Effects of Breathing Training on Voluntary Hypo- and Hyperventilation in Patients with Panic Disorder and Episodic Anxiety

Anxiety disorders are associated with respiratory abnormalities. Breathing training (BT) aimed at reversing these abnormalities may also alter the anxiogenic effects of biological challenges. Forty-five Panic Disorder (PD) patients, 39 Episodic Anxiety patients, and 20 non-anxious controls underwent voluntary hypoventilation and hyperventilation tests twice while psychophysiological measures were recorded. Patients were randomized to one of two BT therapies (Lowering vs. Raising pCO2) or to a waitlist. Before treatment panic patients had higher respiration rates and more tidal volume instability and sighing at rest than did non-anxious controls. After the Lowering therapy, patients had lower pCO2 during testing. However, neither reactivity nor recovery to either test differed between patients and controls, or were affected by treatment. Although the two treatments had their intended opposite effects on baseline pCO2, other physiological measures were not affected. We conclude that baseline respiratory abnormalities are somewhat specific to PD, but that previously reported greater reactivity and slower recovery to respiratory challenges may be absent.

[1]  J. Gorman,et al.  Respiratory psychophysiology of panic disorder: three respiratory challenges in 98 subjects. , 1997, The American journal of psychiatry.

[2]  L. Keene.  A slow recovery. , 1989, The New Zealand nursing journal. Kai tiaki.

[3]  R. Nesse,et al.  Respiratory Psychophysiology and Anxiety: Cognitive Intervention in the Doxapram Model of Panic , 1996, Psychosomatic medicine.

[4]  J. Howell.  Carbon dioxide sensitivity in chronic lung disease. , 1975, Proceedings of the Royal Society of Medicine.

[5]  P. Salkovskis,et al.  Respiratory control as a treatment for panic attacks. , 1985, Journal of behavior therapy and experimental psychiatry.

[6]  F. Wilhelm,et al.  Autonomic and Respiratory Characteristics of Posttraumatic Stress Disorder and Panic Disorder , 2007, Psychosomatic medicine.

[7]  L. Bellodi,et al.  Carbon dioxide/oxygen challenge test in panic disorder , 1994, Psychiatry Research.

[8]  W. Roth,et al.  Are current theories of panic falsifiable? , 2005, Psychological bulletin.

[9]  R. Freire,et al.  Psychopathological profile of 35% CO2 challenge test-induced panic attacks: a comparison with spontaneous panic attacks. , 2006, Comprehensive psychiatry.

[10]  Dc Washington.  Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. , 1994 .

[11]  P. Lachenbruch.  Statistical Power Analysis for the Behavioral Sciences (2nd ed.) , 1989 .

[12]  S. Kroeze,et al.  No superior perception of hyperventilatory sensations in panic disorder. , 1998, Behaviour research and therapy.

[13]  W. Zin,et al.  Panic disorder in a breath-holding challenge test: a simple tool for a better diagnosis. , 2003, Arquivos de neuro-psiquiatria.

[14]  M. A. van den Hout,et al.  Hyperventilation is not diagnostically specific to panic patients. , 1992, Psychosomatic medicine.

[15]  N. Schmidt,et al.  The role of anxiety sensitivity in the pathogenesis of panic: prospective evaluation of spontaneous panic attacks during acute stress. , 1997, Journal of abnormal psychology.

[16]  J. Kinney,et al.  Ventilatory physiology of patients with panic disorder. , 1988, Archives of general psychiatry.

[17]  High-dose carbon dioxide challenge test in anxiety disorder patients , 1990, Biological Psychiatry.

[18]  D. Shapiro,et al.  Continuous physiological changes and subjective reports in panic patients: A preliminary methodological report , 1992, Biological Psychiatry.

[19]  W. Roth,et al.  Physiological evaluation of psychological treatments for anxiety , 2007, Expert review of neurotherapeutics.

[20]  J. Papsdorf,et al.  Physiological and psychological effects of acute intentional hyperventilation. , 1984, Behaviour research and therapy.

