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Psychsocial Aspects of Allergy

Top 10 Scientific Articles in the field of psychosocial aspects of allergy published in 2017 (or 2016 as noted).

Co-morbid psychological dysfunction is associated with a higher risk of asthma exacerbations: a systematic review and meta-analysis.
Zhang L, Zhang X, Zheng J, et al.

Journal of Thoracic Disease. 2016;8:6. doi:10.21037/jtd.2016.04.68.
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Reviewer’s Comments: A direct association between psychological disorders, mainly depression, and asthma exacerbations is demonstrated by a meta-analysis on related studies from the past mid-century up to 2016.

Background: The longitudinal associations between psychological dysfunction (PD) and asthma exacerbations (AE) have not been adequately addressed. This study aimed to systematically assess the influence of PD on AE, and to determine whether different PD affects AE differentially.
Methods: Electronic databases (PubMed, Cochrane library, Web of Science, Embase, and Ovid) were searched for prospective cohort studies on the influence of PD on AE in individuals with asthma. Relative risk (RR) and adjusted RR (RRadj) were pooled across studies. Subgroup analyses assessed the effects of different types of PD and the time-dependent response to the duration of PD exposure.
Results: Ten articles that involved 31,432 adults with asthma with follow-up of 6.0–86.4 months were included. PD significantly increased the risk of AE [RRadj =1.06, 95% confidence interval (95%CI): 1.04–1.09, P<0.001], presenting as hospitalizations (RRadj =1.22, 95% CI: 1.12–1.34, P<0.001), unscheduled doctor visits (RR =4.26, 95% CI: 2.52–7.19), and emergency department (ED) visits (RRadj =1.06, 95% CI: 1.01–1.10, P=0.009) because of asthma. Depression significantly increased the risk of AE (RRadj =1.07, 95% CI: 1.04–1.11, P<0.001), presenting as hospitalizations (RRadj =1.26, 95% CI: 1.07–1.49, P=0.007) and ED visits (RRadj =1.06, 95% CI: 1.02–1.11, P=0.007) because of asthma. Anxiety was only associated with an increased risk of AE in pregnant women (RR =1.05, 95% CI: 1.01–1.08), possibly due to the small amount of data available on anxiety. The influence of PD on AE was only significant when the PD exposure time exceeded one year.
Conclusions: Co-morbid PD adversely affects AE, and there are differential effects of depression and anxiety. Asthmatic subjects with PD may benefit from more attention when establishing a treatment regimen in clinical practice.


Maternal stress and psychological distress preconception: association with offspring atopic eczema at age 12 months.
El-Heis S, Crozier SR, Healy E, Robinson SM, Harvey NC, Cooper C, Inskip HM, Baird J, Southampton Women's Survey Study Group, Godfrey KM.
Clin Exp Allergy. 2017; 47:6. doi: 10.1111/cea.12910
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Reviewer’s Comments: Maternal stress in the prenatal and postnatal periods might be linked to offspring atopic eczema, although the underlying mechanisms remain unclear. This ambitious cohort study, on mothers suffering from significant daily and/or preconceptional stress, followed almost 3,000 children at 6 and 12 months after delivery, showing a positive association between maternal stress and atopic eczema at 12 months.

Background: Perinatal maternal stress and low mood have been linked to offspring atopic eczema.
Objectives: To examine the relation of maternal stress/mood with atopic eczema in the offspring, focusing particularly on stress/psychological distress preconception.
Methods: At recruitment in the UK Southampton Women’s Survey, preconception maternal reports of perceived stress in daily living and the effect of stress on health were recorded; in a sub-sample psychological distress was assessed (12-item General Health Questionnaire). Infants were followed up at ages 6 (n=2956) and 12 (n=2872) months and atopic eczema ascertained (based on UK Working Party Criteria for the Definition of Atopic Dermatitis). At 6 months postpartum, mothers were asked if they had experienced symptoms of low mood since childbirth and completed the Edinburgh Post-natal Depression Scale.
Results: Preconception perceived stress affecting health (OR 1.21 (95%CI 1.08-1.35), p=0.001) and stress in daily living (OR 1.16 (1.03-1.30), p=0.014) were associated with an increased risk of offspring atopic eczema at age 12 months but not at 6 months, robust to adjustment for potentially confounding variables. Findings were similar for maternal psychological distress preconception. Low maternal mood between delivery and 6 months postpartum was associated with an increased risk of infantile atopic eczema at age 12 months, but no significant association between postnatal mood and atopic eczema was seen after taking account of preconception stress.
Conclusion & Clinical Relevance: Our data provide novel evidence linking maternal stress at preconception to atopic eczema risk, supporting a developmental contribution to the aetiology of atopic eczema and pointing to potentially modifiable influences.


