Asthma attacks often bring with them more than constricted breathing. For many patients, the shortness of breath and wheezing also trigger heightened anxiety, says psychologist and certified asthma educator Daphne Koinis-Mitchell, PhD.

"The whole idea of not being able to breathe is, understandably, very frightening to children and their parents, and fear usually influences anxiety and treatment decisions," says Koinis-Mitchell, associate professor of psychiatry and pediatrics at Brown University and director of the university's Community Asthma Program.

Of course, as experts in helping patients overcome anxiety, psychologists have long played a role in helping patients manage their asthma, teaching them techniques to avoid possible triggers, monitor their symptoms and use their medications properly. Now, new research by psychologists is offering a better understanding of the link between stress and our airways, and exploring new asthma treatments, including breathing retraining, biofeedback and cognitive-behavior therapy (CBT).

"It's really an interdisciplinary approach that's needed," and psychologists can help with chronic disease management, Koinis-Mitchell says.

Asthma, the chronic inflammatory disease of the airways, affects at least 22 million Americans, according to the National Asthma Education and Prevention Program of the National Heart, Lung, and Blood Institute. It is one of the most common chronic diseases in children, with about 6 million children affected. The etiology of asthma is complex; genetics, the environment and sensitivity to allergies certainly play a role in the onset of asthma. Asthma symptoms are also influenced by many triggers including stress, pollution, pollen, mold, dust and exercise.

Non-adherence to asthma medications also plays a role, as asthma is primarily treated with long-term control medications that reduce airway inflammation — as well as oral corticosteroids for more severe cases — combined with quick-relief, or "rescue," beta-adrenergic inhaler medications that treat the flare-ups of asthma symptoms that occur when the airways narrow in response to triggers. Stress can significantly exacerbate asthma symptoms, says Thomas Ritz, PhD, a professor of psychology at Southern Methodist University (SMU), who studies how stress and emotion affect lung function. One of his goals is to better understand the biopsychosocial factors that may determine asthma outcomes and may make them particularly unfavorable in disadvantaged populations.

Environmental factors that can contribute to asthma attacks include allergen load, neighborhood violence, and, for children, their parents' stress level, according to a 2013 Journal of Consulting and Clinical Psychology review article by Ritz and colleagues. They believe there is a relationship between psychological stress and long-term worsening of asthma.

"What happens in asthma over the years is that the airways are being remodeled," also likely in response to stressors, Ritz explains. "The membranes thicken and then the muscle mass gets stronger, so the airways get narrower and constrict. What we think we have tapped into there is the relationship between psychological stress and long-term worsening." Ritz and colleagues are in the process of further studying this mechanism.

Breathing retraining

In work with SMU colleague Alicia Meuret, PhD, Ritz is also exploring a newer intervention for asthma: breathing retraining aided by a device that measures patients' exhaled carbon dioxide levels, an indicator of hyperventilation (overbreathing).

"Asthma patients generally overbreathe, or breathe more than is necessary," says Ritz. "If you have to put in extra effort to get enough air, that leads to more breathing than necessary for metabolic demands."

That, in turn, can lead to hyperventilation or drying out of the airways, and then airway constriction, he says. Ritz's and Meuret's research has shown that breathing training — which involves teaching the patient exercises that alter the speed and regularity of breathing patterns — leads to substantial improvements in asthma symptoms, airway hyper-reactivity, bronchodilator use and pulmonary function. Ritz said that recent findings from their NHLBI-funded clinical study show that, in addition to improving asthma control, breathing retraining also substantially reduces anxiety in asthma patients who are anxious. The technique was originally developed by Meuret for panic patients who hyperventilate, and Ritz said that she has two published clinical trials demonstrating efficacy of breathing retraining similar to that for CBT.

In addition to advocating formal treatments, Ritz and other researchers recommend movement and exercise for asthma sufferers. Although patients typically develop symptoms after exercising, most likely due to drying out of the airways, the normal response of the airways to exercise is actually to open up.

"When you tense your muscles, your airways open up," Ritz says. "So when you get active, your airways open up because you need more oxygen." Lack of physical fitness can make exercise-induced asthma symptoms worse, as can obesity and dietary factors, Ritz's 2013 review article reported.

Biofeedback and CBT

Another promising intervention for asthmatics is biofeedback, says Paul Lehrer, PhD, a psychiatry professor at the Robert Wood Johnson Medical School at Rutgers, the State University of New Jersey (formerly the University of Medicine and Dentistry of New Jersey). In biofeedback, sensors track various body functions, including heart rate or respiration, and then the patient receives feedback so he or she can learn how to alter these functions. Heart rate variability biofeedback works by teaching participants to improve asthma symptoms by aligning heart rate and breathing.

