Functionally determined invalidism in chronic asthma

J Chron Dis Val 33. pp. 485 to 490 Q Perpnon Press Ltd 1980. Printed I” Great Bnta~n

FUNCTIONALLY DETERMINED INVALIDISM IN CHRONIC ASTHMA* KENNETH

H. FRoss,t JERALDF. DIRKS,: ROBERTA. KINSMAN~ and NELSONF. JoNEst

tSchool

of Professional Psychology. University of Denver, and the Department of Behavioral Sciences. National Jewish Hospital and Research Center, Denver, Colorado. U.S.A., and :Mcdical Psychology Program, Department of Behavioral Sciences, National Jewish Hospital and Research Center. and the Department of Psychiatry. University of Colorado School of Medicine. Denver, Colorado. U.S.A. (Rrceired

IO Sepfenlhrr

1979)

Abstract Ninety asthmatic patients were divided into three groups according to MMPl Panic Fear scores. The groups were well equated for the actual severity of their asthma as indexed by daily. longitudinal pulmonary function measures during treatment and rates of rehospitalization following discharge from treatment. All patients were surveyed at admission. discharge. 6 months post discharge and 12 months post discharge for their ratings of interference due to illness in their vocational, social and physical activities. As hypothesized, high Panic-Fear patients consistently reported that their asthma created more interference in their daily lives than did moderate and low Panic Fear patients. Additional findings indicated that the asthma interfered most with physical activities. secondly with vocational activities and least with social activities. It was also found that reported interference decreased following intensive, long-term inpatient treatment.

Trr~ WAYS in which an asthmatic patient affectively responds to periods of breathing distress are associated with subsequent medical treatment [I-4] and interact with the level of airways hyperreactivity to affect treatment outcome [S]. Extending this earlier work, the MMPI Panic-Fear scale was developed [6] to assess the relationship between a derived personality dimension and medical intractability in chronic asthma. High scores on the MMPI Panic-Fear scale describe asthmatic patients who are dependent, helpless and anxious in many life situations, and who are apt to give up easily in the face of difficulty. In contrast, extreme low scores describe patients who profess to be unusually independent, stable, self-controlled and apt to persist in the face of difficulty. It has been demonstrated that the personality constellation assessed by the MMPI Panic-Fear scale is also related to the medical outcome in chronic asthma. While being independent of the objective condition, indexed either by daily pulmonary-function measures throughout long-term treatment [&9] or the degree of airways hyperreactivity [9], MMPI Panic-Fear categories relate to the intensity of prescribed discharge medication [5, 10, I I], length of hospitalization [8] and rates of rehospitalization following medical treatment [7, 121. This paper extends previous research by assessing the relationship between the MMPI Panic-Fear scale and the patient’s perception of his own illness. Clinical and research experience with asthmatic patients suggests the following hypotheses. First, prior to intensive, long-term treatment, patients’ reports of interference due to their asthma with vocational, social and physical activities are expected to vary with MMPI Panic-Fear scores, with higher scores associated with reports of greater interference. Second, this relationship between MMPI Panic-Fear scores and reported interference is also expected *Address reprint Jewish Hospital

requests to Robert A. Kinsman, Ph.D., Psychophysiology Research Laboratories. and Research Center, 3800 East Colfax Avenue. Denver. CO 80206. U.S.A. 485

National

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to be apparent in: (A) anticipated continued interference following discharge from intensive, long-term treatment; (B) reports of interference during the first 6 months post discharge; and (C) reports of perceived interference during the second 6 months post discharge. METHOD

Subjects

The subjects were 90 asthmatic patients, 57 females and 33 males, ranging in age from 14 to 73 yr, formerly in intensive treatment at the National Jewish Hospital and Research Center (NJHRC). All were hospitalized at the NJHRC for some period between August 1973 and December 1975. While characteristics of this patient population have been described in depth elsewhere [4,9], it should be noted that they represented a heterogeneous group of severe, perennial asthmatic patients. They were randomly selected, with the restriction that: (A) all routine psychological testing and admission and follow-up information be complete; and (B) equal numbers of patients exist among the three MMPI Panic-Fear categories (high, moderate and low). Because interference ratings can be expected to vary according to the need for hospitalization and because hospitalization rates vary among Panic-Fear types, an additional requirement for subject selection was that the three Panic-Fear groups be equated for rehospitalization rates following discharge. Psychometric testing

