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Background: Severe asthma affects a small population but carries a high psychopathological risk. Therefore, the psychodemographic profile of these patients is of interest. A substantial prevalence of anxiety, depression, alexithymia and hyperventilation syndrome in severe asthma is known, but contradictory results have been observed. These factors can also affect patients' quality of life. For this reasons, our purpose is to evaluate the psychodemographic profile of patients with severe asthma and assess the prevalence of anxiety, depression, alexithymia and hyperventilation syndrome and their impact on the quality of life of patients with severe asthma., Methods: A cross-sectional study of 63 patients with severe asthma. Their psychodemographic profile was evaluated using the Hospital Anxiety and Depression Scale (HADS), Toronto Alexithymia Scale (TAS-20), Nijmegen questionnaire and Asthma Control Test (ACT) to determine the state of anxiety and depression, alexithymia, hyperventilation syndrome and control of asthma, respectively. Quality of life was assessed with the Mini Asthma Quality of Life Questionnaire (Mini-AQLQ)., Results: The mean age was 60 ± 13.6 years. Personal psychopathological histories were found in 65.1% of participants, and 8% reported previous suicidal attempts. The rate of anxiety and/or depression (HADS ≥ 11) was 68.3%. These patients present higher scores on the TAS-20 (p < 0.001) for the level of dyspnea (p = 0.021), and for emotional function (p = 0.017) on the Mini-AQLQ, compared with patients without anxiety or depression. Alexithymia (TAS-20 ≥ 61) was observed in 42.9% of patients; these patients were older (p = 0.037) and had a higher HADS score (p = 0.019) than patients with asthma without alexithymia. On the other hand, patients with hyperventilation syndrome (Nijmegen ≥ 23) scored higher on the HADS (p < 0.05), on the Mini-AQLQ (p = 0.002) and on the TAS-20 (p = 0.044) than the group without hyperventilation syndrome. Quality of life was related to anxiety-depression symptomatology (r =  - 0.302; p = 0.016) and alexithymia (r =  - 0.264; p = 0.036). Finally, the Mini-AQLQ total score was associated with the Nijmegen questionnaire total score (r =  - 0.317; p = 0.011), and the activity limitation domain of the Mini-AQLQ correlated with the ACT total score (r = 0.288; p = 0.022)., Conclusions: The rate of anxiety, depression, alexithymia and hyperventilation syndrome is high in patients with severe asthma. Each of these factors is associated with a poor quality of life.

Panic disorder (PD) pathophysiology is very heterogeneous, and the discrimination of distinct subtypes could be very useful. A subtype based on respiratory symptoms is known to constitute a specific subgroup. However, evidence to support the respiratory subtype (RS) as a distinct subgroup of PD with a well-defined phenotype remains controversial. Studies have focused on characterization of the RS based on symptoms and response to CO2. In this line, we described clinical and biological aspects focused on symptomatology and CO2 challenge tests in PD RS. The main symptoms that characterize RS are dyspnea (shortness of breath) and a choking sensation. Moreover, patients with the RS tended to be more responsive to CO2 challenge tests, which triggered more panic attacks in this subgroup. Future studies should focus on discriminating respiratory-related clusters and exploring psychophysiological and neuroimaging outcomes in order to provide robust evidence to confirm RS as a distinct subtype of PD.

Background: Pitt-Hopkins syndrome (PTHS) is a genetic neurodevelopmental disorder associated with intellectual disability. Although the genetic mechanisms underlying the disorder have been identified, description of its behavioural phenotype is in its infancy. In this study, reported behavioural and psychological characteristics of individuals with PTHS were investigated in comparison with the reported behaviour of age-matched individuals with Angelman syndrome (AS) and Cornelia de Lange syndrome (CdLS)., Methods: Questionnaire data were collected from parents/caregivers of individuals with PTHS (n = 24), assessing behaviours associated with autism spectrum disorder (ASD), sociability, mood, repetitive behaviour, sensory processing, challenging behaviours and overactivity and impulsivity. For most measures, data were compared to data for people with AS (n = 24) and CdLS (n = 24) individually matched by adaptive ability, age and sex., Results: Individuals with PTHS evidenced significantly higher levels of difficulties with social communication and reciprocal social interaction than individuals with AS, with 21 of 22 participants with PTHS meeting criteria indicative of ASD on a screening instrument. Individuals with PTHS were reported to be less sociable with familiar and unfamiliar people than individuals with AS, but more sociable with unfamiliar people than individuals with CdLS. Data also suggested areas of atypicality in sensory experiences. Challenging behaviours were reported frequently in PTHS, with self-injury (70.8%) occurring at significantly higher rates than in AS (41.7%) and aggression (54.2%) occurring at significantly higher rates than in CdLS (25%). Individuals with PTHS also evidenced lower reported mood than individuals with AS., Conclusions: Behaviours which may be characteristic of PTHS include those associated with ASD, including deficits in social communication and reciprocal social interaction. High rates of aggression and self-injurious behaviour compared to other genetic syndrome groups are of potential clinical significance and warrant further investigation. An atypical sensory profile may also be evident in PTHS. The specific aetiology of and relationships between different behavioural and psychological atypicalities in PTHS, and effective clinical management of these, present potential topics for future research.

New Findings: What is the central question of this study? What are the independent effects of hypoxia and hypocapnia on cerebral haemodynamics and cognitive function? What is the main finding and its importance? Exposure to hyperventilation-induced hypocapnia causes cognitive impairment in both normoxia and hypoxia. In addition, supplementation of carbon dioxide during hypoxia alleviates the cognitive impairment and reverses hypocapnia-induced vasoconstriction of the cerebrovasculature. These data provide new evidence for the independent effect of hypocapnia on the cognitive impairment associated with hypoxia., Abstract: Hypoxia, which is accompanied by hypocapnia at altitude, is associated with cognitive impairment. This study examined the independent effects of hypoxia and hypocapnia on cognitive function and assessed how changes in cerebral haemodynamics may underpin cognitive performance outcomes. Single reaction time (SRT), five-choice reaction time (CRT) and spatial working memory (SWM) tasks were completed in 20 participants at rest and after 1 h of isocapnic hypoxia (IH, end-tidal oxygen partial pressure ( P ET O 2 ) = 45 mmHg, end-tidal carbon dioxide partial pressure ( P ETC O 2 ) clamped at normal) and poikilocapnic hypoxia (PH, P ET O 2  = 45 mmHg, P ETC O 2 not clamped). A subgroup of 10 participants were also exposed to euoxic hypocapnia (EH, P ET O 2  = 100 mmHg, P ETC O 2 clamped 8 mmHg below normal). Middle cerebral artery velocity (MCAv) and prefrontal cerebral haemodynamics were measured with transcranial Doppler and near infrared spectroscopy, respectively. IH did not affect SRT and CRT performance from rest (566 ± 50 and 594 ± 70 ms), whereas PH (721 ± 51 and 765 ± 48 ms) and EH (718 ± 55 and 755 ± 34 ms) slowed response times (P < 0.001 vs. IH). Performance on the SWM task was not altered by condition. MCAv increased during IH compared to PH (P < 0.05), which was unchanged from rest. EH caused a significant fall in MCAv and prefrontal cerebral oxygenation (P < 0.05 vs. baseline). MCAv was moderately correlated to cognitive performance (R 2  = 0.266-0.289), whereas prefrontal cerebral tissue perfusion and saturation were not (P > 0.05). These findings reveal a role of hyperventilation-induced hypocapnia per se on the development of cognitive impairment during normoxic and hypoxic exposures., (© 2019 The Authors. Experimental Physiology © 2019 The Physiological Society.)