[21]  W. Zin,et al.  Hyperventilation challenge test in panic disorder and depression with panic attacks , 2001, Psychiatry Research.

[22]  A. Shekhar,et al.  Basilar artery response to hyperventilation in panic disorder. , 1997, The American journal of psychiatry.

[23]  D. Caldirola,et al.  Hypersensitivity to inhalation of carbon dioxide and panic attacks , 1995, Psychiatry Research.

[24]  G. Hibbert,et al.  Respiratory Control: Its Contribution to the Treatment of Panic Attacks , 1989, British Journal of Psychiatry.

[25]  P. Renshaw,et al.  Brain pH response to hyperventilation in panic disorder: preliminary evidence for altered acid-base regulation. , 2006, The American journal of psychiatry.

[26]  Randolph M Nesse,et al.  Persistent respiratory irregularity in patients with panic disorder , 2001, Biological Psychiatry.

[27]  M. First,et al.  Structured clinical interview for DSM-IV axis I disorders : SCID-I : clinical version : scoresheet , 1997 .

[28]  E. Hollander,et al.  Diagnostic and substance specificity of carbon-dioxide-induced panic. , 1993, The American journal of psychiatry.

[29]  E. Griez,et al.  Discrimination between panic disorder and generalized anxiety disorder by 35% carbon dioxide challenge. , 1995, The American journal of psychiatry.

[30]  W. Roth,et al.  Respiratory Biofeedback-Assisted Therapy in Panic Disorder , 2001, Behavior modification.

[31]  D. Heitjan,et al.  Mixed-effects models in psychophysiology. , 2000, Psychophysiology.

[32]  J. Gorman,et al.  Hemodynamic response to respiratory challenges in panic disorder. , 1998, Journal of psychosomatic research.

[33]  J. Gorman,et al.  Anxiogenic effects of CO2 and hyperventilation in patients with panic disorder. , 1994, The American journal of psychiatry.

[34]  Jacob Cohen.  Statistical Power Analysis for the Behavioral Sciences , 1969, The SAGE Encyclopedia of Research Design.

[35]  W. Roth,et al.  Characteristics of sighing in panic disorder , 2001, Biological Psychiatry.

[36]  W. Roth,et al.  Slow Recovery From Voluntary Hyperventilation in Panic Disorder , 2001, Psychosomatic medicine.

[37]  M K Shear,et al.  Multicenter collaborative panic disorder severity scale. , 1997, The American journal of psychiatry.

[38]  E. Griez,et al.  No chronic hyperventilation in panic disorder patients , 1993, Psychiatry Research.

[39]  W. Roth,et al.  Psychophysiological reactions to two levels of voluntary hyperventilation in panic disorder. , 2008, Journal of anxiety disorders.

[40]  J. P. Forsyth,et al.  Classification of panic attack subtypes in patients and normal controls in response to biological challenge: implications for assessment and treatment. , 2002, Journal of anxiety disorders.

[41]  J. Gorman,et al.  Physiological changes during carbon dioxide inhalation in patients with panic disorder, major depression, and premenstrual dysphoric disorder: evidence for a central fear mechanism. , 2001, Archives of general psychiatry.

[42]  D H Barlow,et al.  Response to hyperventilation and inhalation of 5.5% carbon dioxide-enriched air across the DSM-III-R anxiety disorders. , 1992, Journal of abnormal psychology.

[43]  J. Gorman,et al.  Carbon dioxide hypersensitivity, hyperventilation, and panic disorder. , 1993, The American journal of psychiatry.

[44]  Frank H Wilhelm,et al.  Voluntary hyperventilation in the treatment of panic disorder--functions of hyperventilation, their implications for breathing training, and recommendations for standardization. , 2005, Clinical psychology review.

[45]  A. Beck,et al.  An inventory for measuring depression. , 1961, Archives of general psychiatry.

[46]  W. Roth,et al.  Opposing breathing therapies for panic disorder: a randomized controlled trial of lowering vs raising end-tidal P(CO₂). , 2012, The Journal of clinical psychiatry.

