number of trainin, * sessions has varied from three to six. each 30 min in length with instructions (in the case of adults) to practice at home twice a day. items in desensitization hierarchies have concerned asthmatic attacks (e.g. ‘Fighting for breath’), stimuli which evoke attacks (e.g. ‘Very hot day in ciosed

Behabior fable

2. Conxollrd

studies

therap)

for asthma

of relaxation

an.i sijtsmltttc

10: de.ensltx;ln~n

None

Relaxation wth EMG Prdbsck

108

TERRY

J. KNAPP

and LIVDA

,A. WELLS

room’). and idiosyncratic psychologically stressful events (e.g. interpersonal situations). Complete hierarchies may be found in Moorz (1965). Uprranr tschniques. These procedures have been variously described as counter-conditioning or biofeedback reinforcement (Kahn er al.. 1974). instrumental conditioning (Danker et nl.. 1975). visceral learning (Vachon and Rich. 1976), and biofeedback training (Feldman. 1976).* The first three techniques share the procedure of providing subjects with light-on feedback during trials in which the respiratory measure equalled or exceeded a prescribed criterion. The later study presented subjects with an analogue feedback tone which varied as a logarithmic function of TRR. On occasion verbal praise (Kahn et al.. 1974) or points without backup reinforcers (Danker ec al., 1975) have been added as consequences of obtaining the criterion. All but one of the studies reported the nllmber and length of sessions as well as the number of trials per session, however. as Table 3 indicates. there was considerable variability among the studies. ~~f~sc~ll~~eoz~.stec~~tz~~c~es.A few studies have used techniques other than relaxation training or operant conditioning. Walton (1960) employed assertive training to reciprocally inhibit anxiety produced when the patient encountered other persons. Such interpersonal encounters ‘almost always’ produced an asthma attack. While outcome and follow-up are discussed. the assertive training procedure itself is not described beyond fotlowing the ‘suggestions of Wolpe . _ . ‘. Rathus (1973) used *cognitive restructuring’, in addition to relaxation training, to treat a case of hysterical bronchial asthma. Cognitive restructuring consisted of urging the patient to name her attacks. respond to them with welcome rather than dread and thereby demonstrating to herself the ability to deal effectively with them’. Finally Sirota and Mahoney (1974) added two innovations to traditional relaxation training. The first involved the use of a portable timer which the patient would set to varying intervals and then relax on cue whenever the timer sounded. The second innovation required the patient to briefly postpone the use of a broncodilator by setting the timer for 3-4 min practicing relaxation when it sounded, and then employing the broncodilator only if needed. Given the success of self-management techniques in other behavior applications (Watson and l-harp. 1972) the Sirota and Mahoney procedures warrant further study. Additional details of these three reports are contained in Table 4.

Treatment

oiitconie

With the discrepancy in the number of training sessions. types of stimulus hierarchies, and the previously described variation in dependent variables and ‘design difficulties, one must draw conclusions based upon between study comparisons with considerable caution. However, several issues seem well established. Relaxation training has consistently produced stastistically significantly improvement in subjects’ respiratory function measures (PEFR, FEV,) when compared to those subjects receiving no treatment (Alexander, 1972; Alexander et al., 1972; Davis er al., 1973; Philiipp er al., 1972). The mean changes reported for PEFR were 21.63 (per min) (Alexander. 1972) and 23.53 (per min) (Alexander et al., 1972). Ph~lIjpp et nl. found that seven out of 10 subjects given 10 min in which to relax following previous relaxation training improved in FEV, compared to controls (p < 0.05). The largest change was 20%. Similarly, when the pre-post-FEV, training values were compared, the difference was also statistically significant (p < 0.01). The three largest changes were 14, 11 and 7 (“,,I. When comparisons have been made between relaxation training and systematic desensitization the latter procedure (Moore, 1965; Yorkston et ai.. 1974) has always

*The titles augmentation of respiratory

of articles can sometimes misdirect one. The term biofeedback has been used to refer to both of relaxation training with EIMG feedback. and feeding back an analog signal indicating level resistance. Obviously each procedure involves feedback, however. the use of respiratory resist-

ance is an innovative

technique

whereas

EMG

has been in use for some time.

