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Treatment of Psychological Factors ina Child With Difficult Asthma: A CaseReportRan D. Anbar a & Shagun Sachdeva aa Upstate Medical University, State University of New York ,Syracuse, New York, USAPublished online: 08 Jul 2011.

To cite this article: Ran D. Anbar & Shagun Sachdeva (2011) Treatment of Psychological Factors in aChild With Difficult Asthma: A Case Report, American Journal of Clinical Hypnosis, 54:1, 47-55, DOI:10.1080/00029157.2011.569593

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American Journal of Clinical Hypnosis, 54: 47–55, 2011Copyright © American Society of Clinical HypnosisISSN: 0002-9157 print / 2160-0562 onlineDOI: 10.1080/00029157.2011.569593

Treatment of Psychological Factors in a Child WithDifficult Asthma: A Case Report

Ran D. Anbar and Shagun SachdevaUpstate Medical University, State University of New York, Syracuse, New York, USA

Difficult asthma is defined as the persistence of asthma symptoms, abnormal pulmonary functionshowing airway obstruction, and continued requirement for short-acting bronchodilator therapy,despite adequate treatment with inhaled corticosteroids. It calls for a thorough evaluation of thepatient to look into alternate and complicating diagnoses. The authors report a case of a 9-year-oldpatient with difficult asthma who failed to respond to conventional therapy. Although it wasrecognized that he had a number of potential medical complicating factors including allergies,chronic sinusitis, and gastroesophageal reflux, a psychological intervention using hypnosis ultimatelyappeared to help alleviate his symptoms completely. Thus, psychological evaluation and interventionshould be considered early in the course of management of a patient with difficult asthma, because itmay help avoid time-consuming and expensive investigations of potential complicating factors, andit may yield rapid improvement in the patient’s clinical condition.

Keywords: allergies, anxiety, asthma, gastroesophageal reflux, hypnosis, vocal cord dysfunction

The clinical diagnosis of asthma primarily is suggested by the presence of cough, short-ness of breath and wheezing, complemented with the demonstration by spirometry ofreversible obstruction of the airways. A minority of patients with asthma fail to respondto appropriate therapy, even as therapy is escalated. In 1999, a European RespiratorySociety Task Force coined the term difficult asthma, which was defined as poorly con-trolled asthma demonstrated by chronic symptoms, episodic exacerbations, persistentlyabnormal pulmonary function showing airway obstruction and continued requirementfor short-acting bronchodilator therapy, despite adequate treatment with inhaled corti-costeroids (daily dose of at least 800 µg budesonide or equivalent) for 6 months orlonger (Chung et al., 1999). Consideration and evaluation of alternate and complicatingdiagnoses is essential for effective treatment of such patients.

The conventional approach to patients with difficult asthma often begins with (a)assessment of the frequency of their symptoms and use of short-acting bronchodilatorsand (b) documentation of their variations in peak expiratory flow rates and bron-chodilator responsiveness evident during spirometry (Chung et al., 1999). In addition,

Address correspondence to Ran D. Anbar, State University of New York, Upstate Medical University, 750 E. AdamsSt., Syracuse, NY 13210, USA. E-mail: anbarr@upstate.edu

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review of adherence to medications and techniques of inhaler use forms an inte-gral part of the evaluation. When the outcome of these assessments is indeterminate,physicians often consider and execute multiple tests for possible complicating fac-tors such as allergies, chronic sinusitis, gastroesophageal reflux, cystic fibrosis, andimmotile cilia syndrome. Such investigations may include radiological investigations(chest x-ray, and computed tomography of lungs or sinuses), blood investigations(blood counts, especially eosinophils, and serum immunoglobulin levels includingimmunoglobulin E), and miscellaneous tests such as 24-hour esophageal pH monitoring,skin scratch or radioallergosorbent testing for common allergens, sweat testing, geneticassessment of cystic fibrosis mutations, assessment of ciliary function, nasopharen-geoscopy, and bronchoscopy. Perhaps because of physicians’ lack of familiarity, dis-comfort with management of psychological issues, or because of the unavailability ofadequate data on the effectiveness of psychological management (Fleming, Wilson,& Bush, 2007), the evaluation for a psychological basis for difficult asthma usu-ally is considered only after many potential physical complications are investigated(Chung et al., 1999).

