Pages 239-245 from the Management of Mental Disorders, published by World Health Organization, Sydney. Editions in Australia, Canada, China, Italy, New Zealand and the United Kingdom.

Dearousal through hyperventilation control

See also www.climate.tv

The present section discusses the prevention and control of hyperventilation. The first step in preventing and controlling hyperventilation is to recognise how and when hyperventilation occurs. Many people who panic show some signs of hyperventilation. Hyperventilation may act as the initial cue which causes an individual to panic. Alternatively, hyperventilation may also become the way in which the body reacts to a fearful situation (i.e., hyperventilation is part of the panic reaction). The following questionnaire can be used to assess whether hyperventilation is an important part of a particular individual's panic reaction.

Hyperventilation Questionnaire 1

1. In general, do you often feel short of breath, as if
   you are not getting enough air? Yes / No
   
   
2. Do you sometimes feel as if you are suffocating? Yes / No
   
   
3. Do you experience chest pain, tingling, and prickling
   and numbness sensations? Yes / No
   
   
4. Do you sigh or yawn a lot or take in big gulps of air? Yes / No
   
   
5. When you are frightened, do you hold your breath
   or take very quick and shallow breaths? Yes / No

If the individual answered yes to any of the items in the questionnaire it is likely that hyperventilation plays a part in the panic reaction. It is easily possible, however, that the individual will not be aware of his or her breathing patterns. Therefore, it is important to examine the individual's breathing pattern.

One way to test whether individuals are breathing too fast is to get them to monitor their breathing. Ask them to count how many breaths they take in one minute (where breathing in and then out is counted as one breath). At rest the average person needs to take only 10-12 breaths per minute. If the individual's rate of breathing is greater than 10-12 breaths per minute then the individual may need to learn to reduce his or her breathing rate. It will also be useful to monitor breathing rates at other times, particularly during times of stress, anxiety or worry.

Managing hyperventilation
In order to reduce the symptoms of hyperventilation it will be necessary to increase and steady the level of carbon dioxide in the blood. One way of achieving increased levels of carbon dioxide is by breathing into a paper bag. This method is simple and effective, however, it may not always be convenient or socially appropriate to pull out a paper bag in a public place! Additionally, although breathing into a paper bag is useful during a panic attack, this method does nothing to prevent panic attacks from occurring. An alternative method which is less obvious to other people and which will help the individual reduce habitual overbreathing is the slow breathing exercise.

If individuals follow this exercise as soon as they notice the first signs of overbreathing, the symptoms should subside within a minute or two and panic attacks will hopefully be avoided. The more frequently individuals practise this slow breathing exercise the better they will become at using slow breathing to prevent anxiety from escalating. Generally, individuals would be advised to practise this exercise at least 4 times each day, taking as much time on each occasion for the breathing routine to feel comfortable (this may take up to half an hour on early occasions). In addition, the individual would be advised to practise the exercise at any other time that he or she notices sensations of anxiety.

Slow Breathing Exercise
(To be practised regularly and at the first signs of anxiety or panic).

1. Hold your breath and count to 5 (do not take a deep breath)
   .
2. When you get to 5, breathe out and say the word relax to yourself in a calm, soothing manner.
   
   
3. Breathe in and out slowly through your nose in a six second cycle. Breathe in for three seconds and out for three seconds. This will produce a breathing rate of 10 breaths per minute. Say the word relax to yourself every time you breathe out.
   
   
4. At the end of each minute (after 10 breaths) hold your breath again for 5 seconds and then continue breathing using the six second cycle.
   
   
5. Continue breathing in this way until all the symptoms of overbreathing have gone.

A small number of individuals report that they get symptoms of anxiety when they first start to use the breathing exercise. These symptoms are probably due to breathing a little too fast or becoming sensitive to breathing patterns when thinking about them. If individuals persevere on each occasion and continue the breathing exercise, the anxiety will eventually diminish.

It may be useful to demonstrate the slow breathing exercise for the individual and then ask the individual to have a turn at practising the exercise. Make sure the individual performs the slow breathing exercise correctly before leaving.

The slow breathing exercise (as well as a number of other useful techniques for managing anxiety) is demonstrated in a CD-ROM available from the publishers (see end papers).