Behablor Table

3. Controlkd

therapy for asthma studies

of operant condittonmg

Bsha>ior

PEFR

FAdman.

iY76

TRR

Audm

PEFR

fccdhack

MMEF

Suhlcct,

analog al TRR.

wh

mwuciions

proiancnr

that

it /owe,

snd

means

tone

lmprovcd

LtMEF.

brearhmg

three

n,fun~

for dll

A one-half ,
fcrdback.

duccd

and

Iropr”. t,sa,mm,.

rest.

I” PEFR.

35. Is-30

yrzrr

Phdsr

TRR

,ec,s

I: 13 ub-

red-&hi

onset

hacked

by a small

mone,a,y baxline

reward I3 mtnt

iollowed 5 mm

TRR.

rrcludmg

rlrpwa,o,y

d.tta

hj

four

tnais

5 rubJrC,s rccwrd contin$rnt hack

nonlied-

pro-

,ly”~Rca”l

mlp,o=-

men,.

nurmnl

The

,howcd

S,gn,ticmr ,n mean

recclred

hour

no comparahic

\,gn:fnni

8i Rrch.

and “g-

conlrol

suhjec,

1976

I” TRR

cond,r,ons

,c,cnol

Vachon

i*-

approrchcd

su b,dcrs. bto-

xonc

,houcd

rtgoitic3nr

lecdbxk pwsd

no

change

None

decwass TRR

when

,aIucs IO bacltnc

corn-

bto-

TERRY

J.

and LINDA

KMPP

Table

,A. WELLS

3--conrimed

Table 4. AdJunCt behaviors

to asthma

treated

behaviorally

Bcharlor crh!h,icd sorrerpondcd I” Ihat on ihc upe. tndtny I” appropr,Atc hchavlor

Crccr 9: M,kl,oh. IYX

Non-ai,endmg bcha,,orc dccrcas~d ausndmg ,ncrcarrd. rcsuhi gcnCll,zrd 10 classroom whcrc rLSrpo”sc-co,! c”n,l”~r”c) u3, not I” elrrct SlzII,S-

X(,kl,ch.

iYi3

Rclawd sili,ng (hypcrkmew

Enrncd pomrs exchangablc ior

6 months both perlorm ,ng aI ratlrbcrory ,C\CIS

8 months asthmaltc panx contmucd to ~mprovs. h>pcrkmcnc tehawors rzm,8!.zd

Crcer. Wanbcrg Molk. iYi4

I icar appropnxe behawor rrwnramed

Behavior

therap!

