Hyperventilation as a Reaction
to Torture
Stuart W. Turner & Alexandra Hough
 Plenum Press 1993
Reproduced with the kind permission of Plenum Press.
This article first appeared in Wilson, J P & Raphael, B, International Handbook of Traumatic
Stress Syndromes, New York, 1993.
Stuart W. Turner is a former trustee and psychiatrist at the Medical Foundation.
Alexandra Hough was formerly working as a physiotherapist and the Co-ordinator of the
Complementary Therapy Team at the Medical Foundation.
The views expressed in this article are those of the author and do not necessarily reflect
the policy of the Medical Foundation for the Care of Victims of Torture.
www.torturecare.org.uk
Hyperventilation as a Reaction to Torture
Stuart W. Turner & Alexandra Hough
Introduction
A relationship between exposure to psychological stressors and a syndrome variously
titled 'soldier's heart" or "effort syndrome" has long been recognized (Margarion,
1982; Wood, 1941). Now acknowledged to be a consequence of overbreathing (Bass
& Gardner, 1985b; Kerr, Dalton, & Gliebe, 1937), common symptoms include
breathlessness or sighing breathing at rest, chest wall pain, giddiness, fatigue,
numbness and tingling of the hands, blurred vision, and syncope (Bass, 1981). That
these symptoms occur in survivors of organized violence including torture is hardly
surprising. There is an association between breathing and emotion that is recognized
by the gasp of surprise, the sigh of sadness, and the altered breathing patterns of
laughing and
crying. Often, torture is a devastating event for the individual to survive. For those
who do, their problems may be compounded by the stresses of flight to a new country,
loss of society and status, uncertainties over refugee status, and separation from
family.
The severity of the handicaps resulting from hyper- ventilation syndrome
(HVS), the delay in recognizing the nature of the disorder and the good outcome with
appropriate treatment are all good reasons for further study (Evans & Lurn, 1977). Of
equal importance, however, may be the insight that the experiences reported by
survivors of torture offer into the pathophysiological mechanisms of the
hyperventilation syndrome.
Chronic Hyperventilation Syndrome
Hyperventilation may be defined as breathing in excess of metabolic requirements
(Bass & Gardner, 1985a). The chronic hyperventilation syndrome (HVS) is more
difficult to define, but diagnosis should usually rest upon the presence of typical
symptoms and characteristic abnormalities in breathing patterns, either at rest or in
provocation tests (Gardner, Meah, & Bass, 1986). Although HVS may occur in people
Stuart W. Turner :
Department of Psychiatry, University College and Middlesex School
of Medicine, Wolfson Building, Middlesex Hospital, London W1N SAA, England.
Alexandra Hough:
St.Thomas’ Hospital, London, and The Medical Foundation for the
Care of Victims of Torture, 96-98 Grafton Road, London NW5 3EJ, England.
International Handbook of Traumatic Stress Syndromes, edited by John P. Wilson and
Beverley Raphael. Plenum Press, New York, 1993.
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Hyperventilation as a reaction to torture
1
with no demonstrable psychological or respiratory abnormalities (Bass & Gardner,
1985b), it is usually associated with anxiety, panic, and phobic symptoms and
provides an illustration of the often complex relationships between physiological and
psychological processes. The common signs and symptoms are listed in Table 60,1
(Margarion, 1982).
Physiological and Psychological Processes
Under conditions of psychological stress, with sympathetic nervous system
overactivity, a number of
adaptive physiological responses occur. These include increased heart and respiratory
rates and increased tidal volume (Grossman, 1983). It has been suggested that many,
if not all, people may react to stress and anxiety by overbreathing (Hibbert, 1984). An
altered psychological state may therefore be seen as the primary abnormality in the
etiology of this condition. On the other hand, Lum (1983) has persistently argued that
habitual overbreathing is usually the fundamental cause of both the physical and the
psychological symptoms of HVS; anxiety symptoms are secondary to the breathing
habit and may be exacerbated by the failure of doctors to recognize and treat the
disorder. In the established condition, a positive feedback loop commonly exists by
which over- breathing may pr6duce such physical symptoms as chest pain, leading to
increased apprehension and hence to increased overbreathing (Lum, 1983).
