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The hyperventilation syndrome: Research and clinical treatment
I Brhov. Thher. & Erp. Pryrhm. Vol. IV. No 2. pp 157-158. IYX8. Perqamon Press plc. Prmrcd m Great Bntam.
BOOK REVIEWS The Hyperventilation
Syndrome:
Research
and Clinical Treatment
by ROBERT FRIED The Johns Hopkins University Press, Baltimore, Respiration is the bridge between psychology and physiology; it is the only vital function over which we have some direct voluntary control. Although we learn early the psychological sensations produced by breath holding, few of us are consciously aware of the physiological changes and psychological sensations produced by hyperventilation (i.e. prolonged breathing of a volume of air which exceeds metabolic demand). Hyperventilation has a direct, immediate and profound effect on the entire body chemistry, and an indirect but fast and equally profound effect on the body’s organic systems. The direct effect of hyperventilation is a reduction in arterial carbon dioxide, which results in a drop in arterial pCOz and a rise in plasma pH. The indirect effects are a broad array of symptoms which include dyspnea, heart palpitations, faintness, and all of the other symptoms of panic attacks, including hallucinations and general impairment of cognitive function. Recognition of the connection between hyperventilation and its manifold symptoms may be the most important event in behavioral psychophysiology since Pavlov explored the conditioned response. And recognition of the primacy of hyperventilation in disease and the logical development and application of breathing-retraining procedures (see Lum, 1975, 1976, 1977, 1981, 1983) may be the most important behavioral treatment since Wolpe introduced systematic desensitization. Fried’s The Hyperventilation Syndrome: Research and Clinical Treatment is a pioneering effort. It is the first book to be addressed solely to a comprehensive survey of hyperventilation, a survey that covers the anatomy and physiology of respiration, the endocrine, cardiovascular and nervous systems, psychophysiology, mental disorders, pharmacology, and treatment (physiotherapy, yogic, biofeedback and guided imagery). The central role of hyperventilation in psychosomatic disease is better understood in western Europe than in the United States. For seven consecutive years, an international group of scientists has met at a European-hosted symposium to report on research findings and current issues in respiratory psychophysiology, most recently (September, 1987) at the Karolinska Institute’s Nobel Institute of Neurophysiology. By way of contrast, the published program of the 21st annual convention of the Association for the Advancement of Behavior Therapy (November, 1987) did not list a single title for either a paper or symposium which included reference to hyperventilation.
If this is a problem,
Syndrome:
Research
1987 then Fried’s
and Clinical
The Hyperventilation Trearmenr may con-
tribute to the solution. The physiology underlying the connection between hyperventilation. its physical and psychological manifestations, and its treatment is complicated. But Fried’s concise and perspicuous presentation serves well the reader whose recollection of physiology needs refreshing as well as the sophisticated student of physiology who wishes to learn more about the central role of hyperventilation in illness and about biofeedback and other procedures for its treatment. This book is not, however, just a summary of research and methodology; the critical reader will find controversial issues, problematic methods and questionable interpretations of data. For example, in his discussion of the measurement of end-tidal CO? one might take issue with Fried’s statement that: “While the increased respiration rate may usually be taken as a reasonable indication of hyperventilation, especially where subtle chest excursions suggest a low tidal volume, the percentage of end-tidal CO? by itself, may not” (p. 48). Since hyperventilation is a function of excessive minute volume, it would seem that low end-tidal CO, is the best index of hyperventilation, especially when breathing mode suggests low tidal volume. That is, if tidal volume is sufficiently low, a very rapid respiration rate may not result in a sufficient increase in minute volume to produce hyperventilation. An illustration of a problematic method is the “RR/C02” index: “Thus, lacking volume measures, I employed an index considering CO2 dissipation as a function of the respiration rate and end-tidal CO2 percentage and called it the RR/CO? index. It has some shortcomings but has been helpful in estimating CO: loss” (p. 49). The problem here is how to interpret an increase in the index if respiration rate increases while CO2 remains constant. If tidal volume decreases in proportion to increases in respiration rate, minute volume would remain constant, but the index would increase. An example of a questionable interpretation can be found in Fried’s discussion of guided imagery: “Thus, it is reasonable to infer that, if respiration rate in my clients decreased and pCOz decreased, then metabolic rate must have decreased as well” (p. 118). It would seem that a drop in pC02 with a concurrent drop in respiration rate could be accounted for just as reasonably by an increase in tidal volume with or without a decrease in metabolic rate. Perhaps differences such as those illustrated by the
157
1%
BOOK
examples given here should be expected stage of a promising movement.
