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Psychosocial Aspects of Allergy

Selection by: Ignacio Jáuregui Presa, Scientific chair of the Committee on Psychosocial Aspects of Allergy, and Javier Sánchez de Vicente, Junior member of the WAO. Comments by Prof. Ignacio Jáuregui Presa.

Sastre J, Crespo A, Fernandez-Sanchez A, Rial M, Plaza V.; on behalf of the investigators of the CONCORD Study Group. Anxiety, depression, and asthma control: changes after standardized treatment. [https://doi.org/10.1016/j.jaip.2018.02.002] J Allergy Clin Immunol Pract 2018;6:1953-9.

Reasons for recommending the article:

By means of a single tool (the Hospital Anxiety and Depression Scale), a significant improvement in psychological comorbidity was demonstrated after 6 months of standardized asthma treatment. Psychological improvement was correlated with clinical and functional variables. The study confirmed anxiety (mainly) and depression as independent risk factors for poorer asthma control.

Abstract:

Background: It has been documented that anxiety and depression are prevalent in patients with asthma and are associated with greater frequency of exacerbations, increased use of health care resources, and poor asthma control.

Objective: To examine the association of asthma diagnosis with symptoms of depression/anxiety and asthma control not only at baseline but also over a 6-month period of specialist supervision.

Methods: We enrolled 3182 patients with moderate to severe asthma. All were evaluated with spirometry, the Asthma Control Test, and the Hospital Anxiety and Depression Scale at baseline and at 6 months. Treatments were decided by specialists according to published guidelines.

Results: At baseline, 24.2% and 12% of the patients were diagnosed with anxiety and depression, respectively, according to the Hospital Anxiety and Depression Scale. After 6 months, anxiety and depression improved, affecting 15.3% and 8.1% of patients, respectively (P < .001); mean FEV1 and asthma control also improved (FEV1 from 81.6% ± 20.9% to 86% ± 20.8%; Asthma Control Test score from 15.8 ± 4.7 to 19.4 ± 4.4; both P < .001). Patients with anxiety and depression used significantly more health care resources and had more exacerbations. A multivariate analysis showed that patients with anxiety, depression, and lower FEV1 (odds ratio, 0.20, 0.34, 0.62, respectively; P < .001) were independently associated with poor asthma control. A multiple linear regression analysis showed that anxiety had a nearly 4-fold greater influence over asthma control than depression (0.326/0.85 = 4.075).

Conclusion: Under standardized asthma care and after a specific visit with the specialist, patients present significant improvement in these psychological disorders and exhibit better asthma control and functional parameters.

Burg GT, Covar R, Oland AA, Guilbert TW. The Tempest: Difficult to control asthma in adolescence. [http://dx.doi.org/10.1016/j.jaip.2018.02.006]. J Allergy Clin Immunol Pract. 2018;6(3):738-48

Reasons for recommending the article:

An approach to severe asthma in teenagers with a specific focus on psychological issues, adherence and other psychosocial aspects of adolescent asthma. The authors recommend education about asthma, combined with behavioral  or cognitive-behavioral interventions to improve adherence and reduce asthma severity.  They also underline the role of new and emerging biologic phenotype-directed therapies, such as omalizumab and anti-IL5 Mabs, for severe asthma in adolescents.

Abstract:

Severe asthma is associated with significant morbidity and is a highly heterogeneous disorder. Severe asthma in adolescence has some unique elements compared with the features of severe asthma a medical provider would see in younger children or adults. A specific focus on psychological issues and adherence highlights some of the challenges in the management of asthma in adolescents. Treatment of adolescents with severe asthma now includes 3 approved biologic phenotype-directed therapies. Therapies available to adults may be beneficial to adolescents with severe asthma. Research into predictors of specific treatment response by phenotypes is ongoing. Optimal treatment strategies are not yet defined and warrant further investigation.

Miyasaka T, Dobashi-Okuyama K, Takahashi T, Takayanagi M, Ohno I. The interplay between neuroendocrine activity and psychological stress-induced exacerbation of allergic asthma. [http://dx.doi.org/10.1016/j.alit.2017.04.013]. Allergol Int. 2018 ; 67: 32-42

Reasons for recommending the article:

New insights into psychoneuroendocrinology. Psychological stress induces Th2- and Th17-type responses and mitigates regulatory T (Treg) cell responses, leading to enhanced eosinophilic airway inflammation. The authors of this Japanese review suggest a neuropsychiatry phenotype in asthma, in which activation of the hypothalamic-pituitary adrenal pathway and autonomic nervous system would trigger psychological stress-induced exacerbations of allergic asthma.

