Managing Body Distress in the Control of Severe Asthma

Nature of Body Distress

The concept of a bodily distress disorder was proposed to unify overlapping symptoms from the most common functional syndromes described in clinical practice. ³² Fink et al performed a factor analysis of 62 functional symptoms and found limited support for the presence of distinct functional syndromes (chronic fatigue, irritable bowel, fibromyalgia). The identified factors were intercorrelated, meaning that patients with symptoms from one group were inclined to report symptoms from one of the other symptom groups. Latent class analysis found that patients could be more accurately classified along a severity bodily distress continuum into 3 classes defined by the total number of symptoms they presented: nonbodily distress, modest bodily distress, and severe bodily distress. Critical to the success of this single continuum was the inclusion of 5 symptoms that are reflected in dysfunctional breathing: headache, dizziness, memory impairment, concentration difficulties, and fatigue. In fact, these symptoms are described in a classical article on hyperventilation. ³³

In the present context, the term body distress is used to capture a dynamic state characterized by dysfunctional breathing, multiple unexplained physical symptoms, negative thoughts and feelings, poor sleep, and nonspecific body tension/guarding. Vashadze described the clinical picture of the asthma patient exhibiting body distress. ³⁴ In addition to subclinical anxiety and depression, the elements of hypersthenic weakness, sleep-onset insomnia, and “polymorphic pathological corporal sensations (cephalgia, cardialgia, abdominalgia)” were identified in the patients. The most significant psychobiologic symptom was dysfunctional breathing (breath dissatisfaction, feeling short of breath), which developed prior to asthma symptoms. Body distress is often driven by interoceptive information from all organs of the body—including muscles, joints, skin, and connective tissue—and not just the respiratory system. ³⁵

Body distress, when present, is unlikely to resolve with sleep. We have many unpublished patient observations to support this hypothesis. For example, a severe asthma patient with an abuse history remarked that she would awaken in the morning with fists clenched and not know why. Some severe asthma patients manifest clinical symptoms of body guarding outside episodes of worsening respiratory distress. Chronic muscular tension, evidenced by tightness in the neck and shoulders, jaw clenching, teeth grinding, rapid speech, forehead furrowing, and postural rigidity, are readily observed. “Guarded” behavior that occurs during the day may persist through the night, leaving the patient exhausted in the morning. Indeed, unrecognized body distress during sleep may play a significant role in precipitating episodes of nocturnal dyspnea and awakenings in severe asthma patients. ³⁶

The hypothesis that nonspecific body distress contributes to uncontrolled asthma is consistent with self-report data from composite asthma control questionnaires (Asthma Control Questionnaire [ACQ], Asthma Control Test [ACT]).^37,38 These questionnaires include key symptoms of wheeze, cough, shortness of breath, and chest tightness and have been found to predict poor asthma control. ³⁹ Although central to the definition of asthma, these symptoms are not unique to asthma. Similar symptoms are central to anxiety, especially panic anxiety, assessment. Rescue medication use and lifestyle limitations are also multifactorial and not necessarily determined by asthma severity alone. Chronic patient characteristics outside the disease process itself are also involved. The close relationship between mood scores, measured with the Hospital Anxiety and Depression Scale, and ACQ scores adds further evidence for the presence of body distress in uncontrolled asthma. ²⁴ Body distress may also contribute to the relatively high incidence of functional symptoms such as gastroesophageal reflux in severe asthma. ⁴⁰

Additional support for the body distress–asthma control connection comes from a study by Rudell and colleagues. ⁴¹ They asked patients with mild to severe asthma in 4 countries to complete the ACQ and discuss concepts around their asthma control and exacerbations. These patients reported factors beyond respiratory symptoms and lung function as critical, including fatigue, asthma-related panic/fear, difficulty falling asleep, and poor sleep unrelated to asthma episodes. Another study found patients with moderate to severe, uncontrolled asthma more frequently reported feeling fatigue as well as isolation, fear, and depression. ⁴² Fatigue was reported at a much higher frequency than emotional symptoms of anxiety and depression and characterized close to 50% of the sample. Interestingly, severe fatigue is often driven by perfectionism/type A personality and the self-critical judgment that one is never good enough—hence the “all-or-nothing” or “boom or bust” lifestyle. ⁴³