in the inchoate RONALD
LEY
Deparrmenr of Ed. Psychology & Starisrics and Department of Psychology Stare University of Nrlcs York ar Alban) Albany. NY l-7-1.?.?, U.S.A. REFERENCES Lum L. C. (1975) Hyperventilation: The tip of the iceberg. J. Psychosomatic Res. 19. 375-383.
REVIEWS Lum L. C. (1976) The syndrome of habitual chronic hyperventilation. In Hill 0. W. (Ed.) Modern Trends in Psychosomatic Medicine. Vol. 3. Buttenvorths. London. Lum L. C. (1977) Breathing exercises in the treatment of hyperventilation and chronic anxiety states. Chest, Hearr Stroke J. 2. 7-l 1. Lum L. C. (1981) Hyperventilation and anxiety state. /. Royal Sot. Med. 74, l-4. Lum L. C. (1983) Physiological considerations in the treatment of hyperventilation syndromes. J. Drug Res. 8, 1867-1872.
Control Your Depression: Reducing Depression Through Learning Self-Control Techniques, Relaxation Training, Pleasant Activities, Social Skills, Constructed Thinking, Planning Ahead and More by P. M. LEWINSOHN,
R. F. MUNOZ, Prentice-Hall
M. A. YOUNGREN
Press, New York,
In an update of earlier work, the authors apply standard cognitive-behavioral techniques to depression. Using a social learning framework, they propose the etiology of depressive ideation and behavior patterns as well as provide a rationale for self-administration of the treatment suggestions. A strength of their program is that it details ways to assess some functional areas which are often deficient in unhappy people, such as general activity level, social interaction and ability to relax or think optimistically. Another strong point is that it thoroughly describes methods designed to remedy such problems. The assessment and treatment instructions might stand alone to help people deal with routine life problems, or possibly even situational or adjustment difficulties. However, the book is addressed to people with depression. including those with “serious episodes”. For those potential readers. its limitations must be identified. Overall, the recommendations might be sound components of more global depression management when administered with professional assbrance. Significant omissions in the authors’ explanation of etiology, treatment options, and self-efficacy, may seriously limit readers’ efforts to alleviate their depression. There is no attempt to weave biological bases of depression into the social learning framework. This is particularly perplexing, since Akiskal and McKinney’s (1973) seminal work integrating psychosocial and biological determinants of depression is in the suggested reading list. The book leaves the impression that depression may only be a reaction that occurs when people “engage in few interactions with positive outcomes.” Because the biological aspect is not mentioned, the possibility of psychopharmacological treatment is never even addressed. Help for sleep disturbance is advised and readers are cautioned against
and A. M. ZEISS
1986
“hastily accepting sleep medication.” Unfortunately. this scanty warning without mention of anti-depressants could lead readers incorrectly to conclude that “sleep medications” are the only pharmacological options for depression. Seeking professional assistance is presented as a last resort, after readers have “tried conscientiously to use the suggested techniques but have found no relief.” Thus, one could conclude that obtaining help is also a sign of failure. Additionally, the introduction’s disclaimer. “A Word of Caution”, is not adequate to encourage people to seek outside help. It merely states that readers should consult a professional if they are unable to “maintain sufficient motivation” to finish the self-help program. are “afraid” of committing suicide, or doubt that depression is the major problem. In summary, this book is a compilation of cognitivebehavioral assessment and treatment strategies which the authors have applied to depression management. They advocate that seriously depressed people use the recommendations without necessarily seeking professional assistance to monitor their progress. Significant information about treatment options, such as psychopharmacology, is omitted. While the effort to give people information to alleviate stress and increase their enjoyment of life is laudable, the advocacy of a self-administered treatment program for major depression without professional assistance is questionable, if not dangerous. JOHN M. DOWNS Department of Psychiatry University of Tennessee College of Medicine Memphis, TN 381OS, U.S.A.
