Archive for the ‘Allergy Treatment’ Category

Controversy abounds in medicine, especially when it comes to alternative forms of treatment, but there is one thing that almost everyone agrees on: feeling calmer and more

relaxed is good for your health. There are many ways in which a person’s mental and emotional state can affect their allergies or other sensitivity reactions (see pp. 232-7),

and these help to explain the beneficial effects of relaxation.
There are several different types of approach that can help in the quest for a calmer state of mind and a more relaxed state of body:
• Straightforward relaxation techniques which you learn and then practise for yourself, either on a daily basis, or whenever you need them, or both. Examples include

relaxation exercises of various kinds, biofeedback, autogenic training and self-hypnosis.
• Relaxation techniques that are rooted in spiritual practice, such as meditation, yoga, t’ai chi or chi kung (ql gong). Some other martial arts, in addition to t’ai chi,

also have a strong element of spiritual practice.
• Treatment techniques such as massage, aromatherapy, reflexology and short courses of hypnotherapy, that are intended to help you feel more relaxed. Acupuncture (see p.

214) can also have this effect. Some therapists providing this type of treatment will also teach you simple relaxation exercises to use at home.
• Investigative approaches that look into the fundamental causes of tension, and attempt to deal with deep-seated emotional problems: psychotherapy (in its many different

forms), psychoanalysis, long-term hypnotherapy when this has psychotherapeutic aims, and biodynamic massage.
In the long run, approaches that make you dependent on another person (an aromatherapist or reflexologist, for example), in order to feel relaxed, are usually less helpful than

those that give you an active role. If you are learning and practising a technique, as with relaxation exercises or yoga, this puts you in charge of your state of mind.
The techniques that are rooted in spiritual practice, especially meditation and yoga, are particularly helpful because they invite you to take a very broad view of the problems

that face you, and the situations that cause you stress. Firstly, rather than focusing very narrowly on your own tense muscles and recurring difficulties, they look at the human

situation as a whole – at the basic causes of tension and unhappiness in human beings. Secondly, rather than trying to graft a relaxed viewpoint onto a horribly unrelaxed daily

existence (which is what most of us now endure) a regular meditation practice can result in a fundamental and long-lasting change in outlook, with a greater sense of wholeness,

direction and stability. This is something that happens naturally within the stillness of meditation practice, and it should be very much an individual process of change, not

something imposed from outside. At a purely practical level, a spiritual practice tends to improve relationships with other people, and since a great deal of our stress is

caused by the people around us, any improvement in our social interactions can reduce stress enormously.
Some kind of psychotherapeutic approach may be the best choice for those who have tried and failed with other techniques, or achieved only a temporary reduction in stress

levels. By tackling the problems at a deeper level, it is often possible to achieve a more profound and long-lasting solution.
Many people discover that, whenever they try to relax or to meditate, they feel even more agitated and anxious. Others begin to cry, or show other signs of distress. Not

surprisingly, people who react in this way quickly give up their attempts to unwind, because their responses are so disturbing. Underlying these reactions to relaxation

exercises there may be deep-seated problems, usually going back to childhood, that can only be held at arm’s length with the help of a tense and always-busy approach to life.
Constant mental activity is part of this defensive strategy, which is why relaxing or meditating is such a frightening experience. Although it is tempting to run away from the

problem, by plunging back into a life of frenetic activity, mental and physical, this is ultimately no solution. Some form of psychotherapy is usually needed to deal with these

long-standing problems.
Whatever you decide to try, make sure that the teacher or therapist seems a calm and relaxed person. You should also look for someone who is sympathetic and supportive about

your illness. Avoid like the plague those who attribute all allergies and other physical symptoms to mental or emotional problems. Such people can cause immense psychological

damage – if you don’t get 100% better it will, of course, be your fault.
Hypnotherapy
Hypnosis has a distinctly shady reputation, because of its use – or misuse – in stage and television performances. If hypnosis were not so valuable medically, it would probably

be rejected entirely by conventional medicine, on the strength of this reputation. The fact that hypnotherapy is used by some entirely mainstream doctors, as a legitimate

treatment for conditions such as atopic eczema, is a great testament to its effectiveness.
Hypnosis is certainly a mysterious phenomenon, and it is difficult to say exactly what happens when a person is hypnotised. Dr Ruth Lever, a qualified doctor who combines

hypnotherapy with conventional medical practice, describes the hypnotic state as ‘not a form of unconsciousness but rather an altered form of consciousness, in which the patient

is more open to suggestion than he would normally be, and in which a corridor is opened between the conscious and the subconscious mind’.
It is certainly not true that the hypnotised person is under the control of the hypnotist or hypnotherapist. Autonomy is retained, and no one under hypnosis can be forced to do