Maternal Psychosocial Stress Associates With Increased Risk of Asthma Development in Offspring.
Magnus MC, Wright RJ, Røysamb E, Parr CL, Karlstad Ø, Page CM, Nafstad P, Håberg SE, London SJ, Nystad W.
Am J Epidemiol. 2017 Dec 13. doi: 10.1093/aje/kwx366.
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Reviewer’s Comments: As previously established in the USA by Dr. Wright (one of the authors), this Norwegian study confirms an association between maternal psychological dysfunction during pregnancy (as an isolated risk factor) and the development of asthma symptoms at 7 years of age in the offspring.

Abstract: Prenatal maternal psychosocial stress might influence the development of childhood asthma. Evaluating paternal psychosocial stress and conducting a sibling comparison could provide further insight into the role of unmeasured confounding. We examined the associations of parental psychosocial stress during and after pregnancy with asthma at age 7 years in the Norwegian Mother and Child Cohort Study (n = 63,626; children born in 2000–2007). Measures of psychosocial stress included lifetime major depressive symptoms, current anxiety/depression symptoms, use of antidepressants, anxiolytics, and/or hypnotics, life satisfaction, relationship satisfaction, work stress, and social support. Childhood asthma was associated with maternal lifetime major depressive symptoms (adjusted relative risk (aRR) = 1.19, 95% confidence interval (CI): 1.09, 1.30), in addition to symptoms of anxiety/depression during pregnancy (aRR = 1.17, 95% CI: 1.06, 1.29) and 6 months after delivery (aRR = 1.17, 95% CI: 1.07, 1.28). Maternal negative life events during pregnancy (aRR = 1.10, 95%CI: 1.06, 1.13) and 6 months after delivery (aRR = 1.14, 95% CI: 1.11, 1.18) were also associated with asthma. These associations were not replicated when evaluated within sibling groups. There were no associations with paternal psychosocial stress. In conclusion, maternal anxiety/depression and negative life events were associated with offspring asthma, but this might be explained by unmeasured maternal background characteristics that remain stable across deliveries.


The Psychosocial Impact of Atopic Dermatitis.
Gochnauer H, Valdes-Rodriguez R, Cardwell L, Anolik RB.
Adv Exp Med Biol. 2017; 1027. doi: 10.1007/978-3-319-64804-0_6.
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Reviewer’s Comment: A thorough review on the different tools used to measure health-related QoL in atopic eczema patients, in clinical trials and real life settings. The authors underline the difficulties to compare the different tools and give emphasis to the overwhelming psychosocial impact of the disease on patient’s lives.

Abstract: Atopic dermatitis is a chronic skin condition that has significant psychosocial and quality of life impact. The condition causes physical discomfort, emotional distress, embarrassment, social stigma and daily activity limitation. In an effort to assess these aspects of disease burden, quality of life measurement tools were developed. Through use of these tools, we have expanded our knowledge of the psychosocial and quality of life burden of this condition. A variety of quality of life assessment tools exists, yet there is no consensus on which tool is best suited to assess the quality of life impact of atopic dermatitis. Research studies assessing quality of life in atopic dermatitis patients utilize a variety of quality of life measurement tools; this complicates comparisons across research studies. Though comparison across studies is difficult, the data echoes tremendous overall burden of disease, especially pertaining to psychosocial status and life quality.


Psychoneuroimmunoendocrinology: clinical implications.
González-Díaz SN, Arias-Cruz A, Elizondo-Villarreal B, Monge-Ortega OP.
World Allergy Organ J. 2017; 10:1. doi: 10.1186/s40413-017-0151-6.
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Reviewer’s Comment: Socioeconomic status as well as different chronic autoimmune diseases affect mood by producing stress, anxiety and depression, all of which negatively affect immune system function and regulation at the same time. This paper reviews the close relationship between allergic diseases and the so-called psycho-neuro-immune-endocrine axis, and emphasizes the need for a holistic integrative approach, from changes in lifestyle to behavioral models such as mindfulness.

