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Behavioural and Psychological Approaches to Breathing Disorders
Behavioural and Psychological Approaches to Breathing Disorders
Pmynapic neuron
edited by by Beverly H Timmons and Ronald Ley. Plenum Publishing, London, 1994 (ISBN 0 306 44446 1). Illus. 321 pages. $59.40.
This eagerly awaited book is,to my knowledge, the first publication wholly dedicated to the fascinating subject of breathing and the effect of psychology and behaviow on the respiratory system. An interdisciplinary approach is adopted, thereby giving it a broad appeal t o many professions. The editors have assembled an impressive list of contributors, including most of the individuals who have given us a better understanding of the behavioural aspects of breathing. The approach of looking at breathing from different standpoints and perspectives is a recurrent theme throughout the book - it is, however, possible to find completely conflicting ideas and even to come across contradictions from one author to another, expanding upon the disagreements already rife in this field. The book is divided into three sections: anatomy, physiology, physiopathology and pscyhology of the respiratory system; hyperventilation - diagnosis and therapy; and other therapeutic approaches to breathing disorders. The obligatory anatomy and physiology section is clear, informative, well written and covers this huge subject suecintly. The diagrams are well drawn and the whole chapter would provide good revision or even an excellent foundation in understanding for those with little or no knowledge of the respiratory system. Chapter 2 I found particularly fas. cinating, dealing with nasopulmonary physiology. It will become apparent to every reader of this excellent chapter that the role of the nose has been consistently undervalued. The text is well laid out and easy to read, and gives valuable insight into this relatively unknown area. The next chapter concerns abnormalities of breathing during sleep, explaining exactly what sleep apnoea is and the current thinking about its treatment. Following on from this is a useful explanation of the control of
. . aue .ntynur
----Axon
.I
I
/
.
I I I
Transmitter secretion
Anatomy ofa typical nemne and synapse ' R is a receptor on-eht . membrane (from For (1987) with permission). The two diagram on this page and one on p OOO are from 'Behavioural and Psycbbgical Approaches to Breathing Disorders'
breathing and a concise account of how breathing may become deranged. Here we come across one of the direct contradictions mentioned earlier, when the author of this chapter, Sheila Jennett, makes the following point in her finalsentence: 'The ideal state of affairs is to be virtually unaware ofone's b r e a w No voluntary intervention can improve upon its remarkable efficiency in a healthy person.' The opening statement in the next chapter by Ronald Ley states that breathing is under voluntary control as well as reflex control, and is therefore subject to psychological conditioning. He puts forward the
Movement of rib cage and diaphragm during inspimtwn. (A) and (B) Descent of diaphragm and outward movement of rib cage and abdomen. (C) Movement of a rib (from Selkurt (1976) with permkion)
contention that breathing can have an effect on emotion as well as the more common supposition that emotion triggers changes in breathing. He makes the point that more research into this field is needed and that psychologists should be looking at dysfunctional breathing when faced with psychological symptom^. Overall, this chapter is again very well written with many references reinforcing the points made. Section II on hyperventilation starts with chapter 6 by Dr William Gardner, which deals with the diagnosis and organic causes of symptomatic hyperventilation. The diagnosis of hyperventilation is, at present, a contentious issue, and the reader will find here directly opposing views to the next author, Dr Claude Lum. The overriding impression is that there is no definitive diagnostic test for hyperventilation, some physician8 reaching their conclusions via laboratory testa and elimination of organic disorders and others by careful history taking, with special reference to precipitatory events and situations and careful examination of the breathing pattern. Perhaps as well as searching for the test and classification for hyperventilation, physicians should bear in mind the statement by Beverly Timmons to be found on page 8: T h e client who ia