anything that is really against his or her will. While the person may experience a different state of mind, he or she remains aware of what is going on in the room and anything

that is said.
The exact change in mental state during hypnosis varies greatly from one person to another. Some people respond far more readily than others, and go into a deeper hypnotic

state. (These same people are more susceptible to placebo effect, a psychological response to drugs or other forms of treatment –see p. 233.)
At one time, it was thought that only adults could be hypnotised. Children seemed to be immune to hypnosis, but in fact they are just immune to the particular hypnotic

techniques used for adults. With the right techniques, children can also be hypnotised.
Hypnotherapy treatment can be quite brief, taking only a few sessions. This approach relies on suggestions from the therapist to achieve relaxation, a change in perceptions

(e.g. that the skin feels cool and smooth, for someone with atopic eczema) and a change in habits (e.g. stopping scratching).
Another approach is to use hypnosis as a means towards achieving personal insight into emotional problems by accessing suppressed memories. This is a long-term treatment, which

has much in common with psychotherapy. It should only be practised by those who have full psychotherapy training.
Scientific studies show that hypnotherapy can be of benefit in both asthma and atopic eczema. Make sure you get a really well-qualified hypnotherapist –preferably someone who

also has conventional medical training, or psychotherapy training, and plenty of experience.
You may be given exercises in self-hypnosis to do at home, or tapes, possibly music tapes to be played at bedtime for children with eczema. These can be very useful in

reinforcing the messages from the hypnotherapy sessions about sleeping deeply and not scratching,Relaxation exercises
Acquiring the knack of relaxing is a very personal thing – what works for one person will be useless for another. You may have to try several different techniques before you

find one that is right for you.
Guided imagery is often an effective method, and increasingly popular with the widespread availability of relaxation tapes. The tape will ask you to sit in an armchair, or lie

down, and picture the scenes described (’waves are lapping gently on the golden sand…’ etc.). If you are able to visualise the scene, this should induce a more relaxed state

of mind – rather like the relaxation you get from watching a good film.
There are also tapes of special music, or music combined with natural sounds (waves, seagulls etc.) that are intended to produce a relaxed state of mind. Much of this music is

incredibly banal, and it may irritate you more than relax you! However, there are also some excellent tapes available, so shop around.
One time-honoured method of relaxing is to sequentially contract, and then release, muscles in each part of the body, beginning with the hands or feet. This is known as

Jacobsonian systematic relaxation training or progressive muscle relaxation. A study of children suffering from asthma found that this training increased the peak flow by an

impressive 32% for some children, although others did not do quite so well.
Autogenic training
Based loosely on self-hypnosis, autogenic training is a very down-to-earth approach to relaxation which may be useful for anyone who is wary of things esoteric. You are taught

to concentrate on different parts of your body in turn and imagine them growing warm and heavy. Beginning with ‘my right arm is heavy and warm…’ (repeated three times, either

out loud or in your head) you work your way through the rest of the body: ‘my left arm…’ , ‘both my arms…’ , ‘my right leg…’ etc.
You could, in theory, teach autogenic training to yourself, using a book, but it is helpful to have to go to a class. The teacher can encourage you to persist when you feel

discouraged by your slow progress, and can help with any problems that arise.
Teachers of autogenic training often add more specific lines at the end of the exercise, such as ‘my breathing is calm and regular’ for asthmatics, or ‘my skin is soft and cool’

for someone with eczema. A study of asthmatics found that they performed better in basic lung-function tests after eight months of regular autogenic training.
Autogenic training can sometimes evoke strong reactions if there are long-standing problems or suppressed feelings and memories. In these situations, the training sessions may

need to incorporate some elements of psychotherapy. Teachers vary in the extent to which they can offer this.
Yoga
Yoga, in its original form, provides a complex religious philosophy of life. If followed with dedication, it affects the whole person –physical, mental, emotional and spiritual.

Those who have practised yoga seriously for many years achieve a great deal of mental focus and calmness, plus a surprising level of control over bodily functions such as blood

pressure and heart rate. These profound changes are achieved through a combination of breathing exercises (pranayama), yoga postures (asanas), meditation, cleansing practices

and careful attention to diet and way of life.
Yoga has now been practised in the West for over a century, and during that time it has been watered down and very thoroughly Westernised. There are now forms of ‘yoga’ that

consist of little more than stretching and relaxation.
For the greatest benefits from yoga, look for classes with a more rigorous approach. If the particular kind of yoga is specified, e.g. Hatha yoga or Kundallni yoga, the chances

are that you’ll be getting something more authentic,
lyengar yoga is the most common form taught in the West, but it is rather narrow, concentrating almost entirely on postures. A form of yoga that includes breathing exercises is

probably more useful, especially if you have asthma.
Before you sign up for a class, talk to the teacher and find out what it includes. If you are asthmatic, make sure the teacher is really experienced in working with asthmatics.

