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doi: 10.1111/cea.

12138 Clinical & Experimental Allergy, 43, 1000–1008

© 2013 John Wiley & Sons Ltd

Perceived triggers of asthma: key to symptom perception and

T. Janssens1,2 and T. Ritz2
University of Leuven, Leuven, Belgium and 2Southern Methodist University, Dallas, TX, USA

Clinical Adequate asthma management depends on an accurate identification of asthma triggers.
& A review of the literature on trigger perception in asthma shows that individuals vary in
their perception of asthma triggers and that the correlation between self-reported asthma
Experimental triggers and allergy tests is only modest. In this article, we provide an overview of psy-
chological mechanisms involved in the process of asthma triggers identification. We iden-
Allergy tify sources of errors in trigger identification and targets for behavioural interventions
that aim to improve the accuracy of asthma trigger identification and thereby enhance
Thomas Janssens, Health Psychology,
Tiensestraat 102, Box 3726, 3000, asthma control.
Leuven, Belgium. E-mail: thomas.
Cite this as: T. Janssens and T. Ritz,
Clinical & Experimental Allergy, 2013
(43) 1000–1008.

psychological trigger impact is only moderate [9].

Although this discrepancy could be due to a lack of
Asthma and allergies are a major source of health prob- accuracy of the allergy test, this finding suggests that
lems. In Western and Westernized countries, prevalence patients may be unaware of all or some of their trig-
of physician diagnosed asthma is about 9–12% [1–3], gers, which may leave them uncertain about what the
while 28% report at least 1 type of diagnosed allergic dis- exacerbating factors of their disease are and about
order (e.g. asthma, food allergy, rhinitis, dermatitis [2]). which specific triggers to avoid, and could leave them
Allergic asthma and allergies have in common that symp- exposed to critical triggers repeatedly without protec-
toms occur in response to an allergic trigger (e.g. house tion. This way, they are presented with recurrent aver-
dust mite, pollen). In asthma, non-allergic triggers such sive somatic experiences that appear unpredictable and
as air pollution, cigarette smoke, perfume, stress, negative uncontrollable [10, 11]. Alternatively, patients with
emotions or physical activity may also trigger asthma asthma may attribute their respiratory symptoms to a
symptoms [4]. Management of asthma and allergies con- specific trigger despite the absence of a relationship
sists of pharmacological management, combined with between the trigger and actual airway obstruction. In
avoidance of triggers that cause symptom exacerbations other allergic conditions, such as food allergy, the dis-
[4, 5]. However, trigger avoidance interventions have cordance between perceived allergic triggers and trig-
shown mixed results, and systematic evaluations of inter- gers identified by atopy tests or provocation tests is
ventions that focus on a specific environmental control even worse [12, 13]. Misidentification of asthma trig-
measure for a specific trigger have shown only limited gers can lead to unnecessary avoidance of perceived
overall effects on symptoms and disease severity [6, 7]. triggers and thus restrictions in daily functioning and
Although it may be hard to generalize findings from impairments in quality of life. In asthma, a discrepancy
the wide variety of trigger avoidance interventions that between the perception of symptoms and actual lung
have been evaluated [8], we argue that one reason for function effects of benign daily life physical activity
the mixed success of trigger avoidance may be that [14] could be associated with the long-term risk of
individuals have difficulty identifying their personal forgoing the protective effect of exercise.
triggers. In patients with asthma, agreement between In this article, we will review the empirical evidence on
reported asthma triggers and actual tests of physical or trigger perception in asthma, outline psychological
Perceived triggers of asthma 1001

