personality traits asthma

Journal of Asthma, 31(3), 161-170 (1994)

ORIGINAL ARTICLES

Bronchial Asthma and Personality Dimensions: A Multifaceted Association

A. Belloch,' M. Perpifi&,2 T. Paredes,' A. Gimenez,' L. Compte,2 and R. Baiios3

'Department of Personality Psychology University of Valencia

Valencia, Spain 'Service of Pneumology

Hospital Uniuersitario La F6 Valencia, Spain

"Department of Psychology University Jaume I

Castellon, Spain

ABSTRACT

Personality dimensions seem to play an important role in chronic diseases by maintaining or increasing the patient's physical complaints. This study exam- ines in bronchial asthma: (a) the relationships among clinical data, baseline lung function, and personality traits; and (b) the patient's characteristics related to the physician's judgment about his or her asthma severity. Five questionnaires measuring anxiety, depression, self-consciousness, and subjec- l ive symptoms were completed by 51 asthmatic patients. Responses to questionnaires and clinical and demographic data were factor-analyzed. Factor analysis revealed that the physician's severity judgment 11s based on elderly age, high scores on depression, ,and longer duration of asthma.

Address for correspondence: Prof. A. Belloch, Department of Personality Psychology, Facultad de Psicologia, Avda Blasco Ibanez, 21, 46010 V.ilencia, Spain.

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Copyright 0 1994 by Marcel Dekker, Inc

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162 Belloch et al.

INTRODUCTION

The fact that psychological processes are involved in the experience of illness has been well known for many years. Much ground has been covered from the psychosomatic medicine of the 1960s up to the present, dur- ing which time both behavioral medicine and health psychology have taken a broader per- spective in examining the interrelationships among psychological and social factors, bio- logical and physiological functions, and the development of illnesses. Throughout this period, bronchial asthma has been the respiratory disorder most extensively explored by psychologists, and the search for psychological factors that influence its course is now one of the most prominent areas of psychological research (1). In traditional reviews, anxiety seems to be one of the most widely experienced stigmas in asthmatic patients. Other patients with asthma frequently report pessimism about their illness and future, and subgroups of asthma patients report high levels of psychological depression (2-4). However, few studies examining the relationships among personality dimensions, clinical data of the illness, and current airflow obstruction in mentally healthy asthmatic patients have been reported. It is also of great interest to examine the influence of normal and stable personality characteristics on clinical judgment of severity.

Thus, the first aim of this study was to examine, in bronchial asthma, the relationships among clinical data, baseline lung function, and personality traits. The second ob- jective was to examine the psychological traits as well as the clinical data of the patients related to the physicians’ judgment about their asthma severity. To accomplish these goals, we used the heuristic strategy of performing a simultaneous comparison of several aspects of personality and some data about asthma, paying close attention to the strength of the links between personality and disease.

METHODS

Subjects

Subjects were 51 nonsmoker asthmatic patients (24 atopics and 27 nonatopics), diag-

nosed in accordance with the guidelines proposed by the American Thoracic Society (5), who were being treated at the outpatient clinic of the University Hospital La F6, in Valencia, Spain. They were consecutively re- cruited. Their baseline forced expiratory vol- ume in 1 sec (FEVI) [mean (SD)] was 88 (23% of predicted). Twenty-two men and 29 women were included in this study. Their ages ranged from 18 to 71 years [38 (16.46) years]. At the time of the study, their clinical situa- tion was stable and none had had symptoms within the past 2 weeks. All were taking aerosol p2-adrenergic agonists and inhaled steroids.

None of the patients had: a history of mental disorder; cognitive impairment; low in- structional level; recent negative life events; past or present thyroid disorder; cardiac disorder or respiratory tract infection in the pre- vious 4 weeks.

