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Psychosocial Aspects of Bronchial Asthma
EDITORIAL Psychosocial Aspects of Bronchial Asthma*
B
RONCHIAL ASTHMA OCCURS
AT ALL
ages, frequently during early childhood. A survey in Spain reveals that asthma affects about 0.5 per cent of children. The pertinent implications of this disease are complex. To gain an adequate appraisal of the problems, three periods will be reviewed: in f anc y, adolescence and adulthood. One must keep in mind that some of the aspects especially noted in each of the periods may also apply to the other age groups. Infancy: When bronchial asthma develops in an infant, it leaves a marked impact on the family. Because of the severity of attacks, members of the family are afraid of the possibility of sudden death and later on, they are worried about future invalidism. This anxiety will be sensed by the child. The parents' emotional attitude results in overprotection of the child, particularly by the mother. This is interpreted by psychiatrists as an attitude of rejection, of non-acceptance of the diseased child. In our judgment, there does not exist a set psychologic complex in the ashmatic child; rather, the wrong attitude of the family alters the affective sensibility of the little patient. Because of this erroneous conduct on the part of the family, the asthmatic child, generally overprotected and overclad in warm clothes, feels frustrated by not being able to lead a normal life. Often, he misses school and may not be allowed to play. He may turn egocentric, insecure and aware of his disease in which he may take refuge. Some children will rebel against this affective blockade and their games, generally with smaller children or with their own brothers, become more aggressive. In a gTeat many instances, we have observed *From the Institute of Asthmology, Hospital de la Santa Cruz y San Pablo. Condensed and revised version of paper presented at the IX International Congress on Diseases of the Chest, American College of Chest Physicians, Copenhagen, Denmark, August 20-
25, 1966.
the development of hostility toward the parents. Herein lies the beginning of later manifestations of lack of social adaptability. In view of this situation, the physician must offer thorough psychologic guidance to the parents. Of course, the therapeutic regimen of asthmatic children must be augmented by adequate psychotherapy. It is necessary to emphasize that anxiety and lack of exercise are the enemies of the asthmatic child's recovery. Relative to participation in games and other physical activities, it is mandatory to restore the child's self-confidence. If there are no other serious reasons, acute diseases, and/or asthmatic attacks, these children must not miss school. The parents should be told not to overprotect the child wit h clothing and that their pessimistic and indiscreet manner of speaking in the presence of the child is likely to have fateful psychologic repercussions on the youngster. We must not forget that the child is as it was and moreover as we have molded it, and the mother is the affective axis around which the disposition of the child is fonned. Adolescence: When he reaches this stage of life, the anxiety of the young asthmatic shows itself nearly always as a stagnation of his personality in a juvenile sphere. In a great number of cases, the patient's irritability increases and alternates with periods of depression and capriciousness. As the disease progresses, when the patient reaches adulthood, the change in character will become more evident. Compared with normal individuals, the percentage of asthmatics with affective hypersensibilitv, is. greater. During this period, the adaptation to the family milieu and corrective psychotherapy represent tasks of great importance. Of the different problems during adolescence, it is well to emphasize occupational orientation and participation in sports.
227
228
Diseases of lhe Chesl
R. FROUCHTMAN
OccujJational Orientation: The occupational adaptation of the young patient to adequate activity is nearly always possible. Cases which remain permanently incapacitated are few. To overlook such important social implications brings about an increased sense of frustration. The occupational orientation is conditioned not only by the preference and aptitude of the individual, but also by the etiology and stage of his disease. It is well to remember that with the passing of time, the respiratory apparatus of these patient,> becomes less resistant, but also more reactive. It is the doctors' responsibility to recommend the most suitable occupation for each patient. Y?ung asthmatics should avoid occupations WIth exposure to harmful inhalants ' toxic, . . . IrntatlVe or potentially allergenic substances. Participation in sports is another problem in adolescence. In addition to basic respiratory exercises, the older child and young asthmatic should engage in sports. There is nothing that brings about greater confidence than the fact that often they are able to perform the same efforts as their healthy playmates. It is better that the yot~ng person should interrupt or temporanly reduce his participation in games because of cough or dyspnea than to avoid games "a priori" because of fear of asthm~tic attacks. Of course, the planning and onentation of sports must be adapted to the nature and intensity of the disease. Cases with marked and irreversible respiratory invalidism that rules out some of the sport activities are rare. Specially to be recommended are exercises that entail control and training the respiratory rhythm, such as swimming, athletics and rowing. Golf, hunting, hand ball and basketball may also be permissible.
