The Impact of Unpredictability on Dyspnea Perception, Anxiety and Interoceptive Error Processing

Abstract

Dyspnea is a prevalent interoceptive sensation and the aversive cardinal symptom in many cardiorespiratory diseases as well as in mental disorders. Especially the unpredictability of the occurrence of dyspnea episodes has been suggested to be highly anxiety provoking for affected patients. Moreover, previous studies demonstrated that unpredictable exteroceptive stimuli increased self-reports and electrophysiological responses of anxiety such as the startle probe N100 as well as amplified the processing of errors as reflected by greater error-related negativity (ERN). However, studies directly examining the role of unpredictability on dyspnea perception, anxiety, and error processing are widely absent. Using high-density electroencephalography, the present study investigated whether unpredictable compared to predictable dyspnea would increase the perception of dyspnea, anxiety and interoceptive error processing. Thirty-two healthy participants performed a respiratory forced choice reaction time task to elicit an interoceptive ERN during two conditions: an unpredictable and a predictable resistive load-induced dyspnea condition. Predictability was manipulated by pairing (predictable condition) or not pairing (unpredictable condition) dyspnea with a startle tone probe. Self-reports of dyspnea and affective state as well as the startle probe N100 and interoceptive ERN were measured. The results demonstrated greater dyspnea unpleasantness in the unpredictable compared to the predictable condition. Post hoc analyses revealed that this was paralleled by greater anxiety, and greater amplitudes for the startle probe N100 and the interoceptive ERN during the unpredictable relative to the predictable condition, but only when the unpredictable condition was experienced in the first experimental block. Furthermore, higher trait-like anxiety sensitivity was associated with higher ratings for dyspnea unpleasantness and experimental state anxiety ratings. The present findings suggest that unpredictability increases the perception of dyspnea unpleasantness. This effect seems related to increased state and trait anxiety and interoceptive error processing, especially when upcoming dyspnea is particularly unpredictable, such as in early experimental phases. Future studies are required to further substantiate these findings in patients suffering from dyspnea.

The impact of unpredictability of dyspnea offset on dyspnea perception, fear, and respiratory neural gating

“…Moreover, the current results are in line with previous experimental findings in healthy individuals, which similarly showed elevated self-reports of fear, anxiety, and/or distress in conditions with unpredictable compared to predictable dyspnea elicited by carbon dioxide inhalation, breathing occlusions, or inspiratory resistive loads, respectively (Acheson et al, 2007;Schroijen et al, 2016;Tan et al, 2019). For example, Tan et al, (2019) demonstrated that the unpredictable onset of brief resistive load-induced dyspnea was related to increased dyspnea unpleasantness and anxiety when compared to the predictable onset of dyspnea. Notably, the present results extend these findings by showing comparable effects for the offset of dyspnea, which might mirror the clinical situation of patients that cannot predict when their dyspnea episode would stop.…”

“…Notably, in previous studies using both unpredictable respiratory (Acheson et al, 2007;Benke et al, 2018;Schroijen et al, 2016;Tan et al, 2019) as well as exteroceptive stimuli (Grupe & Nitschke, 2011;Meulders et al, 2012;Nelson & Hajcak, 2017;Nelson et al, 2015;Shankman et al, 2011), elevated fear/anxiety ratings were often paralleled by physiological fear responses such as increased electrodermal and startle eyeblink responses and/or elevated startle N100 amplitudes, especially in individuals with high FoS (Benke et al, 2018) and high interoception-related anxiety (Tan et al, 2019). In contrast, while the present study observed higher overall electrodermal responses in the high compared to the low FoS group as in previous studies (Alius et al, 2013), no differences were observed in electrodermal responses, startle eyeblink, and startle N100 amplitudes between the predictable and unpredictable condition.…”

“I had the feeling that I was trapped”: a bedside qualitative study of cognitive and affective attitudes toward noninvasive ventilation in patients with acute respiratory failure

“…Eight patients reported they believed that this technique was supposed to improve their breathing. Three listed other expected benefits (improved breathing regularity; improved sleep; increased feeling of independence) and two possible ICU intensive care unit, COPD chronic obstructive pulmonary disease, ALS amyotrophic lateral sclerosis, PaO 2 oxygen partial pressure in the arterial blood, PaCO 2 carbon dioxide partial pressure in the arterial blood a All patients were hypercapnic with PaCO 2 > 45 mmHg, except 2 (PaCO 2 36 mmHg) b All patients were discharged alive from the ICU; none were intubated during their stay; post-hospitalization home mechanical ventilation was instituted in three cases NIV days 4 [2][3][4][5][6][7][8][9][10][11] barriers (novel experience with doubts about effectiveness; anticipation of a certain discomfort associated with the mask). The remaining two patients had no preconceptions and reported not having understood explanations about NIV or not having paid attention.…”

“…This raises the hypothesis that the information given by caregivers prior to NIV was mostly positive. This makes the failure of NIV to bring the anticipated benefits a source of frustration, worsening the traumatic nature of NIV through an "unpredictability" effect [8][9][10].…”

“…Indeed, NIV aims at correcting gas exchange, but it is also known to alleviate dyspnea and is presented as such to the patients. Should NIV fail to relieve dyspnea-or, worse, should dyspnea worsen during NIV-the conjunction of a vital threat with a feeling of lack of control is bound to aggravate both dyspnea and anxiety [8][9][10], thereby creating a traumatic vicious circle. Such suffering is heightened if it is not met by adequate attention from caregivers-invisible dyspnea or occult respiratory suffering- [11][12][13][14].…”