It is all too easy to get the yoga breathing exercises wrong, making the breaths too deep. This can turn into a form of hyperventilation (see p. 226).
Approaching the breathing exercises with a ‘got to get this right’ attitude is another pitfall for Westerners doing yoga. Most of us have the unfortunate habit – acquired in

early childhood – of tensing up and ‘really trying’ when we are taught anything. This is a major obstacle to doing yoga breathing correctly. Eastern attitudes are much more

easy-going and this helps asthmatics much more, because relaxing as you breathe is the key to it all.
Meditation
Basic meditation involves stilling the mind – either emptying it of all thoughts, or focusing it on one very simple object. This is fantastically difficult for most people at

first, but with time, and regular daily meditation, it gradually becomes easier.
Many different forms of meditation exist. Most are part of a spiritual tradition such as Hinduism, Sri Lankan Buddhism, Tibetan Buddhism, Zen Buddhism, or Taoism (Daoism).

Meditation also forms part of yoga, and it is a cornerstone of most martial arts, though this tends to be played down when these are taught in the West. In each case, meditation

takes a slightly different form and has different psychological effects.
A practice known as transcendental meditation (TM), is one of the most widely available – the teaching is arranged by a large international organisation, and can prove

expensive. It is cheaper, and probably better in the long run, to go to classes in a local Buddhist centre or consult one of the many books and tapes on this subject. ect.
Biofeedback
This is the most thoroughly scientific, rational and high-tech of alternative treatments. Biofeedback uses technology to measure the state of some part of your body – a part

that is usually under automatic control, such as the electrical activity in your brain –and relays this information back to you (hence bio-feedback) .
The feedback is shown by means of swinging needles on dials, flashing lights or bleeping sounds. The idea is that you gradually learn to influence the signal, by noticing that

it has changed very slightly in the desired direction, and then re-running (in your head) the thoughts or feelings which apparently led to that change.
In quite a short space of time, you can, with this method, alter bodily states that are beyond voluntary control in most people. Scientific studies show that biofeedback can

teach people to regulate their heartbeat, for example, or reduce the amount of acid produced by the stomach. Although yoga practitioners have long claimed to be able to

influence such bodily functions. it was only with the invention of biofeedback that scientists accepted this was possible.
Biofeedback can also teach asthmatics to relax tight airway muscles, something that has been demonstrated convincingly in scientific trials. Unfortunately, the specialised

equipment needed for this particular form of training is not generally available.
If you sign up for biofeedback, you will probably be trained with equipment that measures the electrical resistance of the skin (this varies with how tense you are) or the

electrical activity of the brain. This kind of equipment can help you learn to relax at will.
Massage and aromatherapy
There are many different varieties of massage, and most are relaxing to some extent. Regular massage treatments may improve your general sense of calmness and your ability to

cope with life’s stresses and problems. In the case of long-standing asthma,
massage may also help with tension in the muscles of the chest, back and neck, which frequently develop during asthma attacks.
Aromatherapy is really a form of massage, with the use of scented oils. Bear in mind that the strong smell of some oils can provoke asthma attacks (see p. 39), while other oils

can irritate the skin of people with atopic eczema or contact dermatitis.
Biodynamic massage involves a much more subtle touch than other forms of massage and it has different aims. The central objective is to identify bodily tensions that are a

result of repressed memories or blocked impulses, and to rebalance the energies of the body. Think of this more as psychotherapy than as massage. It can be very helpful.
Reflexology and zero balancing
Reflexology is based on the belief that specific zones on the soles of the feet correspond to particular parts of the body, and that stimulating those zones on the feet (by

gentle pressure) can induce a healing process at distant points in the body. It may or may not be true – certainly, having your feet massaged is immensely pleasurable and can

induce a profound relaxation.
Zero balancing is a sequence of static touch, gentle holding and light pressure, applied to specific parts of the body. It can induce a state of great well-being and calmness.
Psychotherapy
The basic tenet of psychotherapy is that it is much more painful and exhausting to keep on repressing bad memories than it is to bring them out into the open, in a safe

therapeutic situation, which allows you to process them and move on. Dealing with deep-seated problems lets you relax and live life more fully. In some cases it may help with

physical symptoms, such as allergies.
There is a bewildering choice here, with so many different varieties of therapy on offer. Fortunately, according to recent research, they a// work to about the same extent, as

long as you have a good rapport with the therapist. But if you don’t click, the therapy usually doesn’t work, however expert the therapist might be. So make sure you have an

introductory meeting before committing yourself to a course of therapy, and don’t be afraid to say ‘no’ and try someone else, if you don’t feel quite right with the therapist.
Counselling can also be valuable, and again you will do much better with someone you feel at home with, but who is not afraid to challenge you when necessary.

