Emotional cues and concerns of patients with a life limiting, chronic illness during advance care planning conversations in general practice.

OBJECTIVE: To explore a) to what extent patients with serious illness express emotional cues and concerns during advance care planning (ACP) conversations with their general practitioner (GP), b) the content of cues/concerns and c) GPs' responses to cues/concerns. METHODS: Cues/concerns and GPs' responses in 20 conversations were coded using the Verona Codes (VR-CoDES and Verona Codes-P). A qualitative thematic analysis was used to identify overarching themes within the content of the cues/concerns. RESULTS: A total of 216 cues/concerns were identified (range: 1-28; mean: 13) in 85% of conversations; with 85% of these being cues/implicit expressions of emotions. In 72% of responses, the GP provided space for the patient to elaborate on cues/concerns. The most common theme cues/concerns were expressed about was "the consequences of illness on quality of life and burdening others". CONCLUSION: Emotions were mainly communicated implicitly as cues and the content varied greatly. The amount of cues/concerns expressed show that ACP can evoke many emotions. PRACTICE IMPLICATIONS: GPs should be attentive to implicit expressions of emotions as these provide opportunities to engage patients in tailored ACP conversations. As patients expressed many cues/concerns, GPs are recommended to have recurrent conversations with patients and actively ask about diverse ACP topics.

Implicit attitudes towards smoking predict long-term relapse in abstinent smokers.

RATIONALE: It has previously been argued that implicit attitudes toward substance-related cues drive addictive behavior. Nevertheless, it remains an open question whether behavioral markers of implicit attitude activation can be used to predict long-term relapse. OBJECTIVES: The main objective of this study was to examine the relationship between implicit attitudes toward smoking-related cues and long-term relapse in abstaining smokers. METHODS: Implicit attitudes toward smoking-related cues were assessed by means of the Implicit Association Test (IAT) and the evaluative priming task (EPT). Both measures were completed by a group of smokers who volunteered to quit smoking (patient group) and a group of nonsmokers (control group). Participants in the patient group completed these measures twice: once prior to smoking cessation and once after smoking cessation. Relapse was assessed by means of short telephone survey, 6 months after completion of the second test session. RESULTS: EPT scores obtained prior to smoking cessation were related to long-term relapse and correlated with self-reported nicotine dependence as well as daily cigarette consumption. In contrast, none of the behavioral outcome measures were found to correlate with the IAT scores. CONCLUSIONS: These findings corroborate the idea that implicit attitudes toward substance-related cues are critically involved in long-term relapse. A potential explanation for the divergent findings obtained with the IAT and EPT is provided.

Illness-specific catastrophic thinking and overperception in asthma.

OBJECTIVE: This study investigated the role of illness-specific catastrophic thinking in symptom perception in asthma. DESIGN AND MAIN OUTCOME MEASURES: A total sample of 72 patients with intermittent to moderate persistent asthma completed the Catastrophizing about Asthma Scale and completed the Asthma Symptom Checklist to measure retrospective symptom reporting. In addition, symptoms were concurrently assessed during different respiratory challenges eliciting mild and ambiguous versus salient and pronounced symptoms. RESULTS: Catastrophic thinking in general, when patients are not having an exacerbation, is related to an increase in emotional symptoms, especially in ambiguous situations where respiratory difficulties could occur. Catastrophic thinking during exacerbations is related to an increase in emotional symptoms as well as in respiratory symptoms during respiratory challenges. CONCLUSION: These strong relationships between catastrophic thinking and increased perception of asthma symptoms suggest a link between illness-specific catastrophic thinking and overperception. Consequently, catastrophic thoughts are an important target for psychological interventions in support of drug treatment.

Differentiation between the sensory and affective aspects of histamine-induced bronchoconstriction in asthma.

Respiratory symptom perception research has focused mainly on respiratory sensations. Because dyspnea is multidimensional, affective aspects should be investigated. Patients with asthma (N=25) underwent a histamine provocation until a 20% fall in forced expiratory volume in 1s (FEV(1)). After each dose level, 6 symptoms of dyspnea intensity and 6 symptoms of dyspnea affectivity were rated. Individual perceptual sensitivity was determined by calculating the linear slope between the fall in FEV(1) and the increase in the total symptom score, and for affective and sensory symptoms separately [Bijl-Hofland, Folgering, van den Hoogen, et al. Perception of bronchoconstriction in asthma patients measured during histamine challenge test. Eur Respir J 1999;14:1049-54]. Trait anxiety, baseline state anxiety, daily asthma symptoms and catastrophizing during an asthma exacerbation were also assessed. Sensitivity was unrelated to physiological indices of disease severity (i.e., baseline FEV(1) and histamine dose level at 20% fall in FEV(1)), whereas it was positively related to trait anxiety, state anxiety, daily asthma symptoms and catastrophic thinking during an asthma exacerbation in daily life. These relationships were overall much stronger for affective than for sensory symptom slopes. In stepwise multiple regressions, state anxiety was the best predictor of the affective symptom slopes, whereas catastrophic thinking during an asthma exacerbation was the best predictor for the sensory symptom slopes. The differentiation between sensory and affective components of dyspnea adds to the understanding of respiratory symptom perception in asthma.

Effects of long-acting bronchodilators and placebo on histamine-induced asthma symptoms and mild bronchusobstruction.