Psychiatric disorders have a high lifetime prevalence affecting about 30% of the global population. Not much is known about high altitude (HA) sojourns in individuals living with a psychiatric condition. This lack of scientific evidence contrasts with the anticipated increase in numbers of individuals with preexisting psychiatric conditions seeking medical advice on HA exposure. Not only are there risks associated with a HA climb, but physical activity in general is known to improve symptoms of many psychiatric disorder and enhance measures of mental well-being like quality of life and resilience. There are additional positive effects of alpine environments on mental health beyond those of physical activity. All individuals going to HA with a preexisting psychiatric condition should be in a state of stable disease with no recent change in medication. Specific considerations and recommendations apply to individual psychiatric disorders. During the HA sojourn the challenge is to separate altitude-related symptoms such as insomnia from prodromal symptoms of the underlying disorder (e.g., depressive episode) or altitude-related hyperventilation from panic attacks. In case an individual with preexisting anxiety disorder decides to go to HA there might be a predisposition toward acute mountain sickness (AMS), but it should always be considered that many symptoms of anxiety and AMS overlap. Any medication that is anticipated to be taken during ascent or at HA should be tested for compatibility with the psychiatric condition and medication before the trip.

Poor distress tolerance (DT) is considered an underlying facet of anxiety, depression, and a number of other psychological disorders. Mindfulness may help to increase DT by fostering an attitude of acceptance or nonjudgment toward distressing experiences. Accordingly, the present study examined the effects of a brief mindfulness training on tolerance of different types of distress, and tested whether trait mindfulness moderates the effect of such training. Undergraduates (n = 107) naïve to mindfulness completed a measure of trait mindfulness and underwent a series of stress tasks (cold pressor, hyperventilation challenge, neutralization task) before and after completing a 15-minute mindfulness training or a no-instruction control in which participants listened to relaxing music. Participants in the mindfulness condition demonstrated greater task persistence on the hyperventilation task compared to the control group, as well as a decreased urge to neutralize the effects of writing an upsetting sentence. No effect on distress ratings during the tasks were found. Overall trait mindfulness did not significantly moderate task persistence, but those with lower scores on the act with awareness facet of mindfulness demonstrated greater relative benefit of mindfulness training on the hyperventilation challenge. Mediation analyses revealed significant indirect effects of mindfulness training on cold pressor task persistence and urges to neutralize through the use of the nonjudge and nonreact facets of mindfulness. These results suggest that a brief mindfulness training can increase DT without affecting the subjective experience of distress., (Copyright © 2018. Published by Elsevier Ltd.)

Symptomatic hyperventilation (SH) is a pathological condition that manifests with breathlessness, dyspnea, light-headedness, anxiety, and paresthesia. However, little is known about the prevalence of SH and its association with health-related quality of life (HRQoL) in a young population. The Nijmegen questionnaire (NQ), which measures severity of SH, had not previously been cross-culturally translated into Korean. In this study, the NQ was cross-culturally translated into Korean (KNQ), using translation and back-translation methods. To examine the reliability and validity levels of the KNQ, as well as its association with HRQoL, 237 college students (21.38 ± 2.45 years) were asked to complete the KNQ, the Korean version of the general health questionnaire (K-GHQ-30) and the short form-36 (K-SF-36). The KNQ showed satisfactory reliability (Cronbach's α = 0.878). In the construct validity test, four factors (neuropsychological, respiratory, neurogastrointestinal, and neuromuscular) were extracted (% of total variance = 59.8). Using a KNQ cut-off score of 23 points, the prevalence of SH was 22.8%. Physical and mental HRQoL levels estimated by the K-GHQ-30 score and the 8 subscale scores of the K-SF-36 were lower in the SH group than in those of the non-SH group. It is concluded that the cross-culturally translated KNQ is reliable and valid, and management of SH may prevent a reduction in physical and mental HRQoL in a young population., Competing Interests: The authors have declared that no competing interests exist.

Objectives: Pitt-Hopkins syndrome (PTHS) is a rare genetic disorder caused by insufficient expression of the TCF4 gene. Most cases are characterized by severe intellectual disability, absent speech, motor delays, and autism spectrum disorder. Many have abnormal brain imaging, dysmorphic facial features, and medical comorbidities: myopia, constipation, epilepsy, and apneic spells. The present case study expands existing understanding of this disorder by presenting a unique phenotype with higher cognitive abilities and fewer medical comorbidities., Methods: The present case study reports on a 13-year-old, Caucasian male with a recent diagnosis of PTHS following genetic testing (i.e., whole exome sequencing). He was referred for a neuropsychological evaluation to document his neurocognitive functioning to assist with intervention planning., Results: Evaluation of intellectual, attention/executive, memory, visual-motor/fine-motor, academic, adaptive, and emotional/behavioral functioning revealed global impairment across all areas of functioning. However, he demonstrated abilities beyond what has been detailed in the literature, including use of full sentences, capacity to learn and solve novel problems, basic academic functioning, and independent ambulation., Conclusions: Children with PTHS may demonstrate a spectrum of abilities beyond what has been documented in the literature thus far. Failure to recognize this spectrum can result in late identification of an accurate diagnosis. (JINS, 2018, 24, 995-1002).

Pitt-Hopkins syndrome (PTHS) is a rare, genetic disorder caused by a molecular variant of TCF4 which is involved in embryologic neuronal differentiation. PTHS is characterized by syndromic facies, psychomotor delay, and intellectual disability. Other associated features include early-onset myopia, seizures, constipation, and hyperventilation-apneic spells. Many also meet criteria for autism spectrum disorder. Here the authors present a series of 23 PTHS patients with molecularly confirmed TCF4 variants and describe 3 unique individuals. The first carries a small deletion but does not exhibit the typical facial features nor the typical pattern of developmental delay. The second exhibits typical facial features, but has attained more advanced motor and verbal skills than other reported cases to date. The third displays typical features of PTHS, however inherited a large chromosomal duplication involving TCF4 from his unaffected father with somatic mosaicism. To the authors' knowledge, this is the first chromosomal duplication case reported to date.

Background: Blood-injection-injury (B-I-I) phobia is capable of producing inaccurate hypoxic challenge testing results due to anxiety-induced hyperventilation., Case Report: A 69-yr-old woman with a history of hypersensitivity pneumonitis, restrictive spirometry, exercise desaturation requiring supplementary oxygen on mobilizing, reduced DLco, and B-I-I phobia was referred for hypoxic challenge testing (HCT) to assess in-flight oxygen requirements. HCT was performed by breathing a 15% FIo2 gas mixture, simulating the available oxygen in ambient air onboard aircraft pressurized to an equivalent altitude of 8000 ft. Spo2 fell to a nadir value of 81% during HCT, although it rapidly increased to 89% during the first of two attempts at blood gas sampling. A resultant blood gas sample showed an acceptable Po2 outside the criteria for recommending in-flight oxygen and a reduced Pco2. Entering the nadir Spo2 value into the Severinghaus equation gives an estimated arterial Po2 of 6 kPa (45 mmHg), which was felt to be more representative of resting values during HCT, and in-flight oxygen was recommended., Discussion: While hyperventilation is an expected response to hypoxia, transient rises in Spo2 coinciding with threat of injury are likely to be attributable to emotional stress-induced hyperventilation, characteristic of B-I-I specific phobia and expected during the anticipation of exteroceptive threat, even in normal subjects. In summary, should excessive hyperventilation be detected during HCT and coincide with transient increases in Spo2, HCT should be repeated using Spo2 only as a guide to the level of hypoxemia, and Spo2 maintained using supplementary oxygen in accordance with alternative methods described in guidelines.Spurling KJ, McGoldrick VP. Blood-injection-injury (B-I-I) specific phobia affects the outcome of hypoxic challenge testing. Aerosp Med Hum Perform. 2017; 88(5):503-506.

