THEO COMPERNOLLE, M.D.

KEES HOOGDUIN. M.D.

LEEN JOELE. M.D.

Diagnosis and treatment ofthe hyperventilation syndrome

Dr. Comperno/le is associated with the Akademisch Ziekenhuis Gasthuisber~ inLeuven. Be/~ium. Dr. Hoo~duin is a p.~rchiatri.ft a( the Stichtin~ Geestell'ke Volh­~e=ondheid. Delji. (he Netherlands; and Dr. Joele is a psrchiatrist at the BloemendaalP.~rchiatric Clinic. The Ha~ue. the Netherlands. Reprint requests to Dr. Compernolle.Child Psrchiat~r Department. A kademisch Ziekenhuis Gasthuisberx. Herestraat 49.B300() Leuven. Belxium.

ABSTRACT: The hyperventilation syndrome is often misdiagnosedbecause attacks do not always involve obvious overbreathing ortetany. Aggressive, self-mutilating, tantrum-like, psychosis-like,and phobic behaviors often accompany these attacks and maymask the underlying problem. These behavioral disorders usuallydisappear along with the attacks when patients are treated forhyperventilation syndrome. A therapeutic procedure based onprovoking a hyperventilation attack, teaching the patient to stopthe attack by breathing into a paper bag, and daily voluntary hy­perventilation was successful in more than 100 patients.

Although the hyperventilation syn­drome (HVS) has been recognizedfor many years and is fairly com­mon,I.11 it is often misdiagnosed.Victims of the syndrome have beenreferred to our psychiatric facilitieswith diagnoses ranging from hyste­ria (most frequent). schizophrenia,and schizophrenia with deperson­alization, to migraine. menopausalproblems, atypical cardiac asthma.epilepsy, myositis. arthritis,

Meniere's disease, asthma. cardiacneurosis. and psychosis. We studied106 such patients to try to deter­mine why HVS is so often misdiag­nosed and why advising patients tobreathe into a bag-the time-testedtreatment-is often unsuccessful.Our study led to two findings: (I)that episodic aggressive. destruc­tive. tantrum-like, psychosis-like,and phobic behaviors are asso­ciated with hyperventilationl~ and

that these behavior patterns couldbe elicited at least partially by vol­untary hyperventilation andstopped by breathing into a bag;and (2) that in many cases, breath­ing into a bag effectively controlsHVS only if the symptoms of thedisorder are first induced in thepatient clinically.

Pathogenesis

The symptoms of the hyperventila­tion attack coincide with a drop inpCO~. The resulting alkalosis, to­gether with a direct influence of thepCO~ level, alters the excitability ofthe peripheral as well as the centralnervous system.S.b.I3.IS The bio­chemical processes leading fromalkalosis toward the various symp­toms of the hyperventilation attack,however. remain largely unknown.Since the symptoms involve theheart and the head. the patientusually feels intense anxiety. oftenexperienced as a fear of death or afear of losing self-control. This in­terpretation reinforces the anxietyand results in a vicious cycle ofincreasing panic and increasing hy­perventilation. Once the patient

612 PSYCHOSOMATICS

Hyperventilation

has suffered a seizure, the mereanticipation of being overcome byanxiety can provoke an attack. Al­most all of the patients suffer fromshortness of breath, and tend tobreathe deeper and faster in re­sponse to anxiety, which also helpsperpetuate the vicious cycle. In ad­dition. the HVS may eventuallybecome an important componentof the patient's interpersonal in­teractions. thus blurring further theoriginal cause of the attacks. Ex­amination of the complex factorsthat perpetuate the attack is thusvitally important. since the pa­tient's achievement of an under­standing of the historical precipi­tating cause alone is seldom of helpin curing the attacks.'~·~lI

Symptoms

The patient usually complains ofepisodic occurrences of headache.dizziness. paresthesias, shortness ofbreath, palpitations. tremblinghands. fatigue. difficulty in think­ing clearly. nervousness, or anxiety,without any obvious immediatecause.~·XI3.~1 Sighing is often pres­ent, but more noticeable to othersthan to the patient himself. Themajor complaints reported by dif­ferent authors studying patientswith HVS are listed in the Table.Clinical examination reveals noobvious physiologic cause. but painis frelJuently produced by pressingthe osteochondral rib joints or themastoids. Chvostek's sign is oftenabsent. Free calcium blood levelsare normal in half to three fourthsof patients.'·~Other laboratory testsshow few if any abnormalities ex­cept during physical exercise.When electrical excitability of themuscles is examined during exer­tion. patients exhibit signs of ex­haustion sooner than normally ex­pectedY

614

Why the diagnosis may be missed

Observation of our patients anddiscussions with referring physi­cians led us to conclude that HVS isoften misdiagnosed for six majorreasons:

• Too many physicians still expectthe hyperventilation attack to re­sult in a real tetany, which is rela­tively rare.