Psychosocial factors share a complex relationship with asthma. Asthma can impactpatients’ emotional status, while psychosocial factors can trigger asthma and also giverise to symptoms that mimic asthma, thereby being an oft neglected cause of diffi-cult asthma (Anbar, 2003; Butz & Alexander, 1993; Sandberg et al., 2000). This casereport presents a patient with difficult asthma who failed to respond to trials of rou-tine therapy, and for whom psychological management helped alleviate his symptomscompletely. This case illustrates that early evaluation of psychosocial factors can beextremely helpful for patients with difficult asthma.

Case Presentation

A 9-year-old patient was referred for evaluation of his asthma and allergies to our pedi-atric pulmonary center. During his first year of life, he was diagnosed with multipleepisodes of croup and associated wheezing, which improved with use of nebulized bron-chodilator therapy. Thereafter, he developed recurrent coughing, and wheezing occurringon inhalation and exhalation, in association with upper respiratory infections, exercise,change in weather, and exposure to allergens. Also, he reported occasional associatedchest pain. These symptoms improved with bronchodilators, and thus were attributedto asthma. In later childhood, even when the patient was well, he would develop night-time cough that would awaken him early in the morning and for which he requiredbronchodilator administration. Additionally, the patient was reported to have developedcoughing and difficulty breathing linked with strong emotions, such as anger or sadness,as well as when he laughed or cried. He required multiple courses of oral steroid ther-apy and several hospitalizations for management of severe asthma exacerbations. Use of

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chronic inhaled steroid therapy, as well as oral montelukast, was not associated with achange in his respiratory symptoms.

The patient had been documented to have multiple environmental allergies, andwas receiving weekly allergy immunotherapy at the time of his referral. He reportedoccasional episodes of regurgitation of food, and rare instances when he experiencedcoughing leading to vomiting after crying. The patient suffered from recurrent sinusitisand otitis media until he underwent bilateral tympanostomy tube placement when hewas 4-years-old, after which he no longer developed otitis. The patient said that he fre-quently heard a ringing in his ears and that from time to time he imagined that he heardscreaming when he tried to fall asleep. The patient was known to have hemorrhoids, andhis mother stated that she wondered whether he had been abused sexually in early child-hood because he was found to have a rectal fissure in early childhood. She explained thatshe divorced her husband of 3 years during the patient’s first year of life because he hademotionally and verbally abused her, and she wondered what he may have done withher son. At 2 years of age, the patient had a grand mal seizure for which he was treatedwith chronic anticonvulsant therapy, and had no further seizures. His mother wonderedwhether he had been a victim of shaken baby syndrome or birth asphyxia as possibleexplanations for his seizure.

At the time of his referral, the patient was in the fourth grade and was reported tohave been a very good student. He said that he made friends easily, but that he didnot have any close friends. The patient was living with his mother, stepfather and 11-year-old brother, who had been diagnosed as having bipolar disorder, attention deficithyperactivity disorder, anxiety disorder, and obsessive-compulsive disorder.

The physical examination of the patient was normal. His pulmonary function test-ing revealed mild airway obstruction with improvement following bronchodilatoradministration, which was consistent with a diagnosis of asthma.

The assessment at presentation was that the patient had asthma that was not in goodcontrol given his recurrent symptoms and abnormal pulmonary function testing results.Upper respiratory infections, allergies, exercise, and emotions appeared to be triggers ofhis asthma. Further, upper airway irritation and swelling from refluxed stomach acid wasthought to be a potential complicating factor given his history of croup and inspiratorywheezing (both of which occur as a result of a narrowed upper airway), and occasionalregurgitation of food. The possibility of stress-induced vocal cord dysfunction also wasconsidered, given the inspiratory nature of some of his symptoms. The nurse practitionerwho evaluated the patient initially felt that lack of adherence to his prescribed therapylikely accounted for his reported lack of response to inhaled steroids, which are thetherapy of choice for the treatment of chronic asthma.