wrongly diagnosed as a hyperventilator is unlikely to experience side &e!cta aa a result of ouch techniques as relaxation and breathing retraining. On the other hand, denying treatment to patients because they do not meet strict research criteria can needlessly prolong their suffering.’ Dr Claude Lum begins with a n overview of the difficulties experienced by the suffers of hyperventilation in finding therapy for their condition. He emphasises the need for the physician to elicit a careful history from the patient so that hyperventilation which presents in so many different guises can be diagnoeed. He states that hyperventilation eyndrome should be renamed hyperventilation syndromes and that the combination of symptoms cannot be defined by a single measurement. This view is in direct contradiction to Dr William Gardner’s statements in the previous chapter, leaving the reader perhaps somewhat confused. Christopher Baee in the next chapter recommends a multidiecip linary approach for psychiatrists, cardiologistsand chest physicians in order to clarify the problem, and states that psychiatrista have found it difficult to ascess and treat a disorder which can caw psychiatric, cardiovascular and respiratory symptoms. Although accepting the existence of breathing retraining in the treatment of this varied symptomology, he is ambivalent about ita egectiveness, prefemng cognitive/ behavioural therapy as the treatment of choice. Next we come to a chapter by Herbert Fenaterheim, which seems to tie together all the preceding contradictions, making the point that the different approaches of the clinical researcher and the practising clinician give them very dif€erent roles to play in the diagnosis of hyperventilation. Possibly of most interest to physic+ therapiete k t h e following chapter by Elizabeth Holloway ‘The role of the physiotherapist in the treatment of hyperventilation’. This is a very comprehensive guide, and will be an invaluable asset to the ever-growing number of phyeiotherapista who are becoming interested in the treatment of this faecinating condition. It is obvious that a lot of thought has
Ph ,-
May 1WS, vol81, no5
Anatomire1 relationship between alveoli and pulmonary capilliaries in the lung (from Vanderetal(l980) withpermission)
gone into this chapter. covering almost all aspects of the care these patients need to allow them to bring their breathing pattern back towards normal and to encourage physical and mental relaxation and coping strategies. The final section on other therapeutic approaches to breathing disorders deals with techniques employed by such diverse professionals as speech therapists, yogic
Assisted Ventilation
practitioners, psychologists, relaxation therapists and Reichian therapists. This makes fascinating reading, and it is interesting to note that symptoms of hyperventilation and asthma have been helped by techniques that do not concentrate on the methods advocated in other parts of this book. The last chapter is an excellent overview written by Beverley Timmons, stressing the point that the technological advances i n medicine today need to be tempered by a humanistic approach - a concept true to all aspects of medicine but probably particularly vital in the treatment of breathing disorders. In summary, this book has attempted to cover both the physiological and psychological aspects of breathing. It must have been a daunting prospect, but Beverly Timmons and Ronald Ley are to be congratulated for editing such a comprehensive, informative and enjoyable book. Not for a long time have I found an academic tome ‘unputdownable’. We would have a healthier, happier population if it found its way on to the best-seller list! Anne Pitman GradDipPhys MCSP
practice) which also includes a very good description of respiratory muscle function in relation to mechanical ventilation. Physiotherapists may be disappointed that The second edition of this book there is only a passing and limited provides an updated overview of the mention of physiotherapy in the field of assisted ventilation. In such chapter on the general care of a rapidly developing field, this ventilated patients. While the update is most welcome. chapter on non-invasive ventilation The five main chapters cover the provides good coverage of indications history of artificial ventilation and techniques, it does not address including equipment and techniques; issues on maintaining ventilatory indications for mechanical ventila- support in the community, which are tion; general care of the ventilated increasingly relevant in such an patient; weaning; and non-invasive expanding field. ventilation. The book is aimed at medical staff, Each chapter is written by a either providing an update for recognised medical specialist within generalists or a basic text for trainee the relevant field. Information is critical care physicians or anaespresented clearly in a very readable thetists. However, it would also be form and is well-referenced.The text a useful addition to the library of is illustrated with helpful diagrams physiotherapists and other profesand photographs. sionals interested in or specialising A particular highlight within the in respiratory care or indeed for book is the excellent chapter on general physiotherapy departments weaning (an area which often re- and physiotherapy schools. ceives insuflicient attention, despite Elizabeth Murray BA MCSP being a common problem in clinical
edited by John Moxham and John Goldstone. BMJ Publishing Group, London, 1994 (2ndedn) (ISBN 0 72790843 Illus. 713 pages. f12.95.
a.
