Psychological correlates of bronchial asthma in young adults: The cognitive orientation approach

Author(s): Yehudah Roth and Shulamith Kreitler* A large body of studies showed emotional, psychopathological and personality correlates of asthma but failed to identify a specific psychological type and specific sources of stress for asthma. The purpose was to identify psychological correlates specific to asthma that would unravel characteristic sources of stress. The study was done in the framework of the cognitiv ... Abstract View Full Article View DOI: 10.17352/oja.000011

about asthma. Thus, in regard to emotions, studies indicate that as compared to healthy controls, asthma patients tend to report higher levels of depression, anxiety and hostility [9][10][11][12], have inhibited hostility [13] or covert aggression [14], are more emotionally unstable [15], have lower emotional control [12], and tend to respond with asthma attacks to strong emotional stimuli in general [16,17]. Updated large scale surveys have confi rmed the relation of asthma with depression and anxiety [18][19][20].
In the psychopathological domain, studies found that as compared with healthy controls asthmatics have more psychopathology in general [21], especially in women [22], more somatization and obsession-compulsion [10], a higher frequency of anxiety disorders, higher neuroticism [23], manifested in neurotic constriction, excessive dependency on the mother, sexual disturbances, irrational fears and guilt feelings [14], and disturbances in self-esteem and fears [24].
As compared with neurotics, they have a stronger superego and more emotional stability [25]. However, they seem to share the neurotic tendency with other chronic patients .
In regard to personality, asthmatics differ from healthy controls in scoring higher on superego strength, sophistication, guilt proneness and self-sentiment [26], submissiveness [27], inhibition [14] (even as compared to neurotics [27], toughmindedness, radicalism [27] and need of approval [12]. In comparison to other chronic patients they are less dominant and more intropunitive [13]. Some studies found that asthmatics tend to be involved in intra-psychic confl icts (often involving repression) [28][29][30][31]. However, on the whole they did not seem to conform to any specifi c type [32]. Also the relation of asthma to stress is still unclear. On the one hand, there is evidence that asthma is affected by stress, that stress in early childhood increases the chances for asthma development [33], that exposure to active stressors and to some degree also passive stressors is associated with an increase in sympathetic nervous system responses, cortisol, and infl ammatory reactions [34], that chronic and toxic stress exacerbate asthma [35], and that asthma attacks were related to posttraumatic symptoms in Katrina hurricane survivors [36]. But on the other hand, studies showed that asthmatics did not differ from healthy controls in stress susceptibility, for example during the Gulf war [37], and that asthma is only weakly related to perceived stress ( [38], to neighborhood stress [39], and not at all to stress perception and frequency of stressors [40,41]. However, the evidence indicates not only that there are emotional, psychopathological and personality correlates of asthma, but also that psychological factors are involved in the course of disease. For example, asthma severity, even intubation, is affected by psychological factors, e.g., more severe asthma is related to higher extraversion, more optimism, under-estimation of asthma severity, higher self reports of anxiety, depression, hostility, anger, fear and disgust [12,[42][43][44]; asthmatics who evaluate their disease as more severe differ psychologically from those who evaluate it as less severe (e.g., they are less gregarious, less trusting, have less self-esteem) [44]; marked psychological confl ict situations serve as releasers of asthma attacks [30] as well as specifi c psychological events, such as disappointments in interpersonal relations or career [45]. Of particular importance is the heightened emotional reactivity of asthmatics [15,46] which may also account for the fi ndings that anxiety and depression may contribute to elicitation of asthma [47], heightened emotionality may lead to its exacerbation [16], and fear and emotional lability may enhance its intractability [48]. Not surprisingly, asthma is improved by psychotherapy [49]. However, some of the most salient fi ndings concerning asthmatics, such as their tendencies for anxiety and depression were found to apply to other categories of patients too [50].

The cognitive orientation approach
For attaining this purpose, the study was done within the framework of the cognitive orientation theory of physiopathology [52]. Its major tenet is that cognitive contents and processes affect physiological processes relevant for disease and health. These health-relevant cognitive contents and processes constitute an integral part of the background conditions promoting disease and health and are disease specifi c.
The cognitive contents relevant for a specifi c disorder are identifi ed by means of a standard interviewing procedure focused on sequential clarifi cation of meanings [53]. Thus, starting with the key terms stating the general meaning of the disease for the patient (e.g., breathing diffi culty, wheezing), the patient is asked to communicate the meaning of each of these key terms, and then in turn the meaning of each of these communications. For example, if the patient states that the disease meant to him or her "to feel pressured" he/she is then asked in turn to express the meaning of "to feel pressured" and says "afraid of what others will think of me", and when asked about the meaning of the latter says "maintaining a facade as if all were normal and fi ne". The meanings stated in the fourth stage of questioning by the majority of pretest subjects are identifi ed as "themes" likely to be characteristic for the studied disorder (e.g., "maintaining a facade...").
The themes extracted from the guided interviewing of the