• Since the physician almostalways sees the patient some timeafter the attack has occurred. hemust rely on the patient's accountof what happened. The patienttends to emphasize those symptomsthat worry him most. One who isfrightened by the sensationsaround the head and/or heart, forinstance, will not recall the numb­ness in his fingers. In our experi­ence, the patient may report anyone of the many symptoms he ex­periences as his chief complaintand fail to mention others unless heis asked. Cultural differences alsoinfluence the nature of the symp­toms reported. Even when theyshow all physiologic and nonverbalsigns of great anxiety during vol­untary hyperventilation. for exam­ple. male patients in the UnitedStates admit their anxiety far lessfrequently than male patients inHolland and female patients ingeneral.

• The most striking symptom ofthe hyperventilation attack inmany patients may be rather bi­zarre, aggressive, self-mutilating,tantrum-like, or psychosis-like be­havior. This may range from anepisode of destroying furniture oraggressive behavior toward familymembers to excessive masturba­tion. crying spells, or even suicideattempts. It may lead physicians to

diagnose psychosis and prescribetranquilizers and sometimes hospi­talization. These behavioral dis­orders are not always due to HVS,of course, but HVS should be con­sidered as a possible explanationfor them. In our patients, many ofwhom had been unsuccessfullytreated with tranquilizers and hos­pitalization. such behavior disap­peared when treated as hyperven­tilation attacks. It is not yet clearwhether these behavioral disordersresult directly from the changes inthe central nervous system due toalkalosis, or from the patient'spanic reactions or futile attempts tostop the dreadful experience, orfrom both.

• An HVS patient may tend toavoid situations that he associateswith the occurrence of the attacks,to the point that he appears to suf­fer from a serious phobia ratherthan HVS. If he experiences hisfirst HVS seizure in a movie the­ater. he may avoid not only movietheaters but all other theaters andstadiums. Or he may avoid crowdsbecause he fears a loss of self-con­trol or the humiliation of fainting inpublic. Some patients avoid beingalone because they fear that adeadly attack may strike when nohelp is available. Obviously. not allphobias of this kind result fromhyperventilation, but in our studywe were very surprised by the highfrequency of HVS victims who suf­fered from phobias that disap­peared when treated as hyperven­tilation attacks.

• HVS has been described in dif­ferent ways by different specialistsand ended up with several names,even though many authon;4.6.'3.21.23have convincingly demonstratedthat hyperventilation is the basic

PSYCHOSOMATICS

Table-Complaints Reported in Studies of HyperventllaUon Syndrome,I

Author Lowry' Pitts' Bultenhuls13 Welmann21

Label Hyperventilation AnXiety Da Cos"'s Hyperventilationattacks neurosl yndrome syndrome

No ofPatients 150 14 69 84

WeightedComplaints Frequency (~) average

Paresthesias 58 71 95 82Numbness or tlng"ng of

hands 73 90 79DIzziness 85 78 73 72 79Shortness of breath 76 90 58 85 75Feeling faint 73 71 72Headache 87 58 71 37 69Little stamina-tires easily 68 93 53 72 67Feeling unsteady 73 54 66Anxiety 61 51 77 65DiZZiness sit1lng or lying

down 62 62Pain In chest 62 85 55 61Trouble thinking clearly 61 61Nervousness 88 71 47 60Lightheadedness 59 59Palpitations 96 62 49 59Transpiration 44 61 58Nausea 69 35 49 56

':Trembling hands 59 53 69 37 55Sleeping problems 52 55 55Tightness In chest 54 51 53Cold shudders 24 61 52 53

umbness or lingllng offee 61 30 50

Ringing In ears 50 50Hands tight, hard to open 36 74 50Feeling far away 49 49Blurred Vision 54 37 48Lump In throat 51 43 48Cold, pale hands 47 53 48DifficullY talking 47 47FOOling unhappy 50 44 45

II Feeling of breathing toofrequently 44 44 44

Excited Without reason 42 42Waking up at night short of

breath 42 42Passing out,

unconsciousness 53 37 44 16 40Frequent urination 19 33 39Numbness or tingling of

face 37 39 38Sighing 79 60 11 37

umbness or ling"ng oftongue 28 40 32

Feeling of unreality 31 31Shaking 46 23 27Crying Without reason 29 15 24Double vision 23 23Vomiting and/or diarrhea 13 28 7 16

