Expressions of the hyperventilation syndrome in childhood: studies in management, including an evaluation of the effectiveness of propranolol

Clinical Aspects and Treatment of the Hyperventilation Syndrome

The Hyperventilation Syndrome is a common disorder and clinical psychologists will be regularly confronted with it, because the syndrome is closely interwoven with psychological problems. The literature is reviewed with respect to pathophysiology of the complaints, aetiology of the syndrome and treatment. A new developmental model is presented and directions for future research are proposed.

A teenage girl with extreme tachypnea

Dyspnea and tachypnea are common presenting complaints in an emergency department. Respiratory and cardiac causes are the most common etiology. Functional respiratory disorders should be considered in patients with atypical presentation to avoid extensive investigations. We describe an adolescent who presented to our emergency department with extreme tachypnea.

Functional symptoms confused with allergic disorders in children and adolescents

The diagnosis of a functional respiratory disorder is sometimes difficult and time-consuming, because the symptoms often resemble those of organic diseases. The most common entities are hyperventilation syndrome, psychogenic cough, sighing dyspnea, and vocal cord dysfunction. Typical signs are heavy breathing or dyspnea, cough or sneezing, various breathing sounds, tightness of the throat or chest, pain, and fear. Criteria for differentiation include the lack of nocturnal symptoms, the sudden occurrence, no typical trigger factors, the variable duration, a quick regression, and that symptoms do not respond to adequate pharmacotherapy and finally normal results of diagnostic work-up. Therapeutic options comprise psychological intervention (by reassurance, relaxation techniques, and behaviour therapy) and physiotherapy (e.g. breathing therapy, voice training). Intensive efforts should be made to diagnose functional symptoms at an early stage because this will prevent stigmatization and fixation of symptoms and disease, and also prevent children from undergoing unnecessary and potentially harmful therapies.

Anxiolytics, adrenergic agents, and naltrexone

OBJECTIVE

To review extant data on the efficacy and safety of anxiolytic medications (benzodiazepines, buspirone, and other serotonin 1A agonists), adrenergic agents (beta-blockers and alpha 2-adrenergic agonists clonidine and guanfacine), and the opiate antagonist naltrexone that have been used to treat various psychopathologies in children and adolescents. To identify critical gaps in our current knowledge about these agents and needs for further research.

METHOD

All available controlled trials of these medications in children and adolescents published in English through 1997 were reviewed. In addition, selected uncontrolled studies are included.

RESULTS

The major finding, that there are virtually no controlled data that support the efficacy of most of these drugs for the treatment of psychiatric disorders in children and adolescents, is both surprising and unfortunate. For some drugs, e.g., buspirone and guanfacine, this is because no controlled studies have been carried out in children and/or adolescents. For other drugs, e.g., clonidine and naltrexone, most of the placebo-controlled studies have failed to demonstrate efficacy.

CONCLUSIONS

The strongest recommendations for controlled studies of safety and efficacy in children and adolescents can be given for the following drugs: benzodiazepines for acute anxiety; buspirone (and newer serotonin 1A agonists as they become available) for anxiety and depression; beta-blockers for aggressive dyscontrol; guanfacine for attention-deficit/hyperactivity disorder; and naltrexone for hyperactivity, inattention, and aggression in autistic disorder.

A critical review of pharmacotherapy for youth with anxiety disorders: things are not as they seem

Given the increasing trend in clinical child psychology and psychiatry toward cost-effective and pharmacological treatment, a review of key factors that influence treatment outcomes in this area seems warranted. This is especially important for the rapidly changing area of childhood anxiety disorders. In this article, we look at different change producing procedures to illustrate the claim that pharmacological studies are not necessarily what they seem. Specifically, pharmacological outcome studies are classified and reviewed on the basis of varying "secondary" treatments described in method sections. Three groups and efficacy rates were determined: (a) pharmacotherapy only (42.83%), (b) pharmacotherapy plus general/supportive psychotherapy (27.74%), and (c) pharmacotherapy plus a behavior therapy component (65.28%). We also discuss the implications of these findings for research as well as other methodological and theoretical concerns regarding the reviewed articles. These concerns include (a) methods used to diagnose participants, (b) methods used to assess improvement, (c) emphasis on diagnostic categories, (d) exclusionary criteria and comorbidity, (e) participant attrition and follow-up, and (f) key developmental and social contextual variables.