Abstract: Psychoneuroimmunoendocrinology, which was first described in 1936, is the study of the interactions between the psyche, neural and endocrine functions and immune responses. The aim of psychoneuroimmunoendocrinology is to apply medical knowledge to the treatment of different allergic, immune, autoimmune, rheumatic, neoplastic, endocrine, cardiovascular and dental pathologies, among other disorders. Epigenetic factors and major stresses from different types of stimuli acting through distinct pathways and neurotransmitters are highly involved in altering the psychoneuroimmunoendocrine axis, resulting in the emergence of disease. The main purpose of this report is to expand the understanding of psychoneuroimmunoendocrinology and to demonstrate the importance of the above-mentioned interactions in the etiology of multiple pathologies. In this review, a search of the medical literature using PubMed (free access search engine for the Medline database of the National Library of Medicine of the United States) over the years 1936 to 2016 was conducted, and descriptive and experimental studies and reviews of the scientific literature were included.


Cognitive behavioural therapy (CBT) for adults and adolescents with asthma.
Kew KM, Nashed M, Dulay V, Yorke J.
Cochrane Database Syst Rev. 2016; 9:CD011818. doi: 10.1002/14651858.CD011818.pub2.
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Reviewer’s Comments: According to the nine randomized clinical trials included this systematic review, involving 407 adults with asthma, different cognitive behavioral therapies can improve asthma control, as well as anxiety levels and quality of life, compared to standard care. Results are valid in adults, unlike adolescents younger than 18.

Background: People with asthma have a higher prevalence of anxiety and depression than the general population. This is associated with poorer asthma control, medication adherence, and health outcomes. Cognitive behavioral therapy (CBT) may be a way to improve the quality of life of people with asthma by addressing associated psychological issues, which may lead to a lower risk of exacerbations and better asthma control.
Objectives: To assess the efficacy of CBT for asthma compared with usual care. Search methods. We searched the Cochrane Airways Group Specialized Register,, and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP). We also searched reference lists of all primary studies and review articles and contacted authors for unpublished data. The most recent searches were conducted in August 2016.
Selection criteria: We included parallel randomized controlled trials (RCTs) comparing any cognitive behavioral intervention to usual care or no intervention. We included studies of adults or adolescents with asthma, with or without comorbid anxiety or depression. We included studies reported as full text, those published as abstract only and unpublished data.
Data collection and analysis: Two or more review authors independently screened the search results, extracted data, and assessed included studies for risk of bias. We analyzed dichotomous data as odds ratios (ORs) and continuous data as mean differences (MDs) or standardized mean differences (SMD) where scales varied across studies, all using a random-effects model. The primary outcomes were asthma-related quality of life and exacerbations requiring at least a course of oral steroids. We rated all outcomes using GRADE and presented our confidence in the results in a ’Summary of findings’ table.
Authors’ conclusions: For adults with persistent asthma, CBT may improve quality of life, asthma control, and anxiety levels compared with usual care. Risks of bias, imprecision of effects, and inconsistency between results reduced our confidence in the results to low, and evidence was lacking regarding the effect of CBT on asthma exacerbations, unscheduled contacts, depression, and medication adherence. There was much variation between studies in how CBT was delivered and what constituted usual care, meaning the most optimal method of CBT delivery, format, and target population requires further investigation. There is currently no evidence for the use of CBT in adolescents with asthma.


Suicidal behaviors in the dermatology patient.
Gupta MA, Pura DR, Vujcic B, Gupta AK.
Clinics in Dermatology 2017; 35. doi: 10.1016/j.clindermatol.2017.01.006. Epub 2017 Jan 23
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Reviewer’s Comments: Up to 30% of chronic dermatologic disorders, including those considered within the allergy spectrum such as atopic dermatitis or chronic spontaneous urticaria, can be associated with psychiatric diseases. The paper analyzes suicidal behaviors among these patients, either due to psychosocial stressors, psychiatric comorbidity, or even as a possible side effect of some medications. According to the authors, higher rates should be considered cautiously and within its demographic context.

Abstract: An assessment of suicidal behaviors in the dermatology patient may be necessary in several situations: (1) in the presence of psychiatric comorbidity (major depressive disorder, body dysmorphic disorder, substance use disorder, posttraumatic stress disorder), encountered in up to 30% of dermatology patients; (2) when dermatologic symptoms (“dysmorphophobia,” dermatitis artefacta) represent psychiatric pathologic conditions; (3) when psychosocial stressors (bereavement, interpersonal violence) increase the risk of suicidal behavior and exacerbate stress-reactive dermatoses (psoriasis, acne); (4) in the presence of high disease burden (chronicity, increased disease severity); (5) in instances of significant pruritus or chronic sleep disruption; (6) in the presence of facial lesions or facial scarring; (7) when social exclusion or feelings of alienation arise secondary to the skin disorder; (8) with use of medications (retinoids, biologics) for which suicidal behavior has been implicated as a possible side effect; and (9) when treating psychiatric patients experiencing a serious reaction to psychotropic medications (eg, Stevens-Johnson syndrome and anticonvulsants). Suicide risk must be assessed within a demographic context because suicide rates rise rapidly in adolescents and young adults, among whom the prevalence of skin disorders associated with suicidal behaviors (acne, psoriasis, atopic dermatitis) is also high, and suicide rates are increasing among white men, who tend to be overrepresented in dermatology clinical trials.


