Psychosomatic Study and Treatment of Asthmatic Children

Psychosomatic Study and Treatment of Asthmatic Children CONSTANTINE

J.

FALLIERS, M.D.'"

Attention to both the psychological aspects of asthma and to its potential clinical severity is evident in some of the earliest medical texts. The Hippocratic corpus, for example, contains advice for the asthmatic to avoid strong emotions, such as anger,27 but it also warns that "such as become hump-backed before puberty from asthma or cough die."5 Regrettably, this comprehensive view of both the disease and the patient is frequently lost through specialization. lO Correlations are attempted in which either the medical identification of the disease, or the objective assessment of psychological variables-or both!-are lacking. The psychosomatic approach to asthma can fulfill its purpose only if it examines certain basic psychophysiologic postulates, ascertains the value of modern psychodiagnostic tools, and defines the role of various therapeutic methods in the practice of pediatric allergy, without ever losing sight of the fact that we are not dealing simply with a disturbance in respiratory behavior, but with a seriously incapacitating disease. Psychosomatic or psychophysiologic research, according to Graham, is the effort to "write the dictionary between the two languages," the somatic and the psychologic,17 Traditionally, the numerous causative or precipitating influences on asthma (Fig. IA) are conceived as distinct stimuli, the summation of which produces the disease. 36 An increase in one factor would accordingly lessen the dependence on the others for exceeding the symptom threshold. Current concepts of dynamic repetitive reciprocal interactions of stimuli,7.10 however, have rendered the old questions of "either-or" and of etiologic priorities meaningless. In Figure IB the same variables as in IA are interconnected in circles (feedback loops), showing that emotional reactions or behavioral changes may result from asthma, but also they may precipitate or aggravate an asth'" Assistant Clinical Professor of Pediatrics, University of Colorado School of Medicine; Medical Director, Children's Asthma Research Institute and Hospital, Denver, Colorado. Studies reported in this article received support from U.S. Public Health Service grants A-5963, HD-01060, HD-0l529, MH-10385, and FR-05523, and from the John A. Hartford Foundation.

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Irritants Psychic Factors Weather Endocrine Factors Other Factors Infection Current A lIergen Expos ure State of Sensitization Heredity

A

~~~ INFECTION ENVIRONMENTAL NON-SPECIFIC

SENSITIZATION

(

IRRITANTS

ALLERGEN EXPOSURE

HEREDITY

WEATHER

NEUROENDOCRINE FACTORS

STRESS)

PSYCHIC INFLUENCES

~~~

B Figure 1. Multiple factors in the pathogenesis of asthma. A, The concept of "total load" (static, cumulative effect). (Slightly modified from Sheldon et al. 36 ) B, The concept of repetitive interaction (dynamic, reciprocal amplification, or positive feedback).

matic attack. Several cycles may take place before the process is either arrested or spirally amplified.

DIAGNOSTIC PROCEDURES

Well recognized medical criteria define asthma as a disease entity. Patients diagnosed as having asthma can of course be subdivided according to their age, sex, specific allergic sensitivities, variability in pulmonary function, additional atopic or other pathology, etc. The use of observations in the domain of psychology and psychiatry is a legitimate effort to refine our discriminatory power and to define all significant variables for distinguishing subgroups of patients. 10 Correct prognostic estimates and therapeutic programs can be based only on such precision in our clinical taxonomy.12 In psychosomatic research, difficulties arise from the inability of most observers to obtain reliable data, from the rarity of sufficiently