Adult Asthmatics: After the age of 20, and sometimes earlier, consultation is sought because of the possible bearing of marriage on asthma. Women are worried about the possibility that the children may inherit the '.L,>thmatic diathesis. It is well to discuss this problem frankly with all concerned. Apropos of this problem, I wish to point out the following: 1) marriage has no influence on the course of asthma; pregnancy is often associated with a temporary alleviation of symptoms; 2) transmission of allergic predisposition through a dominant gene favored by the female sex is not to be denied. In a review of familial antecedents (including grandfathers and uncles) of 300 asthmatic children, we have found allergiC antecedents in 35.5 per cent; 3) this hereditary allergic diathesis does not necessarily manifest itself through the same shock organ. Among 300 children studied, the antecedents with bronchial asthma were noted in 29.8 per cent; 4) more importance is to be attributed to familial antecedents with respiratory diseases. Among 115 asthmatic children, there were anteceden ts with chronic bronchopneumopathies in 90 (79.6 per cent). Our pertinent philosophy can be epitomized by stating that in the management of patients, especially children, with bronchial asthma, the disease itself is not the only issue to be considered. The patient must be thought of as a biopsychologic subject. While amelioration of his physical condition is sought by all rational preventive and therapeutic measures, utmost attention must be given to the psychologic problems of the patient, as well as of his family. R.
FROUCHTMAN, M.D., F.e.C.P.
Director, Institute of Asthmology Barcelona, Spain For reprints, please write: Dr. Frouchtman, Balmes 182, Barcelona 6, Spain.
B
RONCHIAL ASTHMA OCCURS
AT ALL
ages, frequently during early childhood. A survey in Spain reveals that asthma affects about 0.5 per cent of children. The pertinent implications of this disease are complex. To gain an adequate appraisal of the problems, three periods will be reviewed: in f anc y, adolescence and adulthood. One must keep in mind that some of the aspects especially noted in each of the periods may also apply to the other age groups. Infancy: When bronchial asthma develops in an infant, it leaves a marked impact on the family. Because of the severity of attacks, members of the family are afraid of the possibility of sudden death and later on, they are worried about future invalidism. This anxiety will be sensed by the child. The parents' emotional attitude results in overprotection of the child, particularly by the mother. This is interpreted by psychiatrists as an attitude of rejection, of non-acceptance of the diseased child. In our judgment, there does not exist a set psychologic complex in the ashmatic child; rather, the wrong attitude of the family alters the affective sensibility of the little patient. Because of this erroneous conduct on the part of the family, the asthmatic child, generally overprotected and overclad in warm clothes, feels frustrated by not being able to lead a normal life. Often, he misses school and may not be allowed to play. He may turn egocentric, insecure and aware of his disease in which he may take refuge. Some children will rebel against this affective blockade and their games, generally with smaller children or with their own brothers, become more aggressive. In a gTeat many instances, we have observed *From the Institute of Asthmology, Hospital de la Santa Cruz y San Pablo. Condensed and revised version of paper presented at the IX International Congress on Diseases of the Chest, American College of Chest Physicians, Copenhagen, Denmark, August 20-
25, 1966.