The Minnesota Multiphasic Personality Inventory (MMPI) [13] was administered to all patients within 3 weeks following admission to the NJHRC. The MMPI Panic-Fear scale was scored, and patients were classified according to the standard three levels: high (1 S.D. above the mean; raw score of 9 or more), low (1 S.D. below the mean; raw score of 2 or less) and moderate (between the two extremes). Scale items, scoring procedures and normative data for the MMPI Panic-Fear scale are presented elsewhere (8). Pulmonary functions

While having treatment at the NJHRC, the patients were asked to perform daily (8 :00 a.m.) spirometric pulmonary function measures (Vertek 5000 VF Lung Function Analyzer; Hewlett-Packard, Boston, Mass.; calibrated weekly with a 1.5-I. syringe). The highest daily value from at least two forced expiratory maneuvers at maximal effort was used. These provided daily measures of the first-second forced expiratory volume (FEVi) and forced vital capacity (FVC). From these measures, FEV, expressed as a percentage of FVC [(FEV,/FVC)%] was derived [14]. The average daily, longitudinal (FEV,/FVC)% was used.as a measure of the objective severity of the patient’s asthma. Interference

measurements

Routine questionnaires were administered to all patients at admission, discharge, 6 months post-discharge and 12 months post discharge. On admission, patients were asked to rate the extent to which breathing problems associated with their asthma had interfered with their: (A) vocational activities; (B) social activities; and (C) physical activities during the year preceding admission to the NJHRC. The discharge survey asked the patients to rate their expectations of future interference in these three activities. Finally, two post-discharge surveys, completed at 6 and again at 12 months post-discharge, requested the patients to rate interference in the three activities for each previous 6-month period. All interference ratings were made on a five-point scale (1 = interfered not at all; 5 = interfered extremely). Combining the scales provided a possible range from 3 to 15 for an overall interference rating. Statistical analyses

The principal design of the study conformed

to a 3 x 3 x 4 factorial with repeated

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measures on the last two factors. The factors and levels were: MMPI Panic-Fear category (low, moderate and high), interference rating (vocational, social and physical) and time period (admission, discharge, 6 months post discharge and 12 months postdischarge). An analysis of variance (ANOVA) conforming to this design was used to assess differences in interference ratings relative to the Panic-Fear category, and to the various time periods during hospitalization and after discharge [15]. Individual comparisons, supplemental to the ANOVAs, used the least-squares method [15]. Box’s correction was used for the repeated-measures design. Supplemental ANOVAs were performed to evaluate the relationships between average daily pulmonary function measurements throughout hospitalization and MMPI Panic-Fear categories. For all analyses, the 0.05 probability level was used as the criteria for statistical significance. RESULTS

Table 1 presents the average longitudinal (FEV,/FVC)% for the three levels of PanicFear. As can be seen, the Panic-Fear groups were equated in this objective measure of pulmonary function (F 2,87 = 0.08, N.S.). Table 2 indicates that the patient selection procedure was successful in equating among the Panic-Fear groups for rehospitalization following discharge from intensive treatment. Rehospitalization data were available for all patients in the first 6 months post-discharge and for all but four patients in the second 6 months post-discharge. These findings indicate that any differences in interference ratings among Panic-Fear groups cannot be attributed to either objective pulmonary functions or to rehospitalization. Interference ratings, shown in Table 3, varied significantly across time periods (F 1,261 = 68.98, p < O.OOl),according to the type of activity (F,, 174 = 20.88, p < 0.001) and according to the MMPI Panic-Fear category (F,, 87 = 4.47, p < 0.025). There were no significant interaction effects among these three variables. Across the time periods, supplemental individual comparisons indicated that patients reported more interference at admission to treatment (mean k 1 S.D., 11.5 & 2.3) than at

TABLE

1. MEAN

PANIC-FEAR

DAILY

(FEV, FVC)%

GROUPS

VALUES

DURING

FOR

INTENSIVE

TREATMENT

x SD. N

High

Panic-Fear group Moderate

Low

74.61 10.99 30

74.09 9.85 30

75.17 10.49 30

F 2,87 = 0.08, N.S

TABLE

2.

