Stressors Associated with Dyspnea in Childhood: Patients' Insights and a Case Report

American Journal of Clinical Hypnosis,  Oct 2004  by Anbar, Ran D

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Objective: To highlight the concept that stress can be associated with dyspnea in children.

Methods: A chart review identified 22 patients (age range, 9-17 years) referred to a pediatric pulmonologist, who were offered instruction in selfhypnosis for treatment of dyspnea that persisted despite medical therapy. Patients were offered the opportunity to use hypnosis to gain insight into the causes of their dyspnea.

Results: The dyspnea resolved in 18 of the 22 patients within 1 month of instruction in self-hypnosis for relaxation and symptom reduction. Eight of the 22 patients (age range, 11-16 years) chose to use hypnosis for insight. Using automatic word processing, they explained that their dyspnea was associated with stressful situations, or that it reduced the chances of having to experience an uncomfortable situation. For example, a girl with dyspnea resulting from vocal cord dysfunction realized during hypnosis that she developed her symptom in order to prevent herself from talking about information that might cause discomfort were it disclosed. As soon as the patient decided that she could trust herself to handle the information appropriately, her symptom resolved.

Conclusions: Dyspnea may provide patients with a way of expressing their reactions to perceived or anticipated stress. Thus, stress reduction interventions may prove very helpful in resolving this symptom. However, in some cases gaining an insight into the potential cause of the dyspnea may increase the effectiveness of therapy.

Keywords: Dyspnea, hypnosis, Posttraumatic Stress Disorder, somatoform disorder

A somatoform disorder is defined by the presence of physical symptoms that suggest a physical disorder, which are not explained fully by the presence of a general medical condition, the direct effects of a substance, or another mental disorder (such as malingering, factitious disorder, anxiety, or depression, American Psychiatric Association, 1994). Types of somatoform symptoms may be age dependent. Abdominal pain and headaches may be reported most frequently in late childhood and early adolescence, while complaints relating to limb pain, neurologic symptoms, insomnia, and fatigue tend to occur in late adolescence (Campo & Fritsch, 1994; Garber, Walker, & Zeman, 1991; Oster, 1972; Silber & Pao, 2003; Stefansson, Messina, & Meyerowitz, 1976).

Children with somatoform disorders often have family members who have similar physical symptoms, or live with families affected by conflict, bereavement, or trauma (Fritz, Fritsch, & Hagino, 1997; Garralda, 1996). It has been proposed that children's somatization may protect their parents by distracting parents from their own issues (Mullins & Olson, 1990). Similarly, a somatic symptom may keep children's psychological conflict out of their own awareness (American Psychiatric Association, 1994). Stress arising from parental pressure for the child to perform also has been implicated as a trigger for somatization (Greene & Walker, 1997; Silber & Pao, 2003). Finally, children who have been physically or sexually abused often present with somatic complaints (Fritz, et al., 1997; Garralda, 1996; Hunter, Kilstrom, & Noda, 1985; Livingston, Taylor, & Crawford, 1988).

As dyspnea can occur as a psychosomatic symptom (Anbar, 200Ia), identification of associated Stressors may allow for appropriate counseling. This report describes pediatric patients who were taught self-hypnosis in order to resolve their dyspnea. This approach was based on a study that demonstrated self-hypnosis was associated with resolution of chronic dyspnea that occurred in children with normal pulmonary function (Anbar, 200Ia). Hypnosis-facilitated observations made by these patients help characterize the psychosocial dynamics that are associated with development of dyspnea in childhood.

Methods

A retrospective chart review identified patients referred to a pediatric pulmonologist from January 2000 through December 2002, who were offered instruction in self-hypnosis for treatment of recurrent dyspnea that persisted despite medical therapy. Dyspnea was defined as difficulty breathing or shortness of breath, at rest or with exertion.

Hypnosis was offered to the patients described in this report because they had normal pulmonary function at rest, were diagnosed with respiratory problems amenable to hypnotherapy (e.g., habit cough, hyperventilation, or vocal cord dysfunction; Anbar, 2002; Anbar & Hall, 2004), or reported emotional or situational triggers of their dyspnea (e.g., fear), or dyspnea that occurred only during physical competitions (as opposed to during practice).

Patients were taught self-hypnosis by the pulmonologist in a 15- to 45-minute session that included: (1) A description of hypnosis; (2) Demonstration of two or three induction techniques; (3) Employment of favorite place imagery and progressive relaxation while in hypnosis in order to achieve relaxation; and (4) Development of imagery intended to relieve the dyspnea (Anbar, 2001a). Patients were encouraged to practice their self-hypnosis techniques on a daily basis for at least 2 weeks, and on an as-needed basis thereafter. The hypnosis instruction was individualized and no hypnotizability assessment was conducted.