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Table 60.1. Signs and Symptoms of Hyperventilation Syndrome
General
Chronic and easy fatigue, weakness, sleep disturbances, headache, excessive
sweating, sensation of feeling cold, poor concentration and performance of
tasks
Neurologic
Numbness and tingling, especially of distal extremities, giddiness, syncope,
blurring or tunneling of vision, and impaired thinking
Respiratory
Sensation of breathlessness or inability to take a deep enough breath with
sighing,
yawning, and excessive use of upper chest and accessory muscles of
respiration,
nocturnal dyspnea superficially mimicking paroxysmal nocturnal dyspnoea of
cardiovascular origin, and nonproductive cough with frequent clearing of
throat
Cardiovascular
Chest pains often mimicking angina, palpitations, and tachycardia
Gastrointestinal
Aerophagia resulting in full/bloated sensation, belching, flatus, esophageal
reflux
and heartburn, sharp lower chest pain, dry mouth, and sensation of lump in
throat
Musculoskeletal
Myalgias, increased muscle tone with muscular tightness (stiffness), cramps
with
occasional carpopedal spasms and rarely a more generalized tetany
Psychiatric
Anxious, irritable, and tense though may superficially appear calm
(suppression
of emotional release), depersonalization or a feeling of being far away,
phobias,
and panic attacks
.Frorn Margarion (1982).
In their review, Bass and Gardner (1985a) considered the relative merits of
theories which were based upon a psychological predisposition in people with trait
anxiety or neuroticism, or a physiological abnormality with undue reactivity of the
respiratory center. Both extremes are likely to be insufficient. Although it has been
demonstrated that normal volunteers with high neuroticism scores are more likely to
show affective symptoms on hyperventilating (Clark & Hemsley, 1982), Bass and
Gardner (1985b) have demonstrated that some people with HVS have no
demonstrable psychological or respiratory disorders.
Anticipation of an electrical shock (Suess, Alexander, Smith, Sweeney, &
Marion, 1980) during a perceptual task has been demonstrated to produce
overbreathing with lowered end-tidal paCO2 levels (a noninvasive measure of
alveolar and hence arterial paCO2 levels). This result is not easy to interpret. It
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appears to suggest that traumatic stress may be directly responsible for
hyperventilation. However, none of these subjects went on to develop HVS. This has
been taken to indicate that abnormal psychological condition alone may be
insufficient to explain the etiology of HVS.
Lum (1983) appeared to accept that overbreathing is a normal response to
stress, but believes that habitual overbreathing is of fundamental importance in the
etiology of HVS. In experiments on healthy young men, he cited evidence that by
manipulating inhaled CO2 levels, it is possible to demonstrate low-resting paCO2
levels and abnormally sensitive respiratory function in about 12% of subjects
(Lambertsen, 1960). In established HVS, there is evidence in favor of relatively
stable, abnormal respiratory control (Gardner et al., 1986) and there are characteristic
abnormalities in breathing behavior, including sighing, irregular, and thoracic
respiration (Lum, 1983).
The clinical situation is probably more complex, because whatever the
primary abnormality, there are usually both psychological and physiological
disturbances which require treatment. Bass and Gardner (1985a) also pointed out that
the process by which people become "patients” is complex and partly determined by
extraneous factors, such as complaint threshold and symptom attribution. In the
absence of large-scale longitudinal investigations, theories of primary causation of
HVS are in their nature speculative.
Even the mechanisms by which HVS produces symptoms are not always
clear, although the lowered paCO2 levels and increased pH appear to play an
important part (Lum, 1983). Thus, a fall in paCO2 produces cerebral arterial
vasoconstriction and may lead to cerebral hypoxia, with consequent neurological and
psycho- logical symptomatology (Lum, 1983; Pincus, 1978). Other biochemical
processes may also be important, including the Bohr effect by which lowering the
arterial paCO2 levels leads to a reduction in the bioavailability of the circulating
oxygen (Margarion, 1982). However, these simple mechanisms may not be sufficient
to ex plain all the symptoms of HVS. Hyperventilation can also lead to transient
cardiac changes associated with abnormal EKG recordings, and, if associated with air
swallowing, it can lead to gastrointestinal symptoms (Pincus, 1978). There have been
recent attempts, for example, to understand the detailed mechanisms behind the
etiology of chest pain (Freeman & Nixon, 1985a,b) and unilateral neurological
symptoms (O'Sullivan, Harvey, Bass, Sheehy, Toone, & Turner, personal
communication).