STUDY OBJECTIVE: Accurate perception of airway caliber remains an important issue in asthma management. The way bronchodilation is perceived is partly related to the perception of the efficacy of bronchodilators in relieving complaints. In the present study, we compared the effects of salmeterol, formoterol and placebo on relief of histamine-induced asthma symptoms and mild bronchusobstruction. METHODS: In this randomized controlled, double blind study, 30 asthmatics were challenged with histamine until forced expiratory volume in 1s (FEV(1)) fell with > or =20%. Subjects received salmeterol, formoterol or placebo after the histamine provocation. Pulmonary function (FEV(1)) and asthma symptoms (Asthma Symptom Checklist, Borg Dyspnea Scale) were assessed 5 and 20 min later. RESULTS: FEV(1) improved significantly more in the salmeterol and formoterol group than in the placebo group (P<0.001, P<0.001 and P<0.05, respectively). Salmeterol and formoterol were not different with regard to the pulmonary function recovery. No significant differences were found between the effects of salmeterol, formoterol and placebo on any of the symptom responses at the different time points. CONCLUSIONS: We conclude that after a histamine-induced mild bronchusobstruction, a similar asthma symptom recovery occurred when inhaling salmeterol, formoterol or placebo, despite better recovery of pulmonary function in the active drug conditions.

Understanding participation in an asthma self-management program.

STUDY OBJECTIVE: Asthma education programs improve asthma treatment results significantly. Low participation rate is a recurrent problem that impedes the efficiency of those programs. The purpose of this study was to investigate social cognitive determinants of the intention to participate in an asthma self-management program. DESIGN: Structured interview. SETTING: Outpatient clinic, University Hospital Gasthuisberg, Leuven, Belgium. PATIENTS: One hundred seven asthmatic outpatients (mean age 42 years; 35% male). INTERVENTIONS: Patients received a standard explanation about the asthma program, were invited to participate, and were questioned about their beliefs about the program offered. MEASUREMENTS AND RESULTS: A social cognitive framework (attitude, social influence, and self-efficacy model) was used to compose a structured interview that was administered to assess the patients' attitude toward the program (perceived benefits), their social influence, and self-efficacy expectations to participate (perceived barriers). Asthma-related health behavior and clinical and demographic characteristics were evaluated by means of questionnaires. Fifty-nine percent of the patients expressed the intention to participate. Logistic regression analysis resulted in a model explaining 72% of the variance of intentions (Nagelkerke R(2) = 0.72). Having few structural barriers to participate was a significant predictor of participation (odds ratio [OR], 12.5; 95% confidence interval, 5.2 to 19.3), next to believing in the personal benefits of the program (OR, 7.6; 95% confidence interval, 2.4 to 12.5), social influence (OR, 3.3; 95% confidence interval, 1.3 to 8.4), and education level (OR, 2.7; 95% confidence interval, 1.3 to 5.6). CONCLUSIONS: Recruitment of patients with asthma for an educational program should emphasize personal benefits of the program, should include patients' social network, and should consider the impact of structural barriers on participation behavior.

Can subjective asthma symptoms be learned?

OBJECTIVE: We investigated whether perception of subjective asthma symptoms can be brought under control of biomedically irrelevant cues in the environment, i.e., whether subjective asthma symptoms can be learned in response to harmless stimuli. METHODS: Twenty patients with asthma and 20 healthy participants were presented with two placebo-inhalers presented as new chemicals for diagnosing asthma. One inhaler was coupled three times with rebreathing 5% CO2 in oxygen, the other inhaler was coupled three times with rebreathing oxygen. In the subsequent test phase, both inhalers were coupled once with oxygen. We assessed airway resistance and subjective symptoms throughout the study. RESULTS: Both groups expected and reported more symptoms with the inhaler that was previously associated with the CO2 trials compared with trials with the inhaler that was used on trials without CO2 without concomitant effects on respiratory resistance. The learning effects were most pronounced in a subgroup of patients reporting symptoms of hyperventilation during asthma exacerbations in daily life. CONCLUSIONS: Subjective respiratory symptoms can be learned in response to harmless stimuli and a substantial proportion of patients with asthma might be especially vulnerable to this phenomenon. Because asthma patients rely mainly on perceived symptoms for their medication use, it is likely that they will take reliever medication based on expected symptoms instead of real exacerbations of respiratory dysfunction.

Dyspnea: the role of psychological processes.

Breathlessness or dyspnea-the subjective experience of breathing discomfort-is a symptom in many pulmonary, cardiovascular, and neuromuscular diseases. It occurs in normals as well during intense emotional states and heavy labor or exercise. In clinical cases, it generally causes severe suffering. Dyspnea has multifactorial causes and the explanation for the symptom may differ largely among patients. Explanatory models imply the involvement of mechanisms at several levels of functioning, such as afferent signals from the respiratory muscles or blood gas levels related to hypercapnia and hypoxia. Depending on the relative involvement of specific mechanisms and their interactions, dyspnea may be experienced differently and subtypes can be distinguished. More recently, perceptual-cognitive and emotional processes related to symptom perception and interpretation have been investigated in the context of dyspnea. In this review, we focus on the psychological processes that play part in the perception of dyspnea and formulate some practical guidelines for those who are confronted with dyspnea.