mechanisms that are involved in the identification of exacerbations, and a higher frequency of oral
allergens or asthma triggers, and identify potential corticosteroid use [9, 16]. Self-reported asthma triggers
sources of errors in trigger identification. We will con- are also associated with more primary care visits and
clude the review with potential targets for interventions emergency room visits, as well as a higher rate of hos-
that aim to improve accurate trigger identification and pitalization [9, 16]. Moreover, patients with a higher
thus enhance patients’ perception of their disease number of asthma triggers had a greater chance of
activity. relapse defined as urgent or unscheduled physician
visits in the 2 weeks after an emergency room visit [15].
Demographic variables appear to moderate asthma
Perceived triggers of asthma: measurement, structure
trigger reports. Consistently, female patients report
and association with asthma outcomes
more asthma triggers than male asthma patients [16,
Despite the importance of trigger perception in asthma 17, 19]. Higher education levels are associated with the
management, only few studies have investigated patients’ report of fewer asthma triggers [9, 19], although the
self-report of asthma triggers. These studies have been latter association is not always found [16]. Similarly,
carried out in a variety of settings and differ in method- evidence for a relationship with race or ethnicity of
ology, making it difficult to compare their results. In participants is still equivocal [9, 16].
absence of a more established research base, we will try Studies that have examined the association of differ-
to distil some general findings from these studies.1 ent types of triggers with asthma and other health out-
The number of asthma triggers that is reported by comes found that self-report of animals as asthma
patients in different studies varies widely, ranging from triggers is related a lower age of asthma onset [9, 16,
4 to 12 [15–17]. Differences in the number of triggers 19]. Self-report of exercise as an asthma trigger is asso-
reported across studies may be a function of the ques- ciated with obesity [16, 20]. Emotional triggers (e.g.
tions that are used to elicit personal trigger reports, stress, intense emotions) are associated with more
with the number of triggers being evaluated ranging severe asthma, occurrence of night-time symptoms and
from 9 to 32 [9, 15–17]. To assess asthma triggers in a oral corticosteroid use [9, 17, 19]. Furthermore, emo-
standardized form, studies have attempted to develop tional triggers are linked to a decrease in quality of life
measures to probe patients’ trigger perceptions. An ear- and increased anxiety and depression [16, 19]. In gen-
lier instrument, the Asthma Trigger Index, [18] was spe- eral, trigger domains of allergic vs. non-allergic triggers
cifically developed to evaluate emotional triggers of appear to be relatively independent from each other
asthma. It consisted of a list of potential triggers and a and are associated differentially with demographics,
series of situation vignettes linked to emotional experi- asthma manifestations and outcomes [9, 19].
ences. Although the instrument was reported to have a When comparing two studies that used the ATI to
high test-retest reliability and good content validity, investigate asthma triggers in different countries, Britain
results of a psychometric evaluation have never been [9] and Germany [19], we noticed some differences in the
published. More recently, the Asthma Trigger Inventory relationship between ATI subscales and specific demo-
(ATI) [9] has been developed to assess a broad spectrum graphics or disease-related variables (e.g. gender differ-
of asthma triggers in a standardized way. It is a 32-item ences in the report of air pollution and infections as
questionnaire, consisting of seven subscales measuring asthma triggers). On the other hand, consistent associa-
trigger domains of pollen allergens, animal allergens, tions with a standardized asthma symptom exacerbation
physical activity, air pollution/irritants, infections and measure, the asthma symptom checklist [21] were ob-
psychological factors. All domain scales have a high served, in that psychological asthma triggers were linked
internal consistency and test-retest reliability. to hyperventilation symptoms [22]. In terms of the struc-
Despite the variation in the assessment of self- ture of trigger report, remarkable consistency was uncov-
reported asthma triggers, some general findings can be ered with British [9] and German [19] adult asthma
drawn from this literature. Self-reported asthma triggers patients as well as children with asthma in the United
are associated with disease severity and impact. Patients States [23]. The ATI subdomains of trigger perception
with a higher number of asthma triggers report less were also readily identified in an Indonesian sample of
quality of life [16]. Furthermore, a higher number of adult asthma patients using the 32-item set of the ATI,
self-reported asthma triggers is correlated with physi- but discrepancies appeared when the item pool was
cian ratings of more severe asthma [9, 17, 19], more expanded and factors associated with regional specifics,
such as weather conditions and specific aeroallergens,
emerged [24]. These findings suggest both cross-cultural
The search for articles on trigger perception was conducted in Google
consistencies and variations in the perception of asthma
Scholar, using the search term asthma trigger perception OR identification, triggers. More inconsistencies exist in form of culturally
and by identifying papers that cited to key articles identified by our search. idiosyncratic trigger beliefs, such as exposure to cold

© 2013 John Wiley & Sons Ltd, Clinical & Experimental Allergy, 43 : 1000–1008
1002 T. Janssens & T. Ritz

foods in south Asian cultures, or imbalances in hot and allergy skin test results. The association between per-
cold elements often endorsed in Guatemala and Mexico, ceived allergens and skin prick test weal sizes is some-
which are often tied to specific traditional remedies times stronger for triggers with a clearer phenomenal
for asthma that are thought to alleviate these effects [25, presentation, such as cats and dogs, than for less distinct
26]. triggers, such as pollen or moulds [9, 30]. Similarly, the
The variation in self-reported asthma triggers and availability of a potent trigger that is easy to perceive
association of different asthma triggers with different may explain why smokers report fewer asthma triggers,
demographic variables and disease outcome require fur- especially allergic asthma triggers, compared to non-
ther study. Although some of this variation could be smokers [9, 16].
explained by the existence of different asthma pheno- Prior knowledge and beliefs about potential asthma
types (e.g. an adult-onset non-allergic phenotype vs. triggers and their occurrence may help identify asthma
early onset atopic asthma [27], other parts of this varia- triggers that are hard to perceive, whereas a lack of
tion may be clarified by examining the psychological knowledge about potential asthma triggers may hinder
processes involved in asthma trigger identification. perception of triggers. Patients with greater knowledge
about asthma report a higher number of asthma triggers
[16], whereas lack of information about the role of mould
Mechanisms of asthma trigger identification
or cockroaches as asthma triggers may hinder their per-
Asthma trigger identification is a complex task. It ception as personally relevant asthma triggers [30–32].
requires perception of asthma symptoms, perception of Furthermore, given the large inter-individual variability
potential asthma triggers, and perception of a contin- in asthma triggers and allergic triggers [9, 33], knowledge
gency or causal relationship between potential asthma and beliefs about common asthma triggers may both help
triggers and symptoms (cf. Fig. 1). Each of these com- and hinder identification of personal asthma triggers,
ponents of trigger identification is associated with spe- depending on whether general knowledge of asthma trig-
cific challenges. Furthermore, the components are not gers matches personal susceptibilities.
fully independent, as each of the components exerts an
influence on the others. In paediatric asthma, the task
Perception of asthma symptoms
of trigger identification may be further complicated by
potential parent–child discordances on each of these The perception of asthma symptoms occurs when
components [28, 29]. changes in somatosensory information are detected and
matched to mental models of asthma symptoms [34,
35]. In this process, several factors have been identified
Perception of triggers and their identification as
that may cause a divergence between the level of bron-
choconstriction and the level of perceived asthma
Many potential asthma triggers, such as pollen, house symptoms. For example, a person may be unable to
dust mite, mould, small particulate matter or respiratory detect changes in respiratory resistance, and the result-
viruses, do not have a phenomenal appearance that is ing absence of asthma symptoms increases the risk of
easy to perceive. Therefore, presence of these triggers is near-fatal asthma [36] and may also hinder a person to
often inferred from the occurrence of cues that are asso- perceive a contingency between airway obstruction and
ciated with these triggers, such as trees in summer, dust, environmental factors that triggers the obstruction.
damp indoor spaces, diesel smell or the occurrence phys- Furthermore, concurrent affect or contextual informa-
ical symptoms that are indicative of upper respiratory tion may also interfere with the accurate perception of
infections. This difficulty reflects for example on the asthma symptoms [37–41]. Experimental studies have
association between perceived allergic triggers and shown that contextual information that is related to

