Elsevier

Clinical Psychology Review

Volume 24, Issue 5, September 2004, Pages 557-581
Clinical Psychology Review

Dyspnea: The role of psychological processes

https://doi.org/10.1016/j.cpr.2004.05.001Get rights and content

Abstract

Breathlessness or dyspnea—the subjective experience of breathing discomfort—is a symptom in many pulmonary, cardiovascular, and neuromuscular diseases. It occurs in normals as well during intense emotional states and heavy labor or exercise. In clinical cases, it generally causes severe suffering.

Dyspnea has multifactorial causes and the explanation for the symptom may differ largely among patients. Explanatory models imply the involvement of mechanisms at several levels of functioning, such as afferent signals from the respiratory muscles or blood gas levels related to hypercapnia and hypoxia. Depending on the relative involvement of specific mechanisms and their interactions, dyspnea may be experienced differently and subtypes can be distinguished. More recently, perceptual-cognitive and emotional processes related to symptom perception and interpretation have been investigated in the context of dyspnea.

In this review, we focus on the psychological processes that play part in the perception of dyspnea and formulate some practical guidelines for those who are confronted with dyspnea.

Introduction

Dyspnea–breathlessness, or the subjective experience of breathing difficulty or discomfort—is a symptom experienced by many patients with pulmonary, cardiovascular, and neuromuscular diseases, patients on mechanical ventilation (Wong, Lopez-Nahas, & Molassiotis, 2001), as well as by 70% of terminally ill cancer patients (Coyne, Viswanathan, & Smith, 2002). After back pain and fatigue, dyspnea is the third most common presenting symptom in internal medicine (Mahler et al., 1996). It occurs in healthy individuals as well, e.g., during intense emotional states and heavy labor or exercise. As a symptom, it can be hard to treat (Skevington, Pilaar, Routh, & MacLeod, 1997) and often causes poor quality of life and severe disability. In many cases, it is the only reason why a person seeks medical care and sometimes it is also the only complaint patients consult for.

Moreover, there is a close relation between dyspnea and some domains of psychological (mal)functioning: Anxiety is a common symptom among patients with respiratory disease. Anxiety disorders appear to be the most prevalent psychiatric disorders in clinical samples of patients with pulmonary disease (Smoller, Simon, Pollack, Kradin, & Stern, 1999). Sensations of shortness of breath, feelings of choking, and chest pain or discomfort are part of the definition of a panic attack in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994). Dyspnea is part of the symptomatology in agoraphobia and hyperventilation syndrome (Rietveld, Everaerd, & Creer, 2000), and it is a common complaint in Multiple Chemical Sensitivity (MCS; Black, Okiishi, & Schlosser, 2001). The differential diagnosis of dyspnea and anxiety includes both pulmonary and psychiatric conditions (Smoller et al., 1999).

As a result, diagnosing the cause of the dyspnea is a difficult task, complicated by the variety of (patho)physiological and psychological processes that play a role in the origin of the sensation of dyspnea. The current article focuses on psychological aspects in the perception and reporting of dyspnea. In the first section, we try to define the term dyspnea. The second section gives a brief overview of the most prevalent physiological explanations of dyspnea. Because our focus is on the perception of dyspnea and psychological factors playing a role in that process, these are reviewed more thoroughly in sections three and four, respectively. We conclude with some practical guidelines for caregivers confronted with dyspnea.

Section snippets

A definition of dyspnea

Dyspnea is a medical term used for a variety of breathing-related phenomena that should not be considered interchangeable. In general, the term refers to “a subjective experience of breathing discomfort that consists of qualitatively distinct breathing sensations that vary in intensity” (American Thoracic Society, 1999, p. 322). “Shortness of breath,” “breathlessness,” “lack of breath,” and “difficulty breathing” are all dyspneic feelings, the one being more general than the other.

As a

Most prevalent explanations

No specific dyspnea receptors exist and many different mechanisms may be involved (Manning & Schwartzstein, 1995). Take the example of a person with bronchitis who gets short of breath after climbing the stairs to the office on the third floor. Is the shortness of breath the result of airway narrowing due to inflammation, is it caused by fatigue in respiratory muscles, or is it the result of changes in arterial blood gases? It might as well be a combination of two or more of those factors.

An

The perception of dyspnea

Rietveld (1998) adequately summarizes the previous paragraph by stating, “the sensory input into the symptom perception process is often neither clear nor specific” (p. 139). This is the very reason why research on dyspnea is hard to carry out: Although a certain correspondence exists between the physiological limitation of breathing (due to decreased lung volume, bronchus obstruction, or other causes) and the degree of dyspnea, the degree of correspondence varies strongly between and within

Psychological influences on the perception of dyspnea

From the previous paragraphs, one could get the impression that there is no clear link between a stimulus on the one hand and the sensation of dyspnea on the other hand. In fact, dyspnea in some cases is a true alarm of true suffocation and signals real dysfunctional processes in the body. Still, one must admit that the relation is problematic because of the variety of mechanisms involved. Moreover, it can be “heavily influenced by psychological processes” as well (Brand et al., 1992, p. 400).

Is there anything we can do?

It should be clear from the former paragraphs that all too often, no simple cure or remedy is available for dyspnea. If the underlying cause is clear, appropriate treatment is possible (e.g., anti-inflammatory agents, additional oxygen, surgery, etc.), but in many cases this does not alleviate dyspnea completely. Nebulized fentanyl citrate has been suggested as an inexpensive mean to alleviate dyspnea in cancer patients (Coyne et al., 2002), and nebulized morphine or other opioids have been

General conclusion

Dyspnea is a complaint in many disorders and refers to a variety of subjective experiences. Depending on the physiological processes that play a role in the etiology, dyspnea may present in different forms. Although no precise mechanism has been identified, there is consensus that a variety of receptors in lung tissue, airways, upper respiratory tract, and thorax, as well as chemoreceptors in lungs and blood vessels together with multiple brain areas, add to the feeling of dyspnea.

Moreover,

Acknowledgements

The first author was supported by Grant G.0270.01-FWO Flanders and BIL 01/05 of the Bilateral Scientific and Technological Cooperation between Flanders (Belgium) and China. The authors would like to express their gratitude to Dr. K. P. Van de Woestijne for valuable comments on previous versions of this paper.

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