Plants make a great many different chemical substances, mostly for the purposes of dissuading other living beings — fungi, insects and grazing animals — from consuming their

leaves, roots and fruits. These chemical substances are extraordinarily potent and diverse. Many taste disgusting, some are virulent poisons, and many will induce vomiting or

diarrhoea. None of these effects are surprising, given that substances such as these are produced to defend the plant. However, some of the chemical substances produced by

plants happen to have a beneficial drug-like action for people suffering from certain diseases. The effects of these substances are utilised in herbalism, sometimes known as

botanical medicine.
Over the millennia, herbalists have, through trial and error, tried to discover which plants have worthwhile effects. Indeed, this process probably began with our ape ancestors

– chimpanzees have been observed, when they are ill with parasitic infections, for example, to carefully select and eat particular leaves that have therapeutic effects. If

chimpanzees do this, it is a fair guess that the ape-like ancestors of human beings also did so.
At some point in human history – or prehistory – this use of wild plants became a systematic and specialised activity, now known as herbalism. No doubt the patients who went to

see herbalists (like patients visiting their doctors today) expected a cure for every ill, and no doubt herbalists felt bad about telling anyone that the problem was incurable.

At this point, quite a bit of wishful thinking and placebo effect (see p. 233) probably found its way into herbalism. The outcome was a mixed bag of herbal remedies – some that

worked, some that had no effect at all (apart from placebo effect), and a few that were positively toxic but whose bad effects escaped notice because of the seriousness of the

diseases being treated.
In recent times, a few herbal remedies have been put through rigorous scientific tests. As one might expect, some work and some don’t. More details of those that have been shown

to work
for allergies are given on p. 221. First, however, it is important to consider some of the misconceptions that surround herbal medicine, especially those relating to side

effects. These misconceptions are rooted in the basic philosophy of herbalism, so it is also important to look at this – and at other points of view about herbal treatment.
The ‘Mother Nature’ viewpoint
Some modern herbalists maintain that, for every human ill, nature has created a complete cure somewhere in the plant world – the job of herbalists is simply to identify that

cure. This belief is essentially religious and anthropocentric – that is, it assumes that the welfare of human beings is the central focus of the plant world. This goes against

common sense, because it suggests that plants produce a complex array of chemical components, not for their own benefit, but for ours.
A related idea, and one that is far more widely accepted, is that anything ‘natural’ must automatically be either harmless or positively beneficial to human beings. It’s a nice

idea, but nothing could be farther from the truth, as a quick survey of the plant world shows: hemlock is natural, belladonna is natural, and ricin –the most deadly poison known

– is natural. All come from plants.
Belladonna, of course, while being deadly poisonous in sufficient quantities, is also a medicinal plant. Its most significant ingredient, atropine, is a useful drug-like

substance in small amounts, and a poison in larger amounts. There is no sharp dividing line between these positive and negative aspects – even a small beneficial dose will have

some undesirable effects too.
In other words, herbs produce side effects, in just the same way that medicinal drugs do. This is almost inevitable – anything that alters body functions enough to act as a drug

will usually have some other unwanted effects.
In the case of herbal medicines, there is an added complication. Plants contain dozens, even hundreds, of different chemical substances, many of which have no benefits for

humans at all –they are just plain toxic. These plant toxins can produce various unpleasant effects of their own, to add to the side effects of the useful ingredients. So the

possibility of side effects is actually higher with herbal medicines than with medicinal drugs.
The side effects that occur with herbal treatment are sometimes very serious. Deaths have occurred in some cases, and in others, irreversible damage (e.g. to the liver) has been

done.
The ‘pure-is-best’ viewpoint
Many modern anti-allergy drugs were first obtained from plants –cromoglycate (see p. 148), for example, was originally extracted from the roots of an Egyptian plant called

ammivisnaga. The ground-up roots of this plant contain a great many other things besides cromoglycate, whereas the pharmaceutical preparations of cromoglycate are pure and of

known strength. This pure form of the drug has also been tested very thoroughly by pharmaceutical companies, in order to demonstrate its effectiveness, to identify the correct

dose, and to look for any serious side effects.
An advocate of scientific pharmacology would maintain that, with modern drugs, the patient is just taking the substance that works, not a mysterious cocktail of unknown plant