Table Author(>l

Sub,ccrs

Bcharlor

for asthma

III

I-conrinurd Ourcome

Tcchmque

Rcnnc

Rcrnforcemsnr

lVi6

*pproprLlrc

hc-

hawor

,IC-

nlth

FOIIOW-Up

of

kcrs exchangabls for P surprrse gIR when

Promprmg nrcdsd

proved superior. For example, in the Moore (1965) study the changes in PEFR were 23, 25 and 80 (per min) for relaxation. relaxation with suggestion and systematic desensitization respectively. While all of these represent significant differences from pretreatment values, only the systematic desensitization group was significantly different from the other treatments. The same relationships held for the percentage efficiency measure employed by Moore. The reported changes were 7.5, 1.5 and 18.5 (g;) respectively. Finally, while all three procedures produced significant reductions in the number of self-reported asthma attacks, the self-report measure failed to differentiate among the procedures. Yorkston et al. (1974) also concluded that systematic desensitization was superior to relaxation training. The percentage predicted FEV, changed from 56 (%) (1.53 1) to 76 (%) (2.071 1) in the case of systematic desensitization and 68 (‘4) (1.91 1) to 63 (%) (1.75 1) for the relaxation group. Such results do support Moore’s earlier conclusion, but the failure of the relaxation group to improve significantly is perplexing given the prior cited success with such methods. Reference to Table 2 fails to show any substantial differences in the kind or number of relaxation training sessions or instructions which might account for the discrepancy. Given the fairly well supported observation that relaxation training will statistically improve respiratory functioning, future research aimed at achieving clinically relevant levels of improvement may do well to further investigate the use of systematic desensitization as augmentation to mere training in relaxation excercises. The outcome of operant studies is mixed. Kahn et al. (1974), Feldman (1976) and Vachon and Rich (1976) reported success’ at operantly shaping respiratory functions, while Danaker et al. (1975) failed to find any evidence for conditioning. Kahn et al. (1974) employing the light-on feedback procedure found that an experimental group (N = 10 children) was significantly different at 8 months follow-up from a no treatment control group (N = 10) on three (amount of medication. number of emergency room visits and number of attacks) of five dependent measures. Danker er a/. (1975) appropriately criticized the Kahn et ai. study on the grounds that (I) no data are reported to show actual conditioning, and (2) FEV, is effort dependent. The Danker group systematically replicated the Kahn er al. study initially employing six male residents (age 9 to 11 years) from the National Asthma Center in Denver. While the number of training sessions is not reported, none of the subjects showed any evidence of increases in PEFR. A second group of five subjects (ages 8 to 11 years) were given two weeks of daily 20 trial baseline sessions and five weeks of daily reinforcement sessions with an increasing PEFR criterion with each session. Only three of the five subjects showed significant increases in comparing baseline to treatment session. However, when intersession data were analyzed, only one subject showed evidence of a

Uo~]-Ex~laJ

aql

~O~]~Uala~~piC~~ue~y~u~~SSeMuO~)Ez~l~SUaSap pah!aDa_~ q3!qM dnoBaql3't3qI

dn-MO[lOJ .reaiC 5 e l't! leql pallodaJ (~~61) 'ID la uolsy~o~ .po!lad dn-Mol[OJ qluour xfs aql 3.1!~nppasdclal uo!)~q!qu!IeDoJdpal qt!,r\ palea~$ lua!lr?dou IV~I palou (~961) aloom 'luals!xa-uou lsompi!s! slc&l~aIeluaur!ladxa~o/0!1!qcJnpayl uo wcp dn ~ol]oJ ~pa~sa2Bns au!~~s yl!m uo!~a~nu~gs ldfoq3aw 01 asuodsa3 u! saseawap '~33 ~a~ieurs paMOqS SD!SU!J]U! )SlBI )r 33!SU!J)Xap!p UEql %U!U!Wl UO!lEXEla.l LLIo.IJ alotU IyaUaq 01 paJeadde sa!su!wx! 1~q1 pallodal @&I)

"1~ la dd#!qd

'ifl&?f!u~!s .(wapuadap p!oJals

you asoql)sl3a[qnsadahas-uou u! i(luoluauraAoJdw! lUEXJ!U%!S

~l[K)!lS!lWs

pasnpoJd du!

-U!EJ~uoy1exEla.I paluaurBne 9~13 1eq1 punoJ (~~61) '1012 s!Aea‘1~~uu-m~ ynade.wl sa1qxym w[qns jo wiga anyemy pau!urt?xaaheq q3!q.4 sa!pnls asoql Jo .dn-mo]~oJLLIJ~~-~UO~ se ]la,ti se )uauruo.t!Aua [elnleu aql 01 uo!lez![waua8 %r!ssassapue

pue

‘(uo!lal!J:, paxy e ueql laqw sdals papeB u! suo~l~~~xo~ddE Bu!D.toJu!al pue ‘anlEA luaura3JoJu!alaql 8u!seaJ3u!,Cqsdeqlad) wa#a label %!JnpOJd le palsal!paq plnoqs aJnln,li ‘aaf_L IE!+ald ~U!~O~IOJ ayl /cq papaasxa SFM ~81 It?!ll-lsod laafqns