Questionnaires

SELF-CONSCIOUSNESS SCALE REVISED (SCS-R) (6)

This is a 22-item questionnaire, which measures individual differences in private (PRIVSC) and public (PUBSC) self-consciousness. PRIVSC refers to the tendency to think about and attend to the most covert, hidden aspects of the self (for example, one’s pri- vately held beliefs, aspirations, emotions, and feelings). This subscale contains nine items. The PUBSC subscale, containing seven items, refers to the tendency to think about those self-aspects that are matters of public display, qualities of the self from which impressions are formed in other people’s eyes (for example, one’s overt behavior, mannerisms, stylistic quirks, and expressive qualities). The SCS-R also incorporates a measure of social anxiety (SA), obtained from the addition of six items, which in- volves a particular kind of reaction to focus- ing on the public self, that is, a sense of apprehensiveness about being evaluated by other people in one’s social environment or doubt about being able to create adequate self-presentations. Respondents are asked to indicate the extent to which each of the 22 statements is like them, using the following

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Bronchial Asthma and Personality 163

response format: 3 = a lot like me; 2 = somewhat like me; 1 = a little like me; 0 = not at all like me. Three separate scores are obtained for each of the subscales, by adding the responses of their respective items, and this has been the rule we have followed. The applicability of the SCS-R for use with Span- ish samples was examined in a study in which mean values (SD) of 24.7 (4.8) for PRIVSC, of 19.6 (3.3) for PUBSC, and of 13.43 (4.01) for SA were obtained in normal Sam- ples (7).

MINNESOTA MULTIPHASIC PERSONALITY INVENTORY-DEPRESSION (MMPI-D) (8)

This is a 28-item questionnaire widely used as a screening instrument for depression. Respondents are asked to indicate the extent to which each of the statements is like them, using a ”yes” or ”no” response format. A single total score is obtained (range 0-28) by adding the responses. Total scores 220 were usually considered an index of clinical depression in Spanish subjects and mean values (SD) 2 lS(C1.2) were obtained in groups of depressive patients (9).

AUTOMATIC THOUGHTS QUESTIONNAIRE (ATQ) (10)

This questionnaire assesses the occur- rence of intrusive negative self-statements related to depression. For each of the 30 statements, the respondent indicates the extent to which the thought has occurred in the previ- ous week. The responses are on a five-point scale from 1 (“not at all”) to 5 (”all the time”). A single total score is obtained (range 1-150) by adding the responses to each item. From 89 (21) to 93.3 (29.7) mean values (SD) were reported in clinically depressed patients (11,lZ).

TRAIT ANXIETY INVENTORY (STAI-T) (13)

This is a 20-item questionnaire to assess anxiety trait, which is conceived as an endur- ing and stable personality disposition to react with anxiety to a wide range of situations. The respondents are asked to indicate the extent to which each of the items is like them, using a 3, 2, 1, and 0 response format.

A single total score is obtained (range 0-60) by adding the responses to each item. The STAI-T is not used as a diagnostic or screening instrument for anxiety disorders, and mean values (SD) of 20 (8.8) were reported in Spanish normal samples. In addition, mean values (SD) 2 48 (10) were obtained in subjects diagnosed as having an anxiety disorder (14).

ASTHMA SYMPTOM CHECKLIST (ASC) (15)

This is a Likert-type instrument on which asthmatic patients report the frequency with which 36 specific symptoms occur in con- nection with their asthma attacks. Each symptom is rated on a five-point scale from “never” occurring as a part of an attack to ”always” occurring as part of an attack. The ASC factor structure consists of five factors representing highly stable dimensions of the subjective symptomatology of asthma. In our study we only considered the total score in the ASC as a general indicator of subjective symptoma tology.

Clinical Data

We collected the following seven types of data related to the duration, characteristics, and current clinical status of asthma:

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4. 5.

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Duration of asthma, measured by the number of years since the patient was first diagnosed as having asthma. Degree of dyspnea, defined as ”breath- lessness” and estimated by the patient on a four-point scale, ranging from 1 (“maximum effort”) to 4 (“minimal effort“). Presence or absence of nocturnal symptoms when the presence variable was scored 1 and absence was scored 0. Degree of airflow obstruction (FEVI). Number of admissions to hospital and/or visits to the emergency room for an asthma attack in the preceding 12 months. Nonatopic versus atopic status. All subjects underwent skin prick tests with a battery of 15 common inhaled antigen ex- tracts. Atopy was indicated whenever a

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164 Belloch et al.

patient had one or more immediate positive skin reactions. Atopic patients were given a score of 1 and nonatopic a score of 0. Physician’s judgment of severity which was determined by each patient’s physician on a 4-point scale ranging from 1 (“low severity”, defined as very infre- quent attacks with low doses of interim symptomatic treatment) to 4 (”high severity”, defined as continuous symptoms with continuous multiple drug regimen, including some systemic steroids) on the basis of the patient’s clinic record as well as the clinical interview with the patient. In all cases, severity judgment was made before knowing the current FEV, of each patient.