Survivors of Organized Violence
Survivors of torture and other forms of organized violence often have a
multitude of problems. They may present with physical symptoms following torture;
they may, have a depressive reaction; they may share with other survivors of extreme
trauma the features of posttraumatic stress disorder (PTSD) (American Psychiatric
Association [APA], 1987); and they may have had the meaning systems in their life
shaken or destroyed (see Chapter 58, in this volume).
A proportion also have HVS and they may offer a unique insight into the way
that HVS develops. A series of 10 survivors of organized violence, all with HVS and
seen by one or both of us at the Medical Foundation for the Care of Victims of
Torture (Turner, 1989), is reported here (Table 60.2).
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The study group comprised six men and four women with a mean age of 34
years. Most but not all had been tortured. All had been victims of organized violence
under repressive regimes. Eight were from the Middle East, one was African, and the
other South American. All had clinical evidence of HVS and all improved with
relaxation and breathing retraining.
Perhaps the most interesting finding is that although none had any history of
psychiatric disturbance before their traumatic experiences, four reported the onset of
symptoms during exposure to organized violence, three first experienced symptoms
shortly after release from detention, and another developed HVS when she lived in
fear that a friend, who had been detained and was being tortured, would give her
name to the authorities. Two of these cases illustrate the way that the traumatic
procedure is closely implicated in the onset of HVS.
Localization of the Onset of HVS
A 25-year-old woman (Mrs. A.) reported how she had been tortured in her
own country by being beaten, burned with cigarettes, and subjected to falaka (a form
of torture in which the soles of the feet are beaten using a cane or whip). One day,
after several months of detention, she was standing in the interrogation room, hooded
and tied to a post, when she suddenly experienced an agonizing pain as very hot or
corrosive liquid was poured over her legs. At this point she lost consciousness and
woke up in the "sick bay' of the torture center. She was later transferred to the local
hospital, an event which led to her eventual release. Her legs were very badly
damaged and subsequently she spent several months in the hospital. Within a few
days of this assault, she had the first of many pseudoepileptic seizures. She has a
markedly reduced breath-holding time (1-2 seconds) and 10 seconds of voluntary
overbreathing produced symptoms identical to those which precede a typical attack.
An EEG was normal.
Another Example of Onset of HVS
A 32-year-old man (Mr. B.) gave a similar history of imprisonment for 3 years
in his native country. In addition to frequent kicking, punching, and beating during his
detention, he was also subjected to falaka. The falaka was continued for periods
lasting from 1 to 2 hours and, despite the development of swelling and infection, was
repeated frequently. The pain was described as 'appalling’. Early in the torture, he was
repeatedly hit on the head and remembers losing consciousness several times. After
several weeks, he found that, after only 20 to 30 minutes of torture, he would lose
consciousness without head trauma. This was preceded by subjective anxiety with
autonomic accompaniments. He also remembers that his hands and his body would
shake before he passed out. At this point, the torturers would stop and he was usually
transferred to a local hospital. In the United Kingdom, where he is now a refugee, he
experienced similar attacks, usually worst at times of high distress. They were
precisely reproducible by voluntary hyperventilation. He also had evidence of a
depressive illness. An EKG, EEG, and CT scan revealed no significant abnormalities.
