Acute Bronchial Asthma
I. Concomitant Depression and Excitement, and Varied Antecedent
Patterns in 406 Attacks
PETER H. KNAPP, M.D., and S. JOSEPH NEMETZ, M.D.
AN ACUTE ATTACK of asthma is an
impressive event—terrifying as it starts, dis-
maying as it persists. From antiquity cer-
tain persons, more articulate during the
past 40 years, have suggested that in addi-
tion to the terrors and discouragements
engendered by the physiologic process, oth-
er emotional factors may enter into what
Salter called, in 1882, the "nervous dis-
order" of asthma.24
Our understanding of such factors might
start with a dictum attributed to Hughlings
Jackson: "Study of the causes of things
must be preceded by study of things
caused."3 From the pathophysiologic point
of view, it is generally conceded that "the
primary pulmonary feature in asthmatic
breathing is, of course, obstruction within
the smallest air passages."27 If we inquire
more deeply as to how such a lesion occurs,
even physiology cannot provide a clear an-
swer. Bronchospasm, pulmonary edema,
and hypersecretion are all present and lead
to obstruction, but it is not certain which
is primary. They all may follow exposure
to histamine. The introduction of an al-
From the Department of Psychiatry, Boston Uni-
versity School of Medicine, Boston, Mass.
This work was supported by grants from the
U. S. Public Health Service, and the Supreme
Council of the Northern Jurisdiction of the Scottish
Rite.
Received for publication July 15, 1959.
lergen can lead to local release of hista-
mine-like substances. Stimulation of the
parasympathetic nervous system releases
similar substances and may play a signifi-
cant role in initiating and maintaining
asthma in certain circumstances; but this is
not proved.
In the emotional sphere the precise se-
quence before and during asthma is equally
in need of elucidation. To this end we
have reviewed, clinically and retrospective-
ly, 406 acute asthmatic attacks, described in
the records of a study which included more
than 50 cases of bronchial asthma.
Material and Methods
From our larger series, 9 patients were
selected who had severe perennial asthma
and who had been studied by at least 75
interviews, in psychotherapy, or, in 2 cases,
psychoanalysis. During the period of study
all of these subjects were observed sys-
tematically by an internist. The majority
of attacks were documented by vital ca-
pacity tracings or a quantitative score sheet
method described elsewhere.21 In the case
of transient attacks, or those in which re-
cording had been faulty, the criteria for
asthma were the presence or clear report
of wheezing, congestion, expulsive effort,
and the use of antiasthmatic medication.
Three degrees of severity were denned:
PSYCHOSOMATIC MEDICINE
KNAPP 6C N E M E T Z 43
(a) sudden attacks subsiding spontaneously apparent indifference. As one of them
or responding within minutes to oral or (Case W, to be described below) put it,
nebulized medication, (b) attacks requir- "When asthma comes, I can't think of any-
ing repeated or prolonged oral antiasth- thing else. It occupies all my time and
matic medication other than steroids, and energy." Although to a certain extent
(c) attacks requiring steroids, intravenous understandable, such absorption was not
medication, or hospitalization. These de- confined to severe attacks; at times it was
grees of severity, denned chiefly in terms just a$ dramatic in mild ones and seemed
of the medical management they required, to divert the patient from grossly and ob-
shaded into one another. Also severe at- viously important outer threats.
tacks were usually prolonged and tended There were other characteristics of their
to become chronic. absorption. Patient C, described below,
It was not always possible to get clear spoke of how the walls of his room seemed,
information about circumstances surround- during his attacks at night, to go in and
ing the attack. Often therapeutic consid- out like a bellows. Other patients had
erations on the part of the physician or de- distortions of time. One 17
of them (Patient
fensive needs of the patient conspired to B, described elsewhere ) reported endless
prevent extensive investigation of psycho- moments in which almost his entire con-
logical aspects. sciousness seemed directed toward his
Recognizing these limitations, we sought breathing. If he noted outside occurrences,
in the records of this special group of severe they seemed to proceed at a snail's pace: a
asthmatics information about, first, con- drop of water would form at the faucet and
comitant feelings and fantasies accompany- fall off as though in a slow-motion film se-
ing attacks and, second, antecedent events quence. Some of the absorption in asthma,
occurring in the 48-hour period prior to on- it would appear, represented the type of
set. regressive psychic functioning seen in other,
more purely psychological states, having
Results a high defensive value.
Concomitant Feelings and Fantasies These considerations bear on the fact
that, as shown in Table 1, in almost half
Absorption in the Asthmatic Process the attacks there was no report of feelings
During asthma, the patients tended to except those directly concerned with asthma.
be strikingly absorbed in the bodily proc- In part this is an artifact. In Fig. 1, the
ess. Frequently there was only awareness same data are broken down to show that
of local sensations, which were borne with in carefully studied attacks, as well as in

TABLE 1. CONCOMITANT FEELINGS AND FANTASIFS IN ALL ATTACKS OF ASTHMA

Patient
Concomitants of established asthma
Depression B G' K M S* C W W D Total %
"Riddance-poison" fantasy 45 32 5 10 13 13 25 35 5 183 45
Other 12 2 1 1 2 2 3 23 6
None evident 5 9 3 1 1 2 4 25 6
TOTAL 58 32 13 2 7 17 15 29 2 175 43
Prodromal phenomena 406 100
"Angry-anxious arousal" 57 23 3 4 10 10 15 8 6 136 84
"Elated-erotic arousal" 13 4 1 9 14 41 10
Depression 3 12 1 2 1 2 1 22 5
Other 1 4 1 3 2 1 12 S
None evident 46 32 17 5 9 21 15 43 7 195 48
TOTAL 406 100
'Female subjects.