chemicals. In other words, you know what you are getting with a drug. You also know it has a good chance of working, and a relatively small chance of causing serious side

effects. With a herbal remedy, you are, to some extent, taking a leap in the dark.
Ephedra sinica, the herb known to the Chinese as Ma-huang, illustrates this point well. It contains a mixture of substances, including the powerful drug called ephedrine – it

was named after the plant. Ephedrine (see p. 156) can relieve the narrowing of the airways that occurs during an asthma attack. The presence of ephedrine gives Ma-huang the

ability to ease asthma, although it is more often recommended to help with weight loss. Unfortunately, over-use of Ma-huang can cause a spasmodic
contraction of the blood vessels in the brain, which can result in injury or death. Liver toxicity has also been recorded (see p. 220).
As for its anti-asthma ingredient, ephedrine, although this drug was once important in conventional asthma treatment, it is rarely prescribed now. Ephedrine has long been

superseded by other asthma-relievers that have a more precise effect on the airway muscles, and so produce fewer side effects.
The multiple-action viewpoint
Practitioners of Chinese herbal medicine, in preparing a treatment for atopic eczema, combine ten or more different herbs. There are some conditions, they say, that can be

treated with a single plant, but atopic eczema is not one of those. It requires a mixture – and none of the ingredients of that mixture, taken alone, has any effect. What they

are claiming is that the different drug-like substances in the herb mixture have a synergistic action, working together to treat the disease.
This same idea is sometimes applied to the many different chemical substances found in a single plant. Some herbalists argue that a herbal remedy is better than a modern drug

precisely because it contains a cocktail of different drug-like substances, the effect of one augmenting or balancing that of another.
There is no actual evidence to support this claim, but the fact that Chinese herbal mixtures have some success in treating difficult allergic diseases (see p. 221) demands that

Western doctors at least take the possibility of synergistic action seriously.
It might seem that this multiple-action viewpoint goes against the whole grain of Western scientific pharmacology – the ‘pure-isbest’ approach. However, Western medicine

frequently treats certain allergic diseases, such as asthma and chronic sinusitis, with a mixture of drugs.
Using herbal remedies safely
Always talk to your doctor before taking any herbal medicine, because of the risk of side effects, or interactions with any conventional drugs that you may be using.
If possible, get herbal treatment from someone who is also a doctor qualified in conventional medicine. Ideally, your herbalist should have access to laboratory facilities and

should order blood tests to monitor your reaction to the herb(s). Monitoring every 1-3 months is necessary with some herbs, to check for serious side effects such as toxicity to

the kidneys or liver (see p. 220).
Before buying herbal remedies from a health-food shop or via the Internet, contact the manufacturer and ask to see detailed reports of trials showing that the product is safe.
Think very carefully before taking a herb that has not The Chinese approach
One fundamental concept of Chinese medicine is that, rather than just matching the remedy to the disease, the treatment should also be based on the particular characteristics of

the patient concerned. This idea is shared by some other Eastern systems, such as Ayurvedic medicine.
Whereas a Western doctor might see you as a person with atopic eczema, a traditional Chinese doctor sees you as a person with a certain constitution which has got out of balance

and so produced symptoms in the skin. The constitution is usually the main focus of treatment, not the eczema. This approach means that different eczema patients get different

herb mixtures, and the same is true for other allergic diseases.
A traditional Chinese doctor will assess your constitution by taking your pulses (there are several in Chinese medicine, not just one), asking various questions, and studying

the appearance of your tongue – the same sort of diagnostic process that is used prior to acupuncture.
For the purposes of scientific investigations, where a uniform treatment is necessary, this traditional approach has been modified. A single standardised treatment is applied to

a particular disease – and the disease itself is diagnosed by Western medical criteria. Whether this is really comparable with traditional Chinese herbal medicine is open to

question. The same caveat applies to any off-the-peg Chinese herbal formula that is sold direct to the public, rather than being prescribed for an individual patient by a

trained practitioner.
The traditional philosophy of Chinese medicine makes for a lot of variability in herbal preparations. That is why categorical statements about side effects cannot be made –

while one mixture used for atopic eczema may contain a potentially toxic ingredient, another mixture may not.
undergone full safety trials. Find out all you can about the herb and discuss the matter with your doctor. Don’t fall for the ‘it must be safe – people have been taking it for

centuries’ argument. If a herb is only toxic to a minority of people, and its bad effects are slow to emerge (so people don’t get ill or die immediately after taking it for the

first time), its deadliness can escape notice for a very long time, perhaps indefinitely. In the case of pharmaceutical drugs, highly sophisticated information-gathering systems