Food allergy and attitudes to close interpersonal relationships: An exploratory study on attachment.
Polloni L, Schiff S, Ferruzza E, Lazzarotto F, Bonaguro R, Toniolo A, Celegato N, Muraro A.
Pediatr Allergy Immunol. 2017; 28:5. doi: 10.1111/pai.12732. Epub 2017 Jun 20.
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Reviewer’s Comments: The main result of this Italian study in 174 food-allergic young patients was a higher level of attachment avoidance, as indicator of close interpersonal relationships, among patients compared to healthy controls (P<.0001), indicating that food allergy negatively influences on patients' social life and personal relationships.

Background: Food allergy is a common immunologic disease that includes potentially fatal reactions. It impacts considerably on patients' social life including close interpersonal relationships. Attachment theory provides a theoretic framework to evaluate the quality of close interpersonal relationships in chronic disorders. Attachment insecurity, mainly characterized by attachment avoidance, has been found in a variety of health conditions, but still needs to be investigated in food allergy. The study aimed to investigate attachment, as attitude to close interpersonal relationships, among food-allergic young patients, compared to healthy controls.
Methods: This is a cross-sectional study involving patients suffering from IgE-mediated food allergy sequentially recruited and matched to healthy controls for age and gender. The Attachment Style Questionnaire (ASQ) was used to assess five factors and two attachment dimensions (Anxiety-Avoidance). Associations with anaphylaxis and adrenaline prescription were explored among patients.
Results: 174 participants were assessed (female=45%; mean age=17.51; SD=4.26). Food-allergic patients reported significantly higher levels of Discomfort with Closeness (P<.05), Relationships as Secondary (P<.05) and Attachment Avoidance (P<.0001) compared to controls.
Conclusions: Clinicians should be aware of implications of insecure attachment for health and illness. They should support patients in limiting social impairment finding a balance between safety and psychological well-being.


A brief psychological intervention for mothers of children with food allergy can change risk perception and reduce anxiety: Outcomes of a randomized controlled trial.
Boyle RJ, Umasunthar T, Smith JG, et al.
Clin Exp Allergy. 2017;47:10. doi: 10.1111/cea.12981. Epub 2017 Aug 10.
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Reviewer’s Comments: In this study on 200 mothers of children with food allergy, a single session on behavioral therapy did not have any effect on mother’s anxiety at 6 weeks, but after one year, it did impact on anxiety and stress response, compared to standard care.

Background: Mothers of children with food allergy have increased anxiety, which may be influenced by healthcare professionals' communication of risk.
Objective: To evaluate a brief psychological intervention for reducing anxiety in mothers of children with food allergy. Methods: Two hundred mothers of children with food allergy were recruited from allergy clinics. A computer-generated randomization list was used to allocate participants to a single-session Cognitive Behavioural Therapy intervention including a risk communication module, or standard care. Anxiety and risk perception were assessed at 6 weeks and 1 year. Primary outcome was state anxiety at 6 weeks. Secondary outcomes included state anxiety at 1 year, risk perception at 6 weeks and 1 year, and salivary cortisol response to a simulated anaphylaxis scenario at 1 year.
Results: We found no significant difference in the primary outcome state anxiety at 6 weeks, with mean 31.9 (sd 10.2) intervention, 34.0 (10.2) control; mean difference 2.1 (95%CI -0.9, 5.0; P=0.17). There was significantly reduced state anxiety at 6 weeks in the intervention group, in the subgroup of participants with moderate/high anxiety at enrolment (103/200, 52%), with mean 33.0 (sd 9.3) intervention, 37.8 (sd 10.0) control; mean difference 4.8 (95% CI 0.9, 8.7; P=0.016; Cohen's d effect size 0.50). The psychological intervention also reduced risk perception and salivary cortisol response (P=0.032; effect size 0.36).
Conclusion: We found evidence that a brief psychological intervention which incorporates accurate risk information may impact on anxiety, risk perception and physiological stress response in mothers of children with food allergy.

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