y3JeasaJ

&kJaAP 3ql a3UElSU! qXa Lx1*OiH Ku38'E pw? L'f '['p'6.caJaM san[t?Aa,z!lsadsa.I aql :(ql%al u! u!w 2) lE!Jly3eqpaaJ q3Ea a"u!JnppalJn330 sasea.t3ap 1uc3y@!s aql '~'~'PIE!J~

pug :p'p ‘f IF!11:8'@ 'i:lE!.il :;.t?.[ Ir?!Jl :$'t7‘auyaseq aJaM san1e.A[t?!'l-a.id a&.raAe 'awqd puoaas aql JO dnoGl lUa%I!lUO3 (9~61) s‘qD!H pue UoqseA u! ‘aldurexa_iod .[I?A -.ialu! [ey-law! ainu!w a?\yaql~u!~nppau!~lu~~~ IOU ~l)ualeddr?aJtesa3ua~a~!pEf'CIL-)sod -aId aql 'i([luelJodLu! alow .loua.woJdosI JO uo!lElt?qu! auo 01 )ualc,z!nba Llq8noI s! J! '(9L61)y3!8 pue UoqseA 0) %wp"o53v '1lEUIS S! lUawaAOJdw! JO aa.Bap aq3 ‘_laAaMoH .sasuodsal ~EI~~S!Alaylo JO Lpnls aql LI!pa/iolduraIO%!J ames aql ql!M pawlsuowap uaaq aA.eq 01 sleadde 3u!uo!lsunJ holeJ!dsaJ JO %u!uo!)!puoa luejadg .sllnsaJ.'!aql UIOJJ UMBJP aq 0) suo~sn~suo3 aql lnoqe sno!inm

ale sJaded y)oq Jo s~oqlne aqL

'a3uo @IO s[aAalIUE~~!U~!Spaysea suos!leduro:,luaurleaJ1 01 awiaseq pue ‘spuall ou paMoqs alnpaDoJd lua~u!luo~uou aql 'iz~-il pJ!ql aql icq (so.0> d) saaualaa!p lue3y!u%!sL~~E~~~s!~ws pue ‘IE!JI qxa ql!M suo!lanpaJa%el pahoqs $uawaali iua%!iuos aqi /ilug .awn[oA %unl aA!ielaJaql~o a3ueuaiufew SFM luawa+nb -al icluoaql alaqkf iuamaaJoJu!aJ tuopuv~ lua%1~~uo3uou pur? ‘luama3JoJu!a~(aaL

uo)

lua%u!iuo:,ui$sap pa3uEleqJalunos e u! paA!a3aJsiaa[qnsuaail!qL .(amnloA SIB 3!3EJoql %!sea33u! Lq asuws!sa3 u! uotl3npaI 10j foJiuo3 0)) saritEAauqaseq u!ql!~ IlaJawn/on BunI aA!lelaJuaqh

pue 'uo!Jal!J:, pay!gads aql Lq pa3npaJ SEM aa~- uaqM

i(luoluar_u

-ackIoJu!aJ ap!AoJd 01 w&old 33eqpaaJ aqi pay!pow Xpnls aq) JO awqd puo3as aq1 'aal u! uo!l3npaJ 13Jo awap!Aa LUE pa)uasaJd sisafqnsaAy asaql Jo auou ‘luaw!ladxa sno!Aald aql JO )trqlo) .hanbajJ pue uo!l!sod u! lenba y3eqpaaJ sno!l!luaApv pap!Aojd luau+adxa

p.nql v 'papnlau!alar

e)ap (%!q%no3 %a 'walla ap!s LJolEl!dxadq paanpoJd ICl![!qE!JeA a>npaJ 01) uo!lel!dsu! XIUO uaym iuatual3ap ~uecly~u~~s ~el+u!sE patioqs slsafqns51 ‘uo!lEa!~da~ 3!lemalsiis e UI 'slE!~i 73eqpaaJ 1n0J q8noJqi auqast?q u10lJ XaL

u! asvaJ3ap iue3y!u8!sc ‘a%laAe

ayl uo 'pahtoqs sDa[qns ~1 ‘1 waur!jadxa 8u!Jna .swau+adxa aJaM (~10 SleaiC0~ al 81) wa[qns