Recent clinical trial research suggests that baseline low end-tidal CO 2 (ETCO 2 , the biological marker of hyperventilation) may predict poorer response to cognitive-behavioral therapy (CBT) for anxiety-related disorders. The present study examined the predictive value of baseline ETCO 2 among patients treated for such disorders in a naturalistic clinical setting. Sixty-nine adults with a primary diagnosis of a DSM-5 anxiety disorder, obsessive-compulsive disorder, or posttraumatic stress disorder completed a 4-min assessment of resting ETCO 2 , and respiration rate (the first minute was analyzed). Lower ETCO 2 was not associated with a diagnosis of panic disorder, and was associated with lower subjective distress ratings on certain measures. Baseline ETCO 2 significantly predicted treatment dropout: those meeting cutoff criteria for hypocapnia were more than twice as likely to drop out of treatment, and ETCO 2 significantly predicted dropout beyond other pre-treatment variables. Weekly measurement suggested that the lower-ETCO 2 patients who dropped out were not responding well to treatment prior to dropout. The present results, along with previous clinical trial data, suggest that lower pre-treatment ETCO 2 is a negative prognostic indicator for CBT for anxiety-related disorders. It is suggested that patients with lower ETCO 2 might benefit from additional intervention that targets respiratory abnormality., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

A 56-year-old white woman was referred to the pulmonary clinic for evaluation of unexplained shortness of breath. She enjoyed good health until 3 months prior to this visit when she reported experiencing recurrent episodes of shortness of breath and oppressive retrosternal chest discomfort with radiation to the neck. Episodes lasting 5 to 10 min often occurred at rest and were inconsistently related to physical activity. These symptoms became progressively worse and were often associated with light-headedness and presyncope. Her past medical history was uneventful apart from a prior diagnosis of breast cysts and suspected prolactinoma. Her symptoms escalated to such a level that she was forced to seek urgent medical attention at our institutional ED on two separate occasions in the preceding weeks. These visits precipitated a number of investigations and, eventually, a referral to the pulmonary clinic., (Copyright © 2016 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Primary hyperventilation is defined as a state of alveolar ventilation in excess of metabolic requirements, leading to decreased arterial partial pressure of carbon dioxide. The primary aim of this study was to characterise patients diagnosed with primary hyperventilation in the ED., Methods: Our retrospective cohort study comprised adult (≥16 years) patients admitted to our ED between 1 January 2006 and 31 December 2012 with the primary diagnosis of primary (=psychogenic) hyperventilation., Results: A total of 616 patients were eligible for study. Participants were predominantely female (341 [55.4%] female versus 275 [44.6%] male respectively, p <0.01). The mean age was 36.5 years (SD 15.52, range 16-85). Patients in their twenties were the most common age group (181, 29.4%), followed by patients in their thirties (121, 19.6%). Most patients presented at out-of-office hours (331 [53.7%]. The most common symptom was fear (586, 95.1%), followed by paraesthesia (379, 61.5%) and dizziness (306, 49.7%). Almost a third (187, 30.4%) of our patients had previously experienced an episode of hyperventilation and half (311, 50.5%) of patients had a psychiatric co-morbidity., Conclusion: Hyperventilation is a diagnostic chimera with a wide spectrum of symptoms. Patients predominantly are of young age, female sex and often have psychiatric comorbidities. The severity of symptoms accompanied with primary hyperventilation most often needs further work-up to rule out other diagnosis in a mostly young population. In the future, further prospective multicentre studies are needed to evaluate and establish clear diagnostic criteria for primary hyperventilation and possible screening instruments.

Individuals with social anxiety disorder (SAD) commonly experience panic attacks and evidence increased anxiety sensitivity (AS) specific to noticeable anxiety sensations. Interoceptive exposure (IE) is an effective treatment for reducing AS, but few IE tasks target fears of blushing, sweating, or trembling, which are incorporated within AS social concerns and especially feared by individuals with SAD. The primary study aims were trifold: (1) identify novel IE tasks that produce blushing, sweating, and/or trembling; (2) assess the intensity of sensations and anxiety produced by a series of novel and validated IE tasks; and (3) evaluate the incremental validity of combining an IE task and a speech task. Individuals (N = 55) with heightened fear of noticeably blushing, sweating, and/or trembling completed a control task and 8 IE tasks (e.g., hot sauce, hyperventilation). All tasks produced greater intensity of anxiety and sensations compared to the control task (ps < .001; range of η(p)(2) = .20-.50). Responses to the combination of an IE task and social task compared to a social task alone did not differ significantly. Future directions for research and clinical implications of the findings are discussed., (Copyright © 2015 Elsevier Ltd. All rights reserved.)

Panic disorder (PD), a complex anxiety disorder characterized by recurrent panic attacks, represents a poorly understood psychiatric condition which is associated with significant morbidity and an increased risk of suicide attempts and completed suicide. Recently however, neuroimaging and panic provocation challenge studies have provided insights into the pathoetiology of panic phenomena and have begun to elucidate potential neural mechanisms that may underlie panic attacks. In this regard, accumulating evidence suggests that acidosis may be a contributing factor in induction of panic. Challenge studies in patients with PD reveal that panic attacks may be reliably provoked by agents that lead to acid-base dysbalance such as CO2 inhalation and sodium lactate infusion. Chemosensory mechanisms that translate pH into panic-relevant fear, autonomic, and respiratory responses are therefore of high relevance to the understanding of panic pathophysiology. Herein, we provide a current update on clinical and preclinical studies supporting how acid-base imbalance and diverse chemosensory mechanisms may be associated with PD and discuss future implications of these findings.

Drowning is an important cause of preventable injury and mortality, ranking fifth among leading causes of unintentional injury death in the United States. In 2011, two healthy young men died in a drowning incident at a New York City (NYC)-regulated swimming facility. The men became unconscious underwater after performing intentional hyperventilation before submersion. The phenomenon of healthy swimmers becoming unconscious underwater has been described elsewhere as hypoxic blackout. Prompted by this incident, the NYC Department of Health and Mental Hygiene (DOHMH) in collaboration with the New York State Department of Health (SDOH) conducted a case review of New York state fatal and nonfatal drownings reported during 1988-2011 to investigate similar behaviors in other incidents. DOHMH identified 16 cases, three in NYC, with a consistent set of voluntary behaviors associated with unintentional drowning and designated this class of behaviors as "dangerous underwater breath-holding behaviors" (DUBBs). For this small sample, the frequency of different DUBBs varied by age and swimming level, and practicing more than one DUBB increased the risk for fatality. This research contributes to the literature on drowning by focusing on contributing behaviors rather than drowning outcomes. NYC recently enacted public health education and regulations that discourage DUBBs; these interventions have the potential to effectively reduce unintentional drowning related to these behaviors and could be considered by other municipalities and jurisdictions.