These cases may be taken as illustrations of two processes. First, the severity
of the stressor is greater, by many orders of magnitude, than that in any ethical
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34
34
31
37
42
32
40
31
C
D
E
F
G
H
I
J
M
F
M
M
M
F
F
M
M
F
Sex
None
None
None
None
None
None
None
None
None
None
Based on retrospective case note survey
32
B
a
25
A
Age
Previous
Psychiatric
History
Politically active, friend detained 1 year,
lived in fear friend would give her name
Political detainee, tortured, beaten,
burned, denied food
Political detainee for 1 months, tortured,
beaten, burns, forced standing, soiled food
Political detainee subjected to severe
torture
Political detainee for 24 hours, tortured,
electric shocks to arm, genital, teléfono
Political detainee, harassed and forced to
witness husband being beaten
Political detainee for 3 months, tortured,
deprived of food, severely burned, falaka
Political detainee for 3 years, tortured,
falaka, beaten, heard friends’ torture and
death
Political detainee for 31 months, tortured,
falaka, suspension, beaten, mock
executions, required surgery, made to
witness torture
Political forced deportee to country at
war, victim of organized persecution there
Organized Violence
During time of
fear
On release
On release
On release
Uncertain
Uncertain
During
persecution
During torture
During torture
During torture
HVS onset
Headaches, anxiety
symptoms, chest pain,
unilateral neurological
symptoms
Shortness of breath,
palpitations, weakness,
unilateral neurological
symptoms
Fatigue, anxiety, lightheadedness, chest pain,
neurological symptoms,
emotional outbursts
Insomnia, anxiety, chest and
arm pain
Headaches, tension,
dizziness, anxiety, shortness
of breath
Chest pain, palpitations,
headaches, shortness of
breath
Burning sensations, anxiety
symptoms
Insomnia, cramps, peripheral
paresthesiae
Pseudoseizures, headache,
shortness of breath
Pseudoseizures, chest pain,
paresthesiae
Symptoms
Table 60.2. Summary of the Ten Survivors of Organized Violencea
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
PTS
D
N
Y
N
Y
N
Y
Y
Y
Y
Y
Depressio
n
scientific experiment. In torture it is common, and may be the rule, for
survivors to develop psychological reactions even in the absence of any pretorture
psychological disturbance (see Chapter 58, in this volume). The severity. of the
stressor is so great that probably everyone is affected in some way. A similar process
may occur in relation to HVS. The infliction of uncontrollable, severe, and prolonged
pain and deprivation may be sufficient, in the absence of any individual
predisposition, to lead to the development of a sustained breathing abnormality in a
way that the experiments of Suess et al. (1980) could not demonstrate.
Second, they illustrate how, at first, overbreathing may be adaptive by
inducing lightheadedness, by reducing pain perception, by terminating torture, and
sometimes by leading to transfer into a less harsh environment. However, following
release and asylum in another country, this breathing habit may be persistent and
maladaptive. The same responses occur but in a nonspecific and maladaptive way.
Particularly for those with PTSD (APA, 1987), who have persisting intrusive
phenomena and hyperarousal, it is easy to see how HVS may persist and how
symptoms may be made worse at times of intrusive recall of the trauma which first
led to the syndrome. Because of this potential relationship between intrusive
phenomena and symptoms, there may be differences between posttorture HVS and the
HVS seen more commonly in psychiatric practice. Gardner et al. (1986) report
normalization of paCO2 levels during sleep. In those especially troubled by
nightmares following torture, this may not be the case.
Nocturnal Hyperventilation
A 34-year-old man (Mr. C.) complained of severe headaches. He had survived
torture including beating and falaka. For him the worst part of his experience was
witnessing the torture of children. The typical pattern was that the headaches, when
they occurred, would commence on awakening. On these days, his girlfriend later told
him, he would have had a very restless sleep, muttering and looking very distressed.
He told me that his hands would be clenched into fists; the marks of his fingernails
would be deeply scored into his palms. Interestingly, during the day, he had
developed a series of coping strategies to reduce the impact of intrusive thoughts.
Usually, the headache persisted for 12 to 24 hours. There was evidence of a major
depressive disorder. Voluntary overbreathing reproduced his symptoms, and HVS
was confirmed by measuring end-tidal paCO2 levels at rest and on provocation.
It is likely that for this man, the intrusive recall Was worse during sleep and
that the hyperventilation mirrored this process.
Severity of the Handicaps Associated with HVS
HVS can be frankly disabling both in relation to the symptoms of the disorder,
for example, pseudoepileptic seizures, and as a result of the meaning ascribed to the
symptoms.