JO sa!JasE qt?tto>q) )nd

JO load v 'aDuels!saJ KJolel!dsaJ01 palelalSEM las

uo-lq8!ileql plol 3ou ala.%\ ilaql 'ssa33nsl!aqi01 jeuo!llodoJd wawiied I(auow Bu!n!aaaJ sl3a[qns

ql!m

yxqpaaj

lw!a”!p

paioldua

inq 8%~ pasn osp3 (9161) qa!;tI pue uoq3t?A 'ale2MO~J KJOleJ!dXa p!u~ Lunw!xeLu JO mog yead luap

-uadap lJo#a aql ueyl luauraisap Jalea.r% pamoqs ~XJ_ put? ‘uaA!d SCM as!eld leq.Ia,z ou 'IJoqsa_taM suo!ssasasu!s uo!lsa%ns 01 alqElnq!Jlle10~ s! iuawaAoJdm! leyl ani3JE01 aJ&3 sayw

Joqlne aql .suo!ssask!u!wl-lsod

03 paJeduto3 a1a.w suorssas Surute.Il-ajd

uayM aal u! (10'0> d) .i~luesy!ufi!s paAoJduI! slsa[qnsJno] 11~ :uo!Jal!Jsdaft Jalnol E %I!Aa!q3F JOJ 33EqpaaJ %OiEUC? au01 ql!m sl3a~qns JnoJ pap!,toJd (9~61) ueiuplaj -wada uo!lsa%ns 01 alqeinq!we aq lq8!ru ( ‘10 12 uqF>) s,lnsaJ sno!AaJd leql alou pue 2u!uo!lsunJ .kow!dsa~ Jo %U!UO!I!~UOZJluwado lnoqe s!ls!~U -!ssadale sJoqlnr:aqL wawanoJdru! lelauai? JO axap!,ta ou SAM ajaql ‘uo!l!puoas!leur -qW JO W!ua.lia pue Bu!ulow-samsearu xdzd .Jl!ep ‘siuawreaJl uoyepzqu! JO mqmnu p!olals Jo ,unouw) salnseauIa.zyuo palEnye.za 8u!.ti0Il0~ asvaJ3ap lua)s!suos 22Jq1

aJaM sm(qns

Jay50

-sUo!m!paru

Jo

lq%!a.Yi 'uoges!paw

asaqi uaqM

.Bu!u!E~l JO iuauxa3uxmuo3

Behavior

therapy

for asthma

II3

group on general clinical ratings and reduced medication requirements. However. there were no differences between the groups in self-ratings of treatment success or symptoms. Adjunct

beharior

problems

Operant techniques (e.g. time-out, response-cost. shaping, modeling, etc.) have been used effectively to treat a variety of behaviors associated with asthmatic children. These 1968: Miklich. 1973). inappropriate behavior have included hyperactivity (Gardner. (Creer and Miklich, 1970). frequency and duration of hospita,lization (Creer, 1970; Creer, Weinberg and Molk, 1974), attending behavior (Creer and Yoches, 1971), and appropriate use of inhalation equipment (Renne and Creer. 1976). The details of these studies are summarized in Table 4 and a useful description of behavior management procedures for asthmatic children and their parents may be found in Creer and Christian (1976). SUMMARY