Hyperthermia during prolonged exercise leads to hyperventilation, which can reduce arterial CO2 pressure (PaCO2 ) and, in turn, cerebral blood flow (CBF) and thermoregulatory response. We investigated 1) whether humans can voluntarily suppress hyperthermic hyperventilation during prolonged exercise and 2) the effects of voluntary breathing control on PaCO2 , CBF, sweating, and skin blood flow. Twelve male subjects performed two exercise trials at 50% of peak oxygen uptake in the heat (37°C, 50% relative humidity) for up to 60 min. Throughout the exercise, subjects breathed normally (normal-breathing trial) or they tried to control their minute ventilation (respiratory frequency was timed with a metronome, and target tidal volumes were displayed on a monitor) to the level reached after 5 min of exercise (controlled-breathing trial). Plotting ventilatory and cerebrovascular responses against esophageal temperature (Tes) showed that minute ventilation increased linearly with rising Tes during normal breathing, whereas controlled breathing attenuated the increased ventilation (increase in minute ventilation from the onset of controlled breathing: 7.4 vs. 1.6 l/min at +1.1°C Tes; P < 0.001). Normal breathing led to decreases in estimated PaCO2 and middle cerebral artery blood flow velocity (MCAV) with rising Tes, but controlled breathing attenuated those reductions (estimated PaCO2 -3.4 vs. -0.8 mmHg; MCAV -10.4 vs. -3.9 cm/s at +1.1°C Tes; P = 0.002 and 0.011, respectively). Controlled breathing had no significant effect on chest sweating or forearm vascular conductance (P = 0.67 and 0.91, respectively). Our results indicate that humans can voluntarily suppress hyperthermic hyperventilation during prolonged exercise, and this suppression mitigates changes in PaCO2 and CBF., (Copyright © 2015 the American Physiological Society.)

Background: The diagnosis of functional somatic syndromes (FSS) requires 1) presence of somatic symptoms, and 2) absence of medical conditions potentially accounting for these symptoms. Due to the limited feasibility of medical examinations, epidemiological research on FSS has neglected to assess the second criterion. Our objective was therefore to evaluate the implications of considering information on exclusionary medical conditions in epidemiological research on FSS., Methods: A survey among 3'054 students was conducted. We compared prevalence rates and overlap of 17 FSS obtained by: 1) a symptom-based strategy and 2) a symptom-and-exclusion-based strategy including information on exclusionary medical conditions., Results: The symptom-and-exclusion-based strategy led to a marked decrease in prevalence rates compared to the symptom-based strategy. Furthermore, it resulted in fewer individuals who were affected by multiple FSS., Conclusions: Adding self-reported information on exclusionary medical conditions leads to a significant decrease in the prevalence and overlap of FSS. More rigorous approaches to studying FSS should be adopted.

Background and Objectives: Dyspnoea is a common symptom in sarcoidosis and is not predictably related to pulmonary function or radiology. A subjective symptom of dyspnoea is likely to be influenced by patient perception and experience. The aim of this study was to determine the prevalence and nature of dyspnoea in sarcoidosis and describe the relationship of dyspnoea to psychological factors and health-related quality of life (HRQL)., Methods: Fifty-six subjects (31 men, mean age 51 years) with sarcoidosis completed an HRQL measure, St George's Respiratory Questionnaire (SGRQ), Hospital Anxiety and Depression Scale (HADS) and Nijmegen questionnaire. The presence of symptoms of dyspnoea was noted and qualitative descriptors for dyspnoea were chosen at peak exercise. Resting pulmonary function was performed., Results: Sixty-four per cent of the subjects reported dyspnoea. Those with symptoms were older, had a longer duration of disease and with lower forced expiratory volume in 1 s (FEV1 ) and FEV1 /forced vital capacity (FVC) (all P < 0.05). Symptoms of dyspnoea were associated with worse HRQL (P < 0.005) and higher scores on the Nijmegen questionnaire (P < 0.05). Anxiety was not associated with dyspnoea and only a trend to greater depression was observed (P = 0.066). In multivariate analysis, SGRQ and Nijmegen scores predicted dyspnoea independent of demographic factors and resting pulmonary function., Conclusion: Dyspnoea is common in sarcoidosis and is associated with worse HRQL irrespective of baseline pulmonary function. Hyperventilation appears to be a factor contributing to dyspnoea and the Nijmegen questionnaire may be helpful in assessing dyspnoea and hyperventilation in sarcoidosis patients., (© 2014 Asian Pacific Society of Respirology.)

Escape and avoidance behaviors play a prominent role in the maintenance and possibly development of panic disorder, yet the literature regarding the etiology of these emotion-regulation strategies is relatively underdeveloped. The current study experimentally tests hypotheses that parental modeling of escape during a well-established panic-relevant biological challenge increases panic-relevant escape and avoidance among offspring. Fifty physically and psychologically healthy early adolescents (28 females; Mage=11.58; 86% Caucasian), stratified by gender, were randomly assigned to observe one of their parents (39 females; Mage=40.04): either (a) model completing a 3-min voluntary hyperventilation exercise (no escape modeling group) or (b) model premature termination of a similar procedure (escape modeling group). Offspring in the escape modeling group demonstrated a stronger escape response by discontinuing their own challenge sooner than those in the no-escape modeling group (r=.70). No group differences emerged in terms of avoidance responding, as indexed by nearly identical responding in terms of delay time before initiating the challenge, respiration rate, and self-reported willingness to engage in a second proposed challenge. Results suggest that parental behaviors may play an important role in the development of some forms of panic-relevant responding. These preliminary findings may have important implications for future prevention programs targeting parents and at-risk youth., (Copyright © 2014. Published by Elsevier Ltd.)