Panic in children and adolescents: a review

Based on our review of the available data, we conclude that panic attacks are common among adolescents, while both panic attacks and Panic Disorder appear to be present, but less frequent, in children. Furthermore, it is evident that both adolescents and children who report panic attacks describe the occurrence of cognitive symptoms, although with less frequency than physiological ones. Consistent with the cognitive model of panic, it seems that at least some youngsters are capable of experiencing the physiological symptoms of panic accompanied by the requisite catastrophic cognitions. However, a more complete understanding of the cognitive manifestation of panic attacks/disorder among children awaits further investigation. Future research should aim to explore the developmental progression in children's cognitive responses to specific panic symptomatology. Risk factors (e.g. anxiety sensitivity, depression) which may contribute to the likelihood of misinterpreting physiological sensations in a catastrophic manner throughout the course of development should also be assessed: Finally, we are in general agreement with Abelson and Alessi (1992) who argue that we must begin to ask ourselves how panic disorder may be manifested in children. That is, rather than assessing the frequency with which children experience symptoms of adult panic, we should explore what panic would look like in children. They propose that the study of panic in children would be facilitated by a reformulation of separation anxiety as a childhood expression of panic disorder. Although this reformulation makes intuitive sense and is appealing from a developmental perspective, we would insert a strong caveat. Although the research is yet to be conducted, it is probable that childhood separation anxiety is only one of many routes to panic disorder outcome. It is improbable that such direct and continuous pathways are present for the majority of children, adolescents and adults who experience panic disorder. More probably, the pathways are multiple, complex, and discontinuous (Robbins & Rutter, 1990). Much work remains to be done before we are able to ferret out the linkages between developmental processes and clinical outcomes for panic disorder in children and adolescents.

[Panic attacks and panic disorders in the child]

Panic disorders in adults have been the object of many studies. They are better known in adolescents but have been noticed insufficiently in children although panic disorder is potentially dangerous at that age. After demographic considerations, the clinical aspects are examined and illustrated using two detailed observations.

Self-reports of panic attacks and manifest anxiety in adolescents

A recent paper by Nelles and Barlow (1988; Clinical Psychology Review, 8, 359-372) provided the rationale for an investigation of panic attacks in adolescents. A panic attack questionnaire and the Revised Children's Manifest Anxiety Scale were administered to an unselected sample of Australian adolescents. Of 534 adolescents, 42.9% reported having at least one panic attack. Other data are reported on the characteristics of panic attacks, life interference and avoidance behaviour. Panickers reported significantly higher anxiety levels than nonpanickers. Differences between the findings of Australian and American samples were noted and directions for future research were identified. Several methodological issues were also discussed including the reliability and validity of self-report data on panic attacks.

Pediatric psychopharmacotherapy: a review of recent research

In the past 5 years, we have witnessed the continuation of important trends in clinical research that began earlier in the decade. With regard to the treatment of specific disorders in children and adolescents, the most significant developments have been the examination of the tricyclics for the treatment of depression and the initiation of controlled studies for the treatment of Tourette syndrome. Unfortunately, the findings from the depression studies have been uniformly negative, and the results of research on both depression and tic disorders show a relatively high rate of placebo responsivity, which raises nagging questions about the role of case reports and open trials. Another important trend in pediatric psychopharmacotherapy is the search for substitutes for the neuroleptics. Potential candidates include agents such as lithium, naltrexone, fenfluramine, clonidine, and carbamazepine. The most underresearched disorders are a combination of the least common (e.g. schizophrenia, mania) and those that are apparently perceived as less serious (e.g. sleep disorders, certain anxiety disorders). Not surprisingly, the most studied disorder and treatment is hyperactivity and stimulant medication, respectively. Considerable progress has been made in understanding the social implications of the associated symptoms and their response to stimulant drugs, aided greatly by the use of direct observation procedures. Researchers are beginning to attend to the implications of comorbidity for assessing response to medication. There has been additional confirmation of efficacy of stimulant treatment for preschoolers and adolescents. Dose-response issues remain to some extent unresolved, the primary impediments being interpretive misconceptions associated with trend analysis, an overreliance on the syndromal perspective and too little attention to target behaviors and their clinical implications, and the failure to operationalize the minimal effective dose with regard to the normalization and supranormalization of target and collateral behaviors. Disagreement over whether hyperactivity is a learning or a behavior disorder (or both) and what academic underproductivity means clinically and socially is also impeding progress. With regard to developmental disorders, controlled studies indicate that fenfluramine and naltrexone are effective for managing associated symptoms in some individuals. However, given the limited amount of research on these agents, their status as clinically useful palliatives must be considered tentative.(ABSTRACT TRUNCATED AT 400 WORDS)

Somatic complaints in anxious children

Although stomachaches and headaches are considered characteristic of children with anxiety disorders, there is converging evidence that a broader range of somatic symptoms may be associated with children's expressions of anxiety. The purpose of this study was to determine the prevalence of somatic complaints in anxious children. The results indicated that children with anxiety disorders endorsed the presence of many different somatic complaints, and that contrary to clinical intuition, stomaches and headaches were not among the most commonly reported symptoms. In addition, the anxious children endorsed significantly more somatic complaints when compared to normal controls. Furthermore, the symptom pattern reported by anxious children indicated the presence of both the somatic and cognitive components usually associated with panic attacks, although none of the children met diagnostic criteria for panic disorder. The results are discussed in terms of the contribution of somatic symptoms to the understanding of anxiety disorders in children.

