Pergamon

Z Behav. Ther. & Exp. Psvchiat. Vol. 26. No. 1, pp. 77-80, 1995. Elsevier Science Ltd

Printed in Great Britain

BOOK REVIEWS

B e h a v i o r a l a n d P s y c h o l o g i c a l A p p r o a c h e s to Brea th ing D i s o r d e r s

Edited by B. H. TIMMONS and R. LEY Plenum Press, New York, 1994. pp. xvi + 321

Clinical respiratory psychophysiology is in renaissance: We are vastly expanding our knowledge of the sys temic and cerebral consequences of the physiology of breathing, as these affect cognition, emotion, and behavior, on the one hand, and many organic disorders including heart and cardiovascular disease, hypertension, and seizures, on the other. A number of functional and organic breathing disorders concern us, but the main culprit is hyperventilation, i.e., low blood CO2 level: The list of its sequelae is expanding rapidly, as renewed interest in it resul ts in a g rowing number of cl inical and research publicat ions, world-wide. I have spent the past 15 years intensively learning how to diagnose and treat hyperventilation, and other breathing disorders, and I always look forward to a new contribution to this field.

This book begins with a foreword, by Patel, highlighting commonly encountered compliance problems. Then, in the Preface, the editors declare their intention to explain breathing in "an authoritative, comprehensive sourcebook" in respiratory psychophysiology. But, regrettably, this particular set of contr ibut ions , coupled with s ignif icant topic omiss ions , conspires to serve the reader a mixed menu of valuable and dubious knowledge. The contr ibut ions are condensed by Timmons in the Introduction.

The title of Sec t ion I, " A n a t o m y , p h y s i o l o g y , phys iopa tho logy , and the psycho logy of the respiratory system" is confusing. What is the psychology of the respiratory system? In Chapter 1, Basic anatomy and physiology of the respiratory system and the autonomic nervous system, Naifeh teaches selected aspects of these topics. Granted, many of her readers may have little background in biology or chemistry, yet her prose seems, at times, a little quirky and patronizing. Many things that I would have liked to see included here are missing, such as blood gas reference values and nomographs such as Radford's on rate and volume relationships; also missing is a description of the role of vascular chemoreceptors and CO2 in cerebral hemodynamics - - which figure so prominently now in research on panic disorder. The chapter also has a number of confusing explanations. For instance, it fails to mention that the scalenes lie under the clavicles, attach to the first and second rib, lifting the rib cage when chest breathing prevails, giving the reader the erroneous impression that the scalenes raise the clavicles. And, alveolar PCO 2 is rarely mainta ined at 40 mmHg. It changes from breath to breath - - often dramatically.

I found Chapter 2, Nasopulmonary physiology, by Barelli, to be a generally well written, informative and interesting description of the nose and upper airways. I learned many

things here that I did not know and, in particular, that "mid- cycle rest" may indicate heart disease. I would have welcomed greater depth of detail in some places. The statement that nose breathing raises 02 uptake by 10-20% or more is wrong - - 5%, at most, since normal oxihemoglobin saturation is about 95-98%.

Behavioral perspectives on abnormalit ies of breathing during sleep, by Guilleminault and Bliwise, is well written and thorough. It will teach you much of what you need to know about this phenomenon including Pickwickian syndrome, one of the "sleep apnea syndromes." It alerts clinicians, who are somet imes hard to convince, that chronic hypoxia causes mental deterioration. It also describes behavioral treatment for snoring.

Chapter 4, Control of breathing and its disorders by Jennet, overlaps Chapter 1, by Naifeh. It has no references, the prose is sometimes muddled, and there are several errors, including her assertion that ventilation decreases to a greater extent than does the metabol ic rate, dur ing s leep. Tha t is imposs ib l e , metabolism always dictates ventilation.

Chapter 5, Breathing and the psychology of emotion, cognition, and behavior, by Ley is well written, concise and stimulating. He reiterates his model of the bidirectionality of ventilation in the psychology of cognition and emotion. He interweaves conditioning, and proposes a well formulated theory of the connection between hyperventilation and panic attacks, which he attributes to an initial "dyspneic-fear."

