1066 Thorax 1998;53:1066–1074 Occasional reviews Thorax: first published as 10.1136/thx.53.12.1066 on 1 December 1998. Downloaded from Review of psychosocial stress and asthma: an integrated biopsychosocial approach Rosalind J Wright, Mario Rodriguez, Sheldon Cohen Although consensus has emerged from the albeit equally important, determinants of clinical, social science, psychological, and asthma morbidity—for example, by influencing biological literature that psychosocial factors how children and their families perceive and aVect asthma morbidity in children, their role manage their asthma. Although no clear causal in the genesis, incidence, and symptomatology link between psychosocial stress and asthma has of asthma remains controversial since mecha- been established, this review provides a multi- nisms are not well understood. Three recent disciplinary transactional infrastructure that trends in medical research have led both clini- may guide future research priorities. cians and investigators to reconsider the role of psychosocial stress in asthma. Firstly, eVorts to Historical perspective define the aetiological risk factors for the The hypothesis of an association between stress development and expression of disease have and asthma emerges from a wide range of intensified in the face of rising trends in the clinical observation and evolving research. The prevalence and severity of asthma observed 1 general concept of the role of emotion and the worldwide. Thus far, focus on traditional social environment in disease is as old as medi- environmental risk factors has not fully ex- cine itself. Early references to the importance plained these trends. Secondly, evidence of emotional and psychological processes were evolved over the last two decades of important put forth in a treatise on asthma by Maimo- interactions among behavioural, neural, endo- nides, an influential medieval Rabbi, philos- crine, and immune processes provides fresh opher, and physician.9 Sir William Osler http://thorax.bmj.com/ insight into means by which psychosocial referred to asthma as “a neurotic aVection” in stressors may influence the development and his medical textbook which served as a corner- 23 expression of inflammatory diseases. This stone of medical teaching in the latter part of insight emerged in parallel with our increased 10 Channing Laboratory, the 19th century. Indeed, before we under- Department of understanding of the complex cellular and stood the inflammatory basis of asthma, it was Medicine, Brigham molecular basis of asthma as a chronic inflam- among the disorders believed to be “purely” 4 and Women’s Hospital, matory disorder. Finally, hypotheses about the psychogenic in origin and was commonly and the Pulmonary/ substantial role of the social environment and referred to as asthma nervosa. Critical Care Division, social integration in health and disease in gen- on September 24, 2021 by guest. Protected copyright. Boston’s Beth Israel Scientific support for an association between eral have gained significant emphasis over the psychological factors and asthma has its begin- Deaconess Medical 56 Center, Harvard last decade. In particular, prospective epide- nings in the first part of the 20th century and Medical School, miological studies have demonstrated associa- derives from research in widely disparate fields. Boston, tions between life stress, social position or sta- Early research suggesting that asthma had a Massachusetts, USA tus, and quality of social relationships—that is, psychosomatic component was strongly domi- R J Wright social networks, an individual’s ties to friends, nated by psychoanalytical theory, an extension Department of family, work, and community through social of the Freudian idea that symptoms were a 67 Medicine, Allegheny and religious groups—and health. All have symbolic expression of unconscious conflicts University of the led to a paradigm shift that reconsiders the and repressed desires.11 The so called specific Health Sciences, overlap between biological determinates and emotion theory, developed in large part by Philadelphia, psychosocial factors in understanding the Alexander and colleagues12 at the Chicago Pennsylvania, USA 8 M Rodriguez rising asthma burden. Institute of Psychoanalysis beginning in the This review highlights significant insights 1930s, was among the most influential work of Department of into this field from a multidisciplinary (psycho- this era. Concurrently, learning theorists ar- Psychology, Carnegie analytical, behavioural, psychosocial, epidemio- gued that particular emotional experiences Mellon University, logical, and immunological) perspective rather may have reinforced pulmonary physiological Pittsburgh, than being an exhaustive overview of the responses, thus increasing