Patients with hyperventilation syndrome (HVS) report severe symptom-related suffering and often complain from insufficient medical attention. However, quality of life data in this context are scarce. We aimed at assessing the health-related quality of life (HRQoL) of HVS patients. Twenty-one HVS patients with extensive cardiorespiratory workup including cardiopulmonary exercise testing (CPET) filled in the generic SF-36 questionnaire and the results were compared to French normal values. Correlations between SF36 dimensions and clinical and functional data were established. All SF-36 scores were markedly decreased in HVS patients compared to healthy subjects: Physical Functioning: 44 ± 24, Social Functioning: 57 ± 27, Role Physical: 21 ± 32, Role Emotional: 48 ± 42, Mental Health: 51 ± 27, Vitality: 34 ± 20, Body Pain: 41 ± 21, General Health: 42 ± 21. These figures were all significantly lower in the HVS patients respective to the normal reference population. They were also lower than corresponding values published in patients with asthma or chronic obstructive pulmonary disease (COPD). "Vitality" and "Physical Functioning" scores were correlated with Nijmegen score (r = -0.594, p = 0.047) and peak respiratory frequency during CPET (r = -0.644, p = 0.019). The SF-36 Social Functioning score was correlated with the ventilatory threshold (r = 0.629, p = 0.034), peak V'E/V'CO2 (ventilation/CO2 production) (r = 0.650, p = 0.016) and peak PaCO2 (r = -0.664, p = 0.027). In conclusion, this study shows that HRQoL can be severely impaired in patients with HVS, which is one more reason to take this condition seriously., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Background: Biological theories on respiratory regulation have linked separation anxiety disorder (SAD) to panic disorder (PD). We tested if SAD children show similarly increased anxious and psychophysiological responding to voluntary hyperventilation and compromised recovery thereafter as has been observed in PD patients., Methods: Participants were 49 children (5-14 years old) with SAD, 21 clinical controls with other anxiety disorders, and 39 healthy controls. We assessed cardiac sympathetic and parasympathetic, respiratory (including pCO2), electrodermal, electromyographic, and self-report variables during baseline, paced hyperventilation, and recovery., Results: SAD children did not react with increased anxiety or panic symptoms and did not show signs of slowed recovery. However, during hyperventilation they exhibited elevated reactivity in respiratory variability, heart rate, and musculus corrugator supercilii activity indicating difficulty with respiratory regulation., Conclusions: Reactions to hyperventilation are much less pronounced in children with SAD than in PD patients. SAD children showed voluntary breathing regulation deficits., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Cognitive-behavioral treatments for panic disorder (PD) emphasize interoceptive exposure (IE) to target anxiety sensitivity (AS) but vary considerably in its manner of delivery. This randomized controlled trial was conducted to compare the efficacy of the low-dose delivery of IE exercises often prescribed in treatment protocols to an intensive form of IE hypothesized to optimize inhibitory learning. Participants (N = 120) with elevated AS were randomly assigned to one of four single-session interventions: (a) low-dose IE as prescribed in Barlow and Craske's Panic Control Treatment, (b) low-dose IE without controlled breathing or a lengthy between-trial rest period, (c) intensive IE, or (d) expressive writing control. Compared to the other conditions, intensive IE produced significantly greater reductions in AS and fearful responding to a straw breathing task from pretreatment to posttreatment. Maintenance of gains during the follow-up period did not differ between conditions. Changes in fear toleration and negative outcome expectancies fully mediated the superior efficacy of intensive IE over low-dose IE. The two low intensity IE conditions produced particularly high rates of fear sensitization on between-trial and outcome variables. The findings suggest that the intensive delivery of IE exercises has the potential to improve the efficacy of exposure-based treatments for PD., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Exposure to feared stimuli in blood-injection-injury (BII)-phobia is thought to elicit a diphasic response pattern, with an initial fight-flight-like cardiovascular activation followed by a marked deactivation and possible fainting (vasovagal syncope). However, studies have remained equivocal on the importance of such patterns. We therefore sought to determine the prevalence and clinical relevance of diphasic responses using criteria that require a true diphasic response to exceed cardiovascular activation of an emotional episode of a negative valence and to exceed deactivation of an emotionally neutral episode. Sixty BII-phobia participants and 20 healthy controls were exposed to surgery, anger and neutral films while measuring heart rate, blood pressure, respiratory pattern, and end-tidal partial pressure of carbon dioxide (as indicator of hyperventilation). Diphasic response patterns were observed in up to 20% of BII-phobia participants and 26.6% of healthy controls for individual cardiovascular parameters. BII-phobia participants with diphasic patterns across multiple parameters showed more fear of injections and blood draws, reported the strongest physical symptoms during the surgery film, and showed the strongest tendency to hyperventilate. Thus, although only a minority of individuals with BII phobia shows diphasic responses, their occurrence indicates significant distress. Respiratory training may add to the treatment of BII phobia patients that show diphasic response patterns., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: Anxiety and panic are associated with the experience of a range of bodily symptoms, in particular unpleasant breathing sensations (dyspnea). Respiratory theories of panic disorder have focused on disturbances in blood gas regulation, but respiratory muscle tension as a source of dyspnea has not been considered. We therefore examined the potential of intercostal muscle tension to elicit dyspnea in individuals with high anxiety sensitivity, a risk factor for developing panic disorder., Methods: Individuals high and low in anxiety sensitivity (total N=62) completed four tasks: electromyogram biofeedback for tensing intercostal muscle, electromyogram biofeedback for tensing leg muscles, paced breathing at three different speeds, and a fine motor task. Global dyspnea, individual respiratory sensations, nonrespiratory sensations, and discomfort were assessed after each task, whereas respiratory pattern (respiratory inductance plethysmography) and end-tidal carbon dioxide (capnography) were measured continuously., Results: In individuals with high compared to low anxiety sensitivity, intercostal muscle tension elicited a particularly strong report of obstruction (M=5.1, SD=3.6 versus M=2.5, SD=3.0), air hunger (M=1.9, SD=2.1 versus M=0.4, SD=0.8), hyperventilation symptoms (M=0.6, SD=0.6 versus M=0.1, SD=0.1), and discomfort (M=5.1, SD=3.2 versus M=2.2, SD=2.1) (all p values<.05). This effect was not explained by site-unspecific muscle tension, voluntary manipulation of respiration, or sustained task-related attention. Nonrespiratory control sensations were not significantly affected by tasks (F<1), and respiratory variables did not reflect any specific responding of high-Anxiety Sensitivity Index participants to intercostal muscle tension., Conclusions: Respiratory muscle tension may contribute to the respiratory sensations experienced by panic-prone individuals. Theories and treatments for panic disorder should consider this potential source of symptoms.

The fear of arousal sensations characterizes some anxiety disorders and is a core feature of an established risk factor for anxiety and related disorders (i.e. anxiety sensitivity; Taylor, 1999). Anxiety sensitivity (AS) refers to a fear of anxiety-related bodily sensations stemming from beliefs that these have catastrophic consequences. Interoceptive exposure (IE; repeated exposure to feared arousal sensations) has been shown to decrease AS. The 33-item Hyperventilation Questionnaire (HVQ; Rapee & Medoro, 1994) measures state levels of cognitive, affective, and somatic responses to IE and arousal induction exercises more generally. The aim of the present set of studies was to develop and evaluate a brief version of the HVQ, the HVQ-B, in order to facilitate its use in research and clinical settings. In Study 1, three existing data sets that used the long version of the HVQ were combined to select the items to be retained for the HVQ-B. In Study 2, the 18-item HVQ-B was administered and its psychometric properties were evaluated. In Study 3, a confirmatory factor analysis (CFA) was performed on the 18 items of the HVQ-B. The HVQ-B demonstrated excellent psychometric properties, and accounted for most of the variance of the questionnaire's longer version. CFA indicated a reasonably good fit of the three-factor measurement model. Finally, the HVQ-B was able to distinguish between responses to arousal induction exercises by high versus low AS participants. The HVQ-B is a useful tool to assess cognitive, affective, and somatic responsivity to arousal sensations in both research and practice.