AND

RECOMMENDATIONS

The controlled studies reviewed suggest that relaxation training and systematic desensitization can produce statistically significant improvement in the respiratory functioning of asthma patients. Recent reports indicate that such improvement might also be obtainable through operant conditioning techniques. The more general applicability of behavior management procedures to asthmatic children and their parents seems well established. Despite the large number of studies cited here, considerable opportunity remains for future research. The clinical significance and long-term maintenance of the above mentioned improvements is yet to be demonstrated. Assessment techniques to select patients suitable for behavior therapy should be developed. Some preliminary but as of yet unsuccessful attempts have been reported (Tal and Miklich, 1976). The employment of an experimental analysis (Sidman, 1960) rather than statistical evaluation may lead more directly to a concern for clinical levels of effectiveness and individual variation. Operant investigators may wish to examine a wider and perhaps more powerful range of reinforcers than simply light onset or low monetary reward. The apparent superiority of systematic desensitization to mere relaxation training warrants a more careful examination, as does the value of EMG augmented relaxation training. Finally, two other areas merit scrutiny. First, the lack of compliance to medical procedures (Zifferblatt, 197.5) has not been specifically examined in connection with asthmatic patients. Secondly. and perhaps most importantly, the kind of self-control and management techniques employed by Mahoney et al.. would appear particularly appropriate for behavior therapists to examine-perhaps even more so than the circumscribed area of respiratory physiology. REFERENCES ALEXANDER

A. 8. (1972) Systematic relaxation and flow rates in asthmatic children: Relationship to emotional participants and anxiety. J. psychosom. Res. 16. 4OS410. ALEXANDER A. B.. MIKLICH D. R. and HERSHOFF H. (1972) The immediate effects of qstematic relaxation training on peak expiratory flow rates in asthmatic children. P.s~rho.som. ,Lf~d. 34. 388-394. ARONOFF G. M.. ARONOFF S. and PECK L. W. (1975) Hypnotherapy in the treatment of bronchial asthma. Ann. Allergy 34. 356-362. CCIOPER A. .I. (1964) A case or bronchial asthma treated by behaviour therapy. B&r. Rex Ther. I, 351-356. CREER T. L. (1970) The use of a time-out from positive reinforcement procedure with asthmatic children. J. psychosom. Rrs. 14, I 17-120. CREER T. L. and CHRISTIAN W. P. (1976) Chronically ill and handicapped children: Their nmnogernenf and rehabilirarion. Research Press. Champaign, III. CREER T. L. and MIKLICH D. R. (1970) The application of a self-modeling procedure to modify inappropriate behavior: A preliminary report. Behoc. Res. Ther. 8, 91-92. CREER T. L.. WEISBERG E. and MOLK L. (1974) Managing a hospital behavior problem: malingering. J. &hoc. Thrr e.rp. Ps$liar. 5. Z59-XZ. CREER T. L. and Y~CHES C. (1971) The modification of an inappropriate behavioral pattern in asthmatic children. J. chron. Dis. 24, 507-513. DANKER P. S.. MIKLICH D. R., PRATT C. and CREER T. L. (1975) An unsuccessful attempt to instrumentally condition peak expiratory flow rates in asthmatic children. J. psychoson]. Res. 19. 209-213. DAVIS M. H.. SAUNDERS D. R.. CREER T. L. and CHAI H. (1973) Relaxation training facilitated by biofeedback apparatus as a supplemental treatment in bronchial asthma. J. p.~~chosor~. Res. 17. 121-118.

