Negative beliefs about breathlessness increases panic for patients with chronic respiratory disease

Breathlessness is a multidimensional symptom of respiratory disease and is associated with the experience of panic. Patients with panic disorder have increased mortality, morbidity and healthcare utilisation that is unrelated to their disease severity. Our qualitative study aimed to appraise respiratory patients' experiences of breathlessness and whether their cognitions were associated with panic aetiology. The self-regulatory theory was utilised to develop the framework for the semi-structured interview schedule. Twelve individuals with respiratory disease at a U.K. cardiothoracic centre participated and their data were analysed using interpretative phenomenological analysis. Perceived control over the disease, symptoms and panic emerged as the core theme with three related belief systems; (1) Perceived consequences of panic and disease; (2) Illness and symptom coherence; and (3) Emotional adaptation. Panic symptoms were most prevalent in participants with low perceived control over symptoms and the disease, negative beliefs about the life-limiting consequences of unpredictable breathless attacks and by those using emotional coping strategies such as denial and avoidance. The experience of panic for respiratory patients can be explained through the cognitive-behavioural model of anxiety, which highlights the contributory role of catastrophic beliefs about the control and consequences of symptoms and disease as a significant contributory factor for the prevalence and maintenance of panic. The mortality and morbidity of respiratory patients is significantly affected by a co-morbid diagnosis of panic disorder and so it is critical to patients' long-term healthcare that their psychological experiences are assessed. Healthcare services must enhance patients' understanding about their disease to improve their confidence to control symptoms. Recent evidence suggests that cognitive-behavioural interventions that increase problem-solving coping will reduce catastrophic misinterpretations about the perceived consequences of breathlessness and improve emotional adaption to respiratory disease.     

Acquired sensitivity to relevant physiological activity in patients with chronic health problems

The hypothesis that biased symptom perception toward excessive symptoms is common when relatively normal chronic patients enter symptom-relating situations, irrespective of emotional variables, was tested in 19 women with severe asthma, 18 with somatization-like characteristics, and 18 controls. Each underwent three experimental conditions: mental stress, resting, and physical exercise. Each condition included three breathing conditions: breathing normally, normal compressed air, and 5.5% CO2-enriched compressed air. Results yielded no group differences in physiological measures, e.g. elevated CO2 in exhaled air (end-tidal partial pressure of CO2, PetCO2), or lung function. Asthma patients experienced more breathlessness, and somatization-like participants more breathlessness, miscellaneous symptoms, and subjective stress than controls. Although these differences suggested acquired biased symptom perception, as it turned out, breathlessness in asthmatics was more influenced by PetCO2 and less by subjective stress compared to controls. Likewise, breathlessness in somatization-like participants was similarly influenced by PetCO2 and subjective stress compared to controls, and miscellaneous symptoms were even more influenced by PetCO2 and less by subjective stress compared to controls. It was concluded that acquired sensitivity to physiological activity associated with habitual symptoms may account for excessive symptoms in patients with chronic health problems.     

Symptom perception in childhood asthma: the role of anxiety and asthma severity.

This study tested the relationship of anxiety and asthma severity to symptom perception. Eighty-six children diagnosed with mild or moderate asthma had symptom perception and pulmonary function measured throughout methacholine challenge (to induce bronchoconstriction). Higher trait anxiety was associated with heightened symptom perception (controlling for pulmonary function) at baseline. Greater asthma severity was associated with blunted symptom perception (controlling for pulmonary function) at the end of methacholine challenge and with a slower rate of increase in symptom perception across methacholine challenge. These results suggest that anxiety plays a role when children's symptoms are mild, whereas medical variables such as severity play a role in perception of changes in asthma symptomatology as bronchoconstriction worsens.     

Associations between respiratory sinus arrhythmia reactivity and internalizing and externalizing symptoms are emotion specific

