Henry Ford Hospital Medical Journal

Volume 22 | Number 4 Article 4

12-1974 Treatment of the Syndrome Hans von Brauchitsch

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Recommended Citation von Brauchitsch, Hans (1974) "Treatment of the Hyperventilation Syndrome," Henry Ford Hospital Medical Journal : Vol. 22 : No. 4 , 203-210. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol22/iss4/4

This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. Henry Ford Hosp. Med. Journal Vol. 22, No. 4, 1974

Treatment of the Hyperventilation Syndrome

Hans von Brauchitsch, MD*

I HE American Handbook of Psychiatry discusses the hyperventilation syndrome under the heading of "Commonly Neglected Psychosomatic Syndromes".' Considering the fact that this disorder may be more prevalent than schizo­ A review oi the literature on the hyperventila­ phrenia, that subjectively it is pro­ tion syndrome reveals a variety of treatment foundly unpleasant, and that millions of approaches and a virtual absence of con­ dollars are spent yearly for emergency trolled studies of this common problem. At­ care and treatment, one wonders why tempts to treat the condition by changing the respiratory pattern through mechanical most textbooks lend it a few fleeting sen­ means can be traced back to the first century tences, at best. A.D. The "paper bag method" of treatment has many psychological drawbacks and is It has been established that approxi­ often unsuccessful. Several avenues of drug treatment have been explored: acidifiers, mately 5% of all patients ^een in gas­ minor tranquilizers, antidepressants, and troenterology,' over 10% of those stimulants. Reports of success with insight- seen in internal medicine' and up to oriented intensive psychotherapy are scarce. one third of all patients in general prac­ Some forms of group psychotherapy have been tried with success. The model of the tice" suffer from hyperventilation. The "medical friendship" may be most appro­ syndrome is frequently encountered by priate, and abreaction as well as verbal ventila­ the pediatrician^ and is of great con­ tion may prevent respiratory hyperventilation cern to the obstetrician." Of all at least temporarily. Research is badly needed, medical specialities, the psychiatrist's of­ utilizing the physiological changes occurring in the hyperventilation syndrome. fice appears to be the only one in which hyperventilators are seen rarely, if at all.

Since patients with hyperventilation syndromes are almost always first seen by non-psychiatric physicians, one ques­ tions why are they so rarely referred to psychiatrists? It may well be that the seemingly gross organic pathology of 'Formerly, Department of Psychiatry, Henry the syndrome leads the primary physi­ Ford Hospital cian to rule out all possible concomitant organic factors. Or the opposite may be Address requests for reprints to Dr. von true: the sharp discrepancy between the Brauchitsch at the University of Oklahoma, Health Sciences Center, P.O. Box 26901, alleged harmlessness of the condition Oklahoma City, OK 73190. and its dramatic symptomatology may

203 von Brauchitsch

produce a shrug-of-the-shoulder, "just- hyperventilation syndrome is frequently another-hyperventilator" attitude from associated with acute, overwhelming the emergency room physician. The at­ and therefore also called anxiety titude of belittling the seriousness of the state, anxiety neurosis, hysterical attack, syndrome is the least justified. Hyper­ or hyperventilation tetany. The anxiety ventilation attacks may not threaten label is popular among psychiatrists, but physical survival, but the hyperventila­ not entirely correct, since not all hyper­ tion syndrome in its chronic form can ventilation attacks are accompanied by become an exceedingly disabling and in­ overt anxiety, and because not all anxiety tractable condition. In my experience, states produce noticeable hyperventila­ very few hyperventilators are ever cured, tion. It is certainly not related to hysteria and a large percentage become literally in the form of neurosis, although it may crippled to the point of social useless- occur more frequently in patients diag­ ness. For this reason, a review of the un­ nosed as hysterical characters."-'' The fortunately meager therapeutic ar­ chronic hyperventilation syndrome mamentarium available to the physician tends to produce a multitude of physical may help to stimulate efforts to find symptoms often without pronounced more reliable remedies. emotional concomitants. Many physical complaints refer to the heart rather than Nosology and Classification to respiration and account for hyperven­ tilation syndrome being labelled as Da It is reasonable to question whether Costa's syndrome, neurocirculatory as­ the hyperventilation syndrome is a dis­ thenia, effort syndrome, soldier's heart, ease entity or one of the ubiquitous irritable heart, vasomotor instability, physiological concomitants of anxiety. I vasomotor neurosis, cardiac neurosis, have chosen to treat the condition for etc.'" practical reasons as if it were a nosologi­ cal entity. But I am willing to concede that, even in the context of this paper, In many cases, the chronic fatigue the term could delineate a target symp­ (chronic hyperventilation from vigor­ tom rather than a disease. The fact that ous physical exercise') forms a pic­ the hyperventilation syndrome produces ture identical with that of neurasthenia, measurable organic changes of blood effort syndrome, or chronic exhaustion gases, pH of blood and urine, elec­ state. The condition may simulate the trocardiogram, electroencephalogram, symptoms of functional hypoglycemia"; etc would place it theoretically into the the typical dry tongue caused by mouth- category of psychosomatic diseases. has been described under the One source of confusion regarding def­ name of . Finally, it may be inition of the syndrome, however, is associated with chronic aerophagia, that it tends to be grouped with purely producing a multitude of "functional" psychological disturbances, especially gastrointestinal symptoms.Common with the so-called "actual neuroses". to all forms is the pathognomic "sigh­ The list of conditions identical with or ing", open-mouthed respiratory pattern closely related to the hyperventilation which uses intercostal respiratory mus­ syndrome appears endless. cles.