Because the patient’s asthma appeared at times to be triggered by emotions, at theend of his first visit, the patient was offered the opportunity to receive instruction inself-hypnosis calming techniques that can help reduce emotional effect on asthma. Thepatient and his mother were very interested in this option, as this had never been offeredto him.

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Hypnosis Intervention

The patient was instructed in hypnosis by his pediatric pulmonologist, who had receivedtraining in clinical hypnosis at workshops sponsored by the Society of Developmentaland Behavioral Pediatrics and the American Society of Clinical Hypnosis. As a demon-stration of the power of hypnosis, it was suggested that he imagine his hands were giantmagnets and that they would become attracted on their own, which appeared to occur.He stated that he was unable to separate his hands as long as he imagined them to bemagnets. As a second demonstration, the patient was shown how imagining that he washolding a bucket of wet, heavy sand in one hand caused it to fall on its own, while imag-ining he was holding a handful of strings tied to helium balloons caused his other handto levitate.

The patient was asked to pick his own personal relaxation sign that he could use afterhypnosis as a shortcut method to become more comfortable. He picked the gesture oftouching his index fingers together. He chose to hypnotize himself by imagining thathe was going to an amusement park and noticing what he might perceive there witheach of his five senses. He was coached to relax progressively from head to toe. At thatpoint, when the pulmonologist commented that the patient appeared to be “more relaxed,peaceful, calm, content, and in control,” the patient nodded. It was suggested that thepatient could achieve a similar calm state without use of hypnosis: “Simply by touchingyour index fingers together.” The patient was prompted to rehearse putting his fingerstogether while in hypnosis. When he alerted, he reported that his feeling of relaxationhad improved from a 6 to a 9 on an 11-point scale of relaxation ranging from 0 (very,very tense) to 10 (as relaxed as possible). When he was prompted to make his relaxationgesture, the patient’s facial muscles relaxed and his shoulders dropped slightly, and hereported that his relaxation had improved to a 10.

Fifteen minutes were required for the described instruction time beginning with thepower of hypnosis demonstration. The patient was congratulated for his successful use ofhypnosis. He was encouraged to practice his self-hypnosis on a nightly basis for at least2 weeks, so that he would become very adept with its use. It was explained that hypnosisis a mind–body skill, and that the more it is used the better the patient would become atrelaxing himself. The patient was instructed to use his relaxation gesture if he developedany further respiratory difficulties. In addition, he was prescribed an inhaled steroid.

Follow-Up

Two weeks later, the patient reported he had begun using hypnosis immediately after hisfirst visit, and that his night time cough and exercise associated symptoms had resolvedimmediately. He started his inhaled steroid therapy 2 days after the first visit. Sincethen, his mother was surprised that he did not develop any asthma symptoms in asso-ciation with a change in weather or in association with laugher or crying. The patient

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reported using hypnosis in order to calm himself when his brother’s behavior botheredhim. As a result, the patient said he had become happier. He added that he no longerheard screaming voices while he had been in bed. He denied further tinnitus. The patientwas interested in learning further hypnosis techniques at this visit, and he was taughthow to meet an inner advisor, who he reported to be a Native American spirit guide inthe woods. The guide explained that the voices the patient had heard were his parentswho were screaming in anger. The patient said his parents did not do this in real life.

The patient reported 6 weeks later that he continued to be free of respiratory symp-toms. His pulmonary function testing had improved in comparison with the testingperformed at his first visit, but he continued to demonstrate bronchodilator responsive-ness, which reflected incompletely controlled asthma. Therefore, the patient’s inhaledsteroid was switched to a more intensive asthma medication combination of an inhaledsteroid and a long-acting bronchodilator.

Two months later, the patient reported having developed coughing for 3 days inassociation with an upper respiratory infection, but no other respiratory symptoms. Hispulmonary function was normal.