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homogeneous subsets of patients, and from the lack of precise terminology. How can one evaluate "overprotection," for example, when the appropriate and desirable amount of protection a sick child needs has not been clearly standardized? In response to this need, an effort is currently being made within the framework of the Research Council of the American Academy of Allergy (Rehabilitation Therapy Committee), and in cooperation with the Allergy Section of the American Academy of Pediatrics, to develop standardized methodology for the longitudinal study of asthma in relation to child development. Clinical Observations and Interviews In most cases clinical diagnosis and classification can be achieved through observation, physical exaInination, and a rather free, unstructured conversation. The simple tools required for these procedures certainly do not diminish the importance of the information derived, nor do they reduce the complexity of the necessary interpretations and correlations. The illness must be clearly identified and its frequency and severity precisely recorded. Isolated manifestations of asthma, such as asthmoid dyspnea or hyperventilation, cough, frequent use of medication, and school absences, should not be accepted alone as sufficient indicators of the presence or the degree of true pathology.lO Misconceptions or failure to distinguish between symptom and disease will lead to many wrong conclusions on the role of psychological factors. The place and meaning of asthma in the patient's existence, or within the family constellation, must be explored. All precipitants of asthma, known or suspected, must be identified and ranked in order of importance and frequency. The structured interview technique (Table 1) is very useful in this respect. 9, 34 After an initial verbal sensitization (or desensitization when previous biases are known to exist), a second discussion a few days later might be worthwhile. The patient, as an integrated organism, must be described in sufficient detail in every record. Simple,· conventional information from the medical records, such as birth order, developmental milestones, childhood illnesses, and common medical complaints, can be of distinct value to psychosomatic research. 10 For an accurate profile of the patient, the type, range, and duration of various forms of behavior (activity and rest, eating, sleeping, talking, laughing or crying, playing, reading, studying, socializing, fighting) should be repeatedly recorded. The use of standard mood charts (Table 2) permits analysis of the patient's predominant mood, its variability and intensity.41 The parents and the family milieu sometimes play an important role in determining whether a child is or is not going to suffer from asthma. To find out why the incidence of allergic disease among children is so much higher (40 vs. 20 per cent) in the upper socioeconomic levels, or

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Table 1.

J.

FALLIERS

Perception oj Events Related to Attacks oj Asthma: Structured Interview 9 • 34 SEQ.UENCE

REMARKS

1. The patient is asked to list the things he thinks bring on asthma attacks. 2. Detailed information on the time interval between the event and asthma. 3. A list of additional asthma precipitants is read and the patient indicates which, if any, apply.

Emphasize interest in what patient himself has noticed rather than what he has heard. Specific examples are discussed, e.g., damp weather or an argument. Items listed include "colds," overexertion, weather, excitement (positive affect), emotional reactions (worry, anger, sadness, or any other negative affect), laughing, crying, "hard" breathing, coughing, pollens, dust, animals, foods, drugs, other allergies, night asthma, and "I just get it." 4. After listing is obtained, the patient is An estimate is obtained of the frequency with asked to rank the precipitants in the which a given precipitant is tied to the order of their importance. onset of asthma, and the severity of attacks. 5. Appropriate guidelines are offered to Reports on the importance or unimportance "sensitize"-or "desensitize," if there is of emotional precipitants may become previous bias-the patient and the parmore convincing as the person involved ents as observers of the antecedents of becomes a better observer. asthma.

why the known difference between boys and girls in the prevalence of asthma does not exist in some cultural subgroups, we need combined psychologic, sociologic, epidemiologic, and medical studies. 10 The residential community of the patient may also play a role in shaping or modifying the patient's attitude toward asthma and, indirectly, in forcing him to hide or in prompting him to magnify his symptoms. If modem psychophysiologic experiments and theories are correct,31,34 the "reward" or "punishment" bestowed or inflicted upon the patient with asthma may be an important determinant of whether the illness continues or remits. Psychological Tests Conventional psychological tests have been used in an effort to explore personality traits peculiar to the patient with asthma or atopic disease. 3, 4, 11, 13 The results have been controversial, and the currently Table 2.

