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

ORIGINAL ARTICLES

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Bronchial Asthma and Personality Dimensions: A

Multifaceted Association
A. Belloch,' M. Perpifi&,2T. 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 t o play an important
role in chronic diseases by maintaining or increasing
the patient's physical complaints. This study examines 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 subjeclive symptoms were completed by 51 asthmatic patients. Responses t o questionnaires and clinical and
demographic data were factor-analyzed. Factor analysis revealed that the physician's severity judgment
11s based o n elderly age, high scores on depression,
,and longer duration of asthma.

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

161
Copyright 0 1994 by Marcel Dekker, Inc

Belloch et al.

162

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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, during which time both behavioral medicine and
health psychology have taken a broader perspective in examining the interrelationships
among psychological and social factors, biological 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 objective 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 recruited. Their baseline forced expiratory volume 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 situation 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 instructional level; recent negative life events;
past or present thyroid disorder; cardiac disorder or respiratory tract infection in the previous 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, ones privately 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 peoples eyes (for example, ones 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 involves a particular kind of reaction to focusing on the public self, that is, a sense of
apprehensiveness about being evaluated by
other people in ones 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

Bronchial Asthma and Personality

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 Spanish 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 Samples (7).

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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 occurrence 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 previous 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 enduring 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.

163

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 connection 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:

1. Duration of asthma, measured by the

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

Belloch et al.

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164

patient had one or more immediate positive skin reactions. Atopic patients were
given a score of 1 and nonatopic a score
of 0.
7. Physicians judgment of severity which
was determined by each patients physician on a 4-point scale ranging from 1
(low severity, defined as very infrequent 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 patients 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.
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 examination. Moreover, all subjects were individually tested in two sessions conducted on two
consecutive days. Patients were asked to participate 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 examination 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 patients 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 temperature and pressure saturated with water.
Three FEV, maneuvers were performed. In
our sample, all tracings satisfied the European 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 deviations (interval variables) or the number of
observations and percentages (dichotomic
variables) for all the variables considered.
The second step was to compute the intercorrelations for all these 16 variables using the
Spearman rank order correlation coefficient
and, next, to factor-analyze the correlation
matrix obtained. We performed a principalcomponents 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 consensus on what this should be. There is
agreement that there should be more sub-

Bronchial Asthma and Personality

165

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.

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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).

Table 1 .
~

-~~

VARIABLE

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. Finally, there was a group of negative relationships between FEV,, duration of asthma,

Characteristic3 of 51 Asthmatic Patients i n A l l Variables Considered

~~

____-

Sex
Males
Female3
Noc tu rna I sy m ptoni i
Presence
Absence
Atopic statu3
Atopic
Nonatopic
Age
Duration of asthma (years)
Dyspnea
FEV,
Hospitalirations
Severity judgnwnt
Private self-conx iousne5s
Public self-conscioumess
Social Anxietv
MMPI-Depresbion
Automatic Thoughts Questionnaire
Trait Anxiety Inventory
Asthma Symptom Checklist

NUMBER

Yo

22
29

43
57

28
23

55
45

24
27

47
53

RANGt

MEAN

SD

18-71
2-46
1-4
19-1 18
0-1 1
1-4
15-45
13-35
6-24
4-20
30-99
2-49
42-169

38

16 4

"Admissions to hospital and/or v i s i t 3 to the emergency room in the preceding year

7 8
1

88
2 3
2-1
27 4
23 2
14 5
10 2
48 4
23 2
101 2

86
11
23
22
11
61
47

52
40

8 3
11 3
12 3

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Bronchial Asthma and Personality

167

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 correlations, no procedure is known for computing
the standard error of a factor loading. Therefore, loadings are compared with some conventional 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 convention used in the current study.
Five factors were finally retained. The cumulative proportion of the variance explained by these five factors was 68.5%.
Table 3.

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-

f'actor Analysis of 16 Variables w i t h Varirnax Rotation (Loadings

~FACTOR STRUCTURE

VAR IA6 L E
Age
Sex
Duration o f 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

FACTOR 1

FACTOR 2

FACTOR 3

> 0.40)a

FACTOR 4

FACTOR 5

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

Belloch et al.