Internalizing and externalizing disorders are often, though inconsistently in studies of young children, associated with low baseline levels of respiratory sinus arrhythmia (RSA). RSA is thus considered to reflect the capacity for flexible and regulated affective reactivity and a general propensity for psychopathology. However, studies assessing RSA reactivity to emotional challenges tend to report more consistent associations with internalizing than with externalizing disorders, although it is unclear whether this is a function of the type of emotion challenges used. In the present study, we examined whether baseline RSA was associated with internalizing and/or externalizing severity in a sample of 273 young children (ages 5–6) with elevated symptoms of psychopathology. Following motivation-based models of emotion, we also tested whether RSA reactivity during withdrawal-based (fear, sadness) and approach-based (happiness, anger) emotion inductions was differentially associated with internalizing and externalizing symptoms, respectively. Baseline RSA was not associated with externalizing or internalizing symptom severity. However, RSA reactivity to specific emotional challenges was associated differentially with each symptom domain. As expected, internalizing symptom severity was associated with greater RSA withdrawal (increased arousal) during fearful and sad film segments. Conversely, externalizing symptom severity was related to blunted RSA withdrawal during a happy film segment. The use of theoretically derived stimuli may be important in characterizing the nature of the deficits in emotion processing that differentiate the internalizing and externalizing domains of psychopathology.     

Watching diagnoses develop: Eye movements reveal symptom processing during diagnostic reasoning

Finding a probable explanation for observed symptoms is a highly complex task that draws on information retrieval from memory. Recent research suggests that observed symptoms are interpreted in a way that maximizes coherence for a single likely explanation. This becomes particularly clear if symptom sequences support more than one explanation. However, there are no existing process data available that allow coherence maximization to be traced in ambiguous diagnostic situations, where critical information has to be retrieved from memory. In this experiment, we applied memory indexing, an eye-tracking method that affords rich time-course information concerning memory-based cognitive processing during higher order thinking, to reveal symptom processing and the preferred interpretation of symptom sequences. Participants first learned information about causes and symptoms presented in spatial frames. Gaze allocation to emptied spatial frames during symptom processing and during the diagnostic response reflected the subjective status of hypotheses held in memory and the preferred interpretation of ambiguous symptoms. Memory indexing traced how the diagnostic decision developed and revealed instances of hypothesis change and biases in symptom processing. Memory indexing thus provided direct online evidence for coherence maximization in processing ambiguous information.     

Asthma severity, child security, and child internalizing: using story stem techniques to assess the meaning children give to family and disease-specific events

Children with persistent asthma are at increased risk for mental health problems. Although mechanisms of effect are not yet known, it may be that children are less trusting of the family as a source of support and security when they have more severe asthma. This study tested whether asthma severity is related to children's perceptions of insecurity in the family, and whether insecurity is in turn associated with child adjustment. Children (N = 168; mean age = 8 years) completed story stems pertaining to routine family events (e.g., mealtimes) and ambiguous but potentially threatening asthma events such as tightness in the chest. Responses were evaluated for the extent to which appraisals portrayed the family as responding in cohesive, security-provoking ways. Asthma severity was assessed by both objective lung function testing and primary caregiver report. Caregivers reported child symptomatology. Beyond medication adherence, caregiver education, and child age and gender, greater asthma severity predicted more internalizing and externalizing symptoms. Greater asthma severity, assessed using spirometry (but not parent report), was related to less secure child narratives of the family, which in turn related to more child internalizing symptoms. Results suggest that asthma can take a considerable toll on children's feelings of security and mental health. Furthermore, given the difficulty in assessing young children's perceptions, this study helps demonstrate the potential of story stem techniques in assessing children's appraisals of illness threat and management in the family.     

Practice makes perfect: Training the interpretation of emotional ambiguity

The interpretation of emotionally ambiguous words, sentences, or scenarios can be altered through training procedures that are collectively called cognitive bias modification for interpretation (CBM-I). In three experiments, we systematically manipulated the nature of the training in order to discriminate between emotional priming and ambiguity resolution accounts of training effects. In Experiment 1 participants completed word fragments that were consistently related to either a negative or benign interpretation of an ambiguous sentence. In a subsequent semantic priming task they demonstrated an interpretation bias, in that they were faster to identify relatedness of targets that were associated with the training-congruent meaning of an emotionally ambiguous homograph. We then manipulated the training sentences to show that interpretation bias was eliminated when participants simply completed valenced word fragments following unrelated sentences (Experiment 2), or completed fragments that were related to emotional but unambiguous sentences (Experiment 3). Only when participants were required to actively resolve emotionally ambiguous sentences during training did changes in interpretation emerge at test. Findings suggest that CBM-I achieves its effects by altering a production rule that aids the selection of meaning from emotionally ambiguous alternatives, in line with an ambiguity resolution account.     

