In this blog post, we delve into the psychosomatic history of asthma. Long considered an archetypal psychosomatic condition, asthma was said to reflect a suppressed cry for the mother’s help or attention. Patients with asthma were described as neurotic, anxious, and infantile and great emphasis was placed on a smothering relationship with a mother figure. Some experts proposed an intervention called “parentectomy” where children were taken away from their home environment and separated from the emotional factors that were held responsible for their asthmatic episodes. Psychosomatic explanations of asthma remained popular deep into the 20^th century but receded as biomedical understanding increased and patients and their families challenged popular myths surrounding the illness.

Marcel Proust

“An asthmatic never knows if he will be able to breathe”, Marcel Proust (1871-1922) wrote in one of his many letters. The great French novelist, famous for his magnus opus ‘A la recherche du temps perdu’, suffered from severe asthma throughout his life. The illness kept him awake at night as he feared episodes of violent coughing, choking, and gasping for air. Proust led a reclusive life to avoid asthma exacerbations. He sought the advice of eminent physicians but was disappointed when they could not grasp the severity of his illness and the impact it had on his life. Out of desperation he tried multiple experimental treatments, from nasal cauterization to various self-prescribed drugs and diets, but to no avail. He died of pneumonia at the age of 51. 

Proust’s fear of suffocation is far from unique. Nowadays, it is estimated that 6 million people in Europe suffer from severe asthma. Many live in constant concern that their next attack could kill them. In a survey from Asthma UK, one patient stated: “On a bad day I feel like I’m drowning and I can’t reach the surface of the water and I am going to burst, yet a tiny, tiny bit of air keeps me alive. It’s very scary—I feel like I’m living with a time bomb and if I have a bad attack I say to myself: ‘Is this the one that will kill me?”

Another famous sufferer of asthma, the great Roman philosopher and statesman Seneca, highlighted the severity of the illness by referring to its episodes as a rehearsal for death:

“I have suffered every kind of unpleasant or dangerous physical complaint, but none is worse than this. Not surprising, for anything else is just an illness, while this is gasping out your life-breath. That is why doctors call it a ‘rehearsal for death’, since eventually the breath does what it has often been trying to do.”

In Proust’s time, however, asthma was not considered a serious disease. It was thought to be a mild and benign condition, affecting mostly neurotics of the privileged classes. Several doctors suggested to Proust that his symptoms were all in his mind, an explanation he rejected: “… my asthma is real no matter what these fellows say.“

Marcel’s father, Adrien Proust (1834–1903) was one of the prominent doctors who saw asthma as a nervous affliction associated with maternal overaffection and excessive craving for tenderness. In one of his letters Marcel wrote: “… as they wanted to bring me back in the car, Constantin said it was all in my imagination that cold air was bad for me, because Papa told everyone that there was nothing wrong with me and that my asthma was purely imaginary. I know only too well when I wake here in the morning that it is very real.”

One of the ‘holy seven’ psychosomatic illnesses

Deep into the 20^th century, asthma was still frequently viewed as a psychosomatic illness. Andrews and colleagues, for example, state that “historically, asthma was viewed as a result of nervousness and hysteria, and the disorder was perceived as a symptom of mental unrest and psychoneurosis.”

Opolski and Wilson write that “Asthma has long been considered a psychosomatic disease, and during the 1930s–50s, was even known as one of the ‘holy seven’ psychosomatic illnesses. At that time, psychoanalytic theories described the aetiology of asthma as psychological, with treatment often primarily involving psychoanalysis and other ‘talking cures’.”

In ‘Catching My Breath: An Asthmatic Explores His Illness’ (1994) journalist and asthma patient Tim Brooks wrote:

“I was stunned at how many people still think that asthma is psychosomatic – that is, it involves no organic illness and is purely neurotic, like a nervous twitch. One of my students, hearing of my interest in asthma, said flatly, ‘It’s all in your head, right? The medication’s just a placebo right?’ An acupuncturist told me, equally casually, ‘Oh, it’s all caused by your relationship with your mother.’” 