Pseudoseizures caused by hyperventilation resembling absence epilepsy

During the 4-year period, 1982-1986, 18 patients presented to the Children's Hospital, Camperdown, Sydney, with the following features: (1) Recurrent "absences" clinically indistinguishable from childhood absence epilepsy, (2) Normal clinical examination, (3) Electroencephalogram (EEG) demonstrating normal waking background and sleep activity. On hyperventilation, "absences" occurred, characterized on EEG by a marked build-up of paroxysmal slow-wave activity unassociated with evidence of epileptic activity. We designate these attacks "pseudoseizures caused by hyperventilation resembling absence epilepsy." Individual cases demonstrated a variety of other symptoms consistent with the hyperventilation syndrome. There was an identifiable environmental stress in 13 of the 18 cases. Follow-up of 13 patients after a mean period of 20 months revealed that only two children continued to have occasional absences, associated with a clear history of breathing up when upset. Treatment did not influence outcome. On repeat hyperventilation with EEG and respiratory monitoring, five of the 13 had pseudoseizures. There was no indication that susceptibility to these episodes was associated with an abnormal CO2 response. It is postulated that the occurrence of pseudoseizures is related to cerebrovascular immaturity and an excessive vasoconstrictor response to a given level of CO2.

Panic disorder on a child psychiatric consultation service

In a review of all cases seen from 1984 to 1988 by the psychiatric consultation-liaison service of a tertiary referral pediatric hospital, four cases of definite panic disorder meeting DSM-III-R criteria were identified. Three of these children were referred to the consultation service after intensive investigation of physical complaints had failed to yield a diagnosis. These cases of panic disorder differed from those previously reported in child psychiatric populations by their relative absence of psychiatric comorbidity. This suggests that uncomplicated panic disorder may present with primarily somatic symptoms in pediatric subspecialty clinics, while panic disorder, complicated by behavioral or emotional disturbance, is more likely to present directly to child psychiatric services. Children presenting with somatic symptoms are at risk for receiving nonproductive investigations while having delayed diagnosis and treatment of the panic disorder.

Hyperventilation Syndrome in Adolescent Athletes

In brief: Ten high school students (three males, seven females) hyperventilated 12 times during athletic events over a two-year period. Symptoms associated with hyperventilation syndrome include an inability to catch one's breath, rapid deep respirations, anxiety (often associated with losing among athletes), tetany, numbness of lips and hands, chest pain, and even loss of consciousness. Treatment may consist of rebreathing into a paper bag, which is embarrassing in front of observers, or slowly inhaling through the nose and exhaling through the mouth.

Neurological manifestations of the hyperventilation syndrome

Seventy-eight patients with the hyperventilation syndrome are described, none of whom had been diagnosed prior to referral for neurological assessment. There is a constellation of symptoms associated with this condition, and attacks need to be reproduced by hyperventilation in order for the diagnosis to be established. Loss of consciousness and paraesthesiae were more frequent than in previously published series.

Effects of beta-adrenoceptor blockade on exercise performance and respiratory response in healthy, physically untrained humans

The effects of propranolol 80 mg orally were compared with those of placebo on the response to a stepwise increasing exercise test in 17 healthy and physically untrained volunteers, of whom eight were female. Propranolol showed no significant effects on maximum work rate or perceived exertion rate. However, submaximal O2 uptake, CO2 output and minute ventilation tended to be lower after propranolol than after placebo. It is concluded that in subjects with a low work capacity, beta-adrenoceptor blockade does not impair maximal exercise capacity. The mechanisms underlying changes in respiratory response to exercise after propranolol are not fully explained. However, changes in substrate utilisation, the reduction in cardiac output and an alteration in respiratory drive may all be involved.

Panic attack syndrome

Panic attack syndrome in four generations of a family and in six additional pediatric patients is reported. The syndrome appears to have an autosomal dominant mode of inheritance. Diagnosis of panic attack syndrome in children has not been reported previously, but the existence of this disorder has been noted for at least 100 years under various synonyms. There is substantial evidence that the syndrome has an endogenous origin and is therefore a biochemical illness. The triggering effect of sodium lactate infusion and the alleviation of symptoms by use of monoamine oxidase inhibitors or beta-blocking agents support this view. Imipramine hydrochloride, propranolol hydrochloride, phenelzine sulfate, and alprazolam are often useful in the treatment of panic attacks, and except for propranolol, any of them may be effective against depression also.