- - ~ -

SEPTEMBER 1979· VOL 20 • NO 9 615

Hyperventilation

underlying cause of the disorderslabeled as anxiety states. anxietyneurosis. effort syndrome. DaCosta's syndrome. neurocirculatoryasthenia. hyperventilation aHack.and hyperventilation syndrome.Among these descriptive terms thelast two disassociate the diseasefrom neurosis and best explain thephysiologic genesis of the psycho­logical symptoms.~4

• Paradoxically. in many cases ofHVS there are no obvious signs ofoverbreathing. Studies have shownthat after a long period of voluntaryhyperventilation human volunteerscan maintain alkalosis with only anoccasional sigh. without going intoseizures.~'·~t>

Diagnosis by provocationAn awareness of these pitfallsshould lead the clinician to morefrequently consider HVS in dif­ferential diagnosis. The diagnosis iseasily confirmed by inducing vol­untary hyperventilation-the hy­perventilation provocation test(HVPT). In fact. the test should bedone routinely on every patientwith unexplained anxiety, dyspnea,dizziness. fainting. or heart com­plaints.~7 There is nothing in theliterature to substantiate the fearthat provoking hyperventilationmay be dangerous. There are noreports of accidents resulting fromtwo to five minutes of hyperven­tilation followed by breathing intoa bag. The only fatal accidents re­ported followed breath-holdingafter hyperventilation in divingand swimming competitions~x.~~

and hyperventilation by childrenwith sickle cell anemia.J" Voluntaryhyperventilation should not beperformed by patients with vascu­lar disease and chronic anemia.

In general. it is far more danger-

616

ous to leave the hyperventilationattacks untreated, for they mayoccur as often as several times a dayand may eventually lead to the useof more sophisticated and poten­tially harmful diagnostic and ther­apeutic measures. Some of our pa­tients who responded well to theHVPT and the rebreathing treat­ment had undergone ECGs, EEGs.electronystagmograms, spinal taps,the most unusual combinations ofmajor tranquilizers. surgery of thenasal septum (apparently becauseof the feeling of shortness ofbreath). special diets. and even cor­onary angiographyJ'-all of which

Breathing into a bagcontrols HVS only if thesymptoms ofthe disorder arefirst induced clinically.

tended to reinforce their self-imageas very sick people.

Most often. however, the physi­cians concluded that from a medi­cal point of view nothing waswrong. As a rule. neither the pa­tient nor his family members canaccept this conclusion because theyexperience the aHacks as dramati­cally frightening-a fright that phy­sicians and therapists start to fullyunderstand once they actually ob­serve the attacks during HVPTs.The patient and his family thenoften begin to suspect that the con­dition is so serious that the physi­cian has chosen not to inform them.This suspicion may lead to furtheranxiety and perhaps aggravate thesyndrome. Many patients embarkon "doctor shopping." seeking apulmonary specialist for thebreathlessness. a cardiologist forthe palpitations, a neurologist forthe dizziness and paresthesias, and

an ophthalmologist for blurred ordouble vision-until they are finallysent to the psychiatrist. unofficiallylabeled "neurotic complainers."

Therapeutic strategyWe tried several therapeutic pro­cedures, including rebreathing. in­ducing hyperventilation and its ac­companying behavior patterns.medication, and several combina­tions of these treatments. The bestresults were obtained with the fol­lowing treatment given in two ses­sions plus one or more follow-upvisits'~:

In the first session, we took a verydetailed history of the aHack, pay­ing special aHention to listing thesymptoms in their chronologic se­quence. The patient was then toldthat the treatment to be given dur­ing the next session would requirethe provocation of a seizure. Addi­tional information on how thiswould be done was withheld inorder to inspire in the patient ananxious anticipation, which wouldhelp precipitate a full aHack.