VOL. XXII, NO. 1, 1960

44 ACUTE BRONCHIAL ASTHMA: I. ANTECEDENTS
100

80

+> 6 0

§ •V.™

IS
20

li
Depression*
•in
Riddance
Fantasies*
•£3n
Other
1
None
Evident*
^ | All attacks (406)
(5%H Carefully studied attacks (227)
"Severe-Moderate" attacks (236)
Fig. 1. Feelings and fantasies associated with established asthma.
•Both "carefully studied" group and "severe-moderate" group differ signifi
can,tly from main population (p. < .01).

severe episodes, there is a significantly asthma, which had developed originally at

greater proportion of associated feelings
and fantasies.
Feelings and Fantasies with Established
Asthma
Table 1 also shows that of the phenom-
ena that persist through the larger part of
an attack, though not necessarily present
at the start of it, by far the most prominent
are depressive manifestations. These are
clearly present in almost half of all attacks,
and in almost two thirds of the carefully
observed attacks or relatively severe epi-
sodes. Elsewhere we have commented on
the over-all frequency of depressive symp-
tomatology in asthmatics and its accentua-
tion at times of acute illness.19 Helpless-
ness and hopelessness were frequently far
out of proportion to the discouraging reali-
ty of the physiologic distress. Patient H
(Case 1, described elsewhere19), ordinarily
gay and elated, stated that when she had
asthma she had "no desire to go on." Even
"a whiff" made her feel "deflated." She
would turn away from her habitual ex-
treme activity, and at the height of her
her mothers funeral, she would cry, "Mum-
ma, take me with you." Often the urge to
weep was present, and in about 5 per cent
of cases some tears were shed, although
actual crying seemed far less than the ac-
tual discouragement. Mixed with sadness
were frequent descriptions of a sense of
being doomed, of having a deep and perma-
nent defect, often accompanied by feelings
of guilt and shame.
Frequently fantasies were present of
poisonous substances within the body, oth-
er than the products of asthma itself, ac-
companied by powerful efforts to eliminate
them by any available bodily route. These
we have called "poison-riddance" fantasies.
They occurred in about 6 per cent of the
attacks, and were often manifested in the
symptoms of vomiting and diarrhea.
Other concomitant feelings consisted of
various guilty or hypochondriacal con-
cerns. All of these feelings tended to im-
prove dramatically when appropriate medi-
cal procedures were successful in relieving
the asthma. At times the improvement
seemed to go beyond the easing of physical
l'SYCHOSOMATIC MEDICINE
KNAPP Si NEMETZ
suffering, suggesting a sense of something
completed or "settled." One patient (Pa-
tient M) spoke of his asthma's gradually
building up until it came to a "climax,"
leaving him feeling exhausted but "satis-
fied."
Prodromal Feelings and Fantasies
It should be noted that even the most
acute asthmatic paroxysm does not occur
instantly, seldom in a matter of seconds, in
fact. It builds up somewhat slowly, in
minutes, often many of them. Thus one
cannot always specify the exact time of on-
set. However, we noted certain emotional
phenomena that ran an even slower course,
preceding asthma by hours or even the
greater part of a day, and persisting into
the first phase of an actual attack. These
we have called prodromal manifestations.
At times they also were depressive, con-
tinuing directly into the later states of de-
pression. More often they were feelings of
excitement and arousal. Two types of the
latter could be discerned. The first we have
termed "angry-anxious" arousal. It repre-
sented a mixture of fearful and irritable
tension. In some instances one or the other
dominated, especially in a few states ap-
proaching panic, although even such fear
was seldom free from an impatient, irrita-
ble quality. Motor restlessness, sweating,
and at times the report of diuresis in the
hours preceding asthma were additional
features. Such manifestations of tension
may have been more frequent than our
notes indicate. Patient C, described below,
was particularly laconic, if not evasive, in
telling of his attacks. After three years in
treatment, he mentioned something that
does not show in the analysis of his record
up to that time, namely, that for some
hours in advance of attacks always felt
sweaty, hot, cold, and restless unable to
bear the touch of clothing or covers.
One might wonder if these features did
not simply represent anxious emotions
stemming from the distress of asthma,
either actual or anticipated by dim, pre-
conscious signals. Making due allowance
VOL. XXII, NO. 1, 1960
45
for the frightening character of the asth-
matic process, this alone does not seem suffi-
cient as explanation. Patients often spoke
of knowing that they should control them-
selves, yet of being unable to do so. As one
of them (Patient B17) reported, during
asthma "Emotions control me." At times,
after psychotherapy, certain subjects had
their symptoms but reported a marked in-
crease in ability to avoid the excited re-
sponse and apparently to "master" some
aspects of the process. Severe respiratory
symptoms by themselves do not necessarily
lead to such excited distress. One patient
was used for demonstration purposes by his
internist, to whom he was strongly attached.
He would have his vital capacity lowered
by inhalation to the point of cyanosis—
with the greatest equanimity, knowing that
his doctor would "bring him back to life."
In this connection it is pertinent to men-
tion the second, rarer type of prodomal
emotion. This we have designated as
"elated-erotic" arousal. It consisted of epi-
sodes of excitement and feelings of great
well-being with an erotic coloring, often
resembling a miniature hypomania, cul-
minating in asthma. Five of these 9 pa-
tients described such episodes.
Patient G (Case 218) whose mood was
usually gloomy, reported that twice when
she went out to public artistic performances
she felt an enormous sense of excitement,
with a definite sexual coloring, which led
directly into asthma. On two other occa-
sions, when anticipating the return of her
husband and sexual intercourse, she had
similar episodes.
Patient H (Case I19) reported occasional
violent excitement at the start of attacks,
in which she would strip to the waist and
writhe about the room uncontrollably.
Patient K described as a frequent oc-
currence—though unequivocally in only
one attack during this study—the "thrill,"
the feeling of excitement, exaltation, al-
most ecstasy, that he had got from watching
storms off the coast. The sense of arousal
would be pleasurable, frightening, almost
46 ACUTE BRONCHIAL ASTHMA: I. ANTECEDENTS
100