ii4

TERRY J I(\APP and LI\IJA A. M'ELLS

DEKI\ER E. and GROES J J lIYS6) Reproducible ps)chogenlc attacks of asthma. J. p~~ckosom. Rt,s. I. 58-67. DthKCK E. Pt-LSfXH E. end CKOEX J J (19571 Condltlonlng ;1~J ause of Jsthmatic altacks..A labora[or) itud! J pz:ik,,mr. R,,, 2. VT- 111s. DLBOIS .A. B.. BROD~ 4 ‘A’. LEWIS D. H. and BLRGESS B. F. (19561 Osclllatlon mechanics of lung and chest in man. J tippi Pkvrioi. 8. 5S:-591. ED~WDS G. j 196-1) The h>pnotlc treatment oi asthma. In E.~p~,rirnrnrs 1)1 hekaclor rkrrup). (Edited by H. J. E\sEsc~;). p. v3713l. Oxford Press. Neu York. EGGLES~OX P. A. (1976) Asthma in childhood. In Current rkrrap),. (Edited by H. F. Goss). p 571579. Saunders. Phdadciphla. FELDV~\S G. hl. (1976) The effect or biofeedback tralnmg on respiratory resistance of asthmatIc children. P rwiwsorrr. .\i,,d. 38. 27-X FISCHER A. B.. Dr-Bors A. B. and HYDE R. W. (1965) Evaluation of the forced osciilatlon technique for the determmation of resistance to breathing. J. cite. f,llrsr. 47. 204~2007. FRASER R. G. and Ptit J. .A. (1970) Dlnyrzosis o~‘d~st~usc, uj‘rkr chrsr. W. B. Saunders. Philadelphia. FKLFDV+L S. S and P\:LLI-TIFK G .A. (19701 Asthma in chIldhood’ Trearm?nt of 1070 cases. ._lrr,l. .-1iic,ryi. 28. 133-111. GARDNER J. E. 11965) A blendmg of behavior therap! techmques In an approach to an asthmatic child. P.s~ciiatlw~~p~ Tiwr. Rcs. pracr. 5. J&.&9. GOLDWN M.. Kviusos R. J.. MEAD J.. PETLRSON N.. SCHWABER J R. and N’OHL M. E. (1970) A stmpllfed measurement of respiratory resistance by forced oscillation. J. (]ppI. Pk~~s~o/. 28. 113-l 16. H~RSHEI~~ER H. (1951) Induced asthma in man. Lancrt. 23 June 1931. 1337-134!. KAti\ A.. STAIKE \l. and BOUK C. (19741 Role of counter-conditioning in the treatment of asthma. J. psj,cho.AOIII. RL,Y. 18. S9-92. KATZ R. C. and ZLCTNICK S. (Eds.) (1974) Rrha~ior therap! and iwalrh cizre: Principlrs ad applicarions. Pcrgamon. New York, K~\%I>Is A. E. and \VILCOX~U L. A. (1976) Systematic desensitization and nonspecific treatment effects: A methodological svaluation Ps~ckoi. &~I[. 83, 719-75% KINSMAN R. A.. LLPAR~LLO T.. O‘BASNON K. 0 and SPECTOR S. (1973) Multidimensional analysis of the subjective s)mptomalogy of asthma. Ps~ckosorrr. Add. 35. 150-267. KISSW~S R. A.. O‘BA>ION K.. Rrss~~or-F P.. LCPAKLLLO T. J. and SHI.LLXIZS L. (1973) SubJective symptoms of acute asthma withln a heterogeneous sample of asthmatics. J. ._(Ilcrgj, clitr. /~wnud. 52. 284-296. KIN~MAS R. A.. SPE~OR S. L.. SHUCARD D. W. and LUPARELLO T. J. (197-t) Observations on patterns of subjcctivc s)mptomatology of acute asthma. Psrchoson~. ~Llrd. 36. 129-143. K\,\I,I~ T. J. and PI:TI.KSO\ L. W (1976) Behavior management in medical and nursing practice. In Brl!nrior .\lorijfiwriorl: Priwcp/t,\. I.SCUCY,md ~~pplrctrt~m. (Edited by W E. CRAICHEAI). A. E. KAZDIS and M. J %lAtrouf-1). p. 26&?SS Houghton-MIfflln. Boston KKI PP M. A. and CHATTO> M. J. (1976) C~rrro~r ~wlicul (~IU(J~SI* rrrl[/ rrmmwr. pp. I I I-I 13. Lang medical pubhcations. Lo5 Angclcs. Ca. JACOUSES E. (1935) Progrcssice rrluxuiim. Unicersitb of Chicago Press. LACHMAU S. J. (1977) Psrcko~o~~tic disorders- .f hrkariorisric interprerariort. John Wiley. New York. Lf.vt.ssos R W. (1974) Automated system for direct measurement and feedback of total respiratory resistance by the forced oscillation technique. Ps~ckoph~sd. I I. 86-90. LI_P-\KELLO T.. L\o\$ H. A.. BLI-EChtR E. R and M~FAIIIXS E. R. (1965) Influences of suggestion on airway reactivil> in asthma subJects. Ps\~cko.som. .!fed. 30. 8 19-825. MATHISON D. A. (1976) In Conn.. H. F. (Ed.) Cwrenr therapy. Saunders, Philadelphia. pp. 574-579. MII(LICH D. R. (1973) Operant conditioning procedures with systematic desensitization in a hyperkinetic asthmatic bo> J Behal. T/w,-. KY~. P.s~~ckiuf 4. 177-l 82. 1?4t00KEN. (1965) Behaviour therap) In bronchial asthma: A controlled stud!. J. p~~~ckosa~~r.Re.5. 9. 257-276. NEISWOWH J. T. and MOORE F. (1977) Operant trea:ment of asthmatlc responding with the parent as therapist. Beh~lr. Thrr. 3. 95-99, OTTESHFRG P.. STEIN M.. LELVIS J. and HA~~IL~OS C. (19%) Learned asthma in the guinsa pig. Ps~chororn. .LItd. to. 39j_1cc. POMERLEAL. 0.. Btis F. and CROWS V. (19751 The role of behavior modification in preventive medicine. :Ve’r Ew$. J. .Md. 292. I277-1252. PHILIPP R. L.. WILDE G. J. S. and DAY J. H. (1977) Suggestion and relaxation in asthmatics. J. ps~choron~. Rrs. 16. 19)_7M. RA-~HLS S. A. (1973) Motoric. autonomic. and cognitive reciprocal inhibition of a case of hysterical bronchial asthma .~~iolusczw~~, 8. 29-32. RESST C. ,M and CREEK T. L. (1976) Traming children wth asthma to use inhalation therapy equipment. J. lckrm. 5. 65-66 SERUAZT