Abstract:

Psychological stress is recognized as a key factor in the exacerbation of allergic asthma, whereby brain responses to stress act as immunomodulators for asthma. In particular, stress-induced enhanced type 2 T-helper (Th2)-type lung inflammation is strongly associated with asthma pathogenesis. Psychological stress leads to eosinophilic airway inflammation through activation of the hypothalamic-pituitary adrenal pathway and autonomic nervous system. This is followed by the secretion of stress hormones into the blood, including glucocorticoids, epinephrine, and norepinephrine, which enhance Th2 and type 17 T-helper (Th17)-type asthma profiles in humans and rodents. Recent evidence has shown that a defect of the m-opioid receptor in the brain along with a defect of the peripheral glucocorticoid receptor signaling completely disrupted stress-induced airway inflammation in mice. This suggests that the stress response facilitates events in the central nervous and endocrine systems, thus exacerbating asthma. In this review, we outline the recent findings on the interplay between stress and neuroendocrine activities followed by stress-induced enhanced Th2 and Th17 immune responses and attenuated regulatory T (Treg) cell responses that are closely linked with asthma exacerbation. We will place a special focus on our own data that has emphasized the continuity from central sensing of psychological stress to enhanced eosinophilic airway inflammation. The mechanism that modulates psychological stress-induced exacerbation of allergic asthma through neuroendocrine activities is thought to involve a series of consecutive pathological events from the brain to the lung, which implies there to be a “neuropsychiatry phenotype” in asthma.

Magnus MC, Wright RJ, Røysamb E, Parr CL, Karlstad Ø, Page CM, Nafstad P, Håberg SE, London SJ, Nystad W. Maternal psychosocial stress associates with increased risk of asthma development in offspring. (https://doi.org/10.1093/aje/kwx366). Am J Epidemiol. 2018; 187(6):1199-1209

Reasons for recommending the article:

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.

Dunn Galvin A, Hourihane JO. Psychosocial mediators of change and patient selection factors in oral immunotherapy trials. [https://doi.org/10.1007/s12016-018-8700-5] Clin Rev Allergy Immunol. 2018;55(2):217-36

Reasons for recommending the article:

The authors postulate the use of patient-related outcomes such as improved health-related quality of life as a primary outcome, to be measured at multiple intervals during the food immunotherapy trials and after; and propose a common, standardized protocol for the comparison of efficacy of food allergy treatments between different trials in every centre or country, in order to diminish heterogeneity.   

Abstract:

Health-related quality of life (HRQL) is influenced by physiological, psychological, and environmental variables and can be best understood by considering the interactions of factors that cut across multiple levels. One of the most important issues relating to treatment in food allergy is to identify, describe, and define predictors that may contribute to modify HRQL outcomes. The research presented demonstrates that measures of HRQL are able to distinguish key features of known groups (e.g. relating to reaction severity, treatment, allergen type/number, expectation of outcome) and delineate impact on hitherto unknown groups (e.g. relating to personality types and coping styles). This heterogeneity may explain why HRQL or other patient-related outcomes may differ in individuals during, or following any treatment or intervention. Patient-reported outcomes are relatively poorly defined to date. Since HRQL has only been studied in relatively few oral immunotherapy trials to date, primarily looking at caregiver HRQL, it is unclear which factors, measures, or subscales are most predictive of short- and/or long-term treatment outcomes for which type of patient, and which time points for measurement are most informative. A standardised protocol that incorporates HRQL and other relevant patient-related outcome measures and agreed definitions of outcomes would allow for the comparison of efficacy of food allergy treatments between centres, trials, or countries. Further evidence-based research aimed at exploring the effects of interventions on outcomes in food allergy is needed, including the influence of patient and parent factors on protocol design. To this end, it is vital that patient-related outcomes such as improved HRQL are seen as a primary outcome and are measured at multiple intervals during the trial duration and beyond. The creative use of methods and designs (both qualitative and quantitative) to better understand the role of HRQL in immunotherapy treatment trials will enable improved modelling of the costs, risks, and benefits of any treatment. Systematic analysis and modelling of antecedent factors, mediators, and outcomes will be important to boost intervention effects and to maximise the overall benefits of treatment.

