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Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey

BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7294.1098 (Published 05 May 2001) Cite this as: BMJ 2001;322:1098

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Effective therapy for panic disorder should be acknowledged in discussion of treatment...

Effective therapy for panic disorder should be acknowledged in
discussion of treatment for dysfunctional breathing.

Thomas et al [1] report an appreciable prevalence of dysfunctional
breathing in adults with asthma and discuss the scope for wider use of
breathing therapy. Neither investigators nor the authors of the
accompanying editorial [2] consider whether such symptoms might occur
equally frequently in the normal population or represent panic attacks/
disorder, well defined entities common in otherwise healthy people.
Without a control group their study is incapable of identifying the
prevalence of dysfunctional breathing associated specifically with asthma.

Dysfunctional breathing and the hyperventilation syndrome are by no
means the same as panic syndromes, but overlap between them may be
considerable. Thomas et al acknowledge limitations of the Nijmegen
Questionnaire [3]. Notably, the instrument cannot differentiate the
"chimeric" hyperventilation syndrome from the well-defined phenomena of
panic attacks and panic disorder. The sixteen items in the Nijmegen
questionnaire include "anxiety", "feeling tense" and 9 of the 13 panic
attack symptoms listed in DSM-III-R. The questionnaire was not defined to
attempt to make this distinction. A 23% lifetime prevalence of
spontaneous panic attacks has been reported in asthmatics [4]. This figure
is not dissimilar to the 29% of asthmatics labelled by Thomas et al as
having experienced dysfunctional breathing, and again suggests appreciable
overlap. The lifetime prevalence of asthmatics meeting DSM-III-R criteria
for panic disorder in the same study was 9.7% [4].

We reported a significant excess of panic attacks and panic disorder
among primary care and hospital patients with hypertension compared to
matched normotensives, and 202 of 287 people who had experienced panic
attacks related "shortness of breath" or "difficulty catching breath" as
being symptoms in their worst panic attack [5]. The relation of history of
panic attacks to gender in our sample was strikingly similar to that
reported for dysfunctional breathing [1], with a significant excess in
females of around 15% in both studies.

The importance of considering panic disorder in a discussion of
dysfunctional breathing lies in the availability of treatment of proven
efficacy. Thomas et al limit their consideration of therapeutic
intervention to breathing therapy. In a patient with recurrent difficult
breathing and history suggestive of panic disorder, a much broader range
of treatment, from tricyclic antidepressants and selective serotonin
reuptake inhibitors to cognitive therapy may be effective. Failure to
identify panic attacks or panic disorder may deprive patients of valuable
treatment options, some of which can be instigated in primary care.

Dr Simon JC Davies,
Senior House Officer,
Bristol, Bath and Weston
Psychiatry Rotation.

Dr Peter R Jackson,
Reader and Honorary Consultant,

Clinical Pharmacology and Therapeutics, University of Sheffield.

Professor
Lawrence E Ramsay,
Clinical Pharmacology and Therapeutics, University of
Sheffield.

REFERENCES

[1] Thomas M, McKinley RK, Freeman E, Foy C. Prevalence of
dysfunctional breathing in patients treated for asthma in primary care:
cross sectional survey. BMJ 2001; 322: 1098-1100.

[2] Keeley D, Osman L. Dysfunctional breathing and asthma. BMJ 2001;
322: 1075-6.

[3] van Dihoorn J, Duivenvoorden HJ. Efficacy of Nijmegen
Questionnaire in recognition of the hyperventilation syndrome. J Psychosom
Res 1985; 29: 199-206.

[4] Carr RE. Lehrer PM, Rausch LL, Hochron SM. Anxiety sensitivity
and panic attacks in an asthmatic population. Behav Res Ther 1994; 32: 411
-8.

[5] Davies SJC, Ghahramani P, Jackson PR, Noble TW, Hardy P,
Hippisley-Cox J, Yeo WW, Ramsay LE. Association of panic disorder and
panic attacks with hypertension. Am J Med 1999; 107: 310-6.

Competing interests: No competing interests

01 June 2001
Simon J C Davies
*Senior House Officer, Bristol, Bath and Weston Psychiatry Rotation.
Peter R Jackson, L E Ramsey
New Friends Hall, Stapleton, Bristol.