are needed to ensure that such rare-and-slow effects are noticed (see p. 137) but nothing of the kind exists for herbal medicines.
Above all, do not neglect vital medical treatment (e.g. inhaled steroids for asthma) while trying out herbal remedies, as this can be dangerous. Always follow your doctor’s

advice about your drug treatment.
Risks to the liver
Among the side effects recorded for herbal treatment, liver damage is especially alarming. Deaths from liver failure have occurred with both Western and Chinese herbal

treatment. Liver toxicity has been recorded with the following herbal remedies: kava-kava, chaparral, germander, skullcap, mistletoe, senna, valerian root, jin bu huan, and

ma-huang or ephedra (Ephedra sinica). Some Chinese herbal teas prescribed for atopic eczema may also affect the liver, but this is not true of all eczema preparations – several

of the most widely used ones appear to be relatively safe.
Any medicinal herb might, in certain people, harm the liver. Should you feel ill while taking a herbal remedy, stop taking it immediately and see your doctor. The early symptoms

of liver toxicity, which you should watch out for, include jaundice (yellow
skin, and a yellowish tint to the whites of the eyes), pale faeces, dark urine, nausea and pain (usually in the region of the stomach).
Illicit steroids
Be very cautious indeed about pots of Chinese herbal cream sold for atopic eczema. Analysis of a selection of such creams found that two-thirds illicitly contained powerful

steroids – the very drugs that the people buying the creams were anxious to avoid. The dose of steroid in these herbal creams was alarmingly high, considering the purposes for

which some of them had been prescribed – such as use on the face of a baby. A substantial risk of serious side effects exists with these adulterated creams.
Sensitivity reactions to herbs
Like other natural products, herbs can provoke a true allergic reaction, and anyone with a tendency to allergies is at particular risk. Although any herb could, in theory, cause

such a reaction, some seem especially likely to do so:
•    Echinacea, which sometimes causes anaphylaxis or an asthma attack. Severe reactions may occur even in people taking it for the first time, if they are already allergic

to other plants in the daisy family (such as ragweed or mugwort).
•    Preparations containing royal jelly (obtained from honeybees) have sometimes caused near-fatal anaphylaxis in those allergic to pollen. Propolis, obtained from bees,

should also be treated with caution.
Contact dermatitis often occurs with tea tree oil and some other plant-derived substances applied to the skin (see p. 55).Herb—drug interactions
Using herbal remedies and taking medicinal drugs at the same time can be hazardous. These are the herbs that interact with anti-allergy drugs:
•    aloe vera, buckthorn, cascara sagrada bark, ginseng, and senna pod or leaf can all interact with steroid tablets
•    squill, lily of the valley and pheasant’s eye can increase the action and side effects of betamethasone (a steroid); rhubarb root also interacts with this drug
•    kava-kava, if taken with cetirizine (an antihistamine) can increase side effects such as drowsiness and poor coordination; it may have the same effect with other

antihistamines.
Note that many drugs prescribed for conditions other than allergies may interact with herbs. Some of these interactions can be serious, so check with your doctor before taking

any herbal medicine.
Herbs that may work for allergies
Of the herbal treatments that have been tested, the following appear to have potential benefits for people with allergies:
•    Chinese herbal teas for atopic eczema have shown good effects in scientific trials in Britain with both adults and children. Patients with widespread and persistent

eczema —which is particularly difficult to treat — were chosen for these trials. The puzzling thing is that when exactly the same herbal treatment was studied in Hong Kong, with

Chinese youngsters suffering from eczema, there was no improvement.
A combination of Chinese herbal medicine and acupuncture shows some limited benefits for hayfever patients (see p. 215). Pilot studies also suggest that a Chinese herbal

medicine formula may work for asthma.
More surprisingly, another mixture of herbs shows promise in reducing sensitivity for people with severe food allergy (so that there is less risk of fatal anaphylaxis from

accidentally eating the culprit food). Further research is needed to confirm these results. It is hoped that daily treatment for about six weeks will give 6-12 months’

protection.
If you are interested in trying Chinese herbal medicine, it is advisable to be monitored properly, as liver toxicity has sometimes occurred (see p. 220). See a reputable,

medically qualified practitioner, who can vouch for the contents of the herbal mixtures (imported ready-made mixes sometimes contain drugs such as steroids). Be warned that the

stuff tastes vile, and you have the daily chore of boiling it up before taking it. It can have a very mild laxative effect at first. Don’t use Chinese herbal creams unless they