Angry
Anxious*

• I All attack. (406)

L I "Severe-Moderate" attacks (236)

fc:&/jf Carefully studied attacks (227)
Fig. 2. Feelings and fantasies in prodromal phase of asthma.
• Difference between "carefully studied" group and main population significant (p. .01).

uncontrollable, and would progress to an Case W: Asthma and Chronic Depression

attack of asthma.
Patient B. The widespread excitements
of this patient, studied intensively in psy-
choanalysis, form a large part of a sepa-
rate communication.20
Patient W will be described in the next
section.
In our less systematic experience with a
wide group of approximately 50 patients
we have encountered 6 other patients who
described similar states of elated erotic
arousal preceding and leading into the first
phase of an attack of asthma.
Figure 2 and Table 1 show the frequency
of these prodromal feelings and fantasies,
which were reported only in a minority of
instances. In those attacks that had been
the most carefully studied their incidence
was significantly higher. They were, how-
ever, evenly distributed between more
severe and less severe attacks.
One patient will illustrate the early and
late concomitant phenomena, as well as
some of the antecedent circumstances that
preceded them.
Punctuated by Rare Excitement
A 26-year-old, Negro woman, separated, the-
mother of a 6-year-old child, was referred for
study because of chronic, perennial bronchial
asthma, dating to her first year of life, which
had grown worse in the last 10 years. She had
an apparent fixed limitation of vital capacity,
which seldom exceeded 2500 cc. X-rays of the
chest showed emphysema and mild fibrosis with-
out evidence of active disease. Skin tests showed
reactions to numerous air-borne allergens,
though there was not a clear seasonal history.
She was the second of three daughters, born
to a Northern Negro mother and a Portuguese
Negro father. Her childhood had been lived
in the shadow not only of her asthma but of
separation and loss At the age of 6 she was
sent to a tuberculosis preventorium because of
exposure to tubercular neighbors. Although she
never showed evidence of active infection, she
stayed there for a year and a half. In her early
adolescence the death of her younger sister was
followed by the death of a favorite cousin, then
by a sudden loss of a schoolteacher to whom she
was very attached, and finally, when she was
19, the death of her mother. She had been
closely attached to her mother, who had warned
her against too much activity, had sat up with
PSYCHOSOMATIC MEDICINE.
KNAPP SC NEMETZ
her at night and often brought her to the hos-
pital during attacks of asthma.
Her mood was one of chronic sadness, domi-
nated by longings for the mother, who at an
obscure emotional level in the patient's fantasy
had never really died. She was extraordinarily
sensitive to loss, which was the most common
antecedent of her attacks (see Table 2). One
attack started the day after she learned that her
social worker, the female internist, and the
nurse on the asthma project were all about to
depart. As she said, "Everyone is leaving."
Another major attack necessitated hospitaliza-
tion; initially she described no precipitant for
it. Only after three days did she reveal that
just before the onset of this episode of asthma
she had been visiting her aunt in a hospital
and had seen a picture of her mother. The date
of this hospitalization for the patient was the
exact anniversary of her mother's death.
During attacks she tended regularly to have
an enhancement of her sadness and hopeless-
ness. This was true even of attacks that seemed
to follow other precipitants, such as odors, or
things that made her angry. She reported that
when she was little and felt enraged at the
world she could go away by herself and "think
myself into an attack." In adult life she would
often find herself getting angry: "I just hold it
inside and go off and suck on my nebulizer."
As indicated earlier in this paper, she felt that
her illness absorbed all her energy. It made
her want to withdraw from everyone, into her
"own private world of asthma." She often felt
as though someone had sucked the air out of
the room with a vacuum cleaner. She tried to
get it back. "I suck things in through my nose,
my lungs, my pores, and my skin." During the
course of treatment her boy developed some
symptoms of respiratory congestion. She be-
came convinced that he had asthma. When she
looked at him in his distress, she almost seemed
to lose any sense of separateness. She described
one such episode by saying, "There I was"—
meaning that she saw herself in him, doomed
to a lifetime of invalidism.
At other times, in spite of both emotional
and physical closeness to her boy, she found this
closeness frightening. Both with him and later
with a suitor, she described sitting on the
couch with one or the other and having a
sense of oppression, almost physical intermin-
gling, which was followed by asthma. In therapy,
both separations from the therapist and re-
VOL. XXII, NO. 1, 1960
47
unions with him were distressing and seemed
to serve as precipitants for her attacks.
In the therapeutic situation, too, there was
an eroticized current. Despite her chronic de-
pression and inhibition she had an opposite
side. She had been attached to her father, had
felt that she was his favorite. She used to go
off on trips with him, and was the only one be-
sides him in the family to learn Portuguese,
his language. She at times was able to stay up
all night jitterbugging. Ordinarily she felt able
only to confide in her mother, yet she had sex-
ual curiosities which she could not discuss even
with her. During adolescence her asthma grew
gradually worse. Often the family doctor was
called. He gave her various drugs, including
morphine. She would be gasping and would
feel enormously tense when he came. After the
injection, she would get a "talking jag," and
often "babble" for hours about her problems,
as her asthma gradually subsided.
After her mother's death she felt extremely
uncomfortable living with her father. Almost
at once she married, only to separate soon after
becoming pregnant. She returned to a life of
semibondage with her father. During the course
of treatment she began to have violent quarrels
with him. She would feel like "screeching" but
consciously restrain the impulses. A series of
severe attacks were ushered in by this conflict.
During the early phases of these there were
several episodes of marked excitement. Her or-
dinarily meek, submissive behavior was dra-
matically changed. She groaned, cursed, at one
time shouted at the therapist to put out a
cigarette, with an intensity that even surprised
herself: "Imagine me yelling like that at a doc-
tor." On another occasion, on the second day
of an asthma attack, she "babbled," the way
she used to after the injections of her family
doctor. Also in this period she recalled that as
a child she used to spit in anger until one day
that practice seemed revolting to her and she
gave it up forever.
Late in the course of treatment there was a
particularly clear instance of elation preceding
an attack. She went to a dance with a new boy
friend. Although she did not drink she was
"high," dancing, singing, laughing, joking.
There was an aggressive coloring to her mood.
She teased her friend for his inability to dance.
The next day she was still elated. She felt
energetic and active, and went to a chicken
market. Chickens had always caused her a par-
ticular anxiety, traceable to memories of seeing
 ACUTE BRONCHIAL ASTHMA: I. ANTECEDENTS
their heads cut off as a child. For years she
had not been able to eat chicken. Gradually
this aversion had been overcome, but it may
have contributed to the fact that, on this day,