In the second session, we delib­erately provoked hyperventilation.In order to avoid injury shouldfainting occur during the provoca­tion. the patient was asked to lie ona couch with his partner or parentsseated nearby. The patient wasasked to breathe quickly (20 to 30/min) and deeply for two to fiveminutes. The aHending physicianoccasionally monitored the fre­quency and depth of the breathingby placing a hand on the patient'schest. for quick and shallowbreathing is dead-space ventilation.which only dries the mouth. Inorder to intensify the patient's anx­iety and provoke an aHack despitethe reassuring presence of the doc­tor and family. the physician sug­gested to the patient that some of

PSYCHOSOMATICS

the symptoms mentioned duringthe history-taking session maystrike. Any clinical signs the patientshowed. such as pallor, clamminess,and acceleration of the pulse. werealso reported to him. When theresulting hyperventilation intensi­fied beyond the patient's control, orwhen the patient reported thesymptoms to be at or beyond theintensity usually experienced, asmall paper or plastic bag (about 8"x 12") was held over the patient'snose and mouth for two to fiveminutes:l~ A few fingers wereplaced inside the bag to providesome air and prevent hypoxemia,which can cause hyperventilation.In the meantime. the physicianpredicted loudly and reassuringlythe disappearance of the symp­toms. As the patient rebreathed hisown carbon dioxide. the acid levelof the blood returned to normal,the breathing and pulse sloweddown, and the panic vanished.Family members often asked ingreat relief: "Is that all there is toit?" The physician then taughtthem to assist the patient in the useof the bag.

Immediately after the provoca­tion attack. while the patient andhis family were probably most re­ceptive to advice from one who haddemonstrated an ability to makethe symptoms appear and disap­pear, we explained the nature ofHVS and its treatment. We advisedthe patient to practice hyperventi­lation daily until the attacks ceasedto occur. We taught the patient howto elicit the symptoms through hy­perventilation provocation and tostop them by using the bag in thesame way as in the session in thephysician's office. We advised himto always keep a bag with him inorder to stop occasional spontane­ous attacks. emphasizing that his

SEPTEMBER 1979· VOL 20 ' NO 9

success in controlling the attackswith the bag depended on dailyvoluntary hyperventilation exer­cises. We told him to resume thedaily exercises and the use of thebag immediately should a sponta­neous hyperventilation attack recurafter a long symptom-free period.Finally. we instructed the family toremind the patient of his daily ex­ercises. to encourage him. and toassist him in the use of the bag. Wedid not prescribe medication eventhough such drugs as chlordiaz­epoxide have often been reportedeffective against hyperventilationattacks.'·J·l

Results

Hyperventilation attacks were suc­cessfully eliminated in 106 outpa­tients who underwent the above­described treatment in three widelydiffering outpatient departments in1975. The 10% of the patients whosuffered rel:urrences during a 6- to24-month follow-up period wereable to control them without medi­cal intervention. Phobic. self-muti­lating. and tantrum-like behaviorsthat had afflicted many of the pa­tients disappeared in most caseswith the termination of the hyper­ventilation attacks. One third of allthe patients were effectively treatedin only two sessions and one or twofollow-up visits. The remaining twothirds relJuired additional familytherapy (usually less than ten ses­sions) in order to further changedysfunctional interaction patternsthat became more obvious once thedetouring of the interactionsthrough attacks was no longer pos­sible.

Three fourths of the patients re­ferred to us had suffered from HVSfor one to three years. with thefrequency of attacks ranging fromtwo or three a day to once in two

Hyperven ti lation

weeks. Each patient had visited atleast three physicians. and all hadreceived large amounts of majorand minor tranlJuilizers. includingchlordiazepoxide. without obtain­ing good results.

Our treatment procedure hasbeen taught to various medicalspecialists in the Netherlands. Bel­gium, and the United States, withreported results similar to ours.

Discussion

The successful outcome of thistherapy can be attributed not onlyto the normalization of the meta­bolic imbalance but also to a multi­pronged treatment programdirected at the various conditionsperpetuating the altacks.I7·~O..14.1~The main components of this ther­apeutic approach may be sum­marized as follows:

• Restoration of the metabolic im­balance (alkalosis) through a phys­iologic intervention (breathing intoa bag).

• Decreasing anxiety by threemeans: ( I) by reducing the physicalsymptoms (through rebreathing):(2) by extensive explanation [Oneof the authors (T.C) was impressedwith how easily patients can be ledinto a deep trance immediately fol­lowing the hyperventilation provo­cation procedure. The instructionsgiven at that moment may some­times have the effect of a post-hyp­notic instruction. even if a trance isnot explicitly induced.): and (3) bydemonstrating to the patient thathe can have control over his at­tacks:l~.w

• Changing the dysfunctional in­teraction patterns that reinforce theillness. by giving the patient moreattention and concern for exercis-

621

ing and getting better than for hav­ing attacks.

• Reducing the family's anxietyand thus improving their interac­tions with the patient.

• "Actualizing" the transactionalpatterns by provoking an attackand observing the patient and hisfamily members, rather than rely­ing on their accounts. This alsoprovides the therapist with an im­mediate opportunity to startchanging these interactional pat­terns.40.41 0

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