During the next 2 years, the patient met with his pulmonologist on five additionaloccasions in order to learn further hypnosis techniques, such as hypnoanalgesia usingglove anesthesia (Kohen & Olness, 2011), which the patient utilized to help himselfduring dental work and to gain further insight regarding his thoughts and feelings. Thepulmonologist suggested on three occasions that the patient might benefit from workingwith a psychiatrist, psychologist, or counselor, but the patient did not express interest inthese options, and his family did not follow through.

The patient’s asthma and pulmonary function remained under good control for thesubsequent 5 years. At that point, because the patient had developed no respiratorysymptoms for more than a year, he was weaned off of his chronic asthma therapy anddid well.

Discussion

It is clear that this patient’s presentation was consistent with a diagnosis of asthma givenhis respiratory symptoms that were typical of asthma and their improvement followingbronchodilator administration. The diagnosis was confirmed by the obstructive patternand bronchodilator responsiveness demonstrated during his pulmonary function test-ing. His lack of response to preventive asthma therapy including chronic inhaled steroidtherapy qualified him for characterization as having difficult asthma (Chung et al., 1999;Fleming et al., 2007).

He had many potential physical complicating factors including a history of aller-gies, chronic sinusitis and gastroesophageal reflux (Dixon et al., 2006, Wasowaka,Toporowska, & Kroqulska, 2002). The inspiratory nature of some of his symptoms wassuggestive of vocal cord dysfunction (VCD), which frequently coexists with asthma

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(Perkner et al., 1998). VCD also can be triggered by psychological stressors and gas-troesophageal reflux (Anbar & Hehir, 2000; Mikita & Parker, 2006; Morris & Allan,2006; Wood & Milgrom, 1996). Further, lack of adherence to his prescribed therapiescould have been the reason for the difficulty in management of his asthma. There areseveral incidents in this patient’s history that suggested a psychological component inhis presentation: his symptoms being triggered by strong emotions, hearing voices atbedtime, questions of abuse in early childhood, parents’ divorce and history of psycho-logical disturbance in his brother. Thus, the patient’s symptoms could have mainly beenattributable to anxiety or post-traumatic stress disorder (Goodwin, Fischer, & Goldberg,2007).

Other symptoms of patients with asthma that should alert physicians to the possi-bility of a significant psychological contribution to their presentations include patients’reports that during episodes of shortness of breath the obstruction to breathing seemsto be localized to the neck or upper chest, anxious appearance, dizziness, parasthesias(e.g., tingling or numbness in the extremities), shakiness, and shortness of breath despitenormal lung function (Anbar & Geisler, 2005). When a psychological basis for patients’presentations is suspected, physicians who have studied breathing techniques, cognitivebehavioral techniques, hypnosis, or relaxation methods can offer these options to thepatients in the medical office. Alternatively, they can refer the patients to mental healthproviders who have had experiences working with patients who have medical conditions,including psychiatrists, psychologists, and social workers.

In this case, rapid rapport may have been established with the patient in part becausethe pulmonologist provided him the opportunity to use a different kind of therapeuticapproach that did not involve yet another trial of a medication, and thus he and hismother were eager to use it. Furthermore, the pulmonologist’s expressed confidence thatthe patient could help himself may have strengthened the rapport. In turn, such rapportprobably facilitated the successful brief hypnotic interaction during the first visit.

The patient’s symptoms resolved completely after the use of hypnosis and before initi-ation of inhaled steroid therapy. It is notable that he became asymptomatic even when hispulmonary function initially remained abnormal, which demonstrated that his symptomslikely had persisted as a result of psychological factors rather than as a result of physi-ological factors. The escalation of his asthma therapy and subsequent normalization ofhis pulmonary function demonstrated that he was adherent to his prescribed therapy,and thus lack of adherence probably had not been a complicating factor in his man-agement. In retrospect, addressing of this patient’s psychological state appears to havebeen key to the success of his therapy, given that he reported no changes in his socialcircumstances at that time, which might have been associated with his improvement.Thus, early introduction of hypnosis as a psychological approach in the management ofpatients with difficult asthma may preclude expensive, time-consuming, or unnecessaryinvestigations and therapy.