Given the onset of alcohol use, neurological sensitivity, and enhanced panic-relevant vulnerability, adolescence is a key period in which to study the documented linkage between alcohol and panic-related problems. The current study was designed to build upon and uniquely extend extant work via (a) utilization of well-established experimental psychopathology techniques and (b) evaluation of unique associations between alcohol use and panic symptoms after controlling for theoretically relevant behavioral, environmental, and individual difference variables (i.e., age, gender, negative affectivity, anxiety sensitivity, child and parent tobacco use, and parental panic disorder). Participants were 111 community-recruited adolescents ages 12-17 years (M = 15.76 years; n = 50 girls). Youth completed a battery of well-established questionnaires and a voluntary hyperventilation challenge, and parents present at the laboratory completed a structured clinical interview. Adolescent alcohol use was categorized as Non-Users, Experimenters, or Users. Panic symptoms were indexed via retrospective self-report and adolescents' response to a biological challenge procedure (i.e., voluntary hyperventilation). After controlling for theoretically relevant covariates, Users evidenced elevated panic-relevant symptoms and responding compared with Non-Users; Experimenters did not differ from Non-Users. Findings suggest alcohol use history is uniquely associated with panic symptomatology among youth, including "real-time" reactivity elicited by a laboratory challenge. Although there is significant work yet to be done, these data advance extant work and lay the groundwork for the types of sophisticated designs that will be needed to answer the most pressing and complex questions regarding the link between alcohol use and panic symptoms among adolescents., (2013 APA, all rights reserved)

Aim: The aim of the study was to collect detailed data on behavioural, adaptive, and psychological functioning in 10 individuals with Pitt-Hopkins syndrome (PTHS), with specific attention to manifestations of autism spectrum disorder (ASD)., Method: The participants (four females, six males), residing in the Netherlands and Belgium, were ascertained through the Dutch national PTHS support group. Median age of participants was 10 years, the age range was between 32 and 289 months. They underwent psychiatric examinations and neuropsychological measurements using a comprehensive assessment battery. Additionally, parental information was gathered through standardized interviews and questionnaires. Findings were compared with those from the literature., Results: All participants showed profound intellectual disability, amiable demeanour with minimal maladaptive behaviours, severe impairments of communication and language, and intense, frequent motor stereotypies. Impairments in all participants were beyond what would be expected for cognitive abilities, fitting a classification of ASD., Interpretation: Patients with PTHS are characterized not only by specific physical and genetic manifestations but also by specific behavioural and cognitive characteristics. Studying behaviour and cognition may improve diagnosis and prognosis, allows recognition of comorbidities, and contributes to adequate counselling of families., (© The Authors. Developmental Medicine & Child Neurology © 2012 Mac Keith Press.)

Background and Objectives: Physiological arousal serves to maintain social anxiety disorder by skewing self-perception. Anxiety sensitivity is associated with the disorder and exaggerated perceptions of arousal, but has not been tested as explaining exaggerated perceived arousal in social contexts. The aim of this investigation was to address this issue., Methods: A total of 42 individuals participated in three tasks associated with potential social threat (i.e., a speech, typing task, hyperventilation) and completed measures of trait social anxiety and anxiety sensitivity. State anxiety, perceived arousal, and objective arousal were assessed during each task., Results: Trait social anxiety and anxiety sensitivity were correlated with state anxiety and perceived arousal, but not objective arousal, during the tasks. Anxiety sensitivity mediated the relationships between trait social anxiety and perceived arousal and between trait social anxiety and state anxiety for the typing and hyperventilation tasks., Limitations: Although the sample likely included a number of individuals with social anxiety disorder, the sample was mostly comprised of individuals without a diagnosis. The current results can be extended to clinical presentations to some extent, but future research is needed to further explore the demonstrated relationships in samples of individuals with social anxiety disorder., Conclusions: Anxiety sensitivity may play a crucial role in perceptions of arousal and state anxiety in the context of potential social threats, warranting attention from researchers and clinicians focussing on social anxiety disorder., (Copyright © 2012 Elsevier Ltd. All rights reserved.)

Background: The purpose of the study was to identify the style of parental bonding and the personality characteristics that might increase the risk of hyperventilation and adjustment disorder., Methods: A total of 917 males were recruited, 156 with adjustment disorder and hyperventilation syndrome (AD + HY), 273 with adjustment disorder without hyperventilation syndrome (AD-HY), and 488 healthy controls. All participants completed the Parental Bonding Instrument, Eysenck Personality Questionnaire, and Chinese Health Questionnaire., Results: Analysis using structural equation models identified a pathway relationship in which parental bonding affected personality characteristics, personality characteristics affected mental health condition, and mental health condition affected the development of hyperventilation or adjustment disorder. Males with AD-HY perceived less paternal care, and those with AD + HY perceived more maternal protection than those with adjustment disorder and those in the control group. Participants with AD-HY were more neurotic and less extroverted than those with AD + HY. Both groups showed poorer mental health than the controls., Conclusions: Although some patients with hyperventilation syndrome demonstrated symptoms of adjustment disorder, there were different predisposing factors between the two groups in terms of parental bonding and personality characteristics. This finding is important for the early intervention and prevention of hyperventilation and adjustment disorder.

Introduction: Respiratory changes are associated with anxiety disorders, particularly panic disorder (PD). The stimulation of respiration in PD patients during panic attacks is well documented in the literature, and a number of abnormalities in respiration, such as enhanced CO2 sensitivity, have been detected in PD patients. Investigators hypothesized that there is a fundamental abnormality in the physiological mechanisms that control breathing in PD., Methods: The authors searched for articles regarding the connection between the respiratory system and PD, more specifically papers on respiratory challenges, respiratory subtype, and current mechanistic concepts., Conclusions: Recent evidences support the presence of subclinical changes in respiration and other functions related to body homeostasis in PD patients. The fear network, comprising the hippocampus, medial prefrontal cortex, amygdala and its brainstem projections, may be abnormally sensitive in PD patients, and respiratory stimulants like CO2 may trigger panic attacks. Studies indicate that PD patients with dominant respiratory symptoms are particularly sensitive to respiratory tests compared to those who do not manifest dominant respiratory symptoms, representing a distinct subtype. The evidence of changes in several neurochemical systems might be the expression of the complex interaction among brain circuits.

Objective: Relatively few data are available concerning the relations between hyperventilation symptoms and general personality traits in clinical populations. A clear picture of the personality traits associated with hyperventilation symptoms could enhance early detection of those individuals who are at risk for developing hyperventilation. The aim of this study was to investigate the role of general personality in hyperventilation syndrome., Method: Patients (N = 364) with symptoms not explained by an organic disease and supposedly caused by hyperventilation completed the NEO Five-Factor Inventory, the General Health Questionnaire--12, and the Nijmegen Questionnaire. Patients were also subjected to a hyperventilation provocation test and transcutaneous carbon dioxide (TcPCO(2)) values were registered., Results: The results showed that patients with hyperventilation obtained mean Neuroticism scores above the normative mean. Moreover, only Neuroticism was positively linked with self-reported hyperventilation symptoms, and personality traits were more strongly related to self-reported complaints than to objective physical information. Neuroticism clearly differentiated between different diagnostic groups on the basis of Nijmegen Questionnaire and TcPCO(2) values, and an additional small effect of Agreeableness was observed., Conclusions: The present study contributes to the evidence that Neuroticism is strongly associated with self-reported hyperventilation symptoms, and provides substantial evidence that Neuroticism is a vulnerability factor in the development of hyperventilation. Therefore, personality assessment may be helpful in advancing the understanding and the early detection of hyperventilation symptoms.