Objectives
Accordingly, this study was designed to identify a set of themes which, when assessed in the form of a questionnaire in terms of the four types of beliefs, would distinguish between asthma patients and healthy controls. It was expected that identifying the cognitive structures of themes and belief types specifi c for asthma patients would enable a deeper insight into the psychological aspects of the disease which could play a role in its elicitation, maintenance and effects.
Finally, it will be noted that many studies of asthma used participants ranging widely in age, say, from 15 to 71 [60], 15 to 54 [14], or 5 to 34 [42]. There is however evidence that the etiological, clinical and even psychosocial correlates of asthma may differ to some extent in childhood, adulthood and old age.
For example, individuals who got asthma up to the age of 16 were neurotic as children, and those who got it between the ages 17 to 27 least often suffered from depression or obsession [61][62][63][64][65]. In order to attain greater coherence and specifi city in the fi ndings we limited this study to young adults.

Participants
Two groups of subjects participated in the study. The experimental group consisted of 34 asthma patients who were followed up at the Chest and Allergy Clinic of the in a hospital in the center of Tel-Aviv and who had been diagnosed as having bronchial asthma (according to ATS criteria). The control group included 43 individuals matched to the experimental group in the major demographic characteristics. Both groups were in the age range of 18 to 32 years. Table 1 presents demographic information about the 2 groups. The two groups did not differ signifi cantly on the basic demographic features.

Instruments
Each group was administered two questionnaires. One which was designed to assess the cognitive contents -belief types, themes and confl icts -characteristic for asthma. It was constructed in line with the standard procedure for CO questionnaires [53] which consists in interviewing pretest subjects about the personal meanings related to their disease.
In the interview the subject is asked repeatedly, usually 3 times consecutively, to communicate the meanings of his or her response. The themes selected for the CO-AST questionnaire were the meanings mentioned by the majority of the pretest subjects (n=15) at the end-points of the response sequences.
The themes identifi ed in pretests and included in the CO-AST questionnaire are presented in Table 2, in the form of a brief label and one of the beliefs used for assessing it in the CO-AST questionnaire.
The CO-AST questionnaire included 4 parts, one for each type of belief, administered together in random order. One part was devoted to beliefs about self (n=27, e.g., "Order and cleanliness are very important to me"), another to beliefs about goals (n=17, e.g., "I would like everything around me to be always in perfect order and cleanliness"), a third part to beliefs about rules and norms (e.g., n=17, e.g., "One ought to avoid disorder and a mess at all costs"), and one to general beliefs (n=16, e.g., "It is impossible to feel at ease and function well without order and cleanliness" The scoring was computed so that the higher the score the stronger the motivational tendency promoting asthma. Each subject got 4 scores, 1 for each belief type, and a CO score (a summative index score representing the number of belief types in which the subject scored above the group's mean).
In addition, we also considered the scores (a) for each of the Themes were expected to shed light on the specifi c contents characteristic for asthma, whereas confl icts and gaps were expected to provide insight into potentialities for confl icts to which asthmatics may be prone.
Overall reliability of the CO-AST questionnaire in terms of Cronbach's alpha was 0.93 (reliabilities for the four belief types separately ranged from .73 for general beliefs to .85 for beliefs about self). All belief types were interrelated positively and signifi cantly (Table 3).

Procedure
The patients were consecutive asthma patients who addressed the clinic for Lung and Allergy Diseases and whose characteristics corresponded to the inclusion criteria of the sample (i.e., age and suffi cient knowledge of Hebrew to be able to respond to the questionnaires). The study was approved by the hospital's ethics committee. The majority of those addressed (89.47%) consented to participate. The subjects were administered the questionnaires and completed them in the course of their visit to the clinic. All those who got the questionnaires completed them. Medical information was provided by the physician with the patients' consent. The healthy controls were individuals recruited among students and the medical personnel, matched in major demographic characteristics to the patients. They were free of any asthma complaints in the present or the past, according to their personal reports. All statistical analyses were done with the SPSS-25 program.

Control analyses
Preliminary control analyses were carried out in order to assess the potential contribution of gender and age. The means for men and women and for older and younger subjects (defi ned in terms of the median) of all variables assessed by the CO-AST (n=39) were compared within each group (of patients and controls). There were only three signifi cant results for gender (all in the control group -whereby men scored higher on one type of belief, one theme and one confl ict) but these results constitute 7.7% of the comparisons in the group and hence do not deviate signifi cantly from the 5% expected by chance. There were no signifi cant differences for age, possibly because of the limited age range used in the study. Therefore, gender and age were not considered in further analyses. The second factor represents clearly achievement orientation (e.g., ambition, commitments, striving for perfection). The third factor stands for withdrawal from others emphasizing self-suffi ciency (e.g., independence, rejecting help). The fourth and the fi fth are small factors, whereby the former represents self-discipline (i.e., high demands from oneself, avoiding bodily expression) and the latter distancing oneself from others emphasizing defi ance (i.e., rejecting commitments, not caring about rejection from others).