are guaranteed steroid-free (see p. 220).
•    Euphorbia acaulis has shown good effects with atopic eczema. Liquorice root may also help, but can have serious side effects if taken in large amounts.
•    Evening primrose oil taken in capsule form, is known to calm inflammation, and might be helpful for atopic eczema. Don’t chew the capsules, as irritation of the throat

can occur. Epileptics should not take this oil.
•    Ginkgo biloba seems to reduce the reaction to allergens. For those with asthma it may also calm inflammation in the airways.
•    Ayurvedic medicine utilises two herbs, Coleus forskohN and Tylophora asthmatics, in the treatment of asthma. The former relaxes the airway muscles, in much the same way

as beta-2 reliever drugs, making the airways open up. The latter has more general benefits in asthma, but also some unpleasant side effects: it can cause nausea and soreness in

the mouth.
•    Saiboku-to is a Japanese herbal treatment for asthma. Studies suggest that it may have beneficial effects on airway inflammation and may allow a reduction in the dose of

steroids needed.
•    Butterbur has received a lot of publicity following a study which appeared to show that it was as good as the antihistamine cetirizine for hayfever However, the study

did not assess actual symptoms of hayfever, only the patients’ sense of wellbeing. Some preparations of this drug contain substances that could cause cancer, or carry a risk of

liver toxicity. Trials of butterbur for atopic eczema have shown no benefits.
•    Perilla seed oil appears to damp down allergic responses, and may help some asthma sufferers.
Omega-3 oils
These oils are derived from certain types of fish. They are obviously not herbs, but they are often sold alongside herbal remedies in health-food shops, which is why they are

included here. Generally speaking, omega-3 oils have a calming effect on inflammation,
but occasionally they provoke skin rashes, and asthmatics who are sensitive to aspirin may find that they gradually get worse if they take omega-3 oils. This is probably due to

problems with the production of messenger chemicals called prostaglandins in people with aspirin sensitivity (see box on p. 151). The connection is that omega-3 oils can act as

raw materials for the manufacture of prostaglandins and leukotrienes. The details of how omega-3 oils cause trouble for aspirin-sensitive people are not yet understood.

Homeopathy
`We believe that a serious effort to research homeopathy is clearly warranted despite its implausibility.’ That was the conclusion of a group of German and American scientific

researchers who, in 1997, looked at every study of homeopathy they could find. This prestigious trans-Atlantic team carefully assessed the scientific validity of each study, and

then considered the data from studies that were of reasonably good quality.
This kind of study, in which all the available research data on a topic are combined, is called a meta-analysis. There were 119 research studies which were good enough to be

included in this meta-analysis and, taken together, these studies suggested that homeopathy does indeed have some real effects. In other words, it produces significantly more

benefits than simple placebo effect – the psychosomatic improvement which tends to occur with any treatment, even a dummy pill (see p. 233).
Some of the most convincing scientific studies included in the meta-analysis were those relating to homeopathic remedies for allergic conditions (see p. 217). But what exactly

does this mean for allergy sufferers? Is homeopathy a treatment that is worth a try? Unfortunately, it is difficult to say.
Firstly, the evidence from the homeopathy meta-analysis is far from overwhelming, as the researchers themselves point out. The observed improvements – the overall differences

between the placebo and the homeopathic remedy – are not huge. Secondly, even if there are some homeopathic treatments that have real effects, it does not mean that every kind

of homeopathic treatment works. Homeopathy is a very broad field, with a multitude of different approaches. The types of homeopathy that have been tested, and appear to help,

may bear little or no relation to the homeopathic remedies that are generally available (see p. 217).
`Let like cure like’
The central idea in homeopathy – often known as the principle of similars – is that a substance which causes a particular set of symptoms can also, if handled in the right way,

cure symptoms of
a similar kind. In the words of Samuel Hahnemann, the German doctor who invented homeopathy at the beginning of the 19th century, ‘Let like cure like.’
The natural substances that form the basis for homeopathic remedies are mostly derived from toxic plants or minerals. (Sometimes extracts from diseased tissue – called nosodes –

are used instead, but this is a relatively recent development. So is the use of allergen extracts, such as pollen, described on p. 217.) Hahnemann himself began with the

standard drugs of his own day, such as belladonna and arsenic compounds. His innovation was to use them in very much smaller doses than his fellow physicians, and to apply them

to entirely different diseases.
Hahnemann worked by first discovering what the effects of the drugs were, when taken by a healthy person (he experimented on himself and his family for this). Then he tried to

match the symptom pattern produced by the drug with the symptoms of a particular disease. For example, he observed that belladonna produces hallucinations and a hot, dry skin –

symptoms that were also seen in children with scarlet fever. He claimed that, by giving belladonna in very small doses, much less than was normally used, he could stimulate the