Mood Atijective Check List*

CONCENTRATION

DEPRESSION

AGGRESSION

DEACTIVATION

ANXIETY

Concentrating Serious Clear-thinking Confused Unable to concentrate

Unhappy Lonely Regretful Happy Pleased Cheerful

Angry Disobedient Grouchy Obedient Friendly Helpful

Worn-out Sluggish Drowsy Active Lively Alert

Clutched-up Fearful Uneasy Secure Relaxed

* Adapted from Nowlis by Weiss. 41

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prevailing attitude lO is that these medical conditions alone do not constitute sufficient indications for the traditional type of personality inventories, I.Q. tests, etc. Nevertheless, brief mention of a few outstanding studies appears justified,27 not only to inform the reader of what has been done, but also to stimulate further exploration of what may not be a dead-end road. The application of batteries of tests-among them the Brown Personality Inventory, the Cornell Medical Index, The Despert Fables, the Heron 2-Part Personality Inventory, the Maudsley Personality Inventory, and the Minnesota Multiphasic Personality Inventory-have convinced some investigators that the asthmatic is "neurotic" and that his scores fall more often than not in the "disturbed" range. Rorschach tests have been particularly productive (at least of diagnostic terms) and have led many investigators to the diagnosis of "neurosis," "compulsive-type personalities," "emotional tension," "persecutory ideas," "constriction and inhibition," etc., among asthmatic patients.27 More critical studies, including a comparison of asthmatic children with those suffering from cardiac or other chronic disease, and an extensive survey at the Children's Asthma Research Institute and Hospital (CARIH) have not confirmed these impressions. lo . 28. 34 Behavior ratings likewise have failed to provide specific diagnostic guidelines for asthma, and the abnormalities found in psychomotor tests (Bender Gestalt, etc.) reHect organic brain damage resulting from severe hypoxic episodes rather than a disturbance predating these asthmatic paroxysms. The discipline of experimental psychology seems at this point to have accomplished the healthy goal of discouraging further aimless testing and abstract theorizing.28 The allergist, however, who recognizes and appreciates the significance of even one positive skin test is inclined to express some concern that valuable individual data may be lost by pooling all psychological test results. Selective study of subsets of patients (Fig. 2) can inform us whether this intersection of A, B, and C (AnBnC in Boolean notation12 ) is in any way different from A alone, AflB, etc. The predictive value of psychological tests on the outcome of asthma was shown in the course of several studies. 34 The Parents' Attitude Research Instrument ( PARI) effectively discriminated between certain "pathologic" attitudes of parents whose children lose practically all evidence of asthma upon separation, from the parents of children who continue to have asthma in a residential center. An experimental separation -during which arrangements had been made for parents and siblings to leave the home environment for a 2-week period while a substitute mother cared for the patient and recorded all clinical observations and peak expiratory How measurements-revealed that improvement could be predicted by the so-called "asthma precipitant interview technique" (Table 2), which reliably detected psychological factors.34

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Figure 2. Simplified Venn diagram for the psychosomatic study of asthma. Arbitrarily equal circles represent "universes" of cases.1 2 A, All cases of asthma. B, Selected personality trait (dependency, etc.). C, Specified parental attitude (rejection, etc.). The shaded area may represent a fortuitous concurrence of A, B, and C. Alternatively, it may compromise a discrete subset which can be studied and treated adequately only as such, namely, as

An

Bn C.

Psychiatric and Psychoanalytic Studies The diagnostic significance of freely expressed verbal associations and the role of regular psychotherapeutic sessions in guiding this exchange of information have been adequately stressed by the psychoanalytic school of thought. Several monographs from the work of Freud, who considered psychosomatic symptoms mainly as manifestations of hysterical conversion, to French, Alexander, and many others1, 10,24,27,34 have documented the processes that lead from psychic symbolism to bodily symptoms, and from specific emotions to organic disturbances. Lately, however, the pendulum appears to have swung in the direction of experimental psychology, with more emphasis on statistically valid data and less on individual case analyses. The "blind" rating of tape recordings or of verbatim typescripts of interview material, for example, led Heim et apo to the finding that "defensive strain" correlates with increases in sensitivity to inhalations of carbachol. Thus obfective measures of emotional disturbance, like the assessment of the integrity of psychological defenses, prove to be valuable indicators of physiologic responses in psychosomatic studies. Efforts to measure psychopathology were guided in the past by the hypothesis that when the "allergy potential" of the patient is low, more psychological disturbance is required to produce symptoms of asthma. Recent studies 13, 14 have detected "more personal discomfort and unhappiness" among immunologically nonsensitive patients, in contrast to the "relatively satisfied and confident" persons with stronger reactions to allergy skin tests. These reports are not in agreement with the view of the spirally repetitive interaction between asthma and the psyche7,lO and, in fact, appear to be negated by the work of Jacobs et al. 22 ,23 Showing that both allergy and psychopathology tend to be concurrently