Daily stress and anxiety and their relation to daily fluctuations of symptoms in asthma and chronic obstructive pulmonary disease (COPD) patients

Although stress and anxiety have long been assumed to play an exacerbatory role in asthma, no study has systematically documented that daily exacerbations of asthma symptoms are related to stress and/or anxiety. In this study, 24 airways obstruction patients (12 asthmatics and 12 chronic obstructive pulmonary disease patients) were instructed to monitor the severity of daily respiratory symptoms. In addition, subjects recorded their daily anxiety level and the number and perceived impact of daily stressors. The results showed that although there were differences between high- and low-stress days for both groups, there were no differences between groups on symptom severity or between high- and low-anxiety days, as measured by the State-Trait Anxiety Inventory (STAI). Thus, although the number and impact of daily stressors were found to be directly associated with the severity of asthma symptoms, anxiety does not appear to have a direct role in the exacerbation of asthma. The findings failed to support the anxiety theory of asthma but provided an explanation for the poor results obtained in previous treatment studies which employed anxiety management with asthmatics.     

Emotion and adherence to treatment in people with asthma: An application of the emotional Stroop paradigm

This study explored whether an emotional Stroop paradigm might represent an appropriate means of assessing individuals' emotional representations of asthma. In addition, the opportunity was taken to investigate whether emotional representations of asthma, as assessed by this method, were associated with adherence to inhaled preventative medication. An asthma Stroop task was devised which comprised three sets of stimuli: asthma symptom words, general negative words, and neutral words. Three groups of participants were compared on their performance on this task: individuals with asthma, individuals without asthma, and individuals without asthma who had been primed about the condition. It was found that individuals with asthma experienced significantly more interference when colour‐naming the asthma symptom words, but not when colour‐naming the general negative words. Furthermore, their performance on the asthma Stroop task was associated with self‐reported adherence levels. Specifically, individuals who reported the highest and lowest levels of adherence displayed more interference when colour‐naming the asthma symptom words than individuals with intermediate levels of adherence. It is concluded that the emotional Stroop paradigm might provide an objective and sensitive means of assessing individuals’ emotional representations of illness. Additionally, it is proposed that emotional responses to illness should be assessed and included in research designed to explain health behaviours and, furthermore, that such research should not assume that any relationship between emotional representations and health behaviours will be linear.     

Emotional competence and quality of life of children with asthma: The mediating effect of coping strategies

This study explored the mediating effect of coping strategies on the relationship between emotional competence (EC) and quality of life (QOL) among children with asthma. Participants were 87 children (M age?=?11.72, SD?=?2.58) with controlled and partially controlled asthma, undergoing everyday treatment. They filled in questionnaires assessing EC, coping strategies and QOL. Results showed that the association between some ECs and the QOL of children with asthma was fully mediated by two maladaptive cognitive coping strategies. Among children with asthma, a greater ability to differentiate their emotions, a reduced attention to bodily signals of emotions and a reduced analysis of their current emotional state were related to decreased engagement in two coping strategies (‘Ignoring Asthma’ and ‘Worrying about Asthma’), which in turn increased their QOL. These findings show that EC has an indirect effect on QOL through very specific coping strategies. They also emphasise the importance of screening EC in children with asthma and the importance of developing and using multidisciplinary interventions for them.     

Negatively biased emotion perception in depression as a contributing factor to psychological aggression perpetration: a preliminary study

Based on research linking depressive symptoms and intimate partner aggression perpetration with negatively biased perception of social stimuli, the present authors examined biased perception of emotional expressions as a mechanism in the frequently observed relationship between depression and psychological aggression perpetration. In all, 30 university students made valence ratings (negative to positive) of emotional facial expressions and completed measures of depressive symptoms and psychological aggression perpetration. As expected, depressive symptoms were positively associated with psychological aggression perpetration in an individual's current relationship, and this relationship was mediated by ratings of negative emotional expressions. These findings suggest that negatively biased perception of emotional expressions within the context of elevated depressive symptoms may represent an early stage of information processing that leads to aggressive relationship behaviors.     