BOOK REVIEWS The Hyperventilation
Syndrome:
Research
and Clinical Treatment
by ROBERT FRIED The Johns Hopkins University Press, Baltimore, Respiration is the bridge between psychology and physiology; it is the only vital function over which we have some direct voluntary control. Although we learn early the psychological sensations produced by breath holding, few of us are consciously aware of the physiological changes and psychological sensations produced by hyperventilation (i.e. prolonged breathing of a volume of air which exceeds metabolic demand). Hyperventilation has a direct, immediate and profound effect on the entire body chemistry, and an indirect but fast and equally profound effect on the body’s organic systems. The direct effect of hyperventilation is a reduction in arterial carbon dioxide, which results in a drop in arterial pCOz and a rise in plasma pH. The indirect effects are a broad array of symptoms which include dyspnea, heart palpitations, faintness, and all of the other symptoms of panic attacks, including hallucinations and general impairment of cognitive function. Recognition of the connection between hyperventilation and its manifold symptoms may be the most important event in behavioral psychophysiology since Pavlov explored the conditioned response. And recognition of the primacy of hyperventilation in disease and the logical development and application of breathing-retraining procedures (see Lum, 1975, 1976, 1977, 1981, 1983) may be the most important behavioral treatment since Wolpe introduced systematic desensitization. Fried’s The Hyperventilation Syndrome: Research and Clinical Treatment is a pioneering effort. It is the first book to be addressed solely to a comprehensive survey of hyperventilation, a survey that covers the anatomy and physiology of respiration, the endocrine, cardiovascular and nervous systems, psychophysiology, mental disorders, pharmacology, and treatment (physiotherapy, yogic, biofeedback and guided imagery). The central role of hyperventilation in psychosomatic disease is better understood in western Europe than in the United States. For seven consecutive years, an international group of scientists has met at a European-hosted symposium to report on research findings and current issues in respiratory psychophysiology, most recently (September, 1987) at the Karolinska Institute’s Nobel Institute of Neurophysiology. By way of contrast, the published program of the 21st annual convention of the Association for the Advancement of Behavior Therapy (November, 1987) did not list a single title for either a paper or symposium which included reference to hyperventilation.
If this is a problem,
Syndrome:
Research
1987 then Fried’s
and Clinical
The Hyperventilation Trearmenr may con-
tribute to the solution. The physiology underlying the connection between hyperventilation. its physical and psychological manifestations, and its treatment is complicated. But Fried’s concise and perspicuous presentation serves well the reader whose recollection of physiology needs refreshing as well as the sophisticated student of physiology who wishes to learn more about the central role of hyperventilation in illness and about biofeedback and other procedures for its treatment. This book is not, however, just a summary of research and methodology; the critical reader will find controversial issues, problematic methods and questionable interpretations of data. For example, in his discussion of the measurement of end-tidal CO? one might take issue with Fried’s statement that: “While the increased respiration rate may usually be taken as a reasonable indication of hyperventilation, especially where subtle chest excursions suggest a low tidal volume, the percentage of end-tidal CO? by itself, may not” (p. 48). Since hyperventilation is a function of excessive minute volume, it would seem that low end-tidal CO, is the best index of hyperventilation, especially when breathing mode suggests low tidal volume. That is, if tidal volume is sufficiently low, a very rapid respiration rate may not result in a sufficient increase in minute volume to produce hyperventilation. An illustration of a problematic method is the “RR/C02” index: “Thus, lacking volume measures, I employed an index considering CO2 dissipation as a function of the respiration rate and end-tidal CO2 percentage and called it the RR/CO? index. It has some shortcomings but has been helpful in estimating CO: loss” (p. 49). The problem here is how to interpret an increase in the index if respiration rate increases while CO2 remains constant. If tidal volume decreases in proportion to increases in respiration rate, minute volume would remain constant, but the index would increase. An example of a questionable interpretation can be found in Fried’s discussion of guided imagery: “Thus, it is reasonable to infer that, if respiration rate in my clients decreased and pCOz decreased, then metabolic rate must have decreased as well” (p. 118). It would seem that a drop in pC02 with a concurrent drop in respiration rate could be accounted for just as reasonably by an increase in tidal volume with or without a decrease in metabolic rate. Perhaps differences such as those illustrated by the
157
1%
BOOK
examples given here should be expected stage of a promising movement.