Treatment It is possible to distinguish between acute and chronic hyperventilation syn­ A. Increase of Blood Dioxide Content drome. Transitions occur and the pres­ Since the hyperventilation syndrome ence of one form does not preclude the is characterized by carbon dioxide de­ emergence of the other. The acute pletion and paradoxical stimulation of

204 Treatment of the Hyperventilation Syndrome

the medullary respiratory centers, it ap­ ling ("whistling in the dark") to regulate pears logical to treat the condition by their respiratory rates during times of manipulating the inspired gases. This anxiety. approach has almost two thousand years of medical endorsement. Aretaeus of Modern medicine has continued the Capadocia recommended as early as 100 tradition by recommending the use of A.D. blowing "evil-smelling fumes" into the "paper bag method" (increasing ar­ the faces of those afflicted." A 17th cen­ terial carbon dioxide tension by breath­ tury formulary gives the prescription for ing from a bag and thus helping to cor­ a "parfum" consisting of castorea, par­ rect the respiratory alkalosis which ex­ tridge feathers, paper and asa foetida to plains some of the acute symptoms). The be smelled by patients suffering from method can be dramatically effective at "les suffocation de la matrice"." Cas­ times. In my own experience, however, torea is a substance extracted from the the paper bag method is more a liability perineal glands of beavers and its effect than an asset. It may work once or even may have been comparable to the sensa­ twice; but since it does nothing to at­ tion of being sprayed by a skunk — a tenuate the anxiety underlying the hyper­ powerful deterrent to hyperventilation, ventilation attack, the patient soon loses if not respiration of any kind. A textbook faith or feels that he is being ridiculed. of medicine published in 1766 suggests Its use may drive the patient to seek help "stinking and volatile spirits" or just in the emergency room of another hos­ singed feathers, burning leather or burnt pital at the time of his next attack, leav­ horncombs be held under the nose of ing the physician with the erroneous be­ those suffering from "suffocatio lief that he had "cured" his patient. hysterica".'" With theadventof the ageof reason, the method was merely altered, but not abolished. That the ammonia in One simple method to regulate the the smelling-salt bottles of the Victorian patient's breathing rate is by encourag­ lady actually stimulated the medullary ing him or her to talk. Provided that the centers other than momentarily is hard acute hyperventilation attack has not to believe, but it is a permissible as­ progressed too far (in which case the sumption that the act of smelling am­ patient's sensorium may be clouded to monia would slow down an accelerated the point where rational conversation is respiratory rate. One British physician no longer possible), it is usually helpful invented a spring belt to be worn around to ask the patient to give a thorough and the chest in order to reduce the patient's clear description of symptoms. Relatives breathing rate. Since the inventor of this ought to be excluded because they tend gadget applied it indiscriminately to to insist on telling their side of the story. hyperventilators as well as to patients The patient is encouraged to talk loudly suffering from heart disease, it fell un­ and clearly (it may be permissible to de­ derstandably soon into oblivion."' One velop a transient partial deafness during may speculate that the enormous popu­ the interview). The combination of reas­ larity of the cigarette, especially in times surance and enforced respiratory slow­ riddled by the anxiety of strife and war, down is often sufficient to bring relief may not so much be due to "oral fixa­ within five to ten minutes. tion" as to the fact that one cannot smoke and hyperventilate easily at the B. Drugs same time. (It is proverbial to "light up" after a bad scare). Since time immemor­ Evaluation of the efficacy of drugs in ial, people have used singing and whist­ the hyperventilation syndrome is dif­ ficult. First, hyperventilation attacks are