[47]  W. Roth,et al.  Physiologic instability in panic disorder and generalized anxiety disorder , 2001, Biological Psychiatry.

[48]  Frank H Wilhelm,et al.  Breathing Training for Treating Panic Disorder , 2003, Behavior modification.

[49]  M. Kushner,et al.  Suffocation and respiratory responses to carbon dioxide and breath holding challenges in individuals with panic disorder. , 2006, Journal of psychosomatic research.

[50]  G. Andrews,et al.  Hyperventilation and anxiety in panic disorder, social phobia, GAD and normal controls. , 1989, Behaviour research and therapy.

[51]  B. Garssen,et al.  Voluntary hyperventilation: the influence of duration and depth on the development of symptoms , 1995, Biological Psychology.

[52]  N. Schmidt,et al.  Dismantling Cognitive—Behavioral Treatment for Panic Disorder Questioning the Utility of Breathing Retraining , 2000 .

[53]  G. Andrews,et al.  Provocation of panic: three elements of the panic reaction in four anxiety disorders. , 1989, Behaviour research and therapy.

[54]  M. Craske,et al.  Interoceptive exposure versus breathing retraining within cognitive-behavioural therapy for panic disorder with agoraphobia. , 1997, The British journal of clinical psychology.

[55]  S. Woods,et al.  Carbon dioxide-induced anxiety. Behavioral, physiologic, and biochemical effects of carbon dioxide in patients with panic disorders and healthy subjects. , 1988, Archives of general psychiatry.

[56]  W. Roth,et al.  Feedback of end-tidal pCO2 as a therapeutic approach for panic disorder. , 2008, Journal of psychiatric research.

[57]  Richard J. Maddock,et al.  Hyperventilation-induced panic attacks in panic disorder with agoraphobia , 1991, Biological Psychiatry.

[58]  S. Woods,et al.  Carbon dioxide sensitivity in panic anxiety. Ventilatory and anxiogenic response to carbon dioxide in healthy subjects and patients with panic anxiety before and after alprazolam treatment. , 1986, Archives of general psychiatry.

[59]  D. Klein.  Testing the suffocation false alarm theory of panic disorder. , 1994, Anxiety.

[60]  F. Wilhelm,et al.  Respiratory Pathophysiology of Panic Disorder: An Ambulatory Monitoring Study , 2009, Psychosomatic medicine.

[61]  P. Salkovskis,et al.  Respiratory Control in the Treatment of Panic Attacks: , 1986, British Journal of Psychiatry.

[62]  M. Stein,et al.  Triggering the false suffocation alarm in panic disorder patients by using a voluntary breath-holding procedure. , 1994, The American journal of psychiatry.

[63]  R. Ley.  Blood, breath, and fears: A hyperventilation theory of panic attacks and agoraphobia. , 1985 .

[64]  M. Hegel,et al.  Psychophysiological Assessment of Respiratory Function in Panic Disorder: Evidence for a Hyperventilation Subtype , 1997, Psychosomatic medicine.

[65]  E. Gracely,et al.  The Mobility Inventory for Agoraphobia. , 1985, Behaviour research and therapy.

[66]  E. Griez,et al.  Reduction of CO2-induced anxiety in patients with panic attacks after repeated CO2 exposure. , 1987, The American journal of psychiatry.

[67]  R. Rapee.  Differential response to hyperventilation in panic disorder and generalized anxiety disorder. , 1986, Journal of abnormal psychology.

[68]  M. First,et al.  Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Research version (SCID-I RV) , 2002 .

[69]  E. Griez,et al.  Specific sensitivity of patients with panic attacks to carbon dioxide inhalation , 1990, Psychiatry Research.

[70]  W. Roth,et al.  Autonomic instability during relaxation in panic disorder , 1998, Psychiatry Research.

[71]  D. Klein.  False suffocation alarms, spontaneous panics, and related conditions. An integrative hypothesis. , 1993, Archives of general psychiatry.