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high in patients with atopic disease, these studies lend support to the positive interaction model. The meagerness of well-documented reports on distinct personality constellations, nuclear emotional conflicts, or specific interpersonal relationship patterns in asthma has caused a shift of attention to (a) the heterogeneity of asthma and (b) the role of distinct emotions rather than personality traits or mother-child relationships. The psychological precipitants reported are mostly in terms of one of four major affects: ( 1) anger, (2) excitement with pleasurable feeling, (3) anxiety or worry, and (4) depression. The specific circumstances eliciting such emotions or their symbolic content seem to be of lesser importance. Qualifying statements are often made regarding the effect of the intensity or duration of the emotional state on asthma. Therefore the emotional provocation tests applied by a number of investigators to provoke an attack of asthma are of considerable interest.lO These tests have included direct clinical observation and often some objective measurements of lung function or psychophysiologic reactivity. Selected emotional stimuli from a patient's case history, or undifferentiated emotional stress, have been applied during interviews or in the laboratory, and some positive results in terms of wheezing, lowered lung function, or even visible changes in the size of the bronchial lumen during bronchoscopy have been reported. Unfortunately, most of these ingenious experiments were conducted on few patients and the observations were very limited.lO, 34 Psychophysiology Physiologic, biochemical, and pharmacologic studies with asthmatic children have demonstrated an altered reactivity pattern which not only distinguishes these patients from nonasthmatics, but also differentiates cases of asthma of varying severity. IS, 19, 21, 40 The task of psychophysiology is to ascertain whether psychic factors can influence these patterns. The altered immunologic reactivity currently considered the primary element in asthma has not been shown to be affected-in humans, at least-by psychologic or central nervous system influences. The diminution in skin test size (wheal and erythema), reportedly induced by hypnosis,15 suggests a vascular rather than an antigen-antibody effect. The function of the autonomic nervous system is significantly changed in asthma. Cardiac and vascular reactivity, metabolic and endocrine functions, galvanic skin responses, and the bronchial hypersensitivity of the asthmatic to physical, psychologic, and pharmacologic stimuli19. 21. 37. 38. 40 suggest the presence of transient as well as possibly permanent malfunction. An imbalance between the sympathetic and parasympathetic branches of the autonomic nervous system has been considered for a long time as possibly accounting for the manifestations of asthma. 2 • 19 Different recovery rates have been observed after the two branches escalate in opposition to each other, and this "autonomic

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tuning" has been thought to account for a heightened sensitivity to diverse stimuli. 19 A "subliminial vulnerability" of the asthmatic, manifested in spontaneous or drug-induced fluctuations in airway conductance, appeared related to a "defensive breakdown" leading to a "lack of homeostatic regulatory control."20 The likelihood that regulatory failure (cybernetic derangement) could be an appropriate framework for the study of asthma in general has been considered, 7 and this concept is now the basis of an extensive data-analysis project at CARIH. In a current review,38 Szentivanyi clearly summarizes and interprets experimental data. A blockade of beta adrenergic receptors in the lung is proposed as the overall explanation for the altered reactivity in asthma, and the enzyme adenylcyclase is identified as the biochemical substrate for these changes. The variable obstruction of airways in asthma can thus be attributed to alterations in the sympathetic target cells rendering the patient susceptible to a diversity of stimuli. Bronchial reflex arcs mediated through vagal pathways also have been shown to produce bronchospasm.37 A range of stimuli, from inhalation of citric acid and cold air to forced hyperventilation or cough, can measurably increase airway resistance in patients with a history of asthma. To what extent this. nonspecific hypersensitivity relates to the emotional "breakdown" mentioned by Heim et apo remains to be studied. The immunologically, neurophysiologically, or otherwise acquired ("learned") bronchospastic response is generally involuntary. Yet the psychophysiologist-as well as the clinician-must bear in mind that the search for personal gain may motivate a patient to induce an attack of asthma through voluntary exercise, cough, or hyperventilation. The possibility of a "quasivoluntary respiratory maneuver"20 being mistaken for asthma must certainly be ruled out by appropriate and repeated pulmonary function studies,l° and the patient's attitudes should always be explored. EXPERIMENTAL DATA

Apart from the diagnostic significance of psychologic, psychiatric, and psychophysiologic procedures for cases of asthma, basic experience in the research laboratory greatly contributes to our total understanding of this disease. 28 . 34 The new developments selectively mentioned here are those with actual or potential clinical usefulness. Experimental Material and Methods A most important development in psychosomatic research on human subfects has been the recognition of meaningful subgroups of patients. Doubtful data and sweeping generalizations are thus avoided by studying well-defined categories of patients. The application of diagnostic tests, nonspecific stresses, bronchial challenges, and therapeutic proce-