7.

Demographic Data

Demographic variables included age, level of education, and sex. On the sex variable, men were given a score of 1 and women a score of 0. Level of education was considered only to ensure an adequate understanding of the items included in personality questionnaires.

Procedures

Before being included, all potential subjects were screened by full history and exam- ination. Moreover, all subjects were individ- ually tested in two sessions conducted on two consecutive days. Patients were asked to par- ticipate in a medical and psychological research project about asthma on the first day they arrived at the outpatient clinic. After their acceptance, they had an interview with the senior psychologist to rule out any form of present or past mental disorder, following the criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-111-R) of the American Psychiatric Association (16). After the psychologist had completed this exami- nation and decided that the patient could be included in the study, he submitted his evaluation to the physician, who, in turn, assessed the current asthma status of the

patient. This evaluation was made on the basis of a standardized clinical record containing the clinical data previously described, except for the current FEV,. The physician then decided whether the subject could be included in the study. If the patient was considered likely to be included, he or she was sent to the psychologist to fill out the SCS-R and MMPI-D questionnaires.

On the following day the patient completed the ATQ, STAI-T, and ASC questionnaires, in the presence of a psychologist, to assure the patient’s understanding of the questionnaires. Immediately thereafter, the current flow obstruction was assessed. FEV, measurements were performed in a sitting position, with a noseclip, using a 10-L dry spirometer (Mijnhardt, Volugraph 2000), and values were expressed to ambient tempera- ture and pressure saturated with water. Three FEV, maneuvers were performed. In our sample, all tracings satisfied the Euro- pean Coal and Steel Community criteria (17). All tests were performed between 9:OO A.M. and 1:OO P.M.

Statistical Analysis

The first step in the statistical analysis was to compute the means and standard devia- tions (interval variables) or the number of observations and percentages (dichotomic variables) for all the variables considered. The second step was to compute the intercor- relations for all these 16 variables using the Spearman rank order correlation coefficient and, next, to factor-analyze the correlation matrix obtained. We performed a principal- components factor analysis (18,19). For this analysis the commonalities for the diagonal of the intercorrelation matrix were estimated and iterated, and an orthogonal rotation by the Varimax procedure was used to achieve a final solution. The criteria to retain factors were those suggested by the “scree test” (20,21). The ratio of observations to variables was 3 to 1. How reliable the factors are that emerge from a factor analysis depends on the size of the sample, although there is no con- sensus on what this should be. There is agreement that there should be more sub-

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jects than variables. However, how great this ratio should be is a matter of dispute. In two documented and extensive reviews about this topic (21,22), it was concluded that 3 to 1 is an adequate ratio and that, when factor structures are clear, as low as 2 to 1 is viable, although replication would then be essential.

RESULTS

Table 1 summarizes the normative data for all variables considered. The mean values obtained in the three subscales of the SCS-R were higher than those reported in the above-cited study with Spanish samples (7). However, the obtained mean values of the MMPI-D and ATQ questionnaires were lower than those reported in studies with depressed patients (9- 12). Mean values obtained with the STAI-T questionnaire were also lower than those reported for anxious personalities (13,14).

Correlation matrix results are shown in Table 2 . There were three variables with the highest number of significant relationships: depression (MMPI-D), severity judgment, and subjective symptomatology (ASC). In contrast, dyspnea did not show relationship to any variable. The age of patients was significantly related to longer asthma duration, poor respiratory function, judgment of greater severity, and high scores in both the MMPI-D and subjective symptomatology. The severity judgment was also related to the presence of nocturnal symptoms and high scores in depression (MMPI-D), as well as in anxiety (STAI-T) and in subjective symptomatology (ASC). In addition, the three variables last mentioned were also significantly linked. There was also a relationship between severity judgment and sex variable: being an asthmatic woman was related to nocturnal symptomatology, high scores on depression (MMPI-D), and anxiety trait. Fi- nally, there was a group of negative relationships between FEV,, duration of asthma,

Table 1 . Characteristic3 of 51 Asthmatic Patients in A l l Variables Considered ~ -~~ ~~