An emerging pattern of results from panic-relevant biological challenge studies suggests women respond with greater subjective anxiety than men, but only to relatively abrupt and intense challenge procedures. The current investigation examined the relation between biological sex and self-reported anxious reactivity following biological challenges of varying durations and intensity. Participants were 285 (152 females; M(age) = 21.38; SD = 5.92) nonclinical adults who completed one of three protocols: a 3-min voluntary hyperventilation challenge (VH), a 5-min 10% carbon dioxide-enriched air (CO(2)) challenge, or a 25-s 20% CO(2) challenge. As predicted, results indicated that the 20% CO(2) challenge elicited greater self-reported anxiety than the VH and 10% CO(2) challenges. Moreover, women endorsed greater anxious reactivity than men, but only following the 20% CO(2) challenge. Results are discussed in terms of processes likely to account for sex differences in anxious reactivity following relatively abrupt and intense biological challenges., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Hyperventilation syndrome is a separate disease and a symptom of other psychosomatic diseases. A variant of device diagnosis of the disease is proposed--integral rheoplethysmography by M. I. Tischenko and cardiointervalography by R. M. Baevsky. Hyper- and asthenic courses of the disease are described, the pathological psychoemotional pattern is recognized. The proposed treatment combines physiohemotherapy (laser treatment) and pharmacotherapy.

Aim: To investigate verbal dyspnea characteristics in patients with bronchial asthma (BA) and hyperventilation syndrome (HVS)., Material and Methods: The trial covered 52 patients with BA, 10 patients with BA combination with HVS and 18 patients with HVS. Verbal dyspnea characteristics were studied with PM. Simon questionnaire. The examination of the patients was made using scale HADS. Naimigen questionnaire, body plethysmography, bronchodilation test, capnography with spontaneous hyperventilation test, analysis of arterial blood gas composition., Results: Most commonly BA patients characterized dyspnea with such words as "I am breathless" (n = 8, 33.3%), "I breathe with effort" (n = 6, 25%) and "I feel suffocation" (n = 6, 25%). HVS patients characterized their dyspnea most often as "air shortage" (n = 14, 77.8%), "I can't take a deep breath" (n = 10, 55.6%), "breathing needs concentration" (n = 6, 33.3%) and "I have to grasp air with mouth" (n = 5, 17.9%). The latter description correlated with capnometric markers of HVS and responses to Naimigen questionnaire. The description "I feel suffocation" directly correlated with BA stage by GINA and bronchial obstruction severity., Conclusion: Verbal dyspnea characteristics differ in BA and HVS patients and this can be used in differential diagnosis of these conditions.

The current study uniquely extended research that has linked traumatic event exposure to panic-spectrum problems among adolescents. It was hypothesized that among 127 adolescents (age range: 10 to 17 years; M = 14.63, SD = 2.24), those who endorsed a history of traumatic event exposure would evidence significantly greater anxious and fearful reactivity to a well-established 3-min voluntary hyperventilation procedure compared to nonexposed individuals. Results were consistent with hypotheses, suggesting traumatic event exposure is associated with anxious and fearful reactivity to abrupt increases in bodily arousal among adolescents. Moreover, consistent with hypotheses, anxiety sensitivity significantly mediated the relations between traumatic event exposure and both self-reported panic symptoms and panic symptoms elicited by the challenge. Future prospective research is now needed to better understand temporal relations between traumatic event exposure and indices of panic and related vulnerability., (Copyright © 2011. Published by Elsevier Ltd.)

Objective: Despite the importance of respiration and hyperventilation in anxiety disorders, research on breathing disturbances associated with hyperventilation is rare in the field of music performance anxiety (MPA, also known as stage fright). The only comparable study in this area reported a positive correlation between negative feelings of MPA and hyperventilation complaints during performance. The goals of this study were (a) to extend these previous findings to the period before performance, (b) to test whether a positive correlation also exists between hyperventilation complaints and the experience of stage fright as a problem, (c) to investigate instrument-specific symptom reporting, and (d) to confirm gender differences in negative feelings of MPA and hyperventilation complaints reported in other studies., Methods: We assessed 169 university students of classical music with a questionnaire comprising: the State-Trait Anxiety Inventory for negative feelings of MPA, the Nijmegen Questionnaire for hyperventilation complaints, and a single item for the experience of stage fright as a problem., Results: We found a significant positive correlation between hyperventilation complaints and negative feelings of MPA before performance and a significant positive correlation between hyperventilation complaints and the experience of stage fright as a problem. Wind musicians/singers reported a significantly higher frequency of respiratory symptoms than other musicians. Furthermore, women scored significantly higher on hyperventilation complaints and negative feelings of MPA., Conclusion: These results further the findings of previous reports by suggesting that breathing disturbances associated with hyperventilation may play a role in MPA prior to going on stage. Experimental studies are needed to confirm whether hyperventilation complaints associated with negative feelings of MPA manifest themselves at the physiological level., (Copyright © 2010 Elsevier Inc. All rights reserved.)

To study defensive mobilization elicited by the exposure to interoceptive arousal sensations, we exposed highly anxiety sensitive students to a symptom provocation task. Symptom reports, autonomic arousal, and the startle eyeblink response were monitored during guided hyperventilation and a recovery period in 26 highly anxiety sensitive persons and 22 controls. Normoventilation was used as a non-provocative comparison condition. Hyperventilation led to autonomic arousal and a marked increase in somatic symptoms. While high and low anxiety sensitive persons did not differ in their defensive activation during hyperventilation, group differences were detected during early recovery. Highly anxiety sensitive students exhibited a potentiation of startle response magnitudes and increased autonomic arousal after hyper- as compared to after normoventilation, indicating defensive mobilization evoked by the prolonged presence of feared somatic sensations., (Copyright © 2010 Society for Psychophysiological Research.)

Purpose: To evaluate whether certain preinduction clinical characteristics may influence the success rate of induction., Methods: We prospectively enrolled and attempted inductions on 51 patients who were suspected to have psychogenic nonepileptic events based on clinical grounds. In addition to careful examination of the reported ictal semiology, we administered a battery of four psychological instruments to our enrolled patients., Key Findings: We found that among 42 cases of successful induction, 92.9% (n=39) of these cases were successfully induced on the first attempt (i.e., without prior induction exposure). We observed that induction showed significantly higher rate of success in cases that demonstrate: (1) hypermotor ictal semiology (p=0.029); (2) more prevalent self-reporting of uncommon cognitive and affective symptoms (p=0.035); or (3) higher tendency to rely on coping strategies of "instrumental support" (p=0.013) and "active coping" (p=0.027), when compared to noninducible cases., Significance: Singular administration of placebo induction on preselected patients with these clinical characteristics may reduce costs by shortening video electroencephalography-(EEG) monitoring sessions and improve the diagnostic yield of video-EEG even for patients with very infrequent events., (Wiley Periodicals, Inc. © 2011 International League Against Epilepsy.)

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 pCO(2)) 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 pCO(2) 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 pCO(2), 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.

Hyperventilation syndrome is a disorder affecting children and adults, mostly women. It is frequently associated with anxiety disorders, and greatly affects quality of life. Diagnosis, which unfortunately is most often established late, is a diagnosis of elimination. It rests on a wide range of non-specific signs, on Nijmegën's clinical scale as well as on a hyperventilation provocative test. In most cases, specialized therapeutic interventions allow for an adequate control of ventilation and symptom relief.