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168
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 mans direction, a positive
load on this variable indicates the presence of
the mans condition.
DISCUSSION

The results of the present study suggest

that a complex network of relationships exists 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
physicians judgment of high severity. Therefore, it seems that the physicians 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 patients 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). Despite 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 responsible, 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 reduces its significance, since the usefulness of
factor analysis lies in the search for significant patterns of relationships among different 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 discharge, 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,

Bronchial Asthma and Personality

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 lifestyle (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
1. 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.
2. Kaptein AA: Psychological correlates of length of
hospitalization and rehospitalization in patients
with acute severe asthma. Soc Sci Med 16:725-729
(1982).
3. Kaptein AA: lllncss tlehazuor of putients with asthma.
Krips Repro, Meppel, 1982.
4. Friedman HS, Booth-Kewley S: The "disease-prone
personality": A meta analytic review of the construct. A m Psycho/ 42:539-555 (1987).
5. 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).
6. Scheier MF, Carver CS: The Self-Consciousness
Scale: A revised version for use with general populations. \ Appl Soc Psychol 15:687-699 (1985).
7. Banos RM, Belloch A, Perpina C: Self-Consciousness scale: A study of Spanish housewives. Psychol
Rep 66:771-774 (1990:1.
8. Dempsey P: A unidirnensional scale for the MMPI.
Consult Psychol 38:364-370 (1964).
9. Garcia-Merita M, Balaguer I, Ibariez E: Validez de la
Escala de Depresion del MMPI. Rn1 Psicol Gen Apl
.39:313-340 (1984).
10. Hollon SD, Kendall PC: Cognitive self-statements
in depression: Development of an Automatic
Thoughts Questionnaire. Cogrirtizw Tlier Res 4:383395 (1980).
11. Harrell TH, Ryan Ntl: Cognitive-behavioral assessment of depression: Clinical validation of the Automatic Thoughts Questionnaire. ] Consult CIin
Psychol 51 :721-725 ( 1'983).
12. Dobson KS, Shaw BF: Cognitive assessment with
major depressive disorders. C o p i t Ther Res 10:1329 (1986).

169
13. Spielberger CD, Gorsuch RL, Lushene RE: Manual
for the State-Trait Anxiety Inventory. Consulting Psychologist Press, Palo Alto, CA, 1970.
14. Seisdedos N: Cuestionario d e Ansiedad EstadoRasgo. Adaptacion Espanola. TEA Ediciones, SA,
Madrid, 1988.
15. Brooks CM, fichards EJ, Bailey WC, Martin B,
Windsor RA, Soong S-J: Subjective symptomatology of asthma in an outpatient population. Psychosom Med 51:102-108 (1989).
16. American Psychiatric Association: Diagnostic and
Statistical Manual of Mental Disorders, 3rd ed rev.
American Psychiatric Association, Washington,
DC, 1987.
17. Cotes JE, Peslin R, Yernault JC: Dynamic lung volumes and forced ventilatory flow rates. Standardized lung function testing. Bull Eur Physiopathol
Respir IY(Suppl 5):22-27 (1983).
18. Harman HH: Modern Factor Analysis, 3rd ed. University of Chicago Press, Chicago, 1976.
19. McDonald RP: Factor Analysis and Related Techniques.
Lawrence Erlbaum, Hillsdale, NJ, 1985.
20. Cattell RB: The Scree test for the number of factors.
Multivar Behav Res 1:140-161 (1966).
21. Barret IT, Mine P: The observation to variable ratio
in factor analyses. Person Study Group Behav 1:2333 (1981).
22. Mine P: Factor analysis and personality theory. Eur
] Person 1:21-36 (1987).
23. Bailey WC, Higgins DM, Richards BM, Richards
JM: Asthma severity: A factor analytic investigation. A m / Med 93:263-269 (1992).
24. Boulet L-Ph, Deschesnes RN, Turcotte H, Gignac F:
Near-fatal asthma: Clinical and physiologic features, perception of bronchoconstriction and psychologic profile. ] AllerKy Clin Immunol 88:838846 (1991).
25. 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:lOY117 (1979).
26. 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).
27. Kinsman RA, O'Banion K, Resnikof P, Luparello T,
Spector S: Subjective symptoms of acute asthma
within a heterogeneous sample of asthmatics. / AllerKy Clin Itnrnunol 52:284-296 (1973).
28. Kinsman RA, Dahlem N, Spector S, Staudenmayer
H: Observations of subjective symptomatology,
coping behavior and medical decisions in asthma.
Psychosom Med 39102-119 (1977).
29. 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).
30. Dirks JF, Jones N, l n s m a n RA: Panic-fear: A personality dimension related to length of hospital-

170

J Asthma Downloaded from informahealthcare.com by HINARI on 11/09/14

For personal use only.

ization in respiratory illness. I Asthma Res 24:6171 (1977).

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

Belloch et al.
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).