her aggressive elation was abruptly terminated
in the chicken market by a severe, prolonged
attack of asthma.
Asthma was a chronic part of this pa-
tient's personality. She was seldom com-
pletely free from it, and whenever she was
free, she expected catastrophe, waiting for
its return. The actual sharp exacerbations
which she had, however, coincided with
upsurges of strong emotion. This was
either painful, stemming from frustration,
especially loss of a person, or it was pleas-
urable, stimulated by excitement and, par-
ticularly, closeness. Both states were dan-
gerous. They seemed to find ultimate ex-
pression in the state of inner-directed long-
ing and sadness which was predominant
when she was in her "world of asthma."
Antecedent Events
As is apparent from this account of one
patient, there was considerable variation
in antecedents, which we have arbitrarily
defined as changes in the social environ-
ment during the 48 hours prior to an at-
tack.
Obviously these overlap with changes in
the physical milieu, chiefly in respect to
infection or exposure to allergens. The
present retrospective survey cannot sharply
evaluate the role of such factors. In a
small proportion of instances (see Table
2), they were the only "changes" that could
be discerned. At other times, they played
a possible role. It should be noted, how-
ever, that none of our chronic asthmatic
subjects gave clear evidence that seasonal
or other allergic factors were the predomi-
nant ones in their illness. Infection coin-
cided with about 20 per cent of all attacks.
In these cases it is particularly hard to tell
sequence of cart and horse. Our decision
was arbitrarily to designate the onset of a
"cold" leading directly into acute asthma as
the start of the asthmatic episode itself, and
to ascertain what psychological and social
events had immediately preceded it.
In our total series, we could make eight
separate categories of such events, which we
shall define, discuss briefly, and illustrate
by further case material.
Loss of a Person, Actual or Immediately
Threatened
This was the most frequent and appar-
ently disturbing antecedent occurrence.
The female subject of the above vignette
and the male patient described in another
paper20 each on two occasions greeted the
announcement of separation from the
therapist by a sharp, inspiratory gasp, fol-
lowed by a feeling of congestion in the
chest and a mild increase in asthma. More
sustained increases, as already indicated,
were often clearly related to separation or
loss.
Loss of a Substance
This category refers to episodes in which
actual or imminent withdrawal of a sub-
stance, particularly medication, preceded
an attack. We do not mean the late effects-
of such withdrawal, especially of steroids,
that lead to physiologic consequences,
though these, too, can be difficult to evalu-
ate. Rather we refer to exacerbations noted
immediately upon withdrawal, before there
had been time for physiological action or
occurring before a given medication was
actually stopped. On numerous occasions
mere announcement or discussion of the
intention to withdraw medication resulted
in dramatic increases in asthma.
Threat to Integrity
This category is defined as placement of
an individual in a situation of danger, espe-
cially of exposure, or facing him with
markedly increased environmental de-
mands. Examples were the onset of asthma
before appearance at a staff conference, or
following a marked increase in job respon-
sibility, or the episode of asthma in the
hypnotic situation, described below.
PSYCHOSOMATIC MEDICINE
KNAPP SC NEMETZ 49
Provocation of Anger male-female hormonal balance. In sessions just
before this she had told of childhood struggles
The anger is provoked by an important with her mother: on the one hand, she had re-
or feared individual. This category, which sisted pressure to make her eat; on the other
obviously overlaps the previous one to a hand, she had wanted to eat "grown-up" food,
limited extent, will be illustrated in the such as sausage. The dream appeared to repre-
next case, and has been foreshadowed in sent mobilization of an impulse to devour some-
the previous patient (and before that by thing from the mother, leading to fears that
the farsighted, if not overcited, Hippoc- her mother would retaliate by poisoning her
rates, who reputedly said, "The asthmatic and a consequent need to expel the poison.
must guard against anger").
Stimulus to Erotic or Sadomasochistic
Closeness to an Important or Loved Person Fantasies
This type of event, particularly as ob- This was provided by such events as ex-
served in the therapeutic situation, was, posure to an ill person or seeing illness
along with separation, the most common depicted at a theater or on television, in
observable antecedent environment event. which the patient was the passive spectator.
Many graphic instances were observed of This category, illustrated by the next case,
attacks en route to an appointment, or included instances in which an attack fol-
upon resumption of treatment after a vaca- lows immediately upon witnessing dyspnea
tion, or in other circumstances that brought in another person. This was true of our
the patient into more intimate contact with last patient and also of Patient H (de-
the therapist or some other key individual. scribed elsewhere19 Case 1). Her asthma
had started at her mother's funeral, and
Intake of an Ambiwlently Regarded she reported episodes of "sympathetic asth-
Substance ma" whenever she saw another person in
This category designates exposure to respiratory distress.
odors and also intake by a number of other Stimulus to Guilt
routes. Although most of our patients re-
ported that odors did on occasion precipi- A final rare category consisted of environ-
tate their asthma, only 10 attacks in this mental events that seemed almost exclu-
series seemed clearly to follow an olfactory sively to arouse guilt. In a number of in-
stimulus. stances asthma followed a dramatic accusa-
tion, such as that of being a bad mother,
A particularly vivid illustration of the rela- made by her mother-in-law to Patient G
tionship between food intake and conflict-laden (Case 2 described elsewhere18). Though
fantasy comes from Case H (described in detail rare in pure culture, guilty reactions in a
as Case 1 elsewhere.19). While in the hospital she
had a remission of her asthma but suffered in- wider sense were ubiquitous, emerging from
stead from anorexia. She lost weight and had and merging with more obvious eruptions
a characteristic battle over efforts to feed her. of impulse.
Some of this was waged with her stepmother, The distribution of antecedent events by
who one evening brought in some spaghetti, categories among our 9 patients is shown in
which the patient ate with gusto. That night Table 2. Except for the last category, they
she dreamed: A pair of witch-like eyes were at could be divided into two groups— (1)
her beside. Someone was feeding her but also those events that seemed to lead to "frus-
taunting her, saying she was only half a woman.
Then it cried out, "Choke, choke!" The patient tration," defined as "evidence that the en-
grew terrified and woke up with the beginnings vironment is in fact or in fantasy blocking
of a moderately severe attack of asthma. or disappointing the individual with regard
In association, besides recounting the preced- to powerful wishes," and (2) those events
ing circumstances, she mentioned a conscious that seem to lead to "stimulation," defined
fear that her current medicines might alter her as "evidence that the environment is in
vol.. XXII, NO. 1, 1960
50 ACUTE BRONCHIAL ASTHMA: I. ANTECEDENTS
TABLE 2. ANTECEDENT EVENTS IN ALL ATTACKS OF ASTHMA