VARIABLE NUMBER Yo RANGt

Sex ____-

Males 22 43 Female3 29 57

Presence 28 55 Absence 23 45

Atopic 24 47 Nonatopic 27 53

Noc tu rna I sy m ptoni i

Atopic statu3

Age 18-71 Duration of asthma (years) 2-46 Dyspnea 1-4 FEV, 19-1 18

Severity judgnwnt 1-4 Private self-conx iousne5s 15-45 Public self-conscioumess 13-35 Social Anxietv 6-24

Automatic Thoughts Questionnaire 30-99 Trait Anxiety Inventory 2-49 Asthma Symptom Checklist 42-169

Hospitalirations 0-1 1

MMPI-Depresbion 4-20

MEAN SD

38 16 4 7 8 8 6 i 1 1

2 3 2 2 2 - 1 1 1

2 7 4 6 1 2 3 2 4 7 14 5 5 2 10 2 4 0 48 4 8 3 2 3 2 11 3

101 2 12 3

1

88 23

"Admissions to hospital and/or v is i t3 to the emergency room in the preceding year

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judgment of severity, class of asthma, and the age of the patient. This indicates that the worst respiratory function was found in those elderly asthmatic patients who had longer duration of ,asthma, a diagnosis of nonatopic asthma, and high scores on depression.

Table 3 shows the results of factor analysis. The elements in this table are termed factor "loadings." The loading of a given variable on a given factor can be interpreted as the correlation between that variable and the underlying category, or dimension, represented by the factor. Although factor loadings are comparable to Pearson or Spearman correla- tions, no procedure is known for computing the standard error of a factor loading. There- fore, loadings are compared with some con- ventional rules of thumb rather than being tested for statistical significance. One common rule of thumb is to consider loadings of 0.40 or above to be "high"; this was the con- vention used in the current study.

Five factors were finally retained. The cu- mulative proportion of the variance explained by these five factors was 68.5%.

The first factor accounted for 23.58% of the total variance, which means that their group of variables was the best explained of the analysis. It could be labeled "severity of asthma and accuracy of physician's judgment," since these two variables were the most significant in the factor. The other variables loading highly on the factor were duration of asthma, patient's age, and high score on MMPI-D.

The second factor was marked by four variables explaining 14.8% of the total variance. It could be labeled "self-consciousness and negative thoughts" and did not show any relationship with any of the clinical and/ or demographic variables considered.

The third factor accounted for 8.87% of the total variance, which means that it was the least important factor of the analysis. This factor was marked only by one variable, dyspnea; therefore, its validity as a factor is unclear.

The fourth factor explained 12.24% of the total variance. Variables with high loadings on this factor included status of asthma (atopic), subjective asthma symptoms, noc-

Table 3. f'actor Analysis of 16 Variables wi th Varirnax Rotation (Loadings > 0.40)a ~-

FACTOR STRUCTURE

VAR I A6 L E FACTOR 1 FACTOR 2 FACTOR 3 FACTOR 4 FACTOR 5

Age Sex Duration of asthma Dyspnea Nocturnal Symptoms FEV, Hospitalizations" Atopic status Severity judgment Private self-consciousness Public self-consciousness Social Anxiety MMPI-Depressiori Automatic Thoughts Q. Trait Anxiety Inventory Asthma Symptom Checklist

Yo variance explained

0.74

0.76 -

-

-

-0.79 - -

0.79 -

-

-

0.73 -

-

~

23.6%

"The loading of a variable on a factor can be interpreted as the correlation between that variable and the

hAdmissions to hospital and/or visits to the emergency room in the preceding year. underlying category or dimension represented by the factor.

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168 Belloch et al.

turnal symptoms, and anxiety trait. It could be labeled “subjective symptoms of asthma and anxiety in atopic asthmatic patients.” The relationships observed among these variables showed that the patients with atopic asthma were highly anxious and reported more subjective symptoms; since the AT variable was scored in the nonatopic status direction, a negative load on AT indicates the presence of atopic status.

The last factor had high loadings for three variables and explained 9% of the total variance. From this factor, the highest rate of admissions to hospital and/or visits to the emergency room was related, in asthmatic men, to not having negative thoughts, that is, to absence of one of the most usual symptoms of depression; since the sex variable was scored in the man’s direction, a positive load on this variable indicates the presence of the man’s condition.

DISCUSS I ON

The results of the present study suggest that a complex network of relationships ex- ists among psychological traits, demographic characteristics, and clinical data in asthmatic patients.