The Severity of the Symptoms of HVS
Mr. C., a man with severe and intractable headaches, reported that the pain
was so severe that he had tried banging his head against a wall in an attempt to gain
relief and had seriously contemplated suicide. He had been extensively investigated in
two neurological centers but no diagnosis had been established. Successful treatment
has allowed him to take up a job for the first time in this country.
The Ascription of Meaning to Symptoms
Mrs. D., aged 34, reported persistent pain and numbness affecting the right
side of her body. She had not herself been tortured but had been subject to state
Persecution over several years. She had been told by a doctor that she would never be
able to use her right hand again. These symptoms were associated with the
development of PTSD and in 2 months of treatment, including breathing retraining,
she had lost all her right- sided symptoms and also showed a significant improvement
in her psychological state.
Of the sample of 10 clients reported earlier, it is worth pointing out that none
had been correctly diag- nosed elsewhere and for some the symptoms were both
chronic and very severe. In addition to the two cases described above, several had
hospital admissions and investigations and another had been confined to bed.
Diagnosis of HVS
HVS is common yet often undiagnosed in medical Practice (Margarion, 1982).
Reasons for this may include inadequate education and poor communication skills in
doctors who approach patients looking for textbook stereotypes (Bass, 1981; Rice,
1950). HVS may coexist with established organic respiratory disease such as asthma
or multiple pulmonary emboli (Bass & Gardner, 1985b). There is often a failure to
recognize that the overbreathing may not be visibly obvious (Margarion, 1982).
Patients may suffer from early labeling by professionals as “neurotic”, or in survivors
of torture as having the 'torture syndrome" (e.g., Abildgaard, Daugaard, Marcussen,
Jess, Petersen, & Wallach, 1984): an overinclusive attempt to produce a single
syndromal diagnosis to describe what is inevitably a complex psychological reaction
(Coldfeld, Mollica, Pesavento, & Faraone, 1988).
Clinical diagnosis rests on the history and a provocation test (Hibbert, 1984;
Margarion, 1982) which can include breath-holding as well as voluntary
overbreathing. The overbreathing is usually at a rate of 30 to 40 deep breaths per
minute and should be continued for 4 to 5 minutes or until the client complains of
dizziness. If chest pain has been part of the history, the test should be carried out
under EKG control. After the provocation test, rebreathing in and out of a brown
paper bag held loosely over the mouth and nose, which has the effect of raising
paCO2 levels, can be demonstrated to terminate symptoms (Margarion, 1982). If the
provocation test re- produces the symptoms precisely, the diagnosis of HVS becomes
very likely. Indeed, many researchers have argued that this clinical test should be
regarded as diagnostic (Blau, Wiles, & Solornon, 1983; Margarion, 1982). However,
there are several pitfalls. First, organic respiratory disease may be associated with
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HVS, and where the two coexist, the physical pathology may be missed by this
approach. Second, overbreathing may lower the threshold for other disorders, the
obvious example being reduced seizure threshold; in other words, overbreathing may
provoke a genuine epileptic seizure in some predisposed people. Finally, the clinical
provocation test may be negative in the presence of HVS, possibly because of low
levels of perceived threat in the clinical environment.
Therefore, the best method of making the diagnosis, where the equipment and
expertise are available, may be to measure paCO2 levels under several different
conditions. This may be particularly important in people who fail to show a good
initial response to treatment. Overbreathing is reflected by lowering of paCO2 as this
is eliminated through the lungs. The measurement is most conveniently carried out
using nasal catheters and a system which measures end-tidal pCO2, levels as these
closely approximate to arterial paCO2 levels. Where it is demonstrated that a person
is breathing in excess of requirements in different situations and for prolonged periods
after different provocations, the diagnosis is fairly secure (Bass & Gardner, 1985a).
Management of HVS in Survivors of Torture
In treating survivors of torture, who have endured some of the worst
imaginable physical injuries and psy- chological distress, it is particularly important to
look, first of all, at the therapeutic relationship.
Whether psychiatrist, psychologist, psychotherapist, or physiotherapist, the
worker must be prepared to listen to the trauma story, and to offer a "whole person
response.” In torture, where the body is abused for psychological effect, it is
impossible not to look at each symptom as having a range of physical and
psychological meanings. Usually, survivors need to know that their pain can be
acknowledged even if it is beyond the range of experiences that most of us can
understand.