Comparing asthmatics and controls in terms of belief types
Belief types are the major aspect of the CO-AST questionnaire in which the two groups were compared. Table 5 presents the mean scores and comparisons of the 4 belief types in the two groups. It shows that, as expected, asthma patients scored signifi cantly higher than the healthy controls on all 4 belief types as well as the CO score which represents the number of belief types in which the subjects scored above the group's mean. The mean CO score shows that asthma patients had on the average almost 3 belief types supporting motivationally the disease, whereas the healthy controls had not even 1. Table 6 presents the results of a stepwise discriminant analysis with the 4 belief types as predictors and membership in one of the two groups -asthmatics or controls -as the dependent variable. Prediction is defi ned as classifying the subjects, on the basis of their scores in the 4 belief types, into the group to which they actually belong. The overall correct group classifi cation was 83.12%, which is 33% above the 50% based on chance expectation (the result is highly signifi cant, Critical Ratio=4.358, p < .001). Notably, prediction of membership in the healthy group (correct in 88.4%) was signifi cantly better than in the asthmatic group (correct in 76.5%; Critical Ratio=1.94, p<.05). The two belief types that fulfi lled the largest role as predictors were primarily self beliefs, followed by goals beliefs.
Notably both types of beliefs are the more personal ones in contrast to the relatively impersonal beliefs types general and norms.

Comparing asthmatics and controls in terms of themes
Finer-grained analyses were carried out in order to gain deeper insight into the fi ndings. The fi rst of these analyses focused on the themes which provided the contents of the CO-AST questionnaire. The themes are of interest because they may shed light on the concrete issues preoccupying subjects of the studied group. Table 7 presents the mean scores and comparisons of the 19 themes in the two groups.
It shows that asthmatics scored signifi cantly higher than the healthy controls on all 19 themes. Even when we consider that in line with Bonferroni criteria for 20 comparisons the

Comparing asthmatics and controls in terms of confl icts and discrepancies between between belief scores
A second fi ner-grained analysis focused on confl icts. 'rejecting commitments' and 'pro commitments'. Four of the 6 confl icts concern interpersonal relations particularly in the family, and 2 focus on undertaking commitments.  Note. Self = Beliefs about self, Goals = Beliefs about goals, T = Theme, C = Confl ict, G = Gap, CR = Critical Ratio (the observed per cent is compared to that expected by chance, which in this case is 50%). For the list of themes see Table 2, for the list of confl icts see Table 8, for the list of gaps see Table 9. * p < .05 **** p < .0000  Table 2. * p < 0.05 ** p < 0.01 *** p < 0.001 **** p < 0.0000 Citation: Roth  Discrepancies between the scores of the 4 belief types are another way of gaining insight into the potential for confl ict of asthmatic patients. It complements the analysis in terms of confl icts between themes in being of a more formal nature.
The discrepancies or gaps are computed as absolute differences between the mean scores of the belief types in each group.
Comparing the mean gaps in the 2 groups shows that though all the mean gaps in the asthmatics' group were numerically higher than in the controls, only one gap -between beliefs about self and general beliefs -was signifi cantly so ( Table 9).