A good example of the popularity of the psychosomatic view is found in the book “Mornings on Horseback”, a biography of Theodore Roosevelt by the award-winning historian David McCullough, first published in 1982.  Noting the “astonishing” frequency by which the young Theodore had asthma episodes during the weekend, McCullough argued that the illness was psychosomatic and that he used it to avoid going to church and to spend more time with his parents. Many years after the book was published Camargo and colleagues examined this hypothesis. They found no significant difference in the percentage of asthmatic attacks on weekends compared to that expected by chance alone, and concluded that “there is little (if any) support for assertions that Theodore Roosevelt’s asthma was psychosomatic.”

A cry for the mother

Let’s take a closer look at psychosomatic theories of asthma. A recurrent theme is the idea that people with asthma have an infantile personality and a smothering relationship with their mothers. Patients were thought to be “possessed by narcissistic need to regain the lost omnipotence of infancy.” An asthmatic episode was viewed as an outlet for emotional tension or a method to gain the attention of the mother.

James Halliday said one should view an asthmatic attack as “a condensed language of the animal world.” Franz Alexander saw it as an “unconscious suppressed impulse to cry for the mother’s help.” J. J. Groen argued that an asthmatic episode might have evolved through classical conditioning: “during childhood when the asthmatic breathing started, it did serve a useful purpose, because it was rewarded by the attention of the mother, which the child did not succeed in attracting by crying or otherwise.” J. J.G. Prick highlights that “respiration is, […], the first step towards biological independence of the mother” and it is exactly this function that asthmatics fail to control.

Some statements displayed an even stronger contempt for people with asthma. Otto Fenichel, for example, writes that asthmatics display a ‘pregenital’ and compulsive character “with all the features of an increased anal-sadistic orientation.” Margaret Lowenfeld notes an “extraordinary fear of failure, which causes asthmatic children to retreat into the misery of an asthmatic attack rather than to risk the experience of defeat.” Franz Alexander wrote that it is possible to relieve a patient from his asthma attacks by giving him the “opportunity to ‘confess’ his repressed ego-alien tendencies in a few psychotherapeutic interviews.” Helen Flanders Dunbar stated that “asthma may also serve as a means of getting attention which would otherwise be diverted to others, and will finally become an unconscious reaction if the individual is deprived of what he thinks is his due.” Theodore Alcock’s statements about sadomasochistic satisfaction and unconscious need for illness are also worth quoting in full:

“It may be postulated that a personality type showing marked internal conflict around object-relationships, accompanied by weakness in mechanisms of egodefence by which affect can be externalized, can appropriately find relief through the sado-masochistic satisfaction of a physically distressing disorder. Those with an allergic inheritance may find such an outlet in asthma, if their unconscious need is for a disorder so punishing to the patient and his parents, while also so provocative of loving attention.”

Asthmogenic homes and parentectomy

One of the most bizarre episodes in the psychosomatic history of asthma took place at the National Jewish Center For Immunology and Respiratory Medicine in Denver, one of the world’s leading asthma research and treatment centers. Doctor Murray Peshkin, who was the medical director of the Center from 1940 to 1959, noticed that hospitalized children recovered before any of the treatments could take effect. Peshkin thought that those improvements were the result of separating the children from their home where a detrimental emotional environment, and not some allergic agent, was believed to trigger asthmatic episodes. These were sometimes referred to as ‘asthmogenic homes’. The British allergist John Freeman, for example, wrote that such homes were characterized by a great degree of “emotionalism and nervous tension”, resulting in “excessive parental attention” and “emotional infantilism” of the children. Peshkin argued that his patients improved because they were removed from asthmogenic homes:

“I realized then more than ever before that hospitalization and removal of the child to a convalescent home was in effect the separation of the child from the asthmatogenic emotional climate which existed in the child’s own home – and that it was this adverse psychogenic factor which was principally responsible for pushing the asthmatic child into a state of intractable asthma.”

Peshkin advocated what he called ‘parentectomy’: taking children with severe asthma away from their home environment to prevent “the prepotent asthmatogenic psychosomatic factors  from operating adversely on his bronchi.” Although Peshkin reported excellent results obtained with this approach, his proposed treatment plan and rationale never took off.