Slim M, Rico-Villademoros F, Calandre EP.  Psychiatric comorbidity in children and adults with gluten-related disorders: a narrative review. [https://doi.org/10.3390/nu10070875] Nutrients. 2018 Jul 6;10(7). pii: E875

Reasons for recommending the article:

A wide range of psychiatric disorders have been investigated in celiac disease and non-celiac gluten sensitivity in children and adults. This systematic literature review evidences a significant association between gluten-related disease and certain psychiatric comorbidities such as depression and feeding/eating disorders, and points out a more conflicting association with anxiety, panic disorder, autism or ADHD.  

Abstract:

Gluten-related disorders are characterized by both intestinal and extraintestinal manifestations. Previous studies have suggested an association between gluten-related disorder and psychiatric comorbidities. The objective of our current review is to provide a comprehensive review of this association in children and adults. A systematic literature search using MEDLINE, Embase and PsycINFO from inception to 2018 using terms of ‘celiac disease’ or ‘gluten-sensitivity-related disorders’ combined with terms of ‘mental disorders’ was conducted. A total of 47 articles were included in our review, of which 28 studies were conducted in adults, 11 studies in children and eight studies included both children and adults. The majority of studies were conducted in celiac disease, two studies in non-celiac gluten sensitivity and none in wheat allergy. Enough evidence is currently available supporting the association of celiac disease with depression and, to a lesser extent, with eating disorders. Further investigation is warranted to evaluate the association suggested with other psychiatric disorders. In conclusion, routine surveillance of potential psychiatric manifestations in children and adults with gluten-related disorders should be carried out by the attending physician.

Feng C, Kim JH. Beyond avoidance: the psychosocial impact of food allergies. [https://doi.org/10.1007/s12016-018-8708-x]. Clin Rev Allergy Immunol. 2018 Sep 1. doi: 10.1007/s12016-018-8708-x. [Epub ahead of print]

Reasons for recommending the article:

Food allergy diagnosis and treatment has trustfully improved in the last decade. However, there are many unrecognized mental health issues associated to living with food allergies in the pediatric and adult patient, and in parents of food-allergic children as well. This review focuses on these aspects of food allergies and possible psychosocial interventions, from camps and support groups to cognitive behavioral therapy.

Abstract:

Over the past few years, the rates of food allergies have dramatically increased. As a result, the lives of patients and their caregivers have been dramatically altered. While most attention surrounding food allergies has focused on treatment, less consideration has been given to the mental health ramifications of living with this condition, among them depression, anxiety, post-traumatic stress, being bullied, and an overall poorer quality of life. At the same time, patients’ family lives are often disrupted. Parents of food-allergic children, especially mothers, report anxiety, depression, and a decreased quality of life. Indeed, mental health issues associated with food allergies are likely under-recognized. In this review, we describe not only the psychosocial impacts of food allergies but also survey treatments that can be used to address this burgeoning problem. Interventions include educating members of the greater community about food allergies, camps for food allergic children, and support groups for parents. For physicians, treatment options consist of oral challenges, proximity challenges, oral immunotherapy, and cognitive behavioral therapy. Although the existing research is built on an already strong foundation, ultimately more studies are needed to deepen our understanding of the relationship between food allergies and mental health.

Cortes A, Castillo A , Sciaraffia A. Food allergy: Children's symptom levels are associated with mothers' psycho-socio-economic variables. Journal of Psychosomatic Research 2018; 104:48-54 [https://www.ncbi.nlm.nih.gov/pubmed/29275785]

Reasons for recommending the article:

The study of 101 mothers along with 101 children with IgE-mediated food allergy strongly suggested that children's symptoms are significantly associated with socioeconomic and psychological variables of the mothers.

Abstract:

Background: Allergies affect children's health as well as their quality of life, stress levels, and family budget. The available literature suggests that family, social and psychological factors are affected by allergic pathologies such as rhinitis, asthma and atopic dermatitis. However, few studies have focused on quantifying such association in child food allergy. This study aims to enhance the understanding of the associations between caregiver variables and children's Food Allergy (FA).

Methods: The study involved 206 participants: 103 mothers plus 103 children with IgE mediated FA. The analyses excluded two outliers comprising 101 subjects. For statistical analyses, each dyad –mother/child- was considered to be one subject unity. A between-subjects one-way ANOVA determined the association of children's cutaneous, gastric and respiratory symptoms with anxiety, depression, perceived social support and socioeconomic factors in the mothers.