Discussion
The fi ndings showed that a cognitive orientation questionnaire assessing a specifi c set of themes in terms of 4 belief types enables differentiating signifi cantly between the asthmatics and the healthy controls. These fi ndings support the conclusion that there is a cognitive orientation characteristic for asthma patients. It can be characterized in terms of belief types and of themes. In terms of belief types the cognitive orientation of asthma patients consists of the 4 belief types -about self, norms, goals and reality (general beliefs). However, beliefs about self and goals -which express primarily the personal approach -play a major role in differentiating asthmatics from the healthy controls. Notably, asthma patients differ from the controls not only in the scores for each belief type but also in the total number of belief types in which they score high (i.e., above the group's mean). This total number is about 3 belief types, which corresponds to the number necessary for forming a motivational predisposition supporting a given act of behavior. Hence, we may conclude that asthma patients endorse the full set of belief types characteristically necessary for supporting a motivational predisposition, in this case a predisposition for asthma.
In the control group we found hardly one belief type supporting asthma. Similarly, the number of themes characteristic for asthma was in the control group less than half the number in the asthma group (5.74 vs 12.15, i.e., 0.47) and the number of confl icts even less (1.58 vs 4.23, i.e., 0.37). In addition, the identifi cation of the healthy controls was in general better than that of the asthmatics. Hence, we conclude that the motivational tendency underlying asthma is not a continuous variable but rather an all-or-none function.
In terms of themes, the cognitive orientation of asthma patients includes higher scores on all the 19 themes identifi ed in the patients. These themes may be grouped into several clusters: (a) themes referring to self-control and discipline that include the obsessive-compulsive tendency (order and cleanliness, not wasting time, rejecting uncertainty; see Factor I) and self-discipline (placing high demands on oneself and no bodily expression; see Factor IV); (b) themes referring to achievement (ambition, striving for perfection; see Factor II); (c) themes referring to interpersonal relations, both in the positive sense of maintaining good relations with close persons, mainly family, (see Factor I) as well as in the negative sense of withdrawing from others on the basis of self-suffi ciency (e.g., independence, rejecting help, see Factor III) or even defi ance (i.e., rejecting commitments, not caring about rejection from others, see Factor V). The themes that are most characteristic and play the most prominent role in differentiating between asthmatics and healthy subjects are mainly from the two domains of self-discipline (Themes 17-19: high demands, commitments and avoiding bodily expression) and interpersonal relations, both closeness (Themes 2 & 9) and withdrawal (Themes 10, 12 & 16). This list of themes indicates the important role that the confl ict in regard to interpersonal relations plays in asthmatics. As could be expected, the results indicated several confl icts characteristic of the asthmatic group. Notably, of the 6 identifi ed confl icts, 4 refer to interpersonal relations: striving for close relations vs dominating others (Themes 1 & 12), striving for close relations vs independence (Themes 1 &  Table 2. *** p < .001 **** p < .0000 Table 9: Means, standard deviations and mean comparisons of scores of the six gaps between belief types in asthma patients and healthy controls.  [44].

Gaps Asthma Patients Healthy Controls t-test
Our theme of 'dominating others' is similar to the fi nding of 'low submissiveness' [26]. The themes that refer to pro commitment and placing high demands on oneself (Themes 18 & 17) correspond to the fi ndings about the high superego strength of asthmatics [27] while the theme (No. 13) that refers to rejection of commitment could correspond to the fi ndings about the radicalism and tough-mindedness of asthmatics [27].
In sum, the larger number of themes identifi ed in our study, their precise defi nitions and their grounding in a wellestablished theory make it likely that the list of our themes is more comprehensive and coherent than partial fi ndings on different levels of generality, based on diverse instruments.
The comprehensiveness of our fi ndings and their specifi city provide answers to the two questions that have motivated the study. The fi rst was whether there is a specifi c type of asthma patient. Previous investigators could not identify it. Our fi ndings suggest that indeed there is a specifi c type.
It consists of a specifi c set of well-defi ned motivational constructs or themes organized in terms of 4 belief types constituting a vector characteristic for asthma patients, which we call the cognitive orientation of asthma. The importance of the cognitive orientation of asthma consists mainly in that it provides an answer to the second question which referred to the characteristics of the specifi c stressors to which asthmatics are particularly sensitive. Previous investigators could not identify the specifi c stressors [37,41]. Our fi ndings provide guidelines for identifying likely sources of stress characteristic for asthma. One source is "theme anchored" and consists in endorsing specifi c themes likely to produce stress. Examples are the themes of 'avoiding tension' (No. 2), and 'fear of rejection' (No. 9), which may generate tension by sensitizing the patient to sources of tension or likely rejection; the pair of themes (No. 6, 17) focused on high achievements -perfection and placing high demands on oneself -which may generate tension by forcing the patient to strive for attaining very high standards; and the pair of themes (Nos. 5, 19) focused on curbing emotional and other bodily expression, which may generate tension by building up pent-up anger and other negative emotions.
A second potential source of stress is "confl ict anchored" and consists in endorsing discrepant or clashing beliefs. The two major confl icts based on themes are the 'interpersonal confl ict' focused on striving for closeness vs withdrawal (independence, dominating others, rejecting help, indifference to rejection), and the 'commitment confl ict' focused on behaving according to rules, expectations and commitments vs rejecting all in favor of personal freedom. A further source of tension is the discrepancy between the view asthmatics have of their self and personal reality vs the view they have of others and reality at large. These diverse discrepancies in themes and beliefs suggest constant, pervasive, and powerful sources of stress that may endow many apparently innocent actions and states with tension for asthma patients. It is premature to conclude that the indicated sources of tension are risk factors for asthma. All that may at present be safely stated is that there is a cognitive orientation characteristic of asthma, that it refers to broad and basic domains of life -interpersonal relations, action, obsessive style -and that it includes specifi c and salient sources of stress. Further research will deal with the generality of the fi ndings for other age groups and their interrelation with asthma attacks.