Patient
B G* K M S' C H' W D Total %
Loss of person 30 21 6 3 7 3 15 22 3 110 27
Loss of substance 10 2 4 5 4 1 4 30 7
Threat to integrity 8 7 5 1 3 6 4 4 2 40 10
Provocation of anger 9 5 1 1 3 1 8 28 7
Closeness 37 17 5 1 5 3 14 17 4 103 25
Intake 14 8 2 1 1 2 3 31 8
Stimulus: fantasies 1 13 3 6 1 6 1 31 8
Stimulus: guilt 3 4 1 1 9 2
Changes in physical milieu alone, 2 1 1 1 1 2 8 2
(infection, allergen)
None apparent 6 2 2 1 5 16 4
•Female subjects.

fact or in fantasy stimulating or gratifying
erotized or dangerous wishes." In about 10
per cent of attacks more than one category
might have been applicable, though
enumeration was confined to the one which
appeared dominant. The variety of ante-
cedents and the manner in which they
alternate in the same patient, are shown in
the following excerpt from a case history.
Case C—Medical Manipulations and
Asthma in a Passive Man
An obese, 42-year-old married man gave a
history of nonseasonal, paroxysmal asthma since
"flu" at the age of 7. Medical study revealed
no fixed pulmonary disease but marked fluctua-
tions of vital capacity.
His illness was characterized by clear-cut re-
missions and sudden exacerbations. A five-year
period of almost perfect health came to an
abrupt end the day his best friend got married.
He was an anxious, hypochondriacal person.
Despite considerable native intelligence he was
unsuccessful and remained in a menial civil
service job. He had many hostile impulses
which he was scarcely able to feel, much less ex-
press. He admired athletes, and frequently
watched them on television, but often became
excited and got asthma while doing so. A gen-
eral sense of shame and inferiority colored his
life except during rare spurts of activity when
he felt energetic and ambitious. In two suc-
cessive political campaigns he followed the pat-
tern of his father who had been a revolutionary
in the "old country," and worked furiously in
the camp of a liberal underdog. At that time he
was active and free from asthma. Both times
his candidate lost and both times he promptly
developed asthma. In therapy he gained abil-
ity to express some of his feelings. His asthma
improved markedly, though this could not be
attributed to insight. Throughout he main-
tained that treatment made him somewhat un-
comfortable, tending to turn him into someone
who constantly looked at his own motives:
"One of those people who's always worrying
about their health—what do you call them?
—a pyromaniac?"
Three attacks, following three diverse
medical maneuvers, revealed some of the
variety and some of the common threads
in events preceding his asthmatic episodes.
Attack following a barium enema. During the
second spring in treatment he was feeling well,
his vital capacity was nearly normal, his spirits
were cheerful. He was busy, going out a great
deal, comparing himself jokingly to Jack Demp-
sey. On May 27, he had a proctoscopic exami-
nation, which had been arranged several weeks
earlier because of occasional rectal bleeding.
On June 3 he "forgot" an appointment for a
barium enema, which he later kept on June 10.
He described the enema as a "terrible experi-
ence." During it he had the conscious fear that
he would "explode" and let go with his bowels
into the face of the x-ray man. The next day
a definite exacerbation of his asthma began.
As it progressed, his vital capacity dropped by
two-fifths. He was convinced that something
poisonous had been put into him and was re-
maining there. A female physician jokingly
said that his sensation of fullness might be be-
cause the x-ray department had "forgotten"
some barium and left it inside him. His sense
of fullness, along with his asthma, were accom-