Pmynapic neuron
edited by by Beverly H Timmons and Ronald Ley. Plenum Publishing, London, 1994 (ISBN 0 306 44446 1). Illus. 321 pages. $59.40.
This eagerly awaited book is,to my knowledge, the first publication wholly dedicated to the fascinating subject of breathing and the effect of psychology and behaviow on the respiratory system. An interdisciplinary approach is adopted, thereby giving it a broad appeal t o many professions. The editors have assembled an impressive list of contributors, including most of the individuals who have given us a better understanding of the behavioural aspects of breathing. The approach of looking at breathing from different standpoints and perspectives is a recurrent theme throughout the book - it is, however, possible to find completely conflicting ideas and even to come across contradictions from one author to another, expanding upon the disagreements already rife in this field. The book is divided into three sections: anatomy, physiology, physiopathology and pscyhology of the respiratory system; hyperventilation - diagnosis and therapy; and other therapeutic approaches to breathing disorders. The obligatory anatomy and physiology section is clear, informative, well written and covers this huge subject suecintly. The diagrams are well drawn and the whole chapter would provide good revision or even an excellent foundation in understanding for those with little or no knowledge of the respiratory system. Chapter 2 I found particularly fas. cinating, dealing with nasopulmonary physiology. It will become apparent to every reader of this excellent chapter that the role of the nose has been consistently undervalued. The text is well laid out and easy to read, and gives valuable insight into this relatively unknown area. The next chapter concerns abnormalities of breathing during sleep, explaining exactly what sleep apnoea is and the current thinking about its treatment. Following on from this is a useful explanation of the control of
. . aue .ntynur
----Axon
.I
I
/
.
I I I
Transmitter secretion
Anatomy ofa typical nemne and synapse ' R is a receptor on-eht . membrane (from For (1987) with permission). The two diagram on this page and one on p OOO are from 'Behavioural and Psycbbgical Approaches to Breathing Disorders'
breathing and a concise account of how breathing may become deranged. Here we come across one of the direct contradictions mentioned earlier, when the author of this chapter, Sheila Jennett, makes the following point in her finalsentence: 'The ideal state of affairs is to be virtually unaware ofone's b r e a w No voluntary intervention can improve upon its remarkable efficiency in a healthy person.' The opening statement in the next chapter by Ronald Ley states that breathing is under voluntary control as well as reflex control, and is therefore subject to psychological conditioning. He puts forward the
Movement of rib cage and diaphragm during inspimtwn. (A) and (B) Descent of diaphragm and outward movement of rib cage and abdomen. (C) Movement of a rib (from Selkurt (1976) with permkion)
contention that breathing can have an effect on emotion as well as the more common supposition that emotion triggers changes in breathing. He makes the point that more research into this field is needed and that psychologists should be looking at dysfunctional breathing when faced with psychological symptom^. Overall, this chapter is again very well written with many references reinforcing the points made. Section II on hyperventilation starts with chapter 6 by Dr William Gardner, which deals with the diagnosis and organic causes of symptomatic hyperventilation. The diagnosis of hyperventilation is, at present, a contentious issue, and the reader will find here directly opposing views to the next author, Dr Claude Lum. The overriding impression is that there is no definitive diagnostic test for hyperventilation, some physician8 reaching their conclusions via laboratory testa and elimination of organic disorders and others by careful history taking, with special reference to precipitatory events and situations and careful examination of the breathing pattern. Perhaps as well as searching for the test and classification for hyperventilation, physicians should bear in mind the statement by Beverly Timmons to be found on page 8: T h e client who ia