Perception of Perception of Perception of

triggers trigger-Symptom contingencies asthma symptoms

Key determinants: Key determinants: Key determinants:

• Phenomenal appearance • Symptom intensity/unpleasantness • Interoceptive difficulties
• Potency • Expectancies/learning mechanisms • Affect
• Knowledge & beliefs • Concurrent potential triggers • Contextual information
• Temporal characteristics • Memory

Fig. 1. Key determinants of asthma trigger identification.

© 2013 John Wiley & Sons Ltd, Clinical & Experimental Allergy, 43 : 1000–1008
Perceived triggers of asthma 1003

previous experience with asthma triggers can lead to trigger and respiratory symptoms. In laboratory experi-
the perception of asthma symptoms in absence of the ments, prior expectancies have been shown to guide
original asthma trigger [42], whereas being in a situa- perceived contingencies and symptom reports, even
tion that is perceived as unrelated to asthma may also when an objective contingency between the potential
reduce the perception of asthma symptoms [43]. Also, trigger and respiratory symptoms was absent [54].
other factors such as memory, personality, gender and Related research on anxiety disorders suggests that the
cultural norms have been shown to influence percep- effect of prior expectancies may be dependent on fear
tion and report of asthma symptoms [35, 44, 45]. levels. Whereas individuals show an increased expec-
Similar to perception of asthma symptoms, percep- tancy of a negative event following fear-relevant (e.g.
tion of other physical symptom, such as symptoms pictures of spiders) vs. fear-irrelevant (e.g. pictures of
linked to upper respiratory tract infections, is also cor- mushrooms) pictures, only in high fearful individuals,
related with personality characteristics and may also this expectancy persists after repeated confrontation
lack accordance with objective disease criteria [46, 47]. with situations wherein presentation of these pictures is
However, information about the role of perception of non-contingent with the aversive outcome [55]. Fear
upper respiratory tract infections in asthma manage- and anxiety also promote other inaccurate perceptions
ment is currently lacking. of contingencies that may be especially relevant for
These examples show that perception of respiratory asthma trigger identification. For example, individuals
symptoms is a complex process that is prone to inaccu- with panic disorder show an overgeneralized fear
racies. It is therefore unsurprising that inaccurate per- response when confronted with cues that share percep-
ception of asthma symptoms is a widespread problem, tual similarity with a known fear cue [56]. Furthermore,
with an estimated prevalence of 15–60%, depending on after confrontation with a contingency between a cue A
the methodology that is used to assess it [35]. As accu- and an unpleasant outcome, and confrontation with a
rate perception of asthma symptoms is a prerequisite contingency between a compound cue AB and an
for accurate identification of asthma triggers, this may unpleasant outcome, anxious individuals show sus-
further complicate the identification of asthma triggers. tained fear to element B, even though confrontation
with cue A and compound cue AB resulted in the same
aversive outcome [57]. Thus, anxious individuals do not
Perception of contingencies between triggers and
learn that one of the elements of the compound cue
AB, the cue B, is unrelated to the aversive outcome.
Accurate identification of asthma triggers is dependent on This observation is particularly relevant to the percep-
the accurate perception of a contingency between the trig- tion of asthma triggers as many asthma triggers may
ger and asthma symptoms. Humans and animals can be co-occur in complex stimulus configurations, which
very adept at identifying contingencies and rely on this may lead individuals to experience asthma symptoms
ability to reduce uncertainty and unpredictability in their when confronted with individual elements of the com-
environment [48]. In asthma and allergies, contingency pound stimulus. For example, confrontation with
perception is used to predict and avoid onset of asthma asthma symptoms in response to physical exercise may
symptoms. However, contingency perception is often cause high anxious individuals to perceive co-occurring
biased. Several studies have shown that perceived inten- cues, such as particular aspects of the environment in
sity or unpleasantness of an event is associated with an which the exercise takes place, as an asthma trigger,
overestimation of the contingency between this event and even if physical exercise alone (e.g. on a treadmill)
preceding cues [49–51]. Because perceived unpleasant- would cause the same amount of asthma symptoms. In
ness and contingency perception are associated, this may low-anxious individuals, the perception of physical
also explain the discrepancy between self-reported allergy exercise as a trigger would ‘block’ the perception of the
symptoms vs. their diagnosis and treatment [52]. Indeed, exercise context as an asthma trigger.
in a survey on under-diagnosis and under-treatment of These examples suggest that confrontation with an
allergic rhinitis, patients reported that they have had aversive outcome may lead to the adoption of a ‘better
symptoms for quite some time, but only started seeking safe than sorry’ approach, especially in persons with
diagnosis and treatment when their symptoms became asthma that are highly fearful or have comorbid anxi-
intolerable [53]. If individuals with rhinitis perceive their ety disorders. The prevalence of anxiety disorders is
symptoms to be present yet of little importance, this may higher in persons with asthma compared to the general
not only lead to under-diagnosis and under-treatment, population [58].
but may also leave these individuals less inclined to Other biases may occur in depressed individuals with
identify and avoid triggers of their symptoms. asthma. Research on cognitive bias in depression shows
Prior expectancies or beliefs can also have an influ- that depressed individuals are less prone to inflating
ence on the perceived relationship between a potential contingencies when there is no objective contingency