205 von Brauchitsch

too unpredictable and the reassuring ef­ hyperventilators have been exposed fect of medical attention is too pro­ over the years to the entire phar­ nounced to distinguish between a macological armamentarium of office genuine drug and a placebo-effect. Sec­ practice. In my practice, I cannot re­ ond, since many hyperventilators have member a single patient who had not been exposed to a multitude of drugs, had previous drug treatment. This drug prescribed unsuccessfully by their exposure implies limited usefulness but physicians, they tend to be skeptical ineffectiveness may not be so much a about any kind of drug. Subsequently, function of their chemistry, as of the their drug-taking habits are unpredicta­ prescribed dosage. Many physicians ble and there is a pronounced tendency tend to use the minimum recommended to modify or discontinue prescriptions at dosage of any psychotropic drug only, will. Finally, because of the marked anx­ notwithstanding the fact that the massive iety pervading the condition, and the anxiety, encountered especially in the need for medical support, the patient acute hyperventilation syndrome, can­ may reject the very medication which not be expected to yield to such would ultimately be effective, because homeopathic administrations as five or he subconsciously fears that improve­ ten milligrams of chlordiazepoxide. In ment will cut him off from his justifica­ view of the paroxysmal nature of the tion to contact his doctor. These are the actue hyperventilation syndrome, I have patients who develop the strangest and found tranquilizers useful on a demand most outlandish "side effects" to drugs schedule in moderate to high dosage. If which are known to be totally harmless. the fullblown syndrome is already pres­ ent (for instance, at the time of admis­ sion to the emergency room), 100 mgm Prior to the advent of effective and of chlordiazepoxide may be adminis­ safe tranquilizers, the medical literature tered intramuscularly. Patient and family recommended the use of drugs which should be told that drowsiness or sleep would affect the blood pH directly. Am­ will ensue. After establishing a good monium chloride, 1 gm three to four working relationship with a patient, I times daily, was said to be the medica­ prescritje 25 mgm chlordiazepoxide cap­ tion of choice," although to my know­ sules (or an equivalent dosage of any ledge there are no controlled or follow- minor tranquilizer), two capsules to be up studies reported in the literature. taken as soon as an impending attack is Equally unsupported appears the claim felt. Again, the patient is instructed to that acid-ash diets, carbonated water, rest and to abstain temporarily from driv­ phenoxyethylamine, ergotamine, yo­ ing a car or any potentially hazardous himbine, hydrastine, quinine, pilocar­ occupation. Sometimes the dosage has pine, histamine or acetylcholine will to be repeated until the attack is under bring relief. full control. Admittedly this regimen is less effective once the disease has en­ tered a chronic stage. With the development of modern tranquilizers, it is possible to affect the anxiety component of the hyperventila­ Controlled clinical trials have been tion syndrome. Surprisingly enough, al­ conducted of antidepressant drugs'* though much effort has been dedicated with favorable results, although clinically to the evaluation of the various drugs' manifest depression is quite rare in usefulness in anxiety states, very little hyperventilation syndrome. No phar­ has been said about their use in the macological rationale has been offered, hyperventilation syndrome. Many nor are there long-term or follow-up