What is relaxation training?
Relaxation is the voluntary letting go of tension. This tension can be physical tension in the muscles or it can be mental, or psychological, tension. During relaxation, the nerves in the muscles change the types of signals that they send to the brain. These different signals bring about a general feeling of calmness, both physically and mentally. Muscle relaxation has a widespread effect on the nervous system and therefore can be seen as a physical treatment, as well as a psychological treatment.

In order to get the full benefit from relaxation, the individual is required to be an active participant, committed to daily practice for two months or longer.

Importance of relaxation training
When individuals have been under stress for long periods of time, or when they have not taken time away from work or other activities, they seldom allow their high levels of muscle tension to decrease. Therefore, the tension tends to stay with them for longer and longer periods. Eventually they become so used to being tense that this new tense state becomes `normal' to them and they no longer recognise that they are tense. Or, if they do realise that they are tense, they may simply be unable to relax the tension away without assistance. The tension no longer helps them to perform their daily tasks and may even hinder normal activities.Because of the tension, these individuals may feel jumpy, irritable, nervy, or apprehensive. They are also more likely to feel anxious, have unpleasant obsessive thoughts, or develop physical symptoms associated with tension (e.g., headaches and backaches, digestive complaints, diarrhoea or constipation, etc.). Additionally, they may find themselves feeling slightly apprehensive all the time, worrying about things unnecessarily. By learning to relax it is possible to gain control over these difficulties.

Since a small amount of tension may have a positive effect, it is important for individuals to learn to discriminate between tension that is useful and tension that is unnecessary. Actually, much everyday tension is unnecessary. Only a few muscles are involved in maintaining normal posture, for example sitting, standing or walking. Most people use more tension than is necessary to perform these activities. Occasionally, however, an increase in tension is extremely beneficial. For example, it is usually helpful to tense up when you are about to receive a serve in a tennis game. Likewise, it is probably helpful to tense up a bit before a job interview or an examination because this tension keeps you keen and alert. It is important that individuals recognise that such tension is appropriate. However, tension is unnecessary when:

• The tension performs no useful alerting function
• When the tension is too high for the activity involved
• When tension remains high after the threatening situation has passed

Components of relaxation training
In order to be more in control of anxiety, emotions, and general physical well-being, it is important to learn to relax. To do this the individual will need to learn to:

1. Recognise tension
2. Relax

Recognising tension
The following questions will be useful for examining an individual's tension level in greater detail:

1. Where do you feel tension?

• Do you notice tension in your face and jaw?
• Do you clench your fists?
• What other parts of your body feel tense?
• Are there parts of your body where tension goes unnoticed until you feel pain?

2. What are the characteristics of the tension?

• Do your muscles feel stretched and sore?
• Do your muscles feel hard and contracted?
• Do your muscles feel fatigued?
• Does there appear to be effort involved in maintaining normal posture?

3. Which events within yourself lead to an increase in tension?

• Anger or frustration?
• Thinking about your difficulties?
• Changes in breathing or heart rate?
• Loneliness?
• Boredom?
• Impatience?

4. Which external events lead to an increase in tension?

• The way people speak to you?
• Loud noises?
• Having to wait in queues or at traffic lights?
• Being watched while working?
• Your relationships?

At this point it will be useful to give the individual the homework assignment dealing with the severity and location of tension in different parts of the body (see Section 4.14.6). If an individual is learning to relax, he or she will need to be able to recognise these aspects of tension. By knowing where and when the body tenses up, the individual will be able to structure the relaxation sessions at home more effectively.

Progressive muscle relaxation training
Progressive muscle relaxation involves relaxing the muscles in a progressive or step-by-step manner. This form of relaxation is a practical skill which is best learned through instruction from a skilled teacher. Clinicians who do not have experience in teaching relaxation skills, and do not wish to learn this skill, may wish to refer the individual to someone who is experienced in this area. Additionally, many music stores sell relaxation tapes which guide the individual through the progressive relaxation exercises. Although these tapes are useful, they are recommended as training aids rather than as a substitute for training itself.

How to relax
The two main principles of physical relaxation are to:

1. Purposely tense the muscles so as to recognise the feeling of tension
2. Relax the muscles letting the tension flow out of the body
   A full session of progressive relaxation takes around 20 minutes. The individual will need to sit in a supportive, straight-backed chair, with feet flat on the floor, hands resting in the lap, and eyes closed. Lying down is discouraged so as to reduce the likelihood of falling asleep. The room needs to be quiet, dim, and free from interruptions.