Part II, Hyperventilation - - diagnosis and therapy, begins with Chapter 6, Diagnosis and organic causes of symptomatic hyperventilation, by Gardner, a well presented and concise argument that clinicians should pay more attention to the basic physiology and clinical symptomatology of hyperventilation which, he cautions, may not invariably be the consequence of anxiety, and that one must always suspect an organic basis. Objective diagnosis of hyperventilation based on capnography is also important.

Chapter 7, Hyperventi lat ion syndromes, physiological considerations in clinical management, by Lum, is a synopsis of his p ioneer ing publ ica t ions , which were pr incipal ly r e spons ib l e for d rawing the a t ten t ion of the medica l establishment to focus on the clinical symptoms of chronic hypocapnia. He emphasizes both clinical observation and history taking, and incorporation of objective measures of alveolar and blood CO2 in diagnosis and treatment of the symptoms of chronic hyperventilation.

In Psychia t r ic and respira tory aspec t s of func t iona l

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78 Book Reviews

cardiovascular syndromes, Chapter 8, Bass, Gardner, and Jackson, trace the evolution of DaCosta's syndrome - - once considered cardiac neurosis - - to its contemporary form, "functional cardiac syndrome." They "show that its respiratory aspects are due to hypocapnia which can cause significant cons t r i c t ion o f co ronary ar ter ies , and abno rma l EKG manifestations. The chapter is concise, detailed, well written, and very informative. I would, however, be inclined to hold abdominal breathing at 8-12 breaths/min to be an inadequate end-product of treatment.

I also thought highly of Chapter 9, Hyperventilation and psychopathology - - A clinical perspective, by Fensterheim. This is a well-written, provocative chapter. Though 1 do not agree with h im that the d iagnos t ic goals of the clinical researcher and of the working clinician must be quite different, I consider his perspective to be germinal to effective clinical t reatment . It inc ludes the not ion that both detected and undetected hypervent i la t ion may actually interfere with psychotherapy. Here is clinical psychology at its best - - as it was, once, and should still be taught.

Chapter 10, by Bass, titled Management of patients with hyperventilation-related disorders, delivers little other than an off-hand endorsement of discredited reports that breathing retraining is ineffectual . His "comprehens ive reviews of hyperventilation" are four ordinary studies. Yet, he ignored his 1988 review of a monograph with 22 pages of references (nearly 2000), The hyperventilation syndrome - - Research and clinical treatment, for the Journal of Neurology, Neurosurgery, and Psychiatry.

I cannot fathom the aim of breathing training proposed by Holloway, in chapter 11, The role of the physiotherapist in the treatment of hyperventilation. When tidal volume is reduced, breathing rate rises, and PCO 2 diminishes! She tells her patients that with a minimum of two daily practice sessions, constant checks, and vigilance, the respiratory center will eventually adapt to a higher PCO2 level, recognize it as normal, and maintain it involuntarily. This is wishful thinking, in my opinion. At the end, she avers that paper-bag rebreathing "is often done incorrectly," suggesting that this is a skill that the average individual cannot master . Paper-bag rebreathing instructions are, nevertheless, omitted.

Section III speaks to Other therapeutic approaches to b rea th ing d isorders . Chap te r 12, Brea th ing and vocal dysfunction, by Pearce, is a well-intentioned, informative but, to my mind, misplaced effort. It is specific to voice training and would seem more at home in a textbook on speech pathology. It conta ins no "other" approach to breathing disorders.

Chapter 13, Respiratory system involvement in Western relaxat ion and sel f - regulat ion, by Lehrer and Woolfolk, reviews breathing and relaxation techniques and various forms of respiratory biofeedback used to treat different types of functional and organic breathing disorders. It is well written, concise, and thorough. Among the methods it addresses, is paced respiration which, I grudgingly admit, they jus t i fy admirably (I personally loathe the technique). Solely these authors have correctly cited properly executed abdominal breathing to result in a rate of 3-5 breaths per minute. Highly recommended reading.