the development of hostility toward the parents. Herein lies the beginning of later manifestations of lack of social adaptability. In view of this situation, the physician must offer thorough psychologic guidance to the parents. Of course, the therapeutic regimen of asthmatic children must be augmented by adequate psychotherapy. It is necessary to emphasize that anxiety and lack of exercise are the enemies of the asthmatic child's recovery. Relative to participation in games and other physical activities, it is mandatory to restore the child's self-confidence. If there are no other serious reasons, acute diseases, and/or asthmatic attacks, these children must not miss school. The parents should be told not to overprotect the child wit h clothing and that their pessimistic and indiscreet manner of speaking in the presence of the child is likely to have fateful psychologic repercussions on the youngster. We must not forget that the child is as it was and moreover as we have molded it, and the mother is the affective axis around which the disposition of the child is fonned. Adolescence: When he reaches this stage of life, the anxiety of the young asthmatic shows itself nearly always as a stagnation of his personality in a juvenile sphere. In a great number of cases, the patient's irritability increases and alternates with periods of depression and capriciousness. As the disease progresses, when the patient reaches adulthood, the change in character will become more evident. Compared with normal individuals, the percentage of asthmatics with affective hypersensibilitv, is. greater. During this period, the adaptation to the family milieu and corrective psychotherapy represent tasks of great importance. Of the different problems during adolescence, it is well to emphasize occupational orientation and participation in sports.
227
228
Diseases of lhe Chesl
R. FROUCHTMAN
OccujJational Orientation: The occupational adaptation of the young patient to adequate activity is nearly always possible. Cases which remain permanently incapacitated are few. To overlook such important social implications brings about an increased sense of frustration. The occupational orientation is conditioned not only by the preference and aptitude of the individual, but also by the etiology and stage of his disease. It is well to remember that with the passing of time, the respiratory apparatus of these patient,> becomes less resistant, but also more reactive. It is the doctors' responsibility to recommend the most suitable occupation for each patient. Y?ung asthmatics should avoid occupations WIth exposure to harmful inhalants ' toxic, . . . IrntatlVe or potentially allergenic substances. Participation in sports is another problem in adolescence. In addition to basic respiratory exercises, the older child and young asthmatic should engage in sports. There is nothing that brings about greater confidence than the fact that often they are able to perform the same efforts as their healthy playmates. It is better that the yot~ng person should interrupt or temporanly reduce his participation in games because of cough or dyspnea than to avoid games "a priori" because of fear of asthm~tic attacks. Of course, the planning and onentation of sports must be adapted to the nature and intensity of the disease. Cases with marked and irreversible respiratory invalidism that rules out some of the sport activities are rare. Specially to be recommended are exercises that entail control and training the respiratory rhythm, such as swimming, athletics and rowing. Golf, hunting, hand ball and basketball may also be permissible.
Adult Asthmatics: After the age of 20, and sometimes earlier, consultation is sought because of the possible bearing of marriage on asthma. Women are worried about the possibility that the children may inherit the '.L,>thmatic diathesis. It is well to discuss this problem frankly with all concerned. Apropos of this problem, I wish to point out the following: 1) marriage has no influence on the course of asthma; pregnancy is often associated with a temporary alleviation of symptoms; 2) transmission of allergic predisposition through a dominant gene favored by the female sex is not to be denied. In a review of familial antecedents (including grandfathers and uncles) of 300 asthmatic children, we have found allergiC antecedents in 35.5 per cent; 3) this hereditary allergic diathesis does not necessarily manifest itself through the same shock organ. Among 300 children studied, the antecedents with bronchial asthma were noted in 29.8 per cent; 4) more importance is to be attributed to familial antecedents with respiratory diseases. Among 115 asthmatic children, there were anteceden ts with chronic bronchopneumopathies in 90 (79.6 per cent). Our pertinent philosophy can be epitomized by stating that in the management of patients, especially children, with bronchial asthma, the disease itself is not the only issue to be considered. The patient must be thought of as a biopsychologic subject. While amelioration of his physical condition is sought by all rational preventive and therapeutic measures, utmost attention must be given to the psychologic problems of the patient, as well as of his family. R.
FROUCHTMAN, M.D., F.e.C.P.
Director, Institute of Asthmology Barcelona, Spain For reprints, please write: Dr. Frouchtman, Balmes 182, Barcelona 6, Spain.