During the relaxation exercise the individual is required to alternately tense and relax each of the muscle groups in the body, step by step, as described in the handout in Section 4.13.7. By doing so, the individual becomes more adept at recognising tension and then letting go of that tension.
The exercises begin with the hands, moving up the arms to the shoulders, neck, and head, then down through the chest, back and stomach to the buttocks, thighs, calves, and feet. The muscles are tensed for 7-10 seconds, then relaxed for about 10 seconds. The individual may need to refer to the handout to begin with so as to relax the muscles in the right order, however, with practice the exercise will become routine.

While each muscle group is being tensed, the individual is instructed to breathe in and hold his or her breath. As the muscles are being relaxed, the individual is instructed to breathe slowly out, thinking the word relax at the same time. At the end of the exercise the individual rests quietly for a few minutes, enjoying the sensation of total body relaxation. Normal activities are then resumed in a calm and peaceful manner, thus bringing the feeling of relaxation into the daily routine. Achieving deep levels of relaxation requires patience and practice. The more often the individual practises, the deeper and longer lasting the relaxation will be and the more quickly anxiety can be reduced. The individual will need to practise daily for at least eight weeks in order to achieve any long lasting relaxation.

Once progressive muscle relaxation is sufficiently mastered, the individual will be able to use this relaxation technique in any place, at any time, as the need arises. Whenever an increase in muscle tension is recognised, the relevant muscle groups can be targeted for a quick, on-the-spot relaxation exercise. By keeping muscle tension levels in check throughout the day, the individual is able to maintain more continuous feelings of relaxation.

Other relaxation methods
Although progressive muscle relaxation is the most recognised and documented method of relaxation, there are other methods that can achieve similar results. It is preferable for individuals to regularly use an effective method that they feel comfortable with and which has been successful in the past rather than use no method at all. Other methods include: meditation; aerobic exercise; yoga; or tai chi. These methods can be useful if they reduce tension for that individual and are used daily.

Difficulties with relaxation
Some people report that they cannot relax, that relaxation is not working for them, or that they cannot bring themselves to practise relaxation. Since all human beings share a similar biological make-up there is usually no physical reason why relaxation should work for some people and not for others. The reason that relaxation may not work for some people is usually due to some psychological factor or to lack of practice. If the individual is having difficulty relaxing, you will need to explore the reasons for this difficulty. Following are some reasons that individuals often give for not doing their relaxation practice, as well as some useful suggestions for overcoming these problems.

"I'm too tense to relax"
In this case the individual uses the very symptom that needs treating as a reason for not relaxing. Relaxation may take longer than expected but can be achieved with practice. The experience of actually being deeply relaxed often changes this attitude.

"I don't like the feelings of relaxation"
About one in ten people report that when they relax they experience feelings that they do not like or which frighten them. These feelings indicate that they are coming into contact with their body again and noticing sensations that may have been kept under check for many years. Reassure the individual that whilst being relaxed they are still in complete control and can quickly react to any situation if required. With practice they will come to trust and enjoy the sensation of being relaxed.

"I feel guilty wasting so much time"
The individual needs to accept that relaxation is an important part of the recovery process. Many therapies take time. It is not necessary to be active in order to be useful.

"I can't find the place or time"
Encourage individuals to be adaptive. If individuals keep making the excuse that there is no time to relax, you may need to discuss with them whether there are any other factors that are stopping them from relaxing and the need to set priorities.

"I haven't got the self control"
It is important to realise that there are no quick and easy cures for stress or tension that do not require a certain amount of effort. The longest lasting treatment outcomes occur when an individual takes responsibility for his or her recovery. You may need to talk to the individual about what is stopping him or her from being motivated.

"I'm not getting anything out of this"
Unfortunately, many people expect too much too soon from relaxation training. It is unreasonable to expect to undo years of habitual tension in a few relaxation sessions. Impatience is a key symptom of anxiety and as such is an indicator that it is necessary to continue with relaxation training. Set long term goals rather than try to monitor day-by-day improvement.

"I can't stop myself thinking"
Inability to stop thinking often interferes with relaxation. It is only realistic to expect that thoughts will occur during the silence of relaxation. The trick is to not respond to them. Passively register their presence but develop the skill of not elaborating on them or responding emotionally. Ignore thoughts and feelings and they disappear.