We i s s put it succ inc t ly , in Chap te r 14, Behav io ra l management of asthma, that "asthma is a physical, not an emotional, illness. Its primary treatment must be medical." He

is not preaching to converts: many find this a difficult idea to comprehend. He details emotional components , and other "precipitants" in asthma. The chapter is well written, concise, and comprehensively tells you what you need to know about asthma patient management, symptom assessment, and some behavioral treatment. I regret omiss ion of the pursed-lip breathing method of Tiep, and the incentive inspirometer biofeedback method of Peper.

Inclusion ofpranayama in a book on breathing is virtually obligatory. See Chapter 15, Respiratory practices in yoga, by Chandra. Mystical "Eastern" practices capture our imagination. The preoccupation with the idea that cosmic energy "surfs" on our breath, as it were, until the mind transcends reality, is not the least of it. Curiously, this activity has potentially beneficial, even therapeutic, effects. They are nicely detailed here. 1 found this chapter interesting and I recommend it to you.

Psychologists are not of one mind, yet it is baffling that Styles of breathing in Reichian therapy, Chapter 16, by Boadella, found its way into this book. It details no useful methods, considers styles of breathing solely as "central mechanisms of repression," and displays a full panoply of bizarre concepts, including vegetotherapy, intestinal breathing, breathing as sucking, and schizoid (used interchangeably with schizophrenic) breathing.

In Chapter 17, Brea th ing and feel ing, Conway also proposes that the "work" of repress ing emot ion causes hyperventilation. He claims that when clients express grief, cry, and look at their capnogram, symptoms vanish because they cease to be "adaptive." Polar opposite of cognitive theory, which holds that you are disturbed by what you tell yourself. He holds that you are disturbed by what you don't tell yourself.

Maybe you will appreciate Chapter 18, Breathing therapy, by Proskauer, but I confess that I could not fathom it, much as I tried. Assertions like, "Often, sensation evolves, that the breath carries one upright so that no effort is needed for sitting or standing in good posture" left me breathless.

Chapte r 19, Brea th ing- re la ted i ssues in therapy, by Timmons , ends this book with a well meaning attempt to present a fair and balanced forum for ideas and paramount issues. But she sometimes waffles even when she has a strong, valid opinion. For instance: on one hand, she stands, up for empirical validation, when she underscores the need for studies of the prevalence of hyperventilation in grief, on the other, she uncr i t i ca l ly va l ida tes a s ense l e s s p r o n o u n c e m e n t that "breathing reaches the unconscious," because other physical therapists have observed that breathing exercise can occasion unpredictable emotional responses. Eclecticism should not be confused with uncritical judgment.

Many patients seem to have difficulty expressing emotions, and may hyperventilate, yet Timmons might have tempered her endorsement of the hypothesis that one, invariably causes the other. In reviewing panic attacks, she acknowledges that they may come in many varieties; yet there is no mention of the fact that some are known to be hyperventilation-related seizure equivalents . In fact, seizure disorder provided the major impetus to s tudy the phys io log ica l /metabol ic effects of hyperventilation on the brain - - acknowledged in over 4500 scientific references. The book has only two subject index ent r ies on se izures , and one conce rns the fact that hypervent i la t ion rarely induces seizures in those not so predisposed.