Excessive breathlessness through emotional imagery in asthma

Breathlessness and negative emotions during asthma attacks interact in complex patterns. This study tested the influence of emotional imagery on breathlessness during voluntary breath holding. Adolescents with and without asthma (n = 36 + 36) were assigned to positive imagery, negative imagery, or no imagery. There were four trials with close to thresholds for breath holding combined with imagery. Breathlessness and quality of imagery were measured by the end of breath holding. Additional measures were lung function and anxiety. The results showed that positive and negative imagery were only influencing breathlessness in participants with asthma. Although threshold duration for the groups were not significantly different, participants with asthma reported more breathlessness. The intensity of imagery enhanced breathlessness but diminished the accuracy of symptom perception. Positive imagery diminished breathlessness in participants with asthma, but also the difference in breathlessness between 75% and 95% of threshold duration. Breathlessness did not correlate with lung function, anxiety or other variables. It was concluded that emotional imagery during asthma attacks distracts from accurate introspection or enhances breathlessness, irrespective of anxiety.     

Childhood Cancer and Brain Tumor Late Effects: Relationships with Family Burden and Survivor Psychological Outcomes

This study examines illness-specific family burden as a mediator of the association between late effects of childhood cancer and survivors’ emotional and behavioral outcomes. Childhood cancer survivors (n?=?65; ages 10–17) two or more years off-treatment completed measures assessing internalizing and PTSD symptoms. Parents reported on illness-specific family burden, late effects severity, and survivor internalizing/externalizing problems. Providers documented the number of late effects. Illness-specific family burden was correlated with provider-reported late effects (r?=?.29, p?<?.05) and parent report of severe late effects (r?=?.56, p?<?.01). Results supported an indirect effect of illness-specific family burden on number of late effects and parent-reported survivor internalizing problems, p?<?.05. Indirect effects were not found in models predicting PTSD and externalizing problems. Illness-specific family burden is an important intervention target for reducing internalizing problems in childhood cancer survivors with late effects.     

Impact of symptoms and aging attribution on emotions and coping

Two experimental studies and a large field study were designed to examine how symptom severity, symptom duration, symptom ambiguity, and the association of symptoms with aging affected emotional responses and coping with illness threats. In Study 1, 280 respondents from the surrounding community reported the emotional and coping responses they would manifest to scenarios that varied the severity, duration, and ambiguity (i.e., labeled vs. unlabeled) of a common set of symptoms. Severity had more of an impact on coping strategies than did duration or illness label; severe symptoms elicited stronger emotional upset and a higher incidence of both self-care behaviors and seeking of medical care. Symptoms of longer duration also resulted in increased seeking of medical care. Responses of the 334 adults participating in Study 2 replicated and extended these findings: A closed-ended item asking participants whether the symptoms could be attributed to aging showed that attribution of symptoms to aging increased with age, was more frequent for mild symptoms, and was associated with reduced emotional response to symptoms and a tendency to delay seeking treatment. Participants in the field study (168 patients seeking medical care for a variety of symptoms) completed interviews tracing symptom processing and emotional and coping reactions. The results provided evidence for the external validity of the scenario studies, as the attribution of symptoms to aging was greater for older than younger patients and resulted in a significant tendency to delay seeking medical care. Results of these studies suggest that symptom experience and symptom interpretation must be considered in the study of coping responses to illness threats.     

Cognitive predictors of symptom return following depression treatment

This study tested whether poor cognitive change during depression treatment predicted time to return of depressive symptoms. Depressed participants (N = 121) completed assessments of dysfunctional attitudes and extreme thinking (i.e., number of totally agree and totally disagree responses) during hospitalization and again after 6 months of outpatient treatment. Participants then completed monthly depression assessments for 1 year. Survival analyses for time to symptom recurrence during follow-up were conducted among participants who reported 50% improvement in their depressive symptoms and were at least partially asymptomatic at the end of treatment (n = 53). Poor change in dysfunctional attitudes and poor change in extreme thinking both predicted shorter time to return of depressive symptoms.     

Emotion Appraisal and Anxiety Symptomatology in a University Sample

Current conceptualizations for anxiety disorders focus heavily on cognitive and behavioral aspects of anxiety and address other emotions to a far lesser extent. Studies have demonstrated that negative appraisals of anxiety and fear (e.g., anxiety sensitivity) are elevated in each of the anxiety disorders and depressive disorders. Much less is known about how the appraisal of other emotions is related to anxiety disorder symptom presentation. The current study examines the appraisal of specific aversive emotions in relation to anxiety symptomatology. Undergraduate university students (N = 530) completed measures of specific anxiety and depressive symptoms, as well as a measure of emotional appraisal. A maximum likelihood estimated multivariate regression model was used to examine the unique relationships between emotional appraisal and anxiety and depressive symptoms. Results indicated that anxiety symptoms varied in their relationships with emotional appraisal. Each symptom group was highly related to fear of appraisals of anxiety; however, some anxiety symptoms were also related to fear of other emotional states, including guilt, sadness, disgust, lust, and embarrassment. Understanding the full range of appraisals of emotional experiences in anxiety conditions may help inform conceptualizations, and potentially treatments, by guiding the focus to the feared emotional states of the individual. The present study helps to clarify some of the relationships between emotion appraisal and anxiety symptoms.     