A dimension of asthma severity is represented in the first factor, through a pattern of relationships among high scores on MMPI-D, impaired pulmonary function, long duration of asthma, advanced age, and physician’s judgment of high severity. There- fore, it seems that the physician’s judgment of this group of patients is highly accurate, despite the fact that this judgment was made when the doctor was still blind to the patient’s FEV,. Other authors have reported a close relationship among physician rating of severity, the number of years since the first diagnosis of asthma, and high airflow obstruction, measured with the FEV, (23). On the other hand, depression appears to be closely related to impaired pulmonary lung function, as has been reported in other studies (24,25). In our study, none of the patients satisfied the criteria for a clinical diagnosis of depression or obtained high scores in a de-

pression questionnaire ( i .e . , MMPI-D). De- spite this fact, the relationship between high score in MMPI-D and greater airflow obstruction seems to be maintained, which suggests that it is a stable pattern that occurs even when no depression is diagnosed but only high scores in a depression questionnaire are found.

The fact that neither dyspnea nor subjective symptoms were present in the first factor would mean that this class of elderly patients, who had impaired pulmonary function, also had rather poor perception of their symptoms, including both dyspnea and the wide range of subjective symptoms recorded by ASC. Our assumption is consistent with the data reported by other authors describing reduced awareness of bronchoconstriction in elderly asthmatic patients (23,26). Although in the latter study the authors do not report the number of years of asthma duration in their patients, this variable could also be re- sponsible, along with elderly age, for the impaired awareness of bronchoconstriction. On the other hand, from our results subjective perception of dyspnea was not related to any of the variables considered. We do not have any rational explanation for this finding. From a statistical point of view, the fact that one factor is formed by only one variable re- duces its significance, since the usefulness of factor analysis lies in the search for significant patterns of relationships among differ- ent variables. Hence, we think that the validity of this dyspnea factor is uncertain.

The relationship between anxiety trait and subjective symptomatology has been well documented (27-31). But interestingly, our results showed this relationship only in patients with atopic asthma. In addition, the length of hospitalization, medication at dis- charge, and rehospitalization rates were related to a panic-fear disposition and a vigilant attitude about the symptoms (2,30,32), both related to high levels of anxiety.

There was a close relationship between absence of negative thoughts and high rate of admissions to hospital, related to asthma attacks, in men. This suggests that the absence of depressive symptoms, i.e., the absence of worries and negative concerns about oneself,

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could be related, in men, to disregarding asthma symptoms, which turns into a risk factor for asthma attacks requiring emergency treatment. However, in other studies the disregarding of symptoms was related to depression (30,33,34) and its associated life- style (1).

Finally, our results support the usefulness of the multivariate statistical procedures to explore the complex and multidimensional aspects of the relationships between characteristics of a chronic disease, such as asthma, and the personality o f the patient.

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REFERENCES

Kaptein AA, Dekker FW, Van der Waart MAC, Gill K: Health psychology and asthma: current status and future directions. In Topics in Health Psychology (Maes S , Spielberger CD, Defares PB, Sarason IG, editors). Wiley, Chichester, 1988, 157-170. Kaptein AA: Psychological correlates of length of hospitalization and rehospitalization in patients with acute severe asthma. Soc Sci Med 16:725-729 (1982). Kaptein AA: l l lncss tlehazuor of putients with asthma. Krips Repro, Meppel, 1982. Friedman HS, Booth-Kewley S: The "disease-prone personality": A meta analytic review of the con- struct. A m Psycho/ 42:539-555 (1987). American Thoracic Society: Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma. Am R ~ J Respir Dis 136:225-244 (1987). Scheier MF, Carver CS: The Self-Consciousness Scale: A revised version for use with general pop- ulations. \ Appl Soc Psychol 15:687-699 (1985). Banos RM, Belloch A, Perpina C: Self-Conscious- ness scale: A study of Spanish housewives. Psychol Rep 66:771-774 (1990:1. Dempsey P: A unidirnensional scale for the MMPI.