Torture often takes place within a personal, perverted relationship. In other
words, the victim of torture received the focused attention of an adversary determined
to break down the will to resist, and hence to achieve psychological change.
Therapeutic work must take place in a different psychological environment, one in
which a degree of trust has been fostered and in which survivors can be encouraged to
regain their self- confidence and esteem. They must feel welcome and know that their
problem is being taken seriously. They need space, time, privacy, and an attentive ear.
HVS is a good example of a mechanism with, at least in the established
condition, interacting psychological and physiological processes. It demands a holistic
approach.
One of the first and most important steps is to listen to the client's own
understanding of the symptoms. Very often, people will have been given incorrect
diagnoses in the past or will have made erroneous assumptions about their state. The
clinical provocation test is a useful therapeutic as well as diagnostic maneuver. By
demonstrating that symptoms can be provoked by such simple maneuvers as breathholding or voluntary over-breathing, clients can start to learn something about the
nature of their condition. Moreover, they may start to appreciate that they are, at least
to a very limited degree, in control.
Time should be spent informing clients about HVS. This is often reassuring to
those clients who may start to realize that other symptoms which they had not
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mentioned or which have now disappeared are also understandable in relation to
overbreathing. Not only does this reassure survivors about their symptoms, it also
provides some additional reassurance that the diagnosis is correct. It can be quite
puzzling to learn that symptoms affecting so many different parts of the body, and
associated with so many feelings, can be produced by a breathing disorder. There may
be myths which need to be abolished, such as the common belief that breathing
deeply will enhance relaxation. Education is not a single step in treatment; it needs to
be continued as long as it is needed.
Coexisting psychiatric disorders require treatment. For example, a sedative
antidepressant drug may be useful in people with mixed anxiety and depressive
symptoms. The broader psychological meanings must not be overlooked either and
many people will require a psychotherapeutic approach (see Chapter 58, in this
volume). However, these must be coupled with a program of relaxation and breathing
retraining (Bonn, Readhead, & Timmons, 1984; Hough, 1991) and it is this which
will be considered in more detail in the rest of this chapter.
During breathing retraining, the client has to experience the discomfort of air
hunger and learn to resist the drive to overbreathe. This is necessary if there is to be
readjustment of the respiratory control center. This procedure has to be accompanied
by reassurance and relaxation, and must have been explained and accepted in
advance.
A typical program would start with the client's being asked to lie in a
comfortable position on a couch, perhaps with a pillow under the knees for support.
Awareness of breathing is encouraged by asking the client to imagine the air going
into his or her lungs, as if the air is passing down a tube and filling a balloon every
time a breath is taken. Different breathing maneuvers, such as breathing in, breathing
out, and breath-holding (for a short time) can be rehearsed, asking the client to
concentrate on each of these automatic experiences. Asking the client to put one hand
on the upper chest and another on the abdomen is useful in learning awareness of
thoracic and abdominal breathing. One of the aims of treatment is to encourage people
to use abdominal rather than thoracic breathing.
Usually, treatment will include relaxation training. It is very difficult, if not
impossible, to learn new methods of breathing in the presence of high levels of
arousal or tension. Relaxation training will take one of the standard forms, although
the one used in our practice is a simple relaxation program described by Mitchell
(1977).
Sometimes, a combination of education, learning abdominal breathing, and
relaxation training is sufficient, and breathing patterns return to normal. If not, time
should be spent teaching the client to use slower, and if necessary, more shallow
breaths. To do this, the first step is to take a baseline measurement of respiratory rate
and then ask the client to breathe in time with words or numbers. For example, the
therapist could initially repeat aloud "in-and-out" or "in-and-out-two- three," pacing
these words to a steady rhythm, resulting in slight slowing of the client's breathing
(Innocenti, 1987). Care must be taken to watch for any evidence of increasing depth
of breathing, a return to thoracic breathing, or increasing tension. Although some
discomfort is inevitable as breathing is slowed, this should not reach the point of
creating tension.