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dures has confirmed the initial impressions of the heterogeneity of asthma. The existence of so many animal models for the study of asthma, namely, the anaphylactic guinea pig, the beta adrenergically blocked mouse, the tracheal ring of the rat, the passively sensitized skin of primates, the "neurotic" dog, etc., proves that the perfect counterpart has not yet been found. Despite the present limitations, however, studies with animals fruitfully explore the immense complexity of neurologic or psychologic influences on bodily functions. Classical Conditioning Conditioning as a psychophysiologic process capable of producing symptoms of asthma after repeated exposure to specific environmental circumstances has attracted considerable attention. When classical conditioning is successful, the conditioned stimulus alone is able to reproduce the specific response. The historic example of a woman allergic to roses who developed asthma upon seeing an artificial rose has been cited many times. The "hoarse, labored breathing" of Gantt's experimentally neurotic dog has also been frequently mentioned as an example of "conditioned" asthma. Though many other examples, involving both humans and animals, can be found in the literature, one must conclude that the successful conditioning of asthma remains to be demonstrated. Instrumental (Operant) Conditioning That so-called operant conditioning, or instrumental learning, or trial-and-error learning, or Type II conditioning, can alter autonomic nervous system function has been demonstrated only recently.31 Through reinforcing electrical stimulation of the brain, timed to coincide with spontaneous accelerations of heart rate, Miller et al. showed that "learned" tachycardia in rats can persist for months. Vascular tone and intestinal motility also have been modified by the application of reinforcing or inhibitory stimuli. This demonstration of autonomic conditioning suggests that (a) a psychosomatic disorder, possibly asthma, may develop through inadvertent rewarding of autonomically controlled activity, for instance periodically or randomly occurring increase in bronchial muscle tone (subclinical bronchospasm), and (b) retraining of autonomic responses may offer a potentially effective nonpharmacologic treatment for psychosomatic disorders, even if learning was not initially involved in producing the syndrome. The known circadian variability in expiratory flow rates, and the detection of higher frequency rhythms in bronchial smooth muscle tone 7 • 28 make this hypothesis plausible. Developmental Studies Whether the variability in airway size characteristic of asthma is the result of intermittent exposure to allergens, repeated exposure to respiratory infection, or inadvertent psychophysiologic reinforcement, it is obvious that no retrospective analysis of clinical cases, and no experi-

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mental production of asthma in the laboratory can elucidate its pathophysiology. Particularly if instrumental conditioning is to be investigated, individual, rather than group, studies are needed. As Thomas et al,39 have indicated, the individual pattern of primary behavioral activity, which is identified in early infancy, persists for each child. To assess innate or acquired responses to environmental influences, focus on individual patients is necessary as well as developmental studies of groups.

THERAPY

A variety of psychotherapeutic methods including environmental manipulation, psychoanalysis, group psychotherapy, hypnosis, behavior therapy and even electric shock therapy-not to mention drug and other forms of supportive therapy-have been applied to patients with asthma. The majority of published reports contain claims of success, but the indications for the choice of treatment have seldom been scrutinized. The physician trying to make therapeutic decisions will find valuable guidelines in the comprehensive and objective reviews by McGovern and Knight27 and Purcell and Weiss (not yet published). Three fundamental changes have been associated with the manifest alleviation of the symptoms following psychotherapy of any type, namely (a) a modification of physiologic function, such as hormonal homeostasis or autonomic reactivity; (b) a reduction in the range of triggering stimuli, as, for example, the removal of a child from a tense family situation, or treatment of the family to reduce tensions, or teaching the child to modify his anxiety level; and (c) a sufficient alteration in the patient's attitude toward the disease, which results in a reduction of what might be considered "secondary symptoms." A valid therapeutic trial must be based on an unbiased selection of standardized procedures, an adequate number of patients to be treated, matched control groups not treated by the method under study, and sufficiently'long follow-ups (as well as pretreatment observation) to rule out spontaneous variability in the disease. Developmental Surveillance

Whether the slightest deviation from the "normal" (in the context of psychosomatics and allergy) needs therapeutic correction or whether, preferably, physiologic regulatory processes ought to be left alone to operate is debatable. In general, the skillful physician, guided by properly instructed parents, should know when to intervene. In pediatric allergy practice, such therapeutic intervention requires close developmental surveillance. The contributions of developmental scientists, behavioral psychologists and, more recently, of workers in the field of operant conditioning make it evident that detailed records of developmental milestones and appropriate correction of pathologic deviations

