An In-Depth Look at Asthma, a Mystery Disease of Sorts

By Dirk Hoffman

Thomas Ritz, PhD, University Distinguished Professor of psychology at Southern Methodist University in Dallas, was the featured speaker.

His talk, titled “Asthma: Insights Into the Mind-Body Relationship,” was presented Oct. 9 in the M&T Auditorium at the Jacobs School of Medicine and Biomedical Sciences.

Ritz received his doctoral degree from University of Hamburg, Germany, and worked as a postdoctoral fellow at the University of London, St. George’s Hospital Medical School, as well as Stanford University Medical School and the VA Palo Alto.

Following his habilitation and receipt of the venia legendi in Germany, he joined the Department of Psychology at SMU in 2005.

His research for more than 30 years has focused on the neuroscience and psychobiology of respiration, the psychosomatic medicine of respiratory disease and comorbid affective disorders.

Much of his work is interdisciplinary with colleagues in biology, chemistry, and medicine, with an emphasis on consolidating a basic research foundation for asthma management and translating basic findings into psychological, behavioral and lifestyle interventions for asthma and comorbid psychological disorders.

In ongoing research, he studies the role of the central nervous system in asthma, the prevention of stress-induced respiratory infections and the biologically informed treatments for anxiety and anhedonia.

“Asthma is kind of a mystery disease that defies predictions and lay assumptions. That excites researchers,” Ritz said at the beginning of his presentation. “Asthma is a chronic respiratory disease of the airways. It is complex and leads to recurrent symptoms.”

“It is not a trivial illness,” he said, noting that about 262 million people are affected worldwide.

“You can die from asthma. Every 69 seconds of the day, we have one death from asthma,” Ritz noted.

The prevalence rate of asthma for adults in the United States is around 7 to 8 percent, with somewhat higher rates for children.

Ritz noted that in addition to common triggers of symptoms such as air pollution, house dust, infection or physical activity, observational studies show 15 to 30 percent of patients experience psychological triggers such as emotions and stress, fear, anger and frustration.

He talked about some of the possible physical mechanisms associated with psychological triggers. In that, smooth muscles of airways, regulated by the autonomic nervous system, can constrict due to emotions.

His laboratory studies have indeed shown that airways constrict in response to emotions. In one of these, participants (24 asthmatic and 24 nonasthmatic patients) viewed short film sequences selected to induce anxiety, anger, depression, elation, happiness, contentment, or a neutral affective state.

Oscillatory resistance (a measure of airway constriction), heart rate, blood pressure, baroreflex sensitivity, skin conductance level, respiration rate and volume, and self-reported affective state were measured throughout the session.

The study found that various emotional states and stress increase oscillatory resistance largely independently of concurrent increases in ventilatory activity. 

“Anything that is emotional in any way actually increases airways constriction in asthma patients,” he said. When it comes to stressors, passively tolerating them does the same. On the other hand, dealing with stressors actively does not necessarily constrict the airways.

“Studies, including ours, found that longer lasting stress exacerbates airway inflammation and thus makes lung function worse.”

The stress cortisol response in asthma is complex, with individuals with asthma often showing lower basal cortisol levels compared to healthy individuals, which may contribute to chronic inflammation, Ritz noted.

“In one recent neuroimaging study we found that there may be a much stronger connection between brain activity and the airways in those with asthma than in healthy controls,” he said. “We found that to be very exciting and that might eventually lead us to a better explanation of emotion-induced asthma.”

Ritz noted there has been numerous studies on behavioral medicine interventions for asthma, but that the “efficacy of many treatments is not well established and only some show promise.”

“We have preliminary evidence that common behavior therapy helps in reducing anxiety in patients,” he said.

However, traditional relaxation therapy doesn’t really work all that well in asthma patients, Ritz noted.

“We found that muscle tension, not relaxation, may be recommended for improving lung function,” he said, noting that aerobic exercise can improve lung function, but not inflammation, and that breathing training may reduce hyperventilation.

In clinical trial results published in 2023, patients were randomly assigned to either Capnometry-Assisted Respiratory Training (CART) that raises partial pressure of carbon dioxide (PCO₂) by breathing slower and shallower or feedback to only slow their breathing (SLOW). Both treatments improved asthma control, and CART also improved some aspects of lung function and symptoms.

“For asthma patients with high anxiety, our brief training designed to raise PCO₂ resulted in significant and sustained reductions in anxiety sensitivity and negative affect compared with slow-breathing training,” Ritz said. “Potentially, this is a training that solves two things — improves asthma control and helps improve anxiety levels.”

Ritz noted ultimately there is “no one-size-fits-all” approach to behavioral medicine interventions for asthmatics.

“Airway response varies greatly between individuals,” he said.

“A somewhat simplified advice to a patient with asthma who is feeling that emotions lead to symptoms would be to first make sure they take their medication, that’s the most important part,” Ritz added. “And don’t stay passive, get active and get moving. Control your breath, don’t breathe too much.”

Ritz said that much more research is needed and noted that large multi-center clinical trials to test adjunctive behavioral treatments of asthma are necessary.

“We need to study the bidirectional relationship of asthma and the central nervous system,” he said. “We need to collaborate through interdisciplinary efforts of biomedicine and psychobiology and establish multidisciplinary teams in behavioral medicine of asthma.”

In her opening remarks, Allison Brashear, MD, MBA, UB’s vice president for health sciences and dean of the Jacobs School, noted that Ritz brought extraordinary depth and expertise to the topic at hand.

“He has been a leading voice in neuroscience, which is near and dear to my heart,” she said. “This lecture is very unique for a medical school to have and Dr. Ritz brings a strong foundation in translational work and basic science work and is really a bridger.”

The Golden Lectureship was founded in 2001 to expand the traditional medical model to a bio-psycho-social and spiritual model of care.

Named for cardiologist Lawrence Golden, MD, and his wife, longtime family therapist Nancy Golden, the lecture reinforces the Golden family’s longstanding commitment to mind-body medicine, which explores the interaction between the brain, the mind, body and spirit.

Nasir Khan, MD, clinical associate professor of medicine, led a Questions & Answers session following the lecture.

Members of the Golden family who were present for the lecture were Grant Golden, MD ’76; Catherine Golden, PhD; Pamela Golden and Holly Golden.