Anxiety appears to be a contributor to body distress and a powerful determinant of short-acting beta-agonist (SABA) use. Lavoie et al reported an exponential increase in rescue medication in asthma patients diagnosed with generalized anxiety disorder compared with other asthma patients. ⁴⁴ SABA dependence is rarely considered as potentially contributing to the mechanisms leading to poor asthma control. However, frequent use of an SABA can lead to partial loss of effectiveness ⁴⁵ and an increase in airway responsiveness. ⁴⁶ Abrupt discontinuation of SABAs may lead to rebound bronchoconstriction and possible pharmacological dependence. ⁹

Chronic airway inflammation is a key factor in asthma. ⁴⁷ Worsening airway inflammation is associated with loss of asthma control and the risk of an exacerbation. In all individuals, transient activation of a localized inflammatory response to acute stresses such as allergens, pathogens, toxins, or wounds is important in maintaining the health of airway tissue. In nonasthmatics, resolution of the stress and tissue repair occurs in concert with termination of the inflammatory response. ⁴⁸ However, there is growing appreciation that in cases of chronic severe asthma, the inflammatory response is not terminated, which results not in repair but rather in increased tissue damage, which in turn engages a vicious cycle of inflammation. ⁴⁹ Furthermore, there is evidence of systemic distribution of inflammatory mediators found in the airways, suggesting that asthma may be a respiratory consequence of a systemic inflammatory process.^50,51 Body distress can potentially amplify the systemic response by increasing levels of proinflammatory cytokines.^52,53 For example, patients with a history of childhood maltreatment (and high risk of chronic body distress) exhibit an increased risk for systemic inflammation, independent of additional stress in adulthood, or adult health. ⁵⁴ It would seem reasonable that managing body distress may dampen the chronic inflammatory response.

Dysfunctional Breathing

Episodic dysfunctional breathing in the form of breath holding, tightness in the chest, and difficulty breathing deeply is reported by many patients with asthma. ⁵⁵ A European survey reported that 48.1% of patients with poorly controlled asthma experienced dyspnea at least once a day compared with 1.7% of patients with well-controlled asthma. ⁵⁶ Our clinical experience suggests that the origins of dysfunctional breathing often begin during adverse childhood experiences. It is important to assess childhood emotional, physical, and/or sexual abuse with severe asthma patients. The previously mentioned patient who awakened with clenched fists and jaw recalled being repeatedly fondled by an uncle between the ages of 3 to 15. The patient was afraid to mention the incidents, came to dread being alone with the individual, and recalled holding her breath in anticipation of his presence. As an adult severe asthmatic, the patient did not connect these early experiences to how her body remained guarded in a wide variety of current situations, including driving and attending medical appointments. Making the connection serves to increase patient capacity for interoception and identify feelings and sensations related to body distress.

The phrase somatic hypervigilance has been offered to characterize the chronic shortness of breath sensations experienced by severe asthma sufferers. ⁴⁴ The long-term respiratory impact of adverse childhood experiences needs empirical investigation. A community study examined the association of airflow limitation with previous trauma exposure and PTSD. ⁵⁷ The study was predicated on a previous finding that subjects with PTSD had a 3 times higher risk for asthma than those without PTSD. ⁵⁸ Subjects completed the PTSD module of a structured psychiatric interview for both the presence/absence of PTSD as well as number of traumatic events experienced. Overall, PTSD subjects showed the greatest presence of airflow obstruction followed by those with previous trauma exposure but without a PTSD diagnosis. The authors hypothesized that traumatic stress might lead to changes in the hypothalamic-pituitary-adrenal and autonomic axes, which create a low-grade inflammatory state, similar to the “wear and tear” notion of allostatic load. ⁵⁹