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not only serve an immediate clinical purpose, but are part of a process deserving the name of "prehabilitation." In contrast to rehabilitation, which attempts to correct damage already done, prehabilitation ensures the attainment of each patient's full potential capability. Supportive Psychotherapy Pediatricians and allergists handle most cases of asthma in which emotional factors seem to play a role. This is generally advisable provided certain precautions are taken: 1. Sufficient time (at least an hour) should be allowed for a discussion of asthma, drugs and diets, emotions and emulsions, Chihuahua dogs (rumored to take asthma away), and curative climate. If this session is well spent, it will form the foundation of a close relationship for the sound management of the asthmatic child. s,IO 2. Remembering that words may have serious and lasting undesirable effects, the physician should strive to prevent iatrogenic psychopathology and must avoid premature promises, vague and false reassurance, expression of excessive concern about the disease or its prognosis, and stigmatizing interpretations concerning parental responsibility from either the genetic or the psychological points of view. 10 3. Respecting both the patient and his illness, the physician must pay full attention to both without showing undue preoccupation with diagnostic techniques (e.g., immediately performing allergy skin tests, batteries of psychological tests, etc.), and without focusing excessively on personality matters, thus implying that he considers asthma a form of emotional expression. Behavior Therapy Techniques derived from learning and conditioning principles are a rather recent addition to psychotherapy. It may be of interest to the allergist that one of these methods is actually called "desensitization." The goal of such therapy is to train the patient to substitute a useful or adaptive response, for example, relaxation, to a stimulus that is known to evoke a maladaptive one, such as anxiety or phobic withdrawal. The impressive record of successes, added to the relative simplicity of these techniques and the short time required to obtain behavioral modifications, has led to numerous applications with a variety of patients, despite recent criticism. Treating asthma, some have indicated that taking a patient through successive steps of relaxation and, more specifically, reciprocal inhibition (teaching the patient to respond with relaxation to stimuli associated with an asthmatic attack), can substantially alleviate bronchial obstruction. 32 The assumption that no matter how realistic is the course of anxiety the patient can relax "on command" may seem rather naive to the medically trained therapist, but the results may prove our skepticism unjustified.

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The observation that operant conditioning can produce and also can correct a physiologically inappropriate response (such as excessive tachycardia) is of particular interest to the behavior therapist. If asthma can persist as a learned response, it may also be possible to "unlearn" it through behavioral therapeutic maneuvers. Hypnosis In its application to the treatment of asthma, hypnosis may be close in orientation to behavior therapy in that both attempt to substitute new responses for old (e.g., relaxation for anxiety) without exploring the history and the fundamental dynamic implications of the symptoms. Hypnosis differs, however, in that it is usually applied in order to alter the asthmatic response itself, rather than emotional reactions associated with it. Although there is some evidence that a variety of physiological changes may be induced by hypnosis,15 in most of the cases reported improvement in mood was defined only subjectively.15.26 The problem of selecting patients most likely to benefit from hypnosis has been the subject of only one study,26 in which it appeared that younger patients, with mild asthma of relatively short duration, who reported a number of emotional precipitants and were more easily hypnotizable, showed the greatest improvement. Individual Psychotherapy Psychotherapy specifically directed to the treatment of asthma and particularly the analytically oriented type of therapy aim at providing the patient with insight into the psychodynamic meaning of his symptoms, and through emotional release, or redirection of his impulses, cause the somatic expressions to disappear. Despite the fact that the universality of this assumption has been questioned, analytic treatment or any psychotherapeutic intervention may serve as a means of reducing the emotional component in asthma and, in a number of cases, leads to improvement ranging from minimal reduction to virtual elimination of asthma. The qualifications of the psychosomatically oriented therapist for children, the ideal therapeutic setting, the major steps and goals of psychotherapy, as well as the principles and expectations of such an approach have been outlined. 27 Special techniques for children consist of ways for making the child tell a story, interpret situations, or describe dreams. The threefold technique of Miller and Baruch may deserve a special mention as particularly applicable to helping asthmatic children express their "repressed anger."29 Group Therapy As elegantly stated by McGovern and Knight,27 group psychotherapy "is intended to afford a corrective emotional experience, based on the