PSYCHOSOMATIC MEDICINE
KNAPP ec NEMETZ
panied by tendencies to stay by himself, a
phobia about going into the water, feelings of
being discouraged, slowed down, as though his
legs were "made of lead." He had "no ambi-
tion," felt "disgusted and discouraged," and
was acutely uncomfortable about being too fat,
comparing himself to his sick little daughter,
and to a girl he saw killed by a truck. Refer-
ring at this point to psychotherapy, he de-
scribed a fear that it was trying to disclose in-
sanity in him. He said: "You're trying to get
something out, and I'm trying to keep it in."
Gradually he improved. There was a sudden
spurt in his emotional well-being on July 16
when he had an outburst of open aggression
over being re-exposed to psychologic testing,
which had irritated him before, but about
which he had never dared to complain.
Our interpretation is that the intake of
an ambivalently regarded substance, a
barium enema, had mobilized the fantasy
of a poisonous inner material, equated at
one level with a dangerous pregnancy. T h e
fantasy, in turn, seemed to be intimately
involved in his prolonged attack of asthma.
Sustained attack in a setting of suppressed
anger. During the next 10 months, the patient
was essentially free of symptoms except for a
brief period in the middle of the autumn. At
that time he felt that his female physician, on
one of his visits to her, impugned his good faith
and implied that he wanted to stay ill. He had
often felt that such accusations were directed at
him when he had remained away from school
and later from work because of illness. Her
remarks had "upset" him. Only after some
time did he recognize that this feeling was one
of momentary, intense rage. It was immediately
suppressed. Within the next few hours he de-
veloped wheezing, which progressed into a
typical sustained attack of asthma, which he
attributed to a "cold." In his psychiatric inter-
view a week later he told of almost killing him-
self at work by holding on to an electrically
charged bar. He used the word "murdered" in
four different contexts, particularly in speaking
of the impossibility of getting angry at a wom-
an: "If a man hits a woman he gets murdered."
He told of how his religious training had for-
bidden talking back to his mother. Specifically
of his doctor, he said, "I need her; she can get
along without me but I can't get along without
her." Later he also described seeing a woman
giving a man a tongue-lashing in the subway.
VOL. XXII, NO. 1, 1960
51
Again the patient had a momentary angry im-
pulse, and suddenly felt like stuffing her pocket-
book down her throat.
As to interpretation, although the un-
conscious ramifications are not all clear,
the psychological setting of this attack was
that of provocation to anger. The patient
had impulses of furious protest, which had
to be disguised and inhibited, out of fear
and guilt. All of these motives appeared to
reflect themselves in his asthmatic symp-
toms.
Transient Attack During Hypnosis. Another
attack occurred early in the course of our ex-
perience with this patient. He took part, with
two other subjects, in a series of experiments in
hypnosis, during which an effort was made to
induce asthma by hynotic suggestion. The vast
majority of these attempts were unsuccessful,
including five efforts with this subject. Out-
wardly complaint, he went into a light trance
readily, showing posthypnotic suggestion and
amnesia. On direct suggestion that he was be-
ginning to experience asthmatic distress, he,
like the other two patients, hyperventilated,
without evidence of asthma. However, on one
of the six occasions, the third session, the
course with him was different. As part of the
induction process, hypesthesia of the right arm
was suggested. At this point the patient became
agitated, started to breathe rapidly. This time
the hyperventilation progressed to a character-
istic attack of asthma, marked by wheezing,
coughing, expiratory difficulty, and reduction
of the vital capacity, witnessed by the collabo-
rating internist. Furthermore, it was impossi-
ble to hypnotize him out of this unforeseen
attack.
Under hypnosis, however, he did relate that
the night before he had seen a television play.
In this the heroine had had a paralysis of the
right arm, relieved under hypnosis. The tele-
vision hypnotist had shown that the basis of her
symptoms had been murderous wishes, which
she had entertained against her father.
Our interpretation of this attack was
that it was precipitated by not only the
closeness and implied helplessness of the
hypnotic situation, but also the additional
threat, in this instance, that dangerous
hostile impulses might be disclosed. The
patient clearly identified himself with.
52 ACUTE BRONCHIAL ASTHMA: I. ANTECEDENTS
a woman, but one whose outer helplessness
covered inner intense aggressiveness. His
symptoms served the purpose of stopping
the progression of the hypnotic process.
They denied anything but a need for help
because of his illness.
Discussion
The immediate phenomena seen during
an attack of asthma have implications both
psychological and physiological. We wish
to discuss these, and to trace their relation-
ship, as far as possible, to the environmen-
tal changes occurring prior to the onset
of acute asthma. In our extensive case
material not every episode could be studied
or understood thoroughly. Another paper20
is devoted to an intensive psychoanalytic
study of one patient, and supplements the
present observations on this large series of
asthmatic attacks.
Psychological Phenomena
Our data suggest that during asthma, in
addition to realistic anxiety and discour-
agement, other powerful emotions play a
part. We do not intend this statement as
a banal or naive assertion that emotional
factors "cause" a somatic illness. Rather
we wish to point out, in the total asthmatic
process, a characteristic evolution of emo-
tional arousal and partial discharge.
The end point is predominantly depres-
sive. In the subjective reports of our pa-
tients, the most common feelings were sad-
ness, helplessness, and hopelessness. These
intermingled with evidences of physical dis-
tress—from the sharp sigh encountered oc-
casionally at the start of an attack to the
sense of being "full" or "choked up" that
persisted throughout it.
In marked contrast were the early states
of excitement, which appeared at times to
initiate attacks of asthma. In our wider
series, virtually all our patients reported
that at times "excitement" provoked or ag-
gravated their asthma. Such occurrences
may be far more frequent than is shown in
the manifest acts or utterances of the
asthmatic, who soon becomes absorbed in