In his book ‘Catching my breath’, writer and asthma patient Tim Brooks calls parentectomy, “one of the most shameful treatments foisted on the sufferers of any disease”. He adds: “Frighteningly, I’ve met dozens of people who still believe that a child’s asthma is the mother’s fault, and I can’t help thinking that their education is National Jewish’s responsibility…”

Stereotypes of asthma

These theories have led to a stereotype of people with asthma as egocentric, anxious, oversensitive, unable to tolerate frustration, bright but emotionally infantile, and overly dependent on others.

Cindy Clark, Professor of Anthropology at Rutgers University Camden, analyzed 66 movies with scenes displaying asthma. She found that asthma patients are frequently depicted as a wimp, nerd or social outcast. The most common storyline in movies suggests that asthma symptoms are stress-induced, for example, an asthma attack occurring in response to struggle or danger. A good example is the book Lord of the Flies (1954) in which the asthmatic Piggy is bespectacled, fat, anxious, intelligent but oversensitive, a mama’s boy looked down upon by his peers. He has a smothering relationship with his aunt. “My auntie told me not to run,” Piggy says in the book, “on account of my asthma.”

Stereotypes of asthmatics are also used in popular tv-shows such as Stevie from ‘Malcolm in the Middle’, Carl Wheezer from ‘Jimmy Neutron: Boy Genius’, or Milhouse from ‘The Simpsons’. Each of these characters is depicted as weak, nervous, submissive, and nerdy.

Why is Asthma no longer seen as psychosomatic?

In the last couple of decades, psychosomatic explanations of asthma have strongly declined in popularity. The story of Dee Montague is a good illustration of this. Dee suffers from myalgic encephalomyelitis (ME) and endometriosis, two illnesses that are highly stigmatized and often dismissed by doctors. Dee also has asthma and experienced a striking difference in how this condition was treated compared to the other two: “No healthcare professional has ever, ever suggested my asthma symptoms were normal, psychosomatic or something I just had to put up with. Nor have I ever been denied medication or treatment pathways”, she said to inews. “My treatment is almost entirely patient-led, I have regular reviews, and healthcare professionals almost always understand what asthma is and how it can affect patients,” she added. “How long will it be before patients of all chronic illnesses can say the same?”

It’s tempting to speculate what might have caused this development: why is asthma no longer seen as psychosomatic? The most likely explanation is that the popularity of psychosomatic theories declined as biomedical knowledge of the disease increased. An important step was the discovery of immunoglobulin E (IgE) in 1967 by researchers at the Children’s Asthma Research Institute and Hospital in Denver, the same institute where Peshkin promoted the use of parentectomy. Tim Brooks writes about this in his book:

“in a way it is fitting that IgE, the antibody responsible for allergic reactions, was first identified by researchers at National Jewish – in 1966, two years after Pehskin left Denver after his colleagues insisted on research that would prove or disprove his theories, and the board rejected a fundamentally psychoanalytical view of asthma.”

The discovery of IgE, marked a change in the medical understanding of asthma. It gradually shifted from a nervous to an inflammatory disease, a different perspective that led to successful new treatments.

A second factor is that some experts in the field decided to test psychosomatic theories of asthma with a more rigorous study design. They suspected that many of the findings on the asthmatic personality suffered from selection bias so they set up a large community-based study where they could test a representative sample of asthma patients, not just those that went to see psychiatrists. As Dubo et al. write:

“It was evident that if we were to study the relationship between psychological factors and asthma we must use an unselected patient group, drawn not from the psychiatrists’ but from the allergists’ practice. In 1957 such a project was instituted.”

The results showed that there was no characteristic personality profile associated with asthma, a finding that was confirmed by other community-based studies.  

A third possible factor was the impact of patient organizations which came to the forefront in the decades after WWII. As Mark Jackson writes in Asthma: The Biography: “in several countries the parents of asthmatic children, as well as the patients themselves, began to challenge assumptions that mothers and families were to blame or that parentectomy offered a humane solution to childhood asthma.” A good example of this is Nancy Sander, a mother of a child with asthma and founder of the Allergy & Asthma Network Mothers of Asthmatics (AANMA). In the 1980s Sander sent out a newsletter that challenged some common myths about asthma, such as the belief that it is a psychosomatic disease or that children have asthma because they are weak or inferior.

It will be interesting to see if the decline in popularity of psychosomatic explanations in other illnesses is preceded by similar changes. More to come in the following blog posts.

An overview of all articles in this series can be found at the bottom of the introductory article.