wrongly diagnosed as a hyperventilator is unlikely to experience side &e!cta aa a result of ouch techniques as relaxation and breathing retraining. On the other hand, denying treatment to patients because they do not meet strict research criteria can needlessly prolong their suffering.’ Dr Claude Lum begins with a n overview of the difficulties experienced by the suffers of hyperventilation in finding therapy for their condition. He emphasises the need for the physician to elicit a careful history from the patient so that hyperventilation which presents in so many different guises can be diagnoeed. He states that hyperventilation eyndrome should be renamed hyperventilation syndromes and that the combination of symptoms cannot be defined by a single measurement. This view is in direct contradiction to Dr William Gardner’s statements in the previous chapter, leaving the reader perhaps somewhat confused. Christopher Baee in the next chapter recommends a multidiecip linary approach for psychiatrists, cardiologistsand chest physicians in order to clarify the problem, and states that psychiatrista have found it difficult to ascess and treat a disorder which can caw psychiatric, cardiovascular and respiratory symptoms. Although accepting the existence of breathing retraining in the treatment of this varied symptomology, he is ambivalent about ita egectiveness, prefemng cognitive/ behavioural therapy as the treatment of choice. Next we come to a chapter by Herbert Fenaterheim, which seems to tie together all the preceding contradictions, making the point that the different approaches of the clinical researcher and the practising clinician give them very dif€erent roles to play in the diagnosis of hyperventilation. Possibly of most interest to physic+ therapiete k t h e following chapter by Elizabeth Holloway ‘The role of the physiotherapist in the treatment of hyperventilation’. This is a very comprehensive guide, and will be an invaluable asset to the ever-growing number of phyeiotherapista who are becoming interested in the treatment of this faecinating condition. It is obvious that a lot of thought has
Ph ,-
May 1WS, vol81, no5
Anatomire1 relationship between alveoli and pulmonary capilliaries in the lung (from Vanderetal(l980) withpermission)
gone into this chapter. covering almost all aspects of the care these patients need to allow them to bring their breathing pattern back towards normal and to encourage physical and mental relaxation and coping strategies. The final section on other therapeutic approaches to breathing disorders deals with techniques employed by such diverse professionals as speech therapists, yogic
Assisted Ventilation
practitioners, psychologists, relaxation therapists and Reichian therapists. This makes fascinating reading, and it is interesting to note that symptoms of hyperventilation and asthma have been helped by techniques that do not concentrate on the methods advocated in other parts of this book. The last chapter is an excellent overview written by Beverley Timmons, stressing the point that the technological advances i n medicine today need to be tempered by a humanistic approach - a concept true to all aspects of medicine but probably particularly vital in the treatment of breathing disorders. In summary, this book has attempted to cover both the physiological and psychological aspects of breathing. It must have been a daunting prospect, but Beverly Timmons and Ronald Ley are to be congratulated for editing such a comprehensive, informative and enjoyable book. Not for a long time have I found an academic tome ‘unputdownable’. We would have a healthier, happier population if it found its way on to the best-seller list! Anne Pitman GradDipPhys MCSP
practice) which also includes a very good description of respiratory muscle function in relation to mechanical ventilation. Physiotherapists may be disappointed that The second edition of this book there is only a passing and limited provides an updated overview of the mention of physiotherapy in the field of assisted ventilation. In such chapter on the general care of a rapidly developing field, this ventilated patients. While the update is most welcome. chapter on non-invasive ventilation The five main chapters cover the provides good coverage of indications history of artificial ventilation and techniques, it does not address including equipment and techniques; issues on maintaining ventilatory indications for mechanical ventila- support in the community, which are tion; general care of the ventilated increasingly relevant in such an patient; weaning; and non-invasive expanding field. ventilation. The book is aimed at medical staff, Each chapter is written by a either providing an update for recognised medical specialist within generalists or a basic text for trainee the relevant field. Information is critical care physicians or anaespresented clearly in a very readable thetists. However, it would also be form and is well-referenced.The text a useful addition to the library of is illustrated with helpful diagrams physiotherapists and other profesand photographs. sionals interested in or specialising A particular highlight within the in respiratory care or indeed for book is the excellent chapter on general physiotherapy departments weaning (an area which often re- and physiotherapy schools. ceives insuflicient attention, despite Elizabeth Murray BA MCSP being a common problem in clinical
edited by John Moxham and John Goldstone. BMJ Publishing Group, London, 1994 (2ndedn) (ISBN 0 72790843 Illus. 713 pages. f12.95.
a.