Results: There are significant associations between children's allergic symptoms (gastric and cutaneous) and mothers' psychological state (anxiety and depression); family budget; social interactions (with friends, family and partner); understanding of health care required by their child; and sleep disorders. Respiratory symptoms did not show any significant associations with the dependent variables.

Conclusion: FA is a process in which children's symptoms are significantly associated with socioeconomic and psychological variables of the mothers. The presence or absence of some specific symptoms is directly associated with specific impacts on the mothers. An understanding of such dynamics supports the consideration of a comprehensive and multidisciplinary therapeutic approach to offer more ecological healthcare for “families living with FA.”

Knibb RC.  Why do people misdiagnose themselves with food hypersensitivity? An exploration of the role of biopsychosocial factors. [https://www.emjreviews.com/allergy-immunology/article/why-do-people-misdiagnose-themselves-with-food-hypersensitivity-an-exploration-of-the-role-of-biopsychosocial-factors/] Eur Med J/EMJ 2019; 4(1):30-37

Reasons for recommending the article:

The author tries to explain the large discrepancy between self-diagnosed food allergy or intolerance (up to 35% of people) and the real prevalence rate of clinically diagnosed food hypersensitivity (2-5% in the general population) through a biopsychosocial approach, integrating cultural factors, social context, food aversions, psychosomatic reactions, and biological interactions between stress, immune system and conditioning. 

Abstract:

Up to 35% of people self-diagnose food allergy or intolerance (food hypersensitivity [FH]), or diagnose it in their child, and self-manage the condition rather than seek a clinical diagnosis. This is much higher than the latest FH prevalence rate, estimated to affect 2–5% of the general population. The actual prevalence rate may be underestimated due to the lack of diagnostic services; however, this can only account for a small proportion of the discrepancy because only a small percentage of self-reported FH can be clinically confirmed. Many people are therefore misdiagnosing their or their child’s symptoms as FH and needlessly removing foods from their or their child’s diet. There are a number of possible reasons for this misdiagnosis, which can be considered from a biopsychosocial perspective. Psychological factors include a confusion over the diagnosis, coincidental pairing of food and symptom, psychological or psychosomatic reactions, and taste aversions. There are also biological mechanisms that have not been fully considered in food allergy research that may be relevant, such as conditioning of the immune system or stress responses. A social context pertains to a greater awareness of FH due to media coverage and changes in food labelling laws. Any of these theories are plausible, but the research to date has a number of methodological issues. Most studies report on small self-selected samples recruited from clinics and there is a lack of general population data. Studies also tend to be cross-sectional, which does not allow cause and effect to be established. Future research needs to include longitudinal designs that incorporate qualitative elements to enable a detailed exploration of reasons why people self and misdiagnose FH.

Yang EJ, Beck KM, Sekhon S, Bhutani T, Koo J.  The impact of pediatric atopic dermatitis on families: A review. [https://doi.org/10.1111/pde.13727]. Pedriatr Dermatol. 2019;36(1):66-71. doi: 10.1111/pde.13727. Epub 2018 Dec 16.

Reasons for recommending the article:

Severe, treatment‐resistant pediatric atopic dermatitis does have a psychosocial impact in the lives of both patients and their families: Child behavior, parent‐child relationship, parental psychosocial functioning, sleep, home environment and diet and meal preparation are often affected and may result in significant direct and indirect financial costs and pathologic family dynamics. Referring to mental health professionals could help to handle these psychosocial issues.

Abstract:

Background: Atopic dermatitis (AD) is an extremely common childhood disease, with considerable impact on the quality of life of affected children and their families. While pruritus is the hallmark symptom of this disease, AD has been well-documented to impact patients beyond physical symptoms, resulting in behavior problems, mood disorders, and sleep disturbance.

Objective: This literature review outlines how atopic dermatitis impacts the quality of life of families of children affected by AD.

Methods: A total of 3436 articles were identified via an online search of the MEDLINE health literature database and were screened for relevance to quality of life impacts on families with children affected by AD.

Results: Caring for children affected by AD can be an extremely time-consuming task that can impair personal relationships, decrease psychosocial functioning, and cause sleep loss among family members of affected patients. Additionally, AD may result in work absence or decreased work productivity for caregivers. Special diets, irritant and allergen avoidance strategies, and alternative therapies are commonly used by patients to manage their disease and require large amounts of family involvement.

Conclusions: Atopic dermatitis can greatly decrease quality of life of families of affected children in various domains, including sleep, finances, and relationships. Early intervention and psychotherapy may be needed in some patients to address these quality of life impairments.