© 2013 John Wiley & Sons Ltd, Clinical & Experimental Allergy, 43 : 1000–1008
1004 T. Janssens & T. Ritz

between a cue and an outcome [59]. However, increased attention to environmental asthma-specific
depressed individuals do exhibit an underestimation of cues may help identification of asthma triggers, but there
contingency, especially in situations where control is is also a risk of biased contingency perception if inflam-
important [60], which could lead to a reduction in the mation directs attention to asthma-specific cues that are
ability to detect asthma-trigger contingencies in indi- present but not involved in the airway response. Further-
viduals with asthma and comorbid depression. Experi- more, prior beliefs may interact with the effect of inflam-
mental inductions of non-contingency or lack of mation on attention to potential triggers.
control (learned helplessness) have similar effects on
subsequent contingency ratings and task performance
Bronchoconstriction due to trigger perception
[61], and individuals with asthma are more susceptible
to these effects (impaired problem solving after a Perception of an environmental agent as an asthma
learned helplessness induction) compared to matched trigger or suggestion that an pharmacological agent is
controls [62]. an asthma trigger not only can elicit the perception of
Beyond cognitive biases, actual bronchoconstriction asthma symptoms but also can lead to an increase in
due to emotional states [63] may be present in anxiety bronchoconstriction, as the large literature on sugges-
disorders and depression, which might enhance the per- tion-induced bronchoconstriction shows [72]. Although
ception of contingencies between psychological triggers the effect of suggestion on bronchoconstriction and
and resulting symptoms, or contribute to bronchocon- symptom perception appear to occur independently
striction elicited by other triggers and therefore enhance [73], both effects can be conceptualized as feed-forward
their perception. mechanisms, motivating a person to obtain away from
Temporal characteristics of the allergic response may this context before more damage occurs. These feed-for-
further complicate the accurate perception of trigger- ward mechanisms may be involved in the maintenance
symptom contingencies. Allergic reactions consist of of perceived trigger-symptom contingencies, which in
both an acute (within minutes after exposure) as well as turn may have an impact on asthma-related quality of
a late-phase response (4–24 hours after initial exposure) life and may interfere with adequate self-management
[64], which means that by the time the late response of asthma. Furthermore, there are large individual dif-
occurs it may not be easy to determine what triggered ferences in the effect of suggestions on symptom
the response originally. Indeed, a decrease in lung func- experience and bronchoconstriction [72]. Further inves-
tion during the late-phase response is perceived as less tigation of these individual differences may also aide
intense compared to a similar decrease in lung function our understanding of asthma trigger perception.
during the acute phase [65]. In contrast, the airway
constriction to emotional triggers happens while
Potential interventions
exposed to the trigger, thus providing a much better
condition for perceiving trigger-symptom contingencies The effects of suggestion on bronchoconstriction and
[66]. Consequently, reports of psychological asthma symptom perception, as well as the role of contextual
triggers in daily life have been linked to stronger bron- information and trigger beliefs on symptom perception,
choconstriction to emotionally aversive laboratory stim- suggest that interventions that try to modify trigger
uli [9, 66, 67] Furthermore, allergic reactions to specific information or trigger beliefs can be used to correct
triggers have been known to change during the lifetime inaccurate perception of asthma symptoms [35]. Educa-
response in later life [68]. This implies that previous tion about potential triggers (e.g. allergens, irritants,
knowledge about individually relevant asthma triggers respiratory infections) is an essential part of asthma
may become inaccurate when the sensitivity to specific management (GINA, 2010). Asthma education pro-
triggers changes. grammes, which include education about asthma trig-
Activation of the immune system may be involved in gers and environmental control measures have been
the perception of trigger-symptom contingencies. shown to improve clinical outcomes (hospitalizations,
Although no study has directly investigated the effects of emergency room visits, unscheduled doctor visits) and
inflammation on contingency perception, stronger quality of life [74], with newer programmes tailoring
inflammatory responses to allergen provocation have information to patient needs [75, 76].
been found in periods of stress [69], which could make it However, in day to day allergy care, problems may
easier to perceive trigger-symptom contingencies. Fur- occur that can interfere with optimal asthma trigger
thermore, increased immune activation is also associated management. Although clinicians often inquire about
with attention for and avoidance of disease-related cues potential asthma triggers during appointments, education
[70]. Asthma patients also show a specific association of about triggers and environmental control measures is less
airway inflammation and attention for asthma-specific frequent [77]. In addition, patients often have difficulty
cues, but not for general negative cues [71]. This carrying out environmental control measures, or may be

© 2013 John Wiley & Sons Ltd, Clinical & Experimental Allergy, 43 : 1000–1008
Perceived triggers of asthma 1005