in the inchoate RONALD
LEY
Deparrmenr of Ed. Psychology & Starisrics and Department of Psychology Stare University of Nrlcs York ar Alban) Albany. NY l-7-1.?.?, U.S.A. REFERENCES Lum L. C. (1975) Hyperventilation: The tip of the iceberg. J. Psychosomatic Res. 19. 375-383.
REVIEWS Lum L. C. (1976) The syndrome of habitual chronic hyperventilation. In Hill 0. W. (Ed.) Modern Trends in Psychosomatic Medicine. Vol. 3. Buttenvorths. London. Lum L. C. (1977) Breathing exercises in the treatment of hyperventilation and chronic anxiety states. Chest, Hearr Stroke J. 2. 7-l 1. Lum L. C. (1981) Hyperventilation and anxiety state. /. Royal Sot. Med. 74, l-4. Lum L. C. (1983) Physiological considerations in the treatment of hyperventilation syndromes. J. Drug Res. 8, 1867-1872.
Control Your Depression: Reducing Depression Through Learning Self-Control Techniques, Relaxation Training, Pleasant Activities, Social Skills, Constructed Thinking, Planning Ahead and More by P. M. LEWINSOHN,
R. F. MUNOZ, Prentice-Hall
M. A. YOUNGREN
Press, New York,
In an update of earlier work, the authors apply standard cognitive-behavioral techniques to depression. Using a social learning framework, they propose the etiology of depressive ideation and behavior patterns as well as provide a rationale for self-administration of the treatment suggestions. A strength of their program is that it details ways to assess some functional areas which are often deficient in unhappy people, such as general activity level, social interaction and ability to relax or think optimistically. Another strong point is that it thoroughly describes methods designed to remedy such problems. The assessment and treatment instructions might stand alone to help people deal with routine life problems, or possibly even situational or adjustment difficulties. However, the book is addressed to people with depression. including those with “serious episodes”. For those potential readers. its limitations must be identified. Overall, the recommendations might be sound components of more global depression management when administered with professional assbrance. Significant omissions in the authors’ explanation of etiology, treatment options, and self-efficacy, may seriously limit readers’ efforts to alleviate their depression. There is no attempt to weave biological bases of depression into the social learning framework. This is particularly perplexing, since Akiskal and McKinney’s (1973) seminal work integrating psychosocial and biological determinants of depression is in the suggested reading list. The book leaves the impression that depression may only be a reaction that occurs when people “engage in few interactions with positive outcomes.” Because the biological aspect is not mentioned, the possibility of psychopharmacological treatment is never even addressed. Help for sleep disturbance is advised and readers are cautioned against
and A. M. ZEISS
1986
“hastily accepting sleep medication.” Unfortunately. this scanty warning without mention of anti-depressants could lead readers incorrectly to conclude that “sleep medications” are the only pharmacological options for depression. Seeking professional assistance is presented as a last resort, after readers have “tried conscientiously to use the suggested techniques but have found no relief.” Thus, one could conclude that obtaining help is also a sign of failure. Additionally, the introduction’s disclaimer. “A Word of Caution”, is not adequate to encourage people to seek outside help. It merely states that readers should consult a professional if they are unable to “maintain sufficient motivation” to finish the self-help program. are “afraid” of committing suicide, or doubt that depression is the major problem. In summary, this book is a compilation of cognitivebehavioral assessment and treatment strategies which the authors have applied to depression management. They advocate that seriously depressed people use the recommendations without necessarily seeking professional assistance to monitor their progress. Significant information about treatment options, such as psychopharmacology, is omitted. While the effort to give people information to alleviate stress and increase their enjoyment of life is laudable, the advocacy of a self-administered treatment program for major depression without professional assistance is questionable, if not dangerous. JOHN M. DOWNS Department of Psychiatry University of Tennessee College of Medicine Memphis, TN 381OS, U.S.A.