Garcia-Merita M, Balaguer I, Ibariez E: Validez de la Escala de Depresion del MMPI. Rn1 Psicol Gen Apl .39:313-340 (1984). Hollon SD, Kendall PC: Cognitive self-statements in depression: Development of an Automatic Thoughts Questionnaire. Cogrirtizw Tlier Res 4:383-

Harrell TH, Ryan Ntl: Cognitive-behavioral assessment of depression: Clinical validation of the Auto- matic Thoughts Questionnaire. ] Consult CIin Psychol 51 :721-725 ( 1'983). Dobson KS, Shaw BF: Cognitive assessment with major depressive disorders. C o p i t Ther Res 10:13- 29 (1986).

Consult Psychol 38:364-370 (1964).

395 (1980).

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

Spielberger CD, Gorsuch RL, Lushene RE: Manual for the State-Trait Anxiety Inventory. Consulting Psy- chologist Press, Palo Alto, CA, 1970. Seisdedos N: Cuestionario de Ansiedad Estado- Rasgo. Adaptacion Espanola. TEA Ediciones, SA, Madrid, 1988. Brooks CM, fichards EJ, Bailey WC, Martin B, Windsor RA, Soong S-J: Subjective symptomatology of asthma in an outpatient population. Psycho- som Med 51:102-108 (1989). American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd ed rev. American Psychiatric Association, Washington, DC, 1987. Cotes JE, Peslin R, Yernault JC: Dynamic lung vol- umes and forced ventilatory flow rates. Standard- ized lung function testing. Bull Eur Physiopathol Respir IY(Suppl 5):22-27 (1983). Harman HH: Modern Factor Analysis, 3rd ed. Uni- versity of Chicago Press, Chicago, 1976. McDonald RP: Factor Analysis and Related Techniques. Lawrence Erlbaum, Hillsdale, NJ, 1985. Cattell RB: The Scree test for the number of factors. Multivar Behav Res 1:140-161 (1966). Barret IT, Mine P: The observation to variable ratio in factor analyses. Person Study Group Behav 1:23- 33 (1981). Mine P: Factor analysis and personality theory. Eur ] Person 1:21-36 (1987). Bailey WC, Higgins DM, Richards BM, Richards JM: Asthma severity: A factor analytic investiga- tion. A m / Med 93:263-269 (1992). Boulet L-Ph, Deschesnes RN, Turcotte H, Gignac F: Near-fatal asthma: Clinical and physiologic fea- tures, perception of bronchoconstriction and psy- chologic profile. ] AllerKy Clin Immunol 88:838- 846 (1991). Staudenmayer H, Kinsman R, Dirks J, Spector S, Wangaard C: Medical outcome in asthmatic patients: Effects of airways hyperreactivity and symptom-focused anxiety. Psychosom Med 41:lOY- 117 (1979). Connolly MI, Crowley JJ, Charan NB, Nielson CP, Vestal RE: Reduced subjective awareness of bronchoconstriction provoked by methacoline in elderly asthmatic and normal subjects as measured on a simple awareness scale. Thorax 47:410-413 (1992). Kinsman RA, O'Banion K, Resnikof P, Luparello T, Spector S: Subjective symptoms of acute asthma within a heterogeneous sample of asthmatics. / Al- lerKy Clin Itnrnunol 52:284-296 (1973). Kinsman RA, Dahlem N, Spector S, Staudenmayer H: Observations of subjective symptomatology, coping behavior and medical decisions in asthma. Psychosom Med 39102-119 (1977). Dahlem N, Kinsman R, Horton D: Panic-fear in asthma: Request for as-needed medication in relation to pulmonary function measurement. / Allergy Cliri Immunol 60:295-300 (1977). Dirks JF, Jones N, l n s m a n RA: Panic-fear: A personality dimension related to length of hospital-

J A

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oade

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For

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onal

use

onl

y.

170 Belloch et al.

ization in respiratory illness. I Asthma Res 24:61- 71 (1977). Dirks JF, Fross K, Evans, N: Panic-fear in asthma: Generalized personality trait vs. specific situational state. I Asthma Res 14:161-167 (1977). Dirks JF, Kinsman RA: Clinical prediction of medical rehospitalisation: Psychological assessment with the battery of Asthma Illness Behavior. J Pers Assess 45608-613 (1981).

31.

32.

33. Miller BD: Depression and asthma: A potentially lethal mixture J Allergy Clin Zmmunol 80:481-486 (1987).

34. Steiner H, Higgs Ch, Fritz GK, Laszlo G, Harvey JE: Defense style and the perception of asthma. Psychosom Med 49:35-44 (1987).

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