his bodily symptoms, so that only careful
scrutiny may reveal the feelings with which
he is struggling. As one patient put it,
"When I have asthma, my emotions con-
trol me." Much of the struggle seems to
be expressed in the respiratory sphere, re-
vealing itself in the efforts of the asthmatic
to master his unruly breathing. The dra-
matic, excited, often eroticized behavior in
the early phases of asthma may have been
the feature that led earlier writers to refer
to the syndrome as a variant of "anxiety-
hysteria."7' " Earlier medical writers noted
a variety of prodromal manifestations.
Salter states, for example, that sometimes
attacks are ushered in by "extreme wakeful-
ness and unusual mental activity and
buoyancy of spirits" (p. 3324). He also
comments on a phenomenon that we have
observed in a number of patients, namely
a profuse watery diuresis in the hours pre-
ceding an attack. Deutsch, in particular,
emphasizes the importance of the struggle
to take in and to eliminate, in the "panicky
state" of asthma. He also refers to the
accumulation of generalized tension, which
"calls for discharge." He goes on to state:
"The respiratory movements may become
the executors of the discharge."4'5
Thus these excited manifestations seem
to involve more than an anxious or angry
reaction to dawning awareness of the physi-
ologic process, and more than occasional
elations that happen, fortuitously, to termi-
nate while the asthma is beginning. They
are better explained as representing the
arousal of strong emotional and drive proc-
esses, particularly those connected with in-
take and expulsion, which are in part ex-
pressed by the asthmatic symptomatology.
Their evanescence points to the fact that
asthma runs a biphasic course. It resembles
the two-stage progression mentioned by
Graham13 in other syndromes, such as mi-
graine. In our patients the early stage
represents mainly arousal of drives. These
gain partial, disguised expression, which is
succeeded in the later stage by progressive^
more inhibitory phenomena. Generalized
excitement yields to generalized retarcla-
PSYCHOSOMATIC MEDICINE
KNAPP 8C NEMETZ 53
tion. The aggressive and erotic impulses "suck in"; Patient C said, "I try to hold it
that have appeared fleetingly at the start in while you try to get it out." Combining
become drastically curbed. Such late psy- physiological and psychological specula-
chological effects, we suggest, must be re- tion, we suggest that asthma be regarded as
garded not solely as reactions to the acci- a powerful self-reinforcing process involv-
dent of physical adversity but also as mani- ing elements of both intake and expulsion.
festations of emotional conflict, resolved in Such a thesis may be helpful in explain-
a state of inhibition akin to depression. ing how asthma, once initiated, is main-
Physiological Implications
tained. Some recent work on animals sug-
gests that, in this regard, intake as well as
This point of view just described has expulsion may be important. Freedman
physiological implications, regarding both and Fenichel9 described guinea pigs made
the initiation and maintenance of asthma. asthmatic by artificial sensitization. The
Much of the physiology of asthma seems animals rushed about wildly as if some ex-
explicable as an expulsive response. Wolf,28 tensive excitation had been aroused and
speaking particularly of the upper respira- they were frantically engaged not only in
tory passages, described this as a reaction of expulsive efforts but also in a search for
"blocking out and washing away." A noxi- air in the outer environment. The search
ous foreign agent can serve as trigger for was inefficient, exhausting, and often
such a local process. Perhaps even the local proved fatal. Bilateral midbrain lesions at
sensations of an emotion such as grief may the level of the colliculi were capable 9
of
act in a similar way. Presumably, too, ele- extinguishing this excited response. In
ments in the central nervous system rein- other experiments suitable doses of anes-
force the local response. They may even thesia also appeared to protect the ani-
be capable of initiating it. Stimulation of mals who then had asthma 10
without the
vagal areas in the brain stem or their more violent attempts at intake. Their observa-
central connections, up to area 24 in the tions suggest an analogy with clinical find-
cortex, can induce temporarily a local vagal ings. At times, particularly after treatment,
response like that seen in asthma.14 our patients were able to have asthma with-
We question, however, whether it is wise out panic. At other times they seemed
to build a psychophysiologic theory of asth- caught up in similar frantic efforts to get
ma purely on the concept of expulsion. in "good air" and expel "bad air."
Within the central nervous system it is not Asthma might thus be viewed as a mas-
so easy to separate inspiratory and expira- sive and ineffectual adaptive mechanism.
tory forces. They alternate rhythmically At both psychological and physiological
and reinforce each other. Automatic in- levels, we can envisage urges toward intake
spiratory mechanisms are just as strong as, reinforcing urges towards expulsion. In ad-
or stronger than, expiratory ones, and the dition, we can postulate similar circular
two exist in balance with each other. When reinforcement between central and periph-
this balance is tampered with, for example eral factors. Kepecs16 and his co-workers
in a decerebrate animal, one may get the re- have recently brought evidence that in
lease of sustained and vigorous "inspiratory asthmatic subjects local respiratory factors
cramp."14 If symbolic factors do interfere stimulate central fantasy, and vice versa.
with respiratory function, it would seem Emotional conflict, we suggest, acting by
logical that they might include the ma- way of the central nervous system, may in-
chinery of intake as well as that of ex- duce peripheral pulmonary reactions as
pulsion. though to a noxious foreign substance.
At the level of psychologic observation, The peripheral reactions may then lead
impulses to take in precede the urge to automatically to further central excitation,
expel. Patient W spoke of her need to and thus the respiratory apparatus becomes
VOL. xxn, NO. 1, 1960
54 ACUTE BRONCHIAL ASTHMA: I. ANTECEDENTS
involved in a chain of excitation and re-
excitation which has the damaging char-
acteristics of an inefficient feedback system.
Environmental Antecedents
Finally we must ask how the different
antecedent events that we observed might
lead to such a process. Obviously, in and
of themselves they are not specific for asth-
