What is the diagnosis and treatment for a patient with chronic shortness of breath, excessive yawning, and fatigue, with a history of health-related anxiety?

Dysfunctional Breathing (Hyperventilation Syndrome) with Possible Anxiety Disorder

This patient most likely has dysfunctional breathing (hyperventilation syndrome) in the context of health-related anxiety, and should be treated with cognitive behavioral therapy as first-line treatment, with consideration of SSRI/SNRI pharmacotherapy if symptoms persist or significantly impair function. 1

Clinical Reasoning for Diagnosis

Key Diagnostic Features Present

The presentation contains multiple positive clinical features of a functional disorder rather than structural cardiopulmonary disease:

• Inconsistent symptoms: Breathlessness resolves completely the day after physical exertion (badminton), which is internally inconsistent with organic cardiopulmonary disease that would worsen with exercise 1
• Hypervigilance and self-monitoring: Constant hyper-awareness of bodily sensations and symptoms worsening when focused upon are classic perpetuating factors for functional disorders 1
• Excessive sighing and yawning: The pattern of 40-50 yawns daily with frequent sighing represents inefficient, non-ergonomic breathing patterns characteristic of dysfunctional breathing 1
• "Air hunger" sensation: The need to take very long, deep breaths represents the classic sensation of "inability to get a deep breath" seen in dysfunctional breathing and hyperventilation 1
• Breathlessness while talking: This occurs due to disrupted breathing patterns during speech, not structural airway disease 1

Supporting Evidence Against Organic Disease

• No daytime somnolence: Makes obstructive sleep apnea unlikely as primary cause despite reported snoring 1
• No chest pain or palpitations: Reduces likelihood of primary cardiac etiology 1
• Symptom-free periods: Complete resolution of symptoms on some days is inconsistent with progressive cardiopulmonary disease 1
• Exercise tolerance preserved: Ability to play badminton with subsequent symptom improvement contradicts exercise-induced bronchoconstriction or cardiac limitation 1

Predisposing and Perpetuating Factors

The patient demonstrates multiple risk factors from the biopsychosocial model of functional disorders 1:

• Psychological predisposing factors: Health-related anxiety, hypervigilance to bodily sensations 1
• Perpetuating factors: Fear-avoidance behavior, excessive self-monitoring, belief that symptoms indicate serious disease 1
• Physiological arousal: Chronic muscle tension patterns manifesting as fatigue and burning eyes 1

Essential Diagnostic Workup

Initial Testing to Rule Out Organic Disease

Before confirming functional diagnosis, exclude structural causes:

• Spirometry with bronchodilator: Must demonstrate normal pulmonary function to exclude asthma, COPD, or restrictive disease 1
• Complete blood count: Rule out anemia as cause of dyspnea and fatigue 2
• Thyroid function: Exclude hyperthyroidism causing anxiety-like symptoms and dyspnea 1
• Chest radiograph: Rule out structural lung disease, though likely normal 2, 3
• ECG: Exclude arrhythmia or cardiac abnormality, particularly given family history of snoring 3

Nasal Obstruction Evaluation

The alternating nasal obstruction warrants assessment:

• ENT referral: Evaluate for anatomic obstruction (deviated septum) or chronic rhinitis that could contribute to mouth breathing and dysfunctional breathing patterns 1
• This may be a perpetuating factor maintaining abnormal breathing mechanics 1

Consider Sleep Study Only If

• Witnessed apneas are reported (not just snoring) 1
• Daytime somnolence develops 1
• Treatment of dysfunctional breathing fails to improve fatigue 1

Treatment Algorithm

First-Line: Cognitive Behavioral Therapy

CBT is the psychotherapy with the highest level of evidence for anxiety disorders and should be initiated immediately 4, 5, 6:

• Specifically target dysfunctional breathing patterns with breathing retraining 1
• Address hypervigilance and catastrophic thinking about symptoms 1
• Challenge illness beliefs and fear-avoidance behaviors 1
• Expected effect size: Hedges g = 1.01 (large effect) for generalized anxiety disorder 5

Breathing-Specific Interventions

• Breathing retraining: Teach diaphragmatic breathing and reduce sighing/yawning frequency 1
• Reduce self-monitoring: Instruct patient to redirect attention away from breathing sensations 1
• Gradual exposure: Encourage consistent physical activity despite symptoms to break fear-avoidance cycle 1, 2

Pharmacotherapy Considerations

If CBT alone is insufficient or patient preference dictates combined treatment 4, 5, 6:

• First-line medication: Sertraline (SSRI) or venlafaxine XR (SNRI) 4, 5, 6

  • Effect size: SMD -0.55 for generalized anxiety disorder 5
  • Continue for 6-12 months after remission 4

• Avoid benzodiazepines: Not recommended for routine use despite FDA approval for anxiety 7, 4, 8

  • Alprazolam lists "shortness of breath or smothering sensations" as an anxiety symptom it treats, but benzodiazepines cause rebound anxiety after >4 weeks and withdrawal symptoms with prolonged use 7, 8
  • May perpetuate rather than resolve functional symptoms 4, 8

Treatment Sequencing

1. Immediate: Provide psychoeducation explaining functional nature of symptoms and reassurance that symptoms do not indicate serious disease 1, 5
2. Week 1-2: Initiate CBT with breathing retraining; address nasal obstruction if present 1
3. Week 2-4: If inadequate response, add SSRI/SNRI 4, 5
4. Month 1-3: Continue combined therapy, monitor for improvement 4
5. Month 6-12: After remission, continue medication for relapse prevention 4

Critical Pitfalls to Avoid

• Do not perform exercise challenge testing: This patient's symptoms resolve with exercise, making exercise-induced bronchoconstriction extremely unlikely 1
• Do not diagnose based on symptoms alone: The positive clinical features of functional disorder are sufficient, but spirometry should confirm normal lung function 1
• Do not dismiss as "just anxiety": Functional disorders require specific, evidence-based treatment approaches 1
• Do not over-investigate: Excessive testing reinforces illness beliefs and perpetuates symptoms 1
• Avoid "as needed" anxiolytics: This reinforces symptom-focused behavior rather than addressing underlying mechanisms 4, 8

Prognosis and Follow-up

• Symptoms typically improve with appropriate treatment targeting both breathing mechanics and anxiety 1, 4
• Regular follow-up every 2-4 weeks initially to monitor treatment response 4
• Address treatment-refractory symptoms with augmentation strategies or specialist referral 8
• The chronic nature of health anxiety requires sustained treatment to prevent relapse 6, 9