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The follow-up hypnosis work with the patient during the subsequent 2 years wereundertaken because of the patient’s receptivity and the pulmonologist’s interest and abil-ity to provide further counseling including hypnosis. Such long-term interactions in themedical setting are unnecessary for many patients with asthma, whose symptoms canimprove rapidly after only one or two sessions of hypnosis instruction (Anbar, 2001,2003; Anbar & Hummell, 2005). The patient’s rejection of a referral for official counsel-ing was not unexpected. Patients are more likely to be receptive to psychological therapyoffered at their medical office by their physician or by another member of the medi-cal office staff, as opposed to accepting a referral to an outside mental health providerthat entails a delay in the therapy, and establishment of rapport with another individual(O’Donohue, Cummings, Cucciare, Runyan, & Cummings, 2006). Furthermore, somepatients are hesitant about working with a mental health provider because they feel thatthis is an admission that something is wrong with them psychologically (Anbar, 2001,2003). It is helpful to explain to such patients (a) that everyone is able to improve theirmedical symptoms through use of mind/body techniques and (b) that the proposed psy-chological therapy is intended to help the patients use their minds better in order toimprove their health condition.

Hypnosis may have been effective in this case because it induced physiologic changesthat promoted improvement of the asthmatic response (Brown, 2007; Phillip, Wilde, &Day, 1972). Further, asthma is known to be associated with anxiety (Richardson et al.,2006), and the patient may have benefited from the known effectiveness of hypnosis inthe treatment of anxiety (Anbar, 2001). Also, hypnosis has been shown to be effectivein the treatment of VCD (Anbar, 2001, 2003; Anbar & Hehir, 2000), from which thispatient may have suffered. Because this case report represents an anecdote, it is possiblethat the patient’s improvement was related to benefits from interaction with the clini-cian other than the hypnotic intervention (e.g., the additional attention he received orthe feeling of empowerment he developed once the clinician suggested that he can helphimself). In any event, it appears that his rapid improvement was the result of an interac-tion with his pulmonologist that led to a psychological change, including learning howto deal more effectively with psychosocial stressors in his life.

Asthma has been associated with the development of many psychological issuesthat can complicate its management (Bloomberg & Chen, 2005; Chen et al., 2006;Sandberg & Javernpaa, 2004; Sandberg et al., 2000). For example, Ortega, Huertas,Canino, Ramirez, and Rubio-Stipec (2002) reported that children with asthma oftenwere found to have clinical anxiety, which may develop because of patients’ experi-ences with recurrent asthma exacerbations or because asthma can be triggered by anxiety(Anbar, 2003). Further, lower socioeconomic status, high illness severity, and a negativechange in the surroundings have been shown to be predictive of anxiety, depression,and global psychological distress in children with asthma. In turn, depressive or anx-iety disorders have been reported to be associated with increased asthma symptoms(Richardson et al., 2006). Asthma has been found to constitute a significant independent

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psychological stressor among adolescents who already are at high risk for multipleadjustment problems (Gillaspy, Hoff, Mullins, Van Pelt, & Chaney, 2002). A potentialrelationship between the psychology and the pathophysiology in asthma was illustratedin a recent report showing that psychological stress in children with asthma is associatedwith higher production of the inflammatory mediators interleukin 5 and interleukin 13,and increased sputum eosinophil counts (Chen et al., 2006). To date, studies regardingthe effectiveness of psychological therapy for children with asthma have been inconclu-sive because of methodology issues (Huntley, White, & Ernst, 2002; Yorke, Fleming, &Shuldham, 2005; Yorke & Shuldham, 2005).

Conclusion

The high frequency of psychological issues in patients with asthma should lead physi-cians to always consider these as complicating factors in this population. In a patientwith difficult asthma the use of a psychological intervention such as hypnosis may yieldrapid and sustained improvement. Thus, employment of psychological evaluation andintervention should be considered early in the course of management of a patient withdifficult asthma.

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