Influences of habitual and situational bodily symptom focusing on stress responses

Evidence suggests that focusing on bodily symptoms increases perception of internal states. The interaction between situational (experimentally induced) symptom focusing and a disposition to focus on one's bodily symptoms is unclear. We assumed that situational symptom focusing increases perception of stress symptoms only in persons that usually do not focus on their bodily symptoms. Forty participants were divided into two groups (N=20) according to their disposition towards bodily symptom focusing (habitual symptom focusing, HSF+ and HSF?). Ten participants per group were instructed to focus on their neck muscle tension (situational symptom focusing, SSF+), while the others received a control instruction (SSF?). All participants underwent anticipation of a public speech, representing an emotional and mental stressor. There was a significant HSF×SSF interaction in reports on muscle tension and palpitation under stress. While HSF? participants reported more stress symptoms in the SSF+ condition, HSF+ participants reported less symptoms. However, no interaction was found in physiological measures including neck electromyogram, skin conductance reactions, heart rate and blood pressure. Our results indicate either that symptom perception is adjusted by symptom focusing, or that the instruction to use a habitual coping strategy reduces stress symptoms.     

The effect of tape-recorded relaxation training on well-being,symptoms, and peak expiratory flow rate in adult asthmatics: A pilot study

Abstract

Evidence indicates that psychological stress plays a role in precipitating and exacerbating asthma symptoms and suggests that relaxation techniques aimed at reducing stress and autonomic arousal leads to symptom reduction. This study explored the effect of a tape-recorded relaxation intervention on well-being (mood and stresson). asthma symptoms, and a measure of pulmonary function (PEFR). Twenty adult asthmatics were studied for 21 days in their natural environment using a multiple baseline design. Self-administered relaxation training (including both breathing exercises and muscle relaxation) led to decreased negative mood and stressor report. Reporting of asthma symptoms decreased over time, and PEFR was increased by relaxation training. Asthma medication use was unchanged. Results suggest that tape–recorded relaxation training positively impacts well-being, asthma symptoms. and PEFR in a naturalistic setting. Further study of the potential use of inexpensive tape-recorded interventions in chronic illness is warranted.     

Rollercoaster asthma: when positive emotional stress interferes with dyspnea perception

The current study assessed how negative and positive stress is related to dyspnea perception. The participants were 25 young women with a medical diagnosis of severe asthma, and 15 matched controls. Stress was induced during repeated rollercoaster rides. Results showed that negative emotional stress and blood pressure peaked just before, and positive emotional stress and heart beat peaked immediately after rollercoaster rides. Dyspnea in women with asthma was higher just before than immediately after rollercoaster rides, even in women with asthma with a rollercoaster-evoked reduction in lung function. These results suggest that stressed and highly aroused individuals with chronic asthma tend to perceive dyspnea in terms of acquired, familiar associations between dyspnea and positive versus negative feeling states, favoring either underperception or overperception of dyspnea, depending on the emotional valence of a situation.     

Effects of an emotional negative stimulus on the cardiac, electrogastrographic, and respiratory responses

The experiment investigated the effects of two film sequences, one neutral and the other emotional, on the cardiac (ECG), electrogastrographic (EGG) and respiratory activities of 24 healthy students during digestion. The physiological activity was recorded before and during the projection of each film sequence. 12 subjects were shown a neutral film sequence and 12 an emotional film sequence. At the end of each viewing period, each subject completed a self-rating questionnaire on the emotional experience. Analysis indicated, with respect to the previewing (baseline) values, an increase in cardiac and respiratory rates and a decrease in electrogastrographic rates during the viewing of the film sequences. Changes in the EGG rate (baseline to viewing) were negatively correlated with the changes in ECG and respiratory rates, whereas the changes in these latter two were positively correlated. In comparing the effects of the neutral and emotional scenes the only significant result was the heart-rate increase in subjects watching the emotional sequence. Also, the self-rating of emotional experience varied with the emotional value of the sequence.