Timmons is on target when she says that neither breathing

Book Reviews 79

nor hyperventilation can be assessed adequately solely by obse rva t ion of vo lun ta ry ove rb rea tb ing or by a s ing le observation of PCO2; she adds that previous est imates of breathing rate are flawed by hospital-sample bias. Yet nowhere in this book are there specific ins~tructions for abdominal breathing, with or without physiological monitoring of chest and abdominal excursion. Nor is capnometry taught here, i.e., what i n s t r u m e n t is r e c o m m e n d e d , how is it u sed and interpreted? She questions the peculiar assertion by Garssen et al., that breathing training a "rational placebo," then asserts that only assiduous long-term follow-up will determine if somatic, behavioral, cognitive, or psychotherapeutic approaches will put some clients at risk of symptom substitution. But the cognitive approach, well represented in the literature, omitted altogether f rom this book, and there is no empir ica l ev idence for "symptom substitution." Finally, it would also be more prudent not to d iscount the warning by many respected medical specialists, including some contributors to this book, that VHV is a potent ia l ly dange rous procedure . She ci tes data of clinicians who induce hypocapnia in their patients - - some reportedly at PCO2 levels below 20 mm Hg, for up to 8 minutes! Hypocapnia is a powerful peripheral and cerebral vasoconstrictor, jeopardizing the heart and brain blood supply. I would be inclined to proceed with extreme caution.

Summing up, a number of the chapters in this book stand out as excellent. They are well written, informative and thought

provoking, but overall, the book is a disappointing patchwork of " con t r i bu t i ons , " b i a sed in content , and u n e v e n in scholarship, and prose: Some chapters overlap, there are numerous gratuitous assumptions, and misleading conclusions, and the cognitive-behavioral "approach" is omitted altogether. as are also major physiological topics. This book is about selected aspects of breathing disorders, but you will not learn how to do breathing training, capnometry, other physiological assessment, etc. It is a pity that it presents such a distorted view of clinical respiratory psychophysiology.

ROBERT FRIED* Respirato~ Psychophysiology Laboratoo'

Hunter College, CUNY Director of the Stress and Biofeedback Clinic

Institute.~r Rational Emotive and Behavior Therapy NY 10021. U.S,A.

*Robert Fried authored The Psychology and physiology of breathing in behavioral medicine, clinical psychology and psychiatry. Plenum Press, 1993; The breath connection Plenum Press, 1990; and The hyperventilation syndrome - - Research and clinical treatment. Johns Hopkins University Press, 1987.

Seduc t i ve Mi r age : A n Exp lora t ion o f the W o r k o f S i g m u n d F r e u d

by ALLEN ESTERSON Open Court Publishing Company, Peru, Illinois, 1993, 270 pp.

This book is a remarkable review and critique of all of the publications of Sigmund Freud. It starts with a careful and sys temat ic descr ipt ion of F r eud ' s early deve lopment of psychoanalytic theories and their "basis" in Freud's patients. Then, virtually all of Freud's publications are reviewed, and Esterson points out and cites inconsistencies and contradictions from article to article. Esterson presents many illustrations of "repressed memory", a very current area of investigation. He demonstrates from Freud's writings how the therapist pushes upon the patient the therapist's theories and then attributes this material to the patient. In effect the therapist puts words in the patient 's mouth which then seem to confirm the therapist 's theories.

Esterson analyzes most of Freud's classic case histories (e.g., Dora, Little Hans) and points up a whole variety of "'frauds". In one instance Esterson notes that "one is tempted to suggest that it is the physician who is subject to fantasies (though in his case they are conscious) and not the patient." tp. 477

It is of interest to note that Freud was in continual rivalry with his fellow psychoanalysts such as Jung, Adler, and particularly Josef Breuer who had been his early mentor and collaborator. Clearly Freud is portrayed as a dangerous and hostile individual particularly to anyone he considered to be a rival. Among the other less than positive attributes of Freud, Esterson notes (citing Peter Swales) that Freud was a cocaine addict.

Esterson is critical of Freud's veracity, while noting that "few people would be prepared to entertain the notion that a man of such stature migh t be the source of widespread deception." (p. 248). But Esterson demonstrates excellent scholarship and cites other investigators who have been critical of Freud and his theories. There is virtually no Freudian publication about which Esterson does not raise some doubts. " F r e u d ' s whole s y s t e m is in fact pe rvaded by c i rcular arguments". (p. 245) "It is clear that there are good grounds for doubt ing the t rus twor th iness o f F r e u d ' s account of the treatment; it appears that on occasion he is not above inventing the material he needs for his analysis". (p. 72)