FREQUENCY

IZED

WITHIN

OF

PATIENTS

PANIC-FEAR

REHOSPITAL-

GROUPS

Rehospitalization Panic-Fear group

Yes (%)

(A) For the first 6 months High 33.3 Moderate 30.0 Low 36.7 x2 = 0.30, 2 df N.S.

N/Group post-discharge 66.7 70.0 63.3

30 30 30

(B) For the second 6 months post-discharge High 42.9 57.1 28 Moderate 41.4 58.6 29 Low 41.4 58.6 29 x2 = 0.02, 2 df N.S.

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KENNETH H. FROSS ef al.

TABLE

3. MEAN INTERFERENCERATINGS ACCORDING TO TIME PERIODS,ACTIVITYTYPES AND PANIC-FEAR GROUPS

Panic-Fear Vocational

group

Activity type Social

Physical

(A) Admission High Moderate Low

4.4 + 0.7 3.5 + 1.1 3.8 k 0.8

4.3 + 0.8 3.2 + 0.9 3.3 f. 1.1

4.2 f 0.8 3.8 k 1.0 3.9 f 0.7

(B) Discharge High Moderate Low

2.8 f 1.1 2.3 + 1.2 2.3 + 0.9

2.7 + 1.0 2.1 + 0.9 2.2 f 0.9

2.8 + 1.0 2.5 ) 1.0 2.6 + 0.8

post-discharge 3.1 + 1.3 2.3 4 1.0 2.7 f. 1.4

2.8 + 1.2 2.3 + 0.9 2.3 k 1.4

3.2 + 1.1 2.6 + 1.0 2.8 f 1.3

2.9 + 1.2 2.7 k 1.1 2.6 + 1.2

3.2 k 1.2 3.0 * 1.0 2.8 + 1.3

(C) Six months High Moderate Low

(D) Twelve months High Moderate Low

post-discharge 3.0 + 1.5 2.5 + 1.2 2.6 + 1.3

discharge (7.4 f 2.7; p < O.OOl),than at 6 months post discharge (8.0 f 3.3; p < 0.001) and than at 12 months post-discharge (8.4 f 3.4; p < 0.001). However, their reported interference was greater at 6 months (p < 0.05) and 12 months post-discharge (p < 0.01) than their discharge rating. There was no significant difference in reported interference between the two post-discharge time periods. Thus, rated interference decreased during treatment, and increased somewhat following discharge, although not to the pretreatment admission levels. Among the activity types, patients generally reported more physical interference (12.5 f 3.1) than either vocational (11.8 + 3.6; p < 0.01) or social (11.1 f 3.4; p < 0.001) interference. In addition, there was more reported vocational interference than social interference (p < 0.01). Among MMPI Panic-Fear groups, overall individual comparisons found that high Panic-Fear patients reported significantly more interference (39.4 + 9.0) than either moderate (32.8 f 8.9; p < 0.01) or low (34.0 f 9.3; p < 0.025) Panic-Fear patients. There was no difference between low and moderate Panic-Fear patients. Additional comparisons of admission ratings found high Panic-Fear patients reported more interference (12.9 f 1.9) than either moderates (10.6 &-2.3; p < 0.001) or lows (11.0 + 2.1; p -c O.OOl), while moderates and lows did not differ. At discharge, high Panic-Fear patients also reported more interference (8.2 f 3.0) than either moderates (6.9 f 2.6; p < 0.01) or lows (7.2 + 2.3; p < 0.025), while moderates and lows did not differ. At 6 months post discharge, highs also reported more interference (9.1 f 3.3) than moderates (7.2 + 2.5; p < 0.001) or lows (7.8 + 2.3; p < 0.025), while moderates and lows did not differ. Finally, at 12 months post-discharge, highs reported more interference (9.1 f 3.7) than lows (8.0 k 3.5; p -c 0.05), although there were no other significant differences. DISCUSSION

The results of this study indicate that asthmatic patients’ reports of perceived interference due to their asthma vary significantly according to: (A) type of activity; (B) the time at which the reports are made; and (C) the Panic-Fear category of the patient. As expected, the treatment program resulted in decreased ratings of interference from admission to discharge, and while some increase in rated interference occurred following discharge, the interference, nonetheless, was consistently lower than at admission. Furthermore, the study suggests a rough hierarchy of general life situations that are most