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premise that an individual becomes ill within a group and that his illness does not evolve solely from personal maladjustment, but from the nature of his relations with other persons as well." This type of therapy is particularly advocated for the treatment of asthmatics·30 on the premise that the underlying dynamic problem in asthma is the repression of hostility. Both patients and parents of asthmatic children have been reported to be benefitted from participation in group sessions. 35 Experiences at CARIH indicate that information on asthma and associated disorders, drug therapy, etc., given to the patients, and regular weekly group therapeutic sessions with parents have a significant supporting effect. In no instance, however, did such group sessions lead to demonstrable improvement in the medical condition of the children. Family treatment is specifically directed toward a family unit and more realistically deals with problems related to the management of asthma. Examples of temporary relief of family tension by hospitalizing a child, or in reverse, by leaving the child at home for an experimental study and giving the family a 2-week vacation, have resulted in noticeable improvement in many cases. s, 9, 34 This reality-oriented therapy, aimed at the family in general and undertaken by a team including a physician, a psychiatrist or psychologist, social workers, teachers, and representatives of other paramedical services, deserves further emphasis. Psychopharmacology The administration of tranquilizing drugs or other psychopharmacologic agents is intended primarily to "break the cycle" of asthma-anxietymore asthma. In addition, some authors consider the tranquilizers useful for preventing attacks, by reducing the intensity of emotional precipitants. 6 , S Assuming that good results will prove the psychogenic origin of asthma, physicians frequently prescribe hydroxyzine, meprobamate, chlordiazepoxide, and the numerous phenothiazine derivatives for patients with asthma who may take them daily for many months. Antidepressant drugs, such as amitriptyline and imipramine, also have been used. During acute severe episodes of asthma, attempts are made to reduce anxiety (the patient's or the physician's?) and agitation with barbiturates, chloral hydrate, and even narcotics and anesthetics. Such pharmacologic overindulgence must be condemned. There is no good chemical substitute for continuous attention and sympathetic care,S, 9 which the child sick with asthma needs in abundance. The routine inclusion of sedatives and tranquilizers in commercial antiasthmatic preparations, intended to counteract the side effects of the bronchodilators, is also of questionable value. s The end result is a patient who is both overstimulated and oversedated. The qualified clinician of today must combine restraint with pharmacologic expertise.

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Environmental Therapy and Residential Treatment Programs Due to the diverse environmental influences on asthma, it is always probable that a relocation will eliminate at least one factor and thus alleviate or ameliorate the symptoms. The uncommon term "alias sotherapy" may be taken from Dorland's Medical Dictionary to describe such common beneficial effects of nonspecific change. More specifically, the separation of an asthmatic child from his home and family has been thought to exert a therapeutic influence by bypassing or correcting abnormal parent-child relationships or by avoiding family tension. The variable responses of most patients to hospitalization9 and the selective (and only partial) improvement observed during the experimental removal of parents and siblings from the patient's home indicate that "parentectomy"33 is not as predictably effective a procedure as it was thought to be. The failure to provoke asthma by exposing children to house dust during hospitalization was taken as evidence that removal from the psychological environment of the home was indeed the cause of relief. 25 In a brief but pertinent note,16 Glaser questioned the validity of these conclusions by pointing out the complexity of the problem. Although no miraculous cure should be expected, specialized residential centers contribute substantially to the understanding and treatment of asthma. s They provide facilities for the thorough initial evaluation of, and the continuous monitoring of changes in, the patient's condition. They have experienced staff for the investigation of a multiplicity of physical and psychological factors likely to precipitate or to aggravate asthma. They train personnel in various related fields and in interdisciplinary cooperation. And finally they provide the family with a badly needed opportunity to recover from the overwhelming medical, psychological, and (when free care is offered) financial strain of a perplexing recurrent or chronic condition. So, despite our still incomplete knowledge of numerous aspects of asthma, an enlightened and coordinated team can control the disease successfully and can help' the patient and the family return to a healthier life pattern. ACKNOWLEDGMENT

The author wishes to acknowledge his indebtedness to Drs. W. W. Hahn. K. Purcell, A. Szentivanyi, and J. Weiss for providing valuable information and preprints of their current publications.

REFERENCES 1. Alexander, F.: Psychosomatic Medicine. New York, W. W. Norton Co., 1950. 2. Ax, A.: Goals and methods of psychophysiology. Psychophysiology, 1:8-25, 1964. 3. Block, J., Jennings, P. H., Harvey, E., and Simpson, E.: Interaction between allergic potential and psychopathology in childhood asthma. Psychosom. Med., 26:307-320, 1964.

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