ma. The same variety has been reported,
and the same conclusions reached, by other
authors. 1122 Like French and Alexander11
we have searched for a more fundamental,
unconscious common denominator.
Our initial impression was that such a
common element might be found in the
concept of depletion and loss. Many of the
situations leading up to asthma can be seen
in terms of confronting an individual with
actual or threatened loss. Thus anger or
sexual temptation can be seen as threaten-
ing alienation from an important person.
Loss, of course, is a virtually universal ex-
perience. For it to result in asthma more
must be involved, such as "sensitization" of
the respiratory pathway, or its use to com-
municate, in a partially disguised fashion,
pain and protest. French and Alexander
stress the communicative aspect of the vo-
cal-respiratory apparatus and advance their
well-known theory that asthma represents
a "suppressed cry for the mother."11
The theory, so stated, has difficulty in
accounting for the facts we have observed,
on three counts. The first of these is the
sequence of excitement at the start, and
inhibition during the course, of acute asth-
ma. Though fear of loss may play a part in
this pattern, we have already suggested that
more must be involved, namely a complex
arousal of drives, and their persistence, pro-
gressive transformation, and partial dis-
charge in the symptomatology of asthma.
A second problem arises from the fact
that asthma often developed in situations
of closeness. Was such closeness frighten-
ing to patients solely because it might ul-
timately lead to loss of the loved person?
At times our patients suggested that such
might be the case, saying they were afraid
to be close to anyone for fear of losing him.
Yet they seemed to seek out closeness, only
to become overwhelmed by the actual ex-
perience of physical nearness to another
person, as though they feared merging, and
being faced, not with loss of another per-
son, but with loss of their own identity.
Important evidence on this point comes
from work with children. A number of
workers15-28 agree that the asthmatic child
often gets better when removed from his
mother and dramatically worse when
brought back into a situation of closeness
to her. Jessner and her co-workers15 report
fantasies in which the children they studied
saw themselves as fused with and part of
their mothers. Such a group of ideas, im-
plying total surrender, as Anna Freud has
pointed out,12 may be as frightening in
their own right as any threat of the loss of
another person.
A third and related problem is posed by
the small number of attacks that followed
the intake of substances, in fact or fantasy,
by olfactory or other routes. One might
argue that these experiences produced nos-
talgia and longing. Indeed, the reaction to
such substances is likely to be mixed with
memories and feelings about persons. Their
action, however, often seemed more direct,
as though in and of themselves they ac-
tivated impulses toward intake, followed by
impulses toward expulsion. The role of
such fantasy impulses in asthma has been
stressed by Felix Deutsch.4-5 Earlier we
mentioned the girl who woke with acute
asthma; she had eaten spaghetti and after-
ward dreamed of a witchlike figure who
was saying, "Choke, choke." The attack of
this patient epitomizes the need fora theory
of asthma that goes beyond the restricted
concept of loss. It was not loss, in this
instance, but the fantasy of gain, of having
an ambivalently regarded substance inside
her, which appeared to have initiated her
violent expulsive effort.
Going still further, beyond these consid-
erations of emotion and fantasy, we need
a schematic model that will comprehend
all the various types of asthma that can be
PSYCHOSOMATIC MEDICINE
KNAPP & NEMETZ
encountered. Presumably similar physiolog-
ical processes are involved, whether asthma
follows invasion by an allergen, or—in an-
other situation—a train of emotional
events. Such a model, we suggest, may be
found by conceiving a respiratory appara-
tus, with both intake and expulsive func-
tions, which has become vulnerable and
may be affected by either physiological or
psychological stress. The latter may be
mainly frustration, such as loss, leading to
an increased need for intake, or it may be
mainly stimulation, leading to fantasies
that intake has occurred and arousing urges
to expel.
This viewpoint, we recognize, requires
for its corroboration more than our present
case material, which does not give clear
evidence about unconscious factors. An-
other paper,20 based upon detailed psycho-
analytic study, deals more fully with the
questions of fantasy, emotional arousal, and
partial discharge in acute bronchial asthma.
Summary
Four hundred and six asthmatic attacks
occurred in 9 patients with severe, chronic
bronchial asthma who had been studied
intensively in psychiatric or (in two in-
stances) psychoanalytic interviews.
Feelings and fantasies concomitant with
asthma tended to be dominated by absorp-
tion in the physical illness. At times this
appeared to serve as a protection against
obvious psychological problems. In some-
what more than half of the episodes other
emotional concomitants appeared after
asthma had become established. The vast
majority of these were depressive—a sense
of sadness, helplessness, and hopelessness,
at times accompanied by ideas of a dan-
gerous or poisonous inner substance.
Contrasting with these, in somewhat less
than half of the attacks there were prodro-
mal emotional manifestations which pre-
ceded and led directly into acute asthma.
The principal prodromal feature was ex-
citement, usually with an angry or anxious
coloring, occasionally elated and erotic,
resembling a miniature hypomania. We
VOL. xxn, NO. 1, 1960
55
suggest that in asthma an initial phase of
drive arousal and excitement is followed by
a later phase of drive restraint and inhibi-
tion.
Antecedent changes in the environment
occurring in the 48 hours prior to an attack
varied widely. Eight categories could be
discerned, the two most prominent being
loss of a person and closeness to a person.
Most of the categories could be divided into
one of two groups: events which seemed to
lead to frustration of powerful impulses
and those which seemed to stimulate
erotized or dangerous wishes.
We postulate that both types of event,
although neither is of itself specific for
asthma, might activate a respiratory appa-
ratus having both intake and expulsion
functions, which has become vulnerable to
psychological as well as physiological stress.
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PSYCHOSOMATIC MEDICINE