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affected by the asthma. Specifically, asthma was perceived to interfere first and most extensively with basic physical functioning, then with vocational activities, and finally to affect the patients’ social lives. Of most interest to our present thesis, the original hypothesis regarding the relationship of coping styles to perceived interference was confirmed. High Panic-Fear patients consistently perceived more asthma-related interference and incapacitation in their physical, vocational and social lives than did other patients. This finding is all the more salient in that high Panic-Fear patients’ pulmonary-function levels were essentially the same as other patients throughout hospitalization, while their admission and discharge ratings of interference, obtained at points bracketing hospitalization, varied. In addition, the relative rates of rehospitalization among Panic-Fear groups following discharge did not affect these results. High MMPI Panic-Fear patients may be characterized as fearful, dependent, emotionally labile and withdrawn in a hostile manner. They profess to have their feelings hurt more easily than others, to feel helpless and to give up easily in the face of difficulty. The available information suggests that this personality constellation is not dependent on the patient’s asthma, but, in fact, has its roots in the period prior to asthma onset [lo, 163. As Bellak [ 173 notes, those patients with significant psychologic difficulties prior to the onset of physical illness may find it easy to attribute most of their complaints and worries to their current illness, and are candidates for long-drawn-out invalidism, unresponsive to the best of medical care. The present results, coupled with earlier reports of high MMPI Panic-Fear patients being prescribed more intensive oral corticosteroid regimens [6, 10, 1I], having longer hospital stays [S] and being rehospitalized more frequently than others [7, 121, suggests a parallel between high MMPI Panic-Fear patients and Bellak’s assessment of functionally determined invalidism. SUMMARY

Chronic illness is a particularly stressful experience affecting numerous aspects of the patient’s life. Asthma, because of its intermittent nature, is one of the more frustrating of the chronic illnesses. Periods of normal functioning and physical incapacitation may alternate in rapid succession. As such, the asthmatic patient often experiences profound uncertainty about even his most immediate future. He may experience breathing difficulty and resulting interference in his vocational, social and physical life after functioning rather well only the day before. Not only must the patient cope with the physical limitations his illness imposes, but also with the uncertainty of what the next day may bring. The results of this study indicate that patients vary significantly in how much they perceive their illness and its accompanying uncertainty to interfere with their daily lives. Although additional information is desirable, one suspects that some patients may attempt to resolve such issues by replacing the uncertainty of intermittent, physically determined incapacitation with the certainty of chronic, functionally determined incapacitation. REFERENCES 1.

Kinsman RA, Luparello T, O’Banion K et al.: Multidimensional analysis of the subjective symptomatology of asthma. Psychosom Med 35: 25@267, 1973 1 Kinsman RA, O’Banion K, Resnikoff P et al.: Subjective symptoms of acute asthma within a hetero&’ geneous sample of asthmatics. J Allergy Clin lmmun 52: 284-296, 1973 3. Kinsman RA, Spector SL, Shucard DW cr al.: Observations on patterns of subjective symptomatology of acute asthma. Psychosom Med 36: 129-143, 1974 4. Kinsman RA, Dahlem NW, Spector SL et al.: Observations on subjective symptomatology, coping behavior, and medical decisions in asthma. Psychosom Med 39: 102-I 19, 1977 5. Staudenmayer H, Kinsman RA, Dirks JF et al.: Medical outcome in asthmatic patients: effects of airways hyperreactivity and symptom focused anxiety. Psychowm Med 41: 109-l 18, 1979 6. Dirks JF, Jones NF, Kinsman RA: Panic-Fear: a personality dimension related to intractability in asthma. Psychosom Med 39: 12CL-126, 1977 7. Dirks JF, Kinsman RA, Horton DJ et al.: Panic-Fear in asthma: rehospitalization following intensive long-term treatment. Psychosom Med 40: S13, 1978 8. Dirks JF, Kinsman RA, Jones NF er ol.: Panic-Fear: a personality dimension related to length of hospitalization in respiratory illness. J Asthma Res 14: 61-71, 1977

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