hindered by the cost of some of these measures [78]. More ware of crucial asthma triggers [30]. However, given the
problematic is that about half of the environmental con- limited data that is available, more research on trigger
trol measures that are carried out by patients are unlikely identification interventions and integration of these
to be beneficial on the basis of current guidelines [79]. methods in routine clinical care is definitely needed.
A further potential problem with trigger education Interventions that are aimed at increasing accuracy of
and inquiry is that alerting participants to potential trigger identification may be especially beneficial for cer-
asthma triggers may promote unwarranted generaliza- tain subgroups of individuals with asthma. For example,
tion of asthma triggers. Indeed, knowledge about individuals that are susceptible to respiratory infections
asthma is associated with a larger number of self- may benefit more due to the synergistic effects of aller-
reported asthma triggers [16] and experimental research gen exposure and respiratory infections on asthma exac-
has shown that informing participants about the danger erbations [84]. Moreover, persons with comorbid asthma
of environmental agents promotes learned symptom and panic disorder may benefit from interventions aimed
responses [80]. A thorough evaluation of potential at correcting inaccurate asthma trigger beliefs, as these
asthma triggers, including objective allergen tests may persons may fail to differentiate between triggers of
therefore help to identify asthma triggers that the asthma symptoms and triggers of panic [85]. Information
patient was previously unaware of and correct errone- about differences between asthma and panic symptoms
ous trigger beliefs that erroneous symptom-trigger asso- has been included in a pilot trial for treatment of asthma
ciations. For non-allergic triggers, monitoring of and panic disorder that has shown promising results [86].
triggers, peak expiratory flow and asthma symptoms in Furthermore, misidentification of asthma triggers that is
daily life may help to detect previously unidentified associated with anxiety of fear about asthma triggers
and misidentified asthma triggers [81]. To improve par- may benefit from treatment strategies that are adapted
ticipation in physical exercise, it may be important to from the treatment of anxiety and fear. In anxiety disor-
provide patients with a clear plan that includes type of ders, the success of exposure therapy has shown that
exercise and measures patients can take to reduce the repeated exposure to fear-eliciting cues during treatment
occurrence of asthma symptoms [82]. is one of the most effective ways to reduce fear [87]. In a
The improvement of asthma trigger management in similar fashion, we expect that a treatment that exposes
routine clinical care also remains a challenge. One patients to misidentified asthma triggers may result in a
descriptive study of urban paediatric clinic visits sug- reduction in potential anxieties that are associated with
gested that less than half of the parents received advice these triggers and in a reduction in asthma symptoms
about environmental triggers and control measures that are associated with these misidentified triggers. Ide-
[83]. Based on this and other shortcomings reported by ally, such a treatment would be preceded by a thorough
clinicians and patients [77–79], it would be advisable identification of perceived asthma triggers using moni-
for clinicians to routinely inquire about potential toring in daily life, lung function testing and allergy
triggers and tailor information about triggers and diagnosis, but due to practical limitations (e.g. the avail-
environmental control methods to patient needs. Non- ability of trigger challenge chambers) more limited inter-
adherence to environmental control measures may be ventions will probably have a better chance at being
avoided when they are easy to implement and follow- implemented in routine clinical care.
up (e.g. simple steps as part of an asthma action plan).
Furthermore, clinicians would need to be mindful about
inaccurate trigger beliefs and use of ineffective trigger
control methods. Accurate identification of asthma triggers often is a pre-
One way to tailor information to patient needs is the requisite for adequate asthma management. However, so
combination of allergy skin prick tests with trigger evalu- far, research on the identification of asthma triggers has
ation and education, which has been shown to result in not received sufficient attention. Problems with the per-
the identification of discrepancies between asthma trigger ception of asthma symptoms and asthma triggers as well
beliefs and allergic response, an increase in the relation- as difficulties perceiving contingencies between triggers
ship between specific allergic sensitization and trigger- and symptoms may hinder accurate identification of
specific avoidance measures and improvement of lung asthma triggers. Beliefs about asthma triggers can both
function, compared to a limited intervention control help and hinder the identification of trigger-symptom
group [30]. Furthermore, patients receiving a trigger eval- contingencies. Lack of knowledge about an important
uation intervention, who did not report animal triggers asthma trigger may lead to a failure to identify this
among their top triggers at baseline, showed an increase trigger as a personally relevant asthma trigger. Beliefs
in perceived animal-related triggers at follow-up, sug- about asthma triggers can also lead to misidentification
gesting that this type of asthma trigger education may be of asthma triggers, although further research into the role
especially beneficial for persons that were previously una- of anxiety and fear in this misidentification is needed.

© 2013 John Wiley & Sons Ltd, Clinical & Experimental Allergy, 43 : 1000–1008
1006 T. Janssens & T. Ritz

Finally, perceived asthma triggers can elicit the percep-

tion of asthma symptoms and/or elicit bronchoconstric-
tion, which may further complicate the accurate Dr Janssens is supported by grant PDMK/11/062 of the
identification of asthma triggers. The role of beliefs about KU Leuven Research Fund and a travel grant of the
asthma triggers in asthma trigger identification makes Research Foundation – Flanders (FWO). Preparation of
them a key target for interventions that are aimed at this manuscript was partly funded by a National Insti-
improving identification of asthma triggers. We have tutes of Health/National Heart, Lung and Blood Institute
identified educational interventions, daily life monitor- grant, R01 HL-089761 to Dr Ritz.
ing, and exposure to perceived asthma triggers as inter-
ventions that may change trigger beliefs, but further
Conflicts of interest
research is needed to evaluate these interventions
and study the ways in which they can improve asthma The authors declare that no conflict of interest exists.