Study Objective: Elevated arterial lactate levels are closely related to morbidity and mortality in various patient categories. In the present retrospective study, the relation between arterial lactate, partial pressure of carbon dioxide (Pco(2)) and pH was systematically investigated in patients who visited the emergency department (ED) with psychogenic hyperventilation., Methods: Over a 5-month period, all the patients who visited the ED of a university hospital with presumed psychogenic hyperventilation were evaluated. Psychogenic hyperventilation was presumed to be present when an increased respiratory rate (>20 min) was documented at or before the ED visit and when somatic causes explaining the hyperventilation were absent. Arterial blood gas and lactate levels (reference values 0.5-1.5 mmol/l) were immediately measured by a point-of-care analyser that was managed and calibrated by the central laboratory., Results: During the study period, 46 patients were diagnosed as having psychogenic hyperventilation. The median (range) Pco(2) for this group was 4.3 (2.0-5.5) kPa, the pH was 7.47 (7.40-7.68) and the lactate level was 1.2 (0.5-4.4) mmol/l. 14 participants (30%) had a lactate level above the reference value of 1.5 mmol/l. Pco(2) was the most important predictor of lactate in multivariate analysis. None of the participants underwent any medical treatment other than observation at the ED or had been hospitalised after their ED visit., Conclusions: In patients with psychogenic hyperventilation, lactate levels are frequently elevated. Whereas high lactates are usually associated with acidosis and an increased risk of poor outcome, in patients with psychogenic hyperventilation, high lactates are associated with hypocapnia and alkalosis. In this context, elevated arterial lactate levels should not be regarded as an adverse sign.

The observation that hyperventilation was common in men involved in civil court actions compared with my non-medico-legal practice stimulated me to carefully assess 100 consecutively seen men with non-malignant asbestos-related disease(s). A diagnosis of hyperventilation was made in 33 and probable hyperventilation in 12. The development of anxiety symptoms in these men could, in part at least, be prevented or greatly decreased if more emphasis was placed on the education of ex-asbestos workers by solicitors and organisations responsible for the initiation of civil actions.

Sustained or spontaneous hyperventilation has been associated with a variety of physical symptoms and has been linked to a number of organic illnesses and mental disorders. Theories of panic disorder hold that hyperventilation either produces feared symptoms of hypocapnia or protects against feared suffocation symptoms of hypercapnia. Although the evidence for both theories is inconclusive, findings from observational, experimental, and therapeutic studies suggest an important role of low carbon dioxide (CO2) levels in this disorder. Similarly, hypocapnia and associated hyperpnia are linked to bronchoconstriction, symptom exacerbation, and lower quality of life in patients with asthma. Raising CO2 levels by means of therapeutic capnometry has proven beneficial effects in both disorders, and the reversing of hyperventilation has emerged as a potent mediator for reductions in panic symptom severity and treatment success., (2010 Elsevier B.V. All rights reserved.)

Objective: Our objective is to summarize the new findings concerning the respiratory subtype (RS) of panic disorder (PD) since its first description., Methods: Two searches were made in the Institute for Scientific Information Web of Science: with the keywords "panic disorder" and "respiratory symptoms," and all articles that cited Briggs and colleagues' 1993 article "Subtyping of Panic Disorder by Symptom Profile" (Br J Psychiatry 1993;163:201-9). Altogether, 133 articles were reviewed., Results: We describe and discuss RS epidemiology, genetics, psychopathology, demographic features, clinical features, correlations with the respiratory system, traumatic suffocation history, provocative tests, and nocturnal panic. Compared to patients with the nonrespiratory subtype (non-RS), the RS patients had higher familial history of PD, lower comorbidity with depression, longer duration of illness, lower neuroticism scores, and higher scores in severity scales, such as the Panic and Agoraphobia Scale, Panic-Agoraphobia Spectrum scale and the Clinical Global Impression scale. Tests to induce panic attacks, such as those with CO(2), hyperventilation, and caffeine, produce panic attacks in a higher proportion of RS patients than non-RS patients. Differences in the subtypes' improvement with the pharmacologic treatment were found. There are also some controversial findings regarding the RS, including the age of onset of PD, and alcohol and tobacco use in RS patients., Conclusions: Some characteristics, such as the increased sensitivity to CO(2) and the higher familial history of PD, clearly distinguish the RS from the non-RS. Nevertheless, there are also controversial findings. More studies are needed to determine the validity of the RS subtype.

Objective: Mindfulness forms the basis for multiple clinical interventions and has been induced in laboratory settings. However, few studies have examined the effects of dispositional or trait mindfulness. The purpose of this study was to investigate the relationship of trait mindfulness to laboratory stressor responding across fear-based anxiety disorder and non-anxious samples. We hypothesized that trait mindfulness would be associated with diminished stressor responding above and beyond the contribution of anxiety and depression-related variables, and to a greater extent in high anxiety than low anxiety individuals., Methods: 90 participants, including 46 with anxiety disorders and 44 non-anxious controls, were assessed on hyperventilation and relaxation stressors. The relationship of trait mindfulness to stressor-related anxiety, negative affect, and duration was investigated in a hierarchical multiple regression model., Results: Trait mindfulness predicted stressor responding in over 80% of measured outcomes, and predicted to a greater extent among high anxiety individuals in 50% of outcomes., Conclusions: Trait mindfulness was associated with diminished responses to laboratory stressors in clinically anxious and non-anxious samples. Implications for emotion regulation and clinical interventions are discussed., (Copyright (c) 2010 Elsevier Ltd. All rights reserved.)

Acute asthmatic attack is an important emergency medical condition. The author hereby reports a case in the emergency department of an acute exacerbation of asthma, complicated by hyperventilation. In this case, the patient had underlying needle phobia, which suddenly occurred during the salbutamol injection. Nevertheless, both physical and psychological approaches led to the successful control of the condition. This report addresses a situation, which, although rare, should not be overlooked.

Background: We investigated the effects of 4 h of posttraumatic hyperventilation on neurocognitive performance, motor function, and coordination as well as lesion volume in rats subjected to focal traumatic brain injury., Methods: After a 14-day training period with various neurocognitive tests including hole-board, beam walk, and beam balance, 21 male Sprague-Dawley rats (369 +/- 15 g) were anesthetized with halothane, tracheally intubated, their lungs mechanically ventilated, and subjected to controlled cortical impact (1.75 mm depth, diameter 5 mm, 4 m/s). They were then randomized to either normoventilation (n = 10; PaCO(2) = 38-42 mm Hg) or hyperventilation (n = 11; PaCO(2) = 28-32 mm Hg) and ventilated for 4 h, respectively. Posttraumatic performance in the behavioral and motor tests was evaluated for 20 days. Rats were then decapitated under deep anesthesia, and their brains frozen and sliced to evaluate lesion volume., Results: Hyperventilated animals performed significantly worse in explicit memory tests compared with normoventilated rats over time. Both groups showed deficits in advanced motor function and coordination (evaluated by beam walk and beam balance) initially, with a significantly worse performance of hyperventilated compared with normoventilated animals. However, there was no difference between groups by the end of the study. On Day 20 after injury, lesion volume was significantly larger with hyperventilated (69.7 +/- 13.0 mm(3)) compared with normoventilated animals (48.3 +/- 15.6 mm(3))., Conclusions: Although hyperventilation enhanced histologic damage, there was no long-term adverse neurocognitive effect from 4 h of posttraumatic hyperventilation (PaCO(2) = 28-32 mm Hg) in rats.

We examined effects of hypocapnia on burst activity in the piriform-amygdala complex and C(4) inspiratory activity in limbic-brainstem-spinal cord preparations from 0- to 1-day-old rats. Hypocapnia (2% CO(2)) increased the burst rate in the piriform-amygdala complex but decreased the C(4) inspiratory burst rate. Since hyperventilation induces hypocapnia, and enhanced amygdala activity may be involved in induction of a sense of anxiety, our findings might explain the neuronal mechanism of a vicious circle between hyperventilation and an increased sense of anxiety.