As this slowing is practiced, there should be occasional breaks for feedback
and discussion. Clients may be reassured that slight discomfort is usual and indicates
success. This is necessary for there to be resetting of the breathing control
mechanisms.
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From time to time, repeat measurements of resting respiratory rates should be
made to monitor progress. However, although this is useful, the final evidence of
success is loss of symptoms and these provide a much better outcome indicator.
Nonetheless, if the rate can be reduced to six to eight breaths a minute in the resting
state, this is a good result, likely to be associated with loss of symptoms.
The exercise is then transferred from a couch to a sitting position in a chair,
and from there to more normal situations, such as walking and talking. This may take
several sessions. Eventually, breathing control is practiced while hurrying, on stairs,
and even while jogging (Lum, 1983). Because of the nature of the complaint, these
should not be hurried and an undisturbed hour should be set each time. Between
sessions, the client should be encouraged to practice alone. These practice sessions
should be short but frequent. Clients should also be encouraged to set aside 20
minutes each day for relaxation. Only by carrying the treatment techniques into
everyday life, can ultimate success be achieved. Part of each formal treatment session
should be spent reviewing progress in this 'homework" and discussing any difficulties
experienced.
Advice may be offered about dealing with difficult situations. For example,
swallowing is a way of
suppressing the urge to take a deep breath or if a deep breath has been taken, it may
be useful to follow with a compensatory breath-hold to reduce the physiological
effects. Similarly, for those who experience real difficulties in transferring their
practice into their everyday life, it may be helpful to look again at some of the
situations which seem to trigger symptoms and see if other ways can be found to deal
with them.
The Beneficial Role of Education
Mrs. E. was a qualified nurse who had suffered harassment, loss of her home,
and a traumatic flight from her country. She presented with fatigue, insomnia,
lightheadedness, paresthesia in her hands, air hunger, and feelings of a weight on her
chest and of her breath being "cut short.' Her breathing was punctuated with sighs and
her conversation with outbursts of uncontrolled laughter, followed by embarrassed
apologies. The whole of the first treatment session with a physiotherapist was spent
in listening and explaining the purpose of the treatment and in teaching relaxed
abdominal breathing. She found the relationship between her symptoms and
hyperventilation hard to accept at first. However, once convinced, she was an
enthusiastic and highly motivated client. She managed to slow her respiratory rate
with counting, but when practicing deeper relaxation she began to experience feelings
of fear. Once again, she had to be reassured that expression of feeling in a
physiotherapy session is not only permissible but is often therapeutic. Offering a
strategically placed box of tissues was a useful nonverbal communication. At first, the
treatment was slow and she found air hunger particularly difficult to control but the
final outcome was good.
A Whole-Person Approach
Mr. F. had arrived in the United Kingdom 6 years before his presentation for
treatment. He had suffered severe torture and in the United Kingdom, had been
continuously unemployed, disturbed by symptoms of insomnia, anxiety, and chest and
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arm pain. The first treatment session with a physiotherapist was again spent listening,
and in explanation and reassurance. Relaxation was readily achieved, but many weeks
passed before breathing became controlled. During his treatment, as he started to
regain control and learn to trust, he started talking about his feelings. After some time,
he felt able to take up the suggestion of participating in group therapy, where he found
that his ability to support others was a major step in his own path to recovery (see
Chapter 6.5, in this volume, for an explanation of the principles of posttraumatic
therapy).
In the series of 10, there was a good outcome in all cases. Sometimes, the
beneficial effects of treatment were dramatic with a rapid and total loss of all HVS
Symptoms.
Conclusions
HVS is common in survivors of torture. The etiology Of HVS remains a
matter for debate, but, in torture, important elements may be the severity of the
traumatic event and the adaptive functions of overbreathing as the trauma continues.
Following release from detention, the Syndrome of HVS may be a disabling result. It
may lead people to contemplate suicide or to believe that they have a very serious
physical illness. Usually, the treatment is multiprofessional and is often very
successful. Indeed, the outcome may be better for survivors of torture than for others
with HVS, because, in their release from detention, the maintaining factors for HVS
may be reduced. An important element of treatment is breathing retraining and this
procedure has been presented in some detail.
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