naire for perceived triggers of asthma. 18 Janson-Bjerklie S, Boushey HA, Carri-

References Psychosom Med 2006; 68:956–65. eri VK, Lindsey AM. Emotionally trig-
1 Brogger J, Bakke P, Eide GE, Johansen 10 Gillissen A. Managing asthma in the gered asthma as a predictor of airway
B, Andersen A, Gulsvik A. Long-term real world. Int J Clin Pract 2004; response to suggestion. Res Nurs
changes in adult asthma prevalence. 58:592–603. Health 1986; 9:163–70.
Eur Respir J 2003; 21:468–72. 11 Caress A-L, Luker K, Woodcock A, 19 Ritz T, Kullowatz A, Kanniess F, Dah-
2 Brown CW, Hawkins L. Allergy preva- Beaver K. An exploratory study of pri- me B, Magnussen H. Perceived triggers
lence and causal factors in the domes- ority information needs in adult of asthma: evaluation of a German
tic environment: results of a random asthma patients. Patient Educ Couns version of the asthma trigger inven-
population survey in the United 2002; 47:319–27. tory. Respir Med 2008; 102:390–8.
Kingdom. Ann Allergy Asthma Immu- 12 Niestijl Jansen JJ, Kardinaal AFM, 20 Wright A, Lavoie KL, Jacob A, Rizk A,
nol 1999; 83:240–4. Huijbers G, Vlieg-Boerstra BJ, Martens Bacon SL. Effect of body mass index on
3 Akinbami LJ, Moorman JE, Liu X. BPM, Ockhuizen T. Prevalence of food self-reported exercise-triggered asthma.
Asthma prevalence, health care use, allergy and intolerance in the adult Phys Sportsmed 2010; 38:61–6.
and mortality: United States, 2005– Dutch population. J Allergy Clin 21 Kinsman RA, Luparello T, O’Banion K,
2009. Hyattsville, MD: National Center Immunol 1994; 93:446–56. Spector S. Multidimensional analysis of
for Health Statistics, 2011. 13 Rona RJ, Keil T, Summers C et al. The the subjective symptomatology of asthma.
4 Global Initiative for Asthma (GINA). prevalence of food allergy: a meta- Psychosom Med 1973; 35:250–67.
Global strategy for asthma management analysis. J Allergy Clin Immunol 2007; 22 Ritz T, Kullowatz A, Bobb C et al. Psy-
and prevention, 2010. Available from: 120:638–46. chological triggers and hyperventila- 14 Ritz T, Rosenfield D, Steptoe A. Physical tion symptoms in asthma. Ann Allergy
5 Van Cauwenberge P, Bachert C, activity, lung function, and shortness of Asthma Immunol 2008; 100:426–32.
Passalacqua G et al. Consensus state- breath in the daily life of individuals 23 Wood BL, Cheah PA, Lim J et al. Reli-
ment on the treatment of allergic rhi- with asthma. Chest 2010; 138:913–8. ability and validity of the Asthma
nitis. Allergy 2000; 55:116–34. 15 Emerman CL, Woodruff PG, Cydulka Trigger Inventory applied to a pediatric
6 Gøtzsche PC, Johansen HK. House dust RK, Gibbs MA, Pollack CV, Camargo population. J Pediatr Psychol 2007;
mite control measures for asthma. CA. Prospective multicenter study of 32:552–60.
Cochrane Database of Syst Rev 2008; relapse following treatment for acute 24 Zeni SG, Yuniarti KW, von Leupoldt A,
CD001187. doi: 10.1002/14651858. asthma among adults presenting to the Dahme B, Ritz T. Structure and psycho-
CD001187.pub3. emergency department. Chest 1999; metric properties of an Indonesian ver-
7 Custovic A, van Wijk RG. The effec- 115:919–27. sion of the Asthma Trigger Inventory.
tiveness of measures to change the 16 Peterson MGE, Gaeta TJ, Birkhahn 67th Annual Scientific Meeting of the
indoor environment in the treatment RH, Fernandez JL, Mancuso CA. His- American Psychosomatic Society. Chi-
of allergic rhinitis and asthma: ARIA tory of symptom triggers in patients cago, IL: Psychosomatic Medicine,
update (in collaboration with presenting to the emergency depart- 2009.
GA2LEN). Allergy 2005; 60:1112–5. ment for asthma. J Asthma 2012; 25 Griffiths C, Kaur G, Gantley M et al.
8 Platts-Mills TAE. Allergen avoidance 49:629–36. Influences on hospital admission for
in the treatment of asthma: problems 17 G€ € C
oksel O, ß elik GE, Erkekol FO, G€ull€
u asthma in south Asian and white
with the meta-analyses. J Allergy Clin E, Mungan D, Mısırlıgil Z. Triggers in adults: qualitative interview study.
Immunol 2008; 122:694–6. adult asthma: are patients aware of BMJ 2001; 323:962.
9 Ritz T, Steptoe A, Bobb C, Harris AHS, triggers and doing right? Allergol 26 Pachter LM, Weller SC, Baer RD et al.
Edwards M. The asthma trigger Immunopathol (Madr) 2009; 37: Variation in asthma beliefs and prac-
inventory: validation of a question- 122–8. tices among mainland Puerto Ricans,

© 2013 John Wiley & Sons Ltd, Clinical & Experimental Allergy, 43 : 1000–1008
Perceived triggers of asthma 1007