206 Treatment of the Hyperventilation Syndrome

studies in the literature. I tend to agree C. Psychological approaches cautiously that, in chronic hyperventila­ Some authors recommend a very sim­ tion syndrome, antidepressant drugs ple procedure to alleviate the patient's appear more beneficial than tranquiliz­ apprehension. They instruct the patient ers. A trial with antidepressants or to forcibly hyperventilate in the pres­ antidepressant/tranquilizer combina­ ence of the physician. The re-emergence tions appears justified especially if a of the symptoms of the hyperventilation strong pain component (chest wall pain) syndrome then not only secures the cor­ is present. In patients with the chief rect diagnosis, but serves as a major ther­ complaint of lightheadedness, deper­ apeutic tool. It clarifies the underlying sonalization sensations, xerostomia, mechanism of the condition for the pa­ and excessive thirst, such drugs may tient, thus alleviating his anticipatory produce adverse rather than beneficial anxiety and strengthening his confi­ results. From the antidepressants it is a dence in the physician.'.".•",'" short step to the use of stimulants. Again, my own experience is not un­ This technique can be highly effective favorable, especially if the patient com­ but should be used cautiously. First, not plains about chronic fatigue and exhaus­ all hyperventilators are able to repro­ tion. Due precautions against the abuse duce an attack in the physician's office. of these drugs have to be taken. There is no real motivation for pro­ Relevant in this context is the question longed hyperventilation because the which drugs not to use in the hyperventi­ very presence of the physician is reassur­ lation syndrome. The chronic hyperven­ ing to the point where no true anxiety tilation syndrome, especially if chest wall build-up can occur. The more chronic pains are present, may be mistaken for the condition, the less likely is the test to pectoris and treated with nitro­ succeed. The net result may be a mere glycerine or amylnitrite. Both drugs have embarrassment to the patient and the been proven to aggravate abnormal EEC physician alike, or an angry reaction on findings related to hyperventilation.'' If the side of the latter because the patient the psychological roots of the disease "did not cooperate". are recognized, some physician may er­ roneously conclude that the patient is Even if some or all of the acute symp­ "hysterical" and revert to the use of toms can be reproduced, the relief felt by placebos. This does the patient injustice the patient may turn out to be short lived. because it is recognized by many The influence of intellectual understand­ psychiatrists that placebos should be ing on the underlying emotions is mi­ used under no circumstances. nute, and the first recurrence of an un­ controllable hyperventilation attack out­ Finally, since chronic hyperventilators side of the doctor's office may shatter all suffer from such a large number of ills hopes, as well as the faith in the and ailments, the role of over-the- physician's skills. Hyperventilation is a counter drugs should also be assessed. I chronic habit disturbance, and bad have seen hyperventilating patients who habits cannot be overcome by simply consumed staggering doses of acetyl- pointing out to the patient that they salicylic acid day in and day out. Salicy­ exist.^ lates, if used in sufficiently high dosages, can produce hyperventilation alkalosis Psychotherapy is almost universally by themselves, thereby predisposing the recommended, but since not all inves­ hyperventilator to some of the most tigators were psychiatrists, the meaning troublesome symptoms of the disease. of the word is frequently vague. It ranges

207 von Brauchitsch

from simple reassurance, preferably by a In the majority of cases, hyperventilation non-psychiatric physician'" over is a physiological reflex and therefore "psychocatharsis and re-education"," not accessible to psychoanalytic in­ "attitude therapy"''' to intensive, uncov­ terpretation or insight. The actual cause ering, psychoanalytically oriented of the anxiety is, according to my obser­ psychotherapy.' '" The outcome is usu­ vations, not so much repressed by the ally considered favorable, an optimism hyperventilator, but rather suppressed which is as surprising as it is unsup­ or plain ignored. A great many of these ported by clinical data. patients are either too isolated to be able to relate their fears to a sympathetic lis­ To clarify the issue, it will be necessary tener, or have a peculiar sense of shame to digress briefly into the history of the preventing them from "complaining", development of psychotherapeutic con­ which they regard as a sign of weakness. cepts. In classic psychoanalytic nosol­ If encouraged, they are able to recall ogy, the hyperventilation syndrome is traumatic experiences leading directly to viewed as an organ neurosis.^'' The con­ their acknowledged fear of sudden temporary psychiatric term is death. In a large number of cases this psychosomatic disease. Even if viewed as event was either the sudden death of a a modification of an anxiety state (or anxi­ member of the family or the patient's ety neurosis), in the older nomenclature own involvement in an accident. It is the condition would be categorized as quite surprising to observe the rapid de­ an actual neurosis. (The "actual crease of hyperventilation attacks once neuroses" are anxiety states, neuras­ the patient is given the opportunity to thenia, and hypochondriasis). Unfortu­ talk about his worries. The drawback of nately, and obviously caused by a histor­ this therapeutic approach is the fact that ical misunderstanding of the Freudian it is interminable: As soon as the patient use of the word neurosis, contemporary ceases to ventilate his fears, he is bound nomenclature lists the actual neurosis to hyperventilate again. together with the transference neuroses, (hysteria, phobia, obsessive-compulsive and depressive neurosis) with which they Theoretically, the need for ventilation have little in common. Psychoanalytic and catharsis and the disturbances of in­ psychotherapy is the treatment of choice terpersonal communication skills could in the transference neurosis, but almost make the hyperventilator an excellent all psychoanalysts, including Freud and candidate for group psychotherapy. In Fenichel,''' state that it is ineffectual in my experience, that approach works the actual neuroses and the organ only in a few selected cases. Llnless very neuroses. well prepared, the patient will quickly revert into customary silence, feeling The explanation for the lack of success that he cannot afford to "bother" other of insight (interpretative) psychotherapy group members with his apprehensions. in the hyperventilation syndrome is ob­ One important exception to this rule are vious. As in many psychosomatic dis­ inspirational groups like "Recovery Inc." eases, the ultimate root of the condition who are often highly effective in keeping is a physiological emergency reaction. In the patient functioning. the face of danger the organism is biologically prepared for fight or flight.' Thus, the psychotherapeutic approach This is an entirely different mechanism to the hyperventilation syndrome re­ than the one seen in the transference sembles closely the psychotherapy of neuroses, which are symbolic expres­ most psychosomatic diseases. The main sions of repressed instinctual conflicts. accent is on the establishment of a