A 2004 study published by Lehrer and colleagues in the journal Chest found that asthma patients who were given heart-rate variability (HRV) biofeedback had an immediate improvement in pulmonary function, needed less asthma medication and had fewer asthma symptoms. In contrast to individuals in the control condition, the participants in the trial who were given biofeedback had no asthma exacerbations requiring increases in medication. Although the National Institutes of Health (NIH) has not yet recognized this method as a proven treatment for asthma, its guidelines for assessment and treatment of asthma list HRV biofeedback as worthy of further investigation. Lehrer and collaborators at National Jewish Health in Denver, a leading respiratory disease hospital, now have an NIH grant to determine the exact role for biofeedback in asthma therapeutics, including whether it works best as a supplement to steroid medication or possibly can replace the need for these drugs.

Lehrer's research also focuses on the high co-morbidity between asthma and psychopathology. For example, panic disorder is almost five times more prevalent among people with asthma than among the general population, according to a 2005 Journal of Asthma article. And for patients with both asthma and panic disorder, the symptoms can be confusing because they overlap.

"Difficulty breathing, for example, is a symptom of hyperventilation which occurs with panic, but it's also a symptom of asthma," Lehrer says. He's now exploring whether a CBT intervention can treat both asthma and panic disorder. His approach blends the panic disorder treatment protocol developed by Boston University psychologist David Barlow, PhD, with an asthma education module. The panic disorder component involves repeatedly exposing patients to feared situations and sensations, and then teaching them coping skills.

The education module teaches participants the difference between asthma and panic symptoms. Lehrer's pilot study, published in 2008 in the Journal of Anxiety Disorders, found that participants who underwent the CBT intervention had fewer asthma symptoms, took less medication to control their asthma and had fewer panic symptoms. Lehrer is now collaborating with Jonathan Feldman, PhD, of Yeshiva University, to conduct a controlled trial of this treatment with Hispanic patients in the Bronx. The co-morbidity of asthma and panic disorder has a particularly high prevalence among people of Caribbean Hispanic ethnicity.

Educating patients

Of course, patient education continues to be key to helping those with asthma. Thanks to advances in technology, there's a new, simple way to do so: texting children to remind them to take their medicine. In a study with pediatric patients led by Rosa Arriaga, PhD, a developmental psychologist at Georgia Tech, the method led to improvements in pulmonary function and a better understanding of their condition within four months.

Koinis-Mitchell and her colleagues, through the Community Asthma Program, take a more traditional education approach by holding classes for parents and children throughout public schools and at Rhode Island Hospital to teach them asthma management techniques including controlling triggers, monitoring symptoms and using medications properly.

She says the program is also sensitive to how poverty affects people's ability to deal with asthma. "If you don't have a relationship with your [health-care] provider and have difficulty understanding how to manage the disease, it's hard to control asthma effectively and feel supportive in the process," Koinis-Mitchell says. "For families from impoverished backgrounds trying to get food on the table, it's a lot to handle."

In her work, she focuses on the families' strengths and resilience to help them manage their children's asthma. She advocates a culturally sensitive approach, as spelled out in a 2012 Journal of Pediatric Psychology article on cumulative asthma risk. "It's important to develop programs for children and families with asthma that are consistent with their values, belief systems and their environment," she says. "We can't apply cookie-cutter approaches to every family."

Asthma and academics

During her work in administering asthma educational programs throughout urban schools, Koinis-Mitchell saw many children with asthma who came to class fatigued and had difficulty concentrating. "Teachers misconstrued this as learning problems," she says.

But when a child's asthma is controlled, his or her academic functioning improves and anxiety decreases, she says. "Asthma can be a serious barrier to children's health, to their physical activity, to their [engagement] in normal developmentally appropriate activities and to their learning."

Koinis-Mitchell is the principal investigator of a five-year, NIH-funded longitudinal study called Project NAPS (Nocturnal Asthma and Performance in School), which is examining the relationship between disruptions in sleep and academic outcomes in urban children with asthma. So far, she and her colleagues have found a correlation between compromised lung function and poor sleep quality, which then leads to problems in school, including more absences and lower quality schoolwork.

The challenges of teasing apart what is behind a child's fatigue and academic problems or an adult's tendency to hyperventilate has led some psychologists seek out training in physiology. Lehrer would like to see all clinical psychologists trained in applied psychophysiology, including biofeedback, detailed approaches to muscle relaxation and other ways of controlling the body.

"Psychologists treating patients should ask them if they have asthma and, if they do, pay a little bit of attention to the interaction between asthma and the emotional problems," he says.

Julie Cohen, PhD, is a clinical psychologist and writer in Boston.