Behavior TAL A. and children.

MIKLICH D. R. (1976) Emotionally Psychosom. Med. 38. 190-199.

therapy induced

115

for asthma decreases

in pulmonary

flow rates

in asthmatic

J. W. (1962) Asthma conceived as a learned response. J. ps$wsom. Res. 6. 59-70. ULL&tAs L. and KRGNER L. (1975) r( psychological approach ro abnormal beharior. Second Edition. Engelwood Cliffs, N.J. VACHOX L. and RICH E. S. (1976) Visceral learning in asthma. Psychosom. Med. 38. 121-130. Vital and health statistics. (1973) Prevalence of selected chronic respiratory conditions United States-1970. and Welfare. Public Health Services. Series IO-No. 84, U.S. Department of Health, Education. HRA-74-151 I. September, p. 17. YORGTON N. J. (1975) Behavior therapy In the treatment of bronchial asthma. In Applmrions of hvharior modification. (Edited by T. THOF.IPSON. and W. S. DOCI;ENS). pp. 97-103. Academic Press. New York. YORKSTOF;N. J.. MCHUGH R. 9.. BRADY R.. SERBER M. and SERGEANT H. G. S. (1974) Verbal desensitization in bronchial asthma. J. ps.vchosom. Res. 18. 371-376. WALTON D. (1960) The application of learnin g theor) to the treatment of a case of bronchial asthma. In Bejwciour rhrrap~ owl rhr nwr~ses (Edited by H. J. E>SENCL;). pp. 18%IS9. Pergamon Press. New York. WATSON D. L. and THARP R. G. (1972) Se&directed behavior: Self-modification for personal adjustment. Brooks and Cole, Monterey, California. WOHL T. H. (1971) Behavior modification: Its application to the study and treatment of childhood asthma. J. Asrhrna Res. 9, 41-45. ZIFFERBLATT S. M. (1975) Increasing patient compliance through applied behavior analysis. Prer. Med. 4. 173-182.

TLRSBALL