the likelihood of Pennsylvania, USA 13 S Cohen subject. We examine behavioural, neural, and them recurring in the same context. More immunological pathways, underscoring recip- recently, published clinical studies have dem- Correspondence to: rocal relations that might link psychological onstrated the benefit of psychotherapy in treat- Dr R J Wright, Channing factors to both the onset of asthma and exacer- ing asthmatic patients,14 and relaxation tech- Laboratory, 181 Longwood Avenue, Boston, bation of established disease. We also focus on niques have been associated with improvement Massachusetts 02115, USA. stress and psychological factors as indirect, in respiration.15 Review of psychosocial stress and asthma 1067 25 Eventually, purely psychoanalytical and be- stimuli. Key to recent advances in the field of Thorax: first published as 10.1136/thx.53.12.1066 on 1 December 1998. Downloaded from havioural formulations gave way to physiologi- asthma is an emerging understanding of cal studies providing more objective support asthma and allergic disease as chronic inflam- for the idea that emotions play an important matory processes regulated through compli- role in asthma. Stress and psychological factors cated immune phenomena in which many cells have been associated with asthma symptoma- (mast cells, eosinophils, and T lymphocytes) tology16 and with bronchoconstriction and and associated cytokines play a part. Mecha- reduction in pulmonary flow rates in asthmatic nisms of airway inflammation involve a cascade children.17 When subjected to stressful experi- of events that include the release of immuno- ences such as performing mental arithmetic logical mediators triggered by both IgE de- tasks,18 watching emotionally charged films,19 pendent and independent mechanisms. Pro- and listening to stressful interactions,20 15– cesses regulated through cytokines of the T 30% of asthmatic subjects respond with helper cell (Th2 phenotype) such as interleukin increased bronchoconstriction. (IL)-4, IL-5, and IL-13 are thought to promote Taken together, these data clearly support an recruitment of inflammatory cells which may association with stress, although mechanisms initiate and/or potentiate allergic inflammation linking stress and asthma remain poorly and the release of mediators that cause defined. To explore potential mechanisms link- contraction of smooth muscle and influence ing stress and asthma, it is helpful first to con- mucus production.26 The leukotrienes (LTs), sider how environmental and social stressors including LTC4, LTD4, and LTE4, are known may influence disease in general and, second, potent constrictors of human airways,27 have to frame these hypotheses within the current been observed to play a part in mucus asthma paradigm. secretion,28 and are thought to have an impor- tant role in asthma. A substantial body of Life stress model evidence supports the role of complex neural A general model of the link between environ- mechanisms and alterations of autonomic mental demands as psychological stressors and nervous system control in the pathophysiology health is reproduced in fig 1. When confronting and symptomatology of asthma.29 30 Autonomic environmental demands, individuals cogni- nerves can impact airway calibre and function tively appraise whether the event is threatening via eVects on airway smooth muscle, bronchial or potentially overwhelming to their existing vessels, and mucus glands. Hormones and 21 coping resources. If environmental demands neuropeptides released into the circulation are found to be taxing or threatening, and at when individuals experience stress are also the same time coping resources are viewed to thought to be involved in regulating both be inadequate, we perceive ourselves as being inflammatory and airway responses.31 There- under stress. This perception is presumed to fore, consideration of recent advances in the result in negative emotional states including field of psychoneuroimmunology—linking psy- fear, anger, anxiety, and depression. Changes in chosocial stress, the central nervous system, http://thorax.bmj.com/ behavioural and emotional states that accom- and alterations in immune and endocrine pany the perception of, and the eVort to adapt function—provide plausible biological path- to, environmental circumstances are accompa- nied by complex patterns of neuroendocrine and immunological changes.22 Both the duration and the frequency of Environmental demands experienced stress are important determinants (stressors or life events) of its impact on health and illness.22 23 Psycho- logical stress and its biological concomitants on September 24, 2021 by guest. Protected copyright. can last for a few minutes or for years. Appraisal of demands Chronicity is to some degree based on