Effortless Breathing and the Mindful Body

Awareness and management of dysfunctional breathing is important to reduce overall body distress and possibly help improve asthma control. Uncontrolled patients are not likely to suspect dysfunctional breathing as acting as a subtle trigger or lowering their threshold for worsening asthma symptoms. Effortless (relaxed, abdominal) breathing can be readily demonstrated by having the patient sit back in a recliner and place his/her hands on the abdomen and chest and breathe in a relaxed manner. It is important to understand that the objective of such a demonstration is not breathing retraining per se but having the patient experience a moment of relaxation, termed somatic awareness, outside the more familiar state of body distress. The goal of using effortless breathing is to direct the patient to body experience and associated feelings for the purpose of self-management and achieving health. Somatic awareness, a normal property of consciousness, is defined as the utilization of body sensations and feelings for the purpose of achieving health. ⁶⁰ The experiential concept serves to network the physiological, psychological, and contextual variables unique to each patient that need to change. Used as a self-management heuristic, somatic awareness can guide changes in disease/illness beliefs, coping styles, body guarding schema, coping styles, interpersonal dynamics, sleep, and medication dependence. ⁶¹

The approach of reducing body distress and improving asthma control through somatic awareness is organized around the mindful body. This concept refers to the phenomenally experienced body self and provides the means to connect cognitive, affective, and bodily experience. It is the link of one’s psychological, social, and physiological life. The term mindful body is not the same as the concept of mindfulness. Mindfulness refers to an open-ended and nonjudgmental awareness of whatever is happening at each successive moment of perception. The mindful body is a more encompassing term and comes from medical anthropology and is derived from embodiment. ⁶² Embodiment refers to one’s lived experience of one’s body as well as one’s experience of life mediated through the body. The critical insight of embodiment is that the body has a life of its own. Embodiment is a dynamic process and results in one’s culture, experiences, and memories becoming embedded in associational fields composed of feelings and sensations. ⁶²

In some asthma patients, somatic awareness may reduce their reliance on asthma medications. For example, we observe some asthma patients who have experienced a negative childhood fail to appreciate how embodied experiences may continue to influence their breathing and vulnerability to other physical symptoms. The emotional basis of their adult functioning is organized around negative anticipation that includes apprehension, worry, and anxiety as well as guarded breathing. A clinic patient remarked, “I just realized how much I don’t breathe. I was making dinner and caught myself not breathing. I also noticed by taking a breath the thought that was bothering me vanished.” They discover, through guidance in somatic awareness training, that their body remains hypervigilant and continues to influence and be influenced by current feelings and interpersonal interactions.

The use of the least amount of medication to provide disease control is a central goal of asthma care. ⁶³ Unrecognized body distress may be a clinically important factor in the overreliance on high doses of inhaled and systemic corticosteroids and dependence on short-acting bronchodilators by uncontrolled asthmatics. Adoption of a step-down protocol, in particular, may be of benefit in these patients by addressing the distress and fear that can occur with the plans to lessen the use of medication. Body distress may hamper success at implementing a step-down asthma drug protocol, as any act of stopping or reducing a medication can be expected in a susceptible individual to lead to a worsening of symptoms, not necessarily because of the asthma disease, but due to treatment-induced distress related to the “fear of fear,” or nocebo effect. ⁶⁴

Developing somatic awareness as a transformational wellness skill represents a new paradigm for many asthma patients who have believed, to this point, that body experiences outside of an asthma attack are to be ignored. Health care professionals, including asthma educators, can apply the concept directly or as a guide to select which community-based resources might best address each patient’s unique biobehavioral body distress phenotype.

Conclusion

Severe asthma is ideally managed in a specialized clinic with expertise in biologic and psychobiologic asthma knowledge. The psychobiologic and experiential concepts of body distress and somatic awareness have significant potential for improving asthma control in selected patients. Body distress is a patient-centered experiential concept that is readily accepted by many asthma patients. Dysfunctional breathing can be used as a proxy for body distress in discussions of emotional, behavioral, interpersonal, and adherence issues with patients. It is much easier for the patient to accept, experience, and alter the impact of current and previous trauma, personality, stress, and emotions if he/she views the body as the mediator of these experiences. In this way, patients may learn to connect their body distress to asthma symptoms and understand the total experience changes needed to improve asthma control. The psychobiological components of body distress within each patient can be pinpointed with clinical precision and integrated within a broad patient-centered management plan.