208 Treatment of the Hyperventilation Syndrome

"medical friendship", involving the severity of the illness. None of these are therapist as a person who is capable of possible in the hyperventilation syn­ showing sympathy and understanding, drome. Here, conditions for research who will not hesitate to help the patient are still pre-scientific. Any attempt at in­ with everyday decisions and the resolu­ vestigating the efficacy of treatment is at tion of environmental problems, if war­ such an early and unsophisticated stage ranted. Since fear of death is one of the that results may sound like a treatise on mainsprings of the condition, the physi­ the remedy of swamp fever written in cian will do well to emphasize the medi­ the early nineteenth century. cal role. Dependency on the physician is bound to develop but must be regarded This is a surprising state of affairs. The as a reasonable price to prevent invalid­ physiological findings in the hyperventi­ ity. As in many other psychosomatic lation syndrome have been well ex­ conditions, therapy can offer cure only plored. At least the physical aspects of in very few cases, some degrees of im­ the condition should be easily accessible provement in many, and prevention of to exact, scientific measurement. There further deterioration in patients who al­ seems to be no valid excuse for diagno­ ready have entered into the chronic sing a condition characterized by simple stage of the disease. and clear metabolic and physiological abnormalities by the same intuitive and impressionistic criteria as "neurasthe­ Discussion nia" and "hypochondriasis." If the approach used in this paper is impressionistic and possibly even poly- If this observation is true for diagnos­ pragmatic in an era of strict scientific tic methods, it should be equally valid demands, one has to realize that this for therapy. If the metabolic aberrations less-than-scientific treatment of the responsible for the condition can be issue was not by choice, but by neces­ measured, then, one may assume, they sity. can also be reversed. A medical science that feels competent to modify the genet­ Dealing with a problem with scientific ic code ought to be capable of dealing objectivity requires operating in a de­ with the biochemical sequelae of tran­ fined conceptual framework. Criteria for sient . One may anticipate diagnosis must be standardized and the that correction of the underlying somatic natural history of the disease — its factors may do very little to influence the course without treatment — must have emotional maladjustment reaction. But, been established. To assess the effec­ that is an indispensible first step to ren­ tiveness of therapy there must be some dering the patient accessible to other yardstick to measure the degree and means of treatment.

References

Wahl CW: Commonly neglected psy- 3. Rice RL: Symptom patterns of hyperventi­ chosomatic syndromes. In Arieti, S. ed.: lation. Amer J Med 8:691-700, 1950 American Handbook of Psychiatry. Vol. Ill, pp 158-65, New York Basic Books 4. Kerr WJ, Dalton JW and Gliebe PA: Some Inc, 1966 physical phenomena associated with the anxiety states and their relation to hyper­ McKell TE and Sullivan T: The hyperventi­ ventilation. Ann Intern Med 37:962-92, lation syndrome in gastroenterology. 1937 Gastroenterology 9:6-16, 1947

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5. Enzer NB and Walker PA: Hyperventila­ 10. Wood P: DaCosta's syndrome (or effort tion syndrome in childhood. J Pediat syndrome). Brit Med J 1:767-72, 1941 70:521-32, 1967 11. Edwards WL and Lummus WL: Functional 6. Motoyama EK, Rivard G, Acheson F and hypoglycemia and the hyperventilation Cook, C: Adverse effects of maternal syndrome: A clinical study. Ann Intern hyperventilation on the foetus. Lancet Med 42:1031-40, 1955 1:286-8, Feb 1966 12. Ackerknecht E: A short history of 7. Ames, F: The hyperventilation syndrome. psychiatry. Translated by S. Wolff, New / Ment 5c/ 101:466-525, 1955 York, London: Hafner, 1959

8. Wittkower ED and White KL: 13. Tencke H: Formules de medecine tirees Psychophysiologic aspects of respiratory de la pharmacie galenique et chymique. disorders. Arieti, S., Ed.: American Part I,Sec IV, Chapitre VI: Des parfums, Handbook of Psychiatry, 1:690-707. New pp 270-2. Lyon: Jean Certe 1640 York, Basic Books Inc. 1959 14. Heisters DL: Practisches Medizinisches 9. Engel CL, Ferris EB and Logan M: Hyper­ Handbuch. Capitel 10: Von den Mutter- ventilation; analysis of clinical symp­ beschwerden. Malum hystericum, pp tomatology. Ann Intern Med. 27:683-704, 192-5, Nuernberg: Gabriel Raspe, 1766 1947

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