Mexican-Americans, Mexicans, and 38 Meek PM. Influence of attention and 50 Janssens T, Van den Bergh O. Per-
Guatemalans. J Asthma 2002; 39: judgment on perception of breathless- ceived Symptom Intensity is Associated
119–34. ness in healthy individuals and with Perceived Predictability of Respi-
27 Haldar P, Pavord ID, Shaw DE et al. patients with chronic obstructive pul- ratory Symptoms. Poster presented at
Cluster analysis and clinical asthma monary disease. Nurs Res 2000; the 24th Annual Convention of the
phenotypes. Am J Respir Crit Care 49:11–9. Association for Psychological Science.
Med 2008; 178:218–24. 39 Wilson RC, Jones PW. Influence of Chicago, IL, 2012.
28 Lara M, Duan N, Sherbourne C et al. prior ventilatory experience on the 51 Sarinopoulos I, Grupe DW, Mackiewicz
Differences between child and parent estimation of breathlessness during KL et al. Uncertainty during anticipa-
reports of symptoms among Latino exercise. Clin Sci 1990; 78:149–53. tion modulates neural responses to
children with asthma. Pediatrics 1998; 40 Main J, Moss-Morris R, Booth R, aversion in human insula and amyg-
102:e68. Kaptein AA, Kolbe J. The use of relie- dala. Cereb Cortex 2010; 20:929–40.
29 Yoos HL, Kitzman H, McMullen A, Si- ver medication in asthma: the role of 52 Nolte H, Nepper-Christensen S, Backer
dora K. Symptom perception in child- negative mood and symptom reports. V. Unawareness and undertreatment of
hood asthmas: how accurate are J Asthma 2003; 40:357–65. asthma and allergic rhinitis in a gen-
children and their parents? J Asthma 41 von Leupoldt A, Riedel F, Dahme B. eral population. Respir Med 2006;
2003; 40:27–39. The impact of emotions on the per- 100:354–62.
30 Bobb C, Ritz T, Rowlands G, Griffiths ception of dyspnea in pediatric 53 Maurer M, Zuberbier T. Undertreatment
C. Effects of allergen and trigger factor asthma. Psychophysiology 2006; 43: of rhinitis symptoms in Europe: findings
avoidance advice in primary care on 641–4. from a cross-sectional questionnaire
asthma control: a randomized- 42 De Peuter S, Put C, Lemaigre V, Demedts survey. Allergy 2007; 62:1057–63.
controlled trial. Clin Exp Allergy 2010; M, Verleden G, Van den Bergh O. Con- 54 Devriese S, Winters W, Diest I et al.
40:143–52. text-evoked overperception in asthma. Perceived relation between odors and a
31 Li JTC, Andrist D, Bamlet WR, Wol- Psychol Health 2007; 22:737–48. negative event determines learning of
ter TD. Accuracy of patient predic- 43 Rietveld S, van Beest I. Rollercoaster symptoms in response to chemicals. Int
tion of allergy skin test results. Ann asthma: when positive emotional stress Arch Occup Environ Health 2004;
Allergy Asthma Immunol 2000; interferes with dyspnea perception. 77:200–4.
85:382–4. Behav Res Ther 2006; 45:977–87. 55 Davey GCL. Preparedness and phobias:
32 Saengpanich S, Chochaipanitnon L, 44 Fritz GK, McQuaid EL, Kopel SJ et al. specific evolved associations or a gen-
Auemjaturapat S, Supiyaphun P. Accu- Ethnic differences in perception of eralized expectancy bias. Behav Brain
racy of patients’ prediction in peren- lung function: a factor in pediatric Sci 1995; 18:289–325.
nial allergic rhinitis. Chula Med J asthma disparities? Am J Respir Crit 56 Lissek S, Rabin S, Heller R et al. Over-
2004; 48:531–8. Care Med 2010; 182:12–8. generalization of conditioned fear as a
33 Heinzerling LM, Burbach GJ, Edenharter 45 Watson D, Pennebaker JW. Health pathogenic marker of panic disorder.
G et al. GA2LEN skin test study I: complaints, stress, and distress: explor- Am J Psychiatry 2010; 167:47–55.
GA2LEN harmonization of skin prick ing the central role of negative affec- 57 Boddez Y, Vervliet B, Baeyens F,
testing: novel sensitization patterns for tivity. Psychol Rev 1989; 96:234–54. Lauwers S, Hermans D, Beckers T.
inhalant allergens in Europe. Allergy 46 Van Diest I, De Peuter S, Eertmans A, Expectancy bias in a selective condi-
2009; 64:1498–506. Bogaerts K, Victoir A, Van den Bergh O. tioning procedure: trait anxiety
34 Brown RJ. Psychological mechanisms Negative affectivity and enhanced increases the threat value of a blocked
of medically unexplained symptoms: symptom reports: differentiating stimulus. J Behav Ther Exp Psychiatry
an integrative conceptual model. Psy- between symptoms in men and women. 2012; 43:832–7.
chol Bull 2004; 130:793–812. Soc Sci Med 2005; 61:1835–45. 58 Weiser E. The prevalence of anxiety
35 Janssens T, Verleden G, De Peuter S, 47 Cohen S, Doyle WJ, Skoner DP, Fire- disorders among adults with asthma: a
Van Diest I, Van den Bergh O. Inaccu- man P, Gwaltney JM, Newsom JT. meta-analytic review. J Clin Psychol
rate perception of asthma symptoms: a State and trait negative affect as pre- Med Settings 2007; 14:297–307.
cognitive-affective framework and dictors of objective and subjective 59 Alloy LB, Abramson LY. Judgment of
implications for asthma treatment. Clin symptoms of respiratory viral infec- contingency in depressed and nonde-
Psychol Rev 2009; 8:211–9. tions. J Pers Soc Psychol 1995; pressed students: Sadder but wiser? J
36 Davenport PW, Cruz M, Stecenko AA, 68:159–69. Exp Psychol Gen 1979; 108:441–85.
Kifle Y. Respiratory-related evoked 48 Alloy LB, Tabachnik N. Assessment of 60 Abramson LY, Alloy LB, Rosoff R.
potentials in children with life-threat- covariation by humans and animals: Depression and the generation of com-
ening asthma. Am J Respir Crit Care the joint influence of prior expecta- plex hypotheses in the judgment of
Med 2000; 161:1830–5. tions and current situational informa- contingency. Behav Res Ther 1981;
37 Affleck G, Apter A, Tennen H et al. tion. Psychol Rev 1984; 91:112–49. 19:35–45.
Mood states associated with transitory 49 Grupe DW, Nitschke JB. Uncertainty is 61 Abramson LY, Seligman ME, Teasdale
changes in asthma symptoms and peak associated with biased expectancies JD. Learned helplessness in humans:
expiratory flow. Psychosom Med 2000; and heightened responses to aversion. critique and reformulation. J Abnorm
62:61–8. Emotion 2011; 11:413–24. Psychol 1978; 87:49–74.

