The impact of lung disease on the patient varies greatly with the nature of the ailment, as does the subjective sensation of air hunger. Some patients with lung disease are hardly aware of the dyspnea. The decrease in exercise tolerance is so insidious that these patients may not be aware of any problem. Only when asked to try to quantify the dyspnea do these patients realize their deficiency. In other patients, dyspnea is so rapidly progressive that they experience severe depression. They recognize that little can be done to improve their lung conditions and thus markedly alter their lifestyle. Many become incapacitated and are forced to retire from work. They can no longer experience the slightest exertion without becoming dyspneic.
Often, chronic lung disease develops as a result of occupational hazards. Affected patients may become embittered and hostile. There has been much publicity about occupational exposure, but some industries still provide little protection for their employees.
Chronic obstructive pulmonary disease can be divided into two types: emphysema and chronic bronchitis. Both are characterized by a slowly progressive course, obstruction of airflow, and destruction of the lung parenchyma. Classically, patients with emphysema are the ''pink puffers.'' They are thin and weak from severe dyspnea associated with little cough or sputum production. The classic ''blue bloaters'' suffer primarily from bronchitis. They are cyanotic and have a productive cough but are less troubled by dyspnea; they are usually short and stocky. These classic descriptions are interesting, but most patients with chronic obstructive pulmonary disease have characteristics of both types.
Since ancient times, clinicians have recognized that emotional factors play a role in the onset and maintenance of symptoms in bronchial asthma. Attacks of asthma can be provoked by a range of emotions: fear, anger, anxiety, depression, guilt, frustration, and joy. It is the patient's attempt to suppress the emotion, rather than the emotion itself, that precipitates the asthmatic attack.
A patient having an asthmatic attack becomes anxious and fearful, which tends to perpetuate the attack. Hyperventilation may contribute to the breathlessness of the frightened patient. Despite being given adequate medical therapy, these patients remain dyspneic. In such patients, it is the anxiety and its causes that require attention. They need continuing medical and psychologic support after an acute attack. As early as the 12th century, Maimonides recognized that ''mere diet and medical treatment cannot fully cure this disorder.''
Asthma in children presents a special problem. Anxiety, underachievement, peer pressure, and noncompliance with medications can exacerbate episodes of asthma. These children are absent from school more often than their nonasthmatic peers, which causes schoolwork to suffer;this creates a vicious cycle. The incidence of emotional disorders is greater than twofold higher in asthmatic school-aged children than in the general population.
Asthma can affect a person's sexual function both physiologically and psychologically. Asthmatic patients may become more dyspneic as a result of the increased physical demands of sexual intercourse. Bronchospasm may occur, owing to excitement, anxiety, or panic. Anxiety about precipitating an asthmatic attack during sexual intercourse worsens the patient's dyspnea and sexual performance; another vicious cycle is set into motion. Patients may then tend to avoid sexual intercourse.
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