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While Dr David's article is an excellent introduction to CBT, the asthma case history raises another issue that is important to recognise (Clinical, May 7).

In the past, many youngsters were labelled with asthma on the slenderest of evidence. Since the advent of the enthusiastic asthma nurse, these patients have been indoctrinated into taking their inhalers regularly with religious zeal but with no critical evaluation of the diagnosis.

I have found that many such patients have had intermittent dyspnoea but never cough or wheeze; their spirometry exceeds normal values and their symptoms are triggered by anxiety. If one can catch them during an attack they clearly have hyperventilation/dysfunctional breathing.

Andrew may well not need his inhaler, especially as the ?-agonist effect will only exacerbate his anxiety. I have successfully withdrawn inhalers in many such cases and addressed their anxiety.

Dr CI Pelton


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