© 2013 John Wiley & Sons Ltd, Clinical & Experimental Allergy, 43 : 1000–1008
1008 T. Janssens & T. Ritz

62 Chaney JM, Mullins LL, Uretsky DL, asthma symptom exacerbation. Proc 79 Cabana MD, Slish KK, Lewis TC et al.
Pace TM, Werden D, Hartman VL. An Natl Acad Sci U S A 2005; Parental management of asthma trig-
experimental examination of learned 102:13319–24. gers within a child’s environment. J
helplessness in older adolescents and 72 Isenberg SA, Lehrer PM, Hochron S. Allergy Clin Immunol 2004; 114:
young adults with long-standing The effects of suggestion and emo- 352–7.
asthma. J Pediatr Psychol 1999; tional arousal on pulmonary function 80 Winters W, Devriese S, Van Diest I
24:259–70. in asthma: a review and a hypothesis et al. Media warnings about environ-
63 Ritz T. Airway responsiveness to psy- regarding vagal mediation. Psychosom mental pollution facilitate the acquisi-
chological processes in asthma and Med 1992; 54:192–216. tion of symptoms in response to
health. Front Physiol 2012; 3:343. 73 Put C, Van den Bergh O, Van Ongeval E, chemical substances. Psychosom Med
64 Skoner DP. Allergic rhinitis: definition, De Peuter S, Demedts M, Verleden G. 2003; 65:332–8.
epidemiology, pathophysiology, detec- Negative affectivity and the influence 81 Dahl J. A behavioural medicine
tion, and diagnosis. J Allergy Clin of suggestion on asthma symptoms. approach to the analysis and treatment
Immunol 2001; 108:S2–8. J Psychosom Res 2004; 57:249–55. of childhood asthma. Scand J Behav
65 Turcotte H, Boulet L-P. Perception of 74 Gibson PG, Powell H, Wilson A et al. Ther 1998; 27:30–41.
breathlessness during early and late Self-management education and regular 82 Lucas SR, Platts-Mills TAE. Physical
asthmatic responses. Am J Respir Crit practitioner review for adults with activity and exercise in asthma: rele-
Care Med 1993; 148:514–8. asthma. Cochrane Database of Syst Rev vance to etiology and treatment.
66 Ritz T, Rosenfield D, Wilhelm FH, Roth 2002; CD001117. doi: 10.1002/14651858. J Allergy Clin Immunol 2005;
WT. Airway constriction in asthma CD001117. 115:928–34.
during sustained emotional stimulation 75 Sundberg R, Tuns€ater A, Palmqvist M, 83 Halterman JS, Kitzman H, McMullen A
with films. Biol Psychol 2012; 91:8– Ellbj€ar S, L€
owhagen O, Toren K. A ran- et al. Quantifying preventive asthma
16. domized controlled study of a comput- care delivered at office visits: the Pre-
67 Ritz T, Kullowatz A, Goldman MD erized limited education program ventive Asthma Care - Composite
et al. Airway response to emotional among young adults with asthma. Index (PAC-CI). J Asthma 2006;
stimuli in asthma: the role of the cho- Respir Med 2005; 99:321–8. 43:559–64.
linergic pathway. J Appl Physiol 2010; 76 Thoonen BPA, Schermer TRJ, van den 84 Bush A. Coughs and wheezes spread
108:1542–9. Boom G et al. Self-management of diseases: but what about the environ-
68 Scichilone N, Callari A, Augugliaro G, asthma in general practice, asthma ment? Thorax 2006; 61:367–9.
Marchese M, Togias A, Bellia V. The control and quality of life: a rando- 85 Deshmukh VM, Toelle BG, Usherwood
impact of age on prevalence of posi- mised controlled trial. Thorax 2003; T, O’Grady B, Jenkins CR. Anxiety,
tive skin prick tests and specific IgE 58:30–6. panic and adult asthma: a cognitive-
tests. Respir Med 2011; 105:651–8. 77 Rank MA, Wollan P, Li JT, Yawn BP. behavioral perspective. Respir Med
69 Liu LY, Coe CL, Swenson CA, Kelly EA, Trigger recognition and management 2007; 101:194–202.
Kita H, Busse WW. School examina- in poorly controlled asthmatics. Allergy 86 Lehrer PM, Karavidas MK, Lu SE et al.
tions enhance airway inflammation to Asthma Proc 2010; 31:99–105. Psychological treatment of comorbid
antigen challenge. Am J Respir Crit 78 Brandt DM, Levin L, Matsui E, Phi- asthma and panic disorder: a pilot
Care Med 2002; 165:1062–7. patanakul W, Smith AM, Bernstein JA. study. J Anxiety Disord 2008; 22:
70 Miller SL, Maner JK. Sick body. Vigi- Allergists’ attitudes toward environ- 671–83.
lant mind. Psychol Sci 2011; 22: mental control: insights into its current 87 Emmelkamp PMG. Behavior therapy
1467–71. application in clinical practice. J with adults. In: Lambert MJ ed. Bergin
71 Rosenkranz MA, Busse WW, Johnstone Allergy Clin Immunol 2008; 121: and Garfield’s handbook of psychother-
T et al. Neural circuitry underlying the 1053–4. apy and behavior change. New York:
interaction between emotion and Wiley, 2003:393–446.

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