body to heal itself of scarlet fever.
Hahnemann, unlike his medical contemporaries, also advocated a good diet, fresh air and exercise. And he was heartily opposed to the conventional medicine of his day, a brutal

business that involved a great deal of blood-letting and large doses of very toxic medicines. Considering how useless, and indeed dangerous, the orthodox medicine of the time

frequently was, Hahnemann’s successes were not really surprising.Less is more’
Homeopathy today is the ultimate version of the ‘less is more’ philosophy. A homeopathic remedy is prepared by taking the basic ingredient, dissolving it in water, and then

diluting that solution over and over again. Imagine pouring a bottle of wine into the Pacific Ocean, and you have a rough idea of how dilute homeopathic remedies are. Making

extreme dilutions was an idea introduced by some of Hahnemann’s followers, after his death.
Dilution is only part of the story, however. With each dilution, homeopaths apply a special shaking-and-tapping technique known as percussing. This was originally done by hand,

but now is often done mechanically. Homeopaths believe that percussing makes the active substance more powerful, despite the dilution. The term used by homeopaths is potency,

and a homeopathic remedy of the highest potency is the one that has been most thorDughly diluted and percussed.
In fact, a simple calculation, using the basic laws of physics, shows that there is nothing there at all but water – many homeo pathic remedies are watered down so thoroughly

that not one Jingle molecule of the active substance is likely to remain. It is  which leads medical researchers to use words such as ,nplausibility’ (see p. 216) when talking

about homeopathy.
Nhat homeopaths do
\ homeopath starts by considering all your symptoms (not just allergies, but any other symptoms as well) and various other characteristics that conventional doctors do not

usually consider, including physical appearance and psychological traits. The homeopath then chooses a substance which, if taken at full strength, would produce a comparable set

of symptoms and characteristics. This approach is called classical homeopathy.
In addition, homeopaths often give advice on diet, sleep, exercise and allergen avoidance. As in the early days of homeopathy, this may be the most important part of the

treatment.
Like many other complementary therapists, homeopaths will listen if you need to talk about personal problems and emotional difficulties, and will offer reassurance or advice.

This can be valuable, though not everyone would agree that a homeopath is the best source for such help. There are two distinct traditions within homeopathy – a scientifically

inclined tradition (represented today by experiments with homeopathic immunotherapy – see right) and a highly metaphysical tradition. Among the many ideas floating about within

the metaphysical tradition is the notion that all illness is a result of psychological or moral failings. Attitudes of this kind, which are quite common among complementary

therapists, can be very damaging (see p. 209).
Sometimes homeopaths recommend avoiding certain foods, on the assumption that the patient suffers from food intolerance, though they rarely use an elimination diet (see p. 194),

the only way to achieve accurate diagnosis.
In addition to all this, some homeopaths also give herbal remedies where they think it will help. This approach is called complex homeopathy.
A much more recent development within homeopathy is homeopathic immunotherapy or HIT, which uses an extreme dilution of an allergen (such as pollen or dust mite) to treat people

who are allergic to that substance. While homeopathic immunotherapy was inspired by conventional immunotherapy, the relationship between the two is a very distant one indeed.

The extensive dilution process means that the liquid used for homeopathic immunotherapy is unlikely to contain even one molecule of the allergen. This puts it in a completely

separate realm from conventional immunotherapy, where the presence of the allergen, and the steadily increasing dose with successive injections, is what produces the beneficial

effect (see p. 166).
Does it work for allergy?
Two scientific trials suggest that HIT makes a difference, albeit a small one, for hayfever and pollen asthma. In the meta-analysis described on p. 216, one of these trials was

given a good rating for scientific reliability, and the other was considered fairly good.
Another type of homeopathic treatment that appeared to be effective for patients with allergic asthma was one using a nosode – an extract of the asthmatic airway itself. A small

sample of the airway was taken from each asthmatic patient, diluted and per-cussed, then given to the patient as a treatment. It seemed to work, and the scientific rating of

this trial was very high.
The third homeopathic treatment that appeared to have an effect in valid scientific studies was Galphimia, used for symptoms in the eye caused by pollen allergy.
If you go to a local homeopath, it is very unlikely that you will be given either of the first two treatments – these are only used experimentally, in large research centres.
The Galphimia treatment might be available from a local homeopath, but it will not necessarily be in the same form as the treatment used in the scientific trial.
Note that all the studies described above are trials with a positive outcome. If you are trying to assess homeopathy overall, you should also consider the many trials that found

no effect. For example, a very careful study of homeopathy for children with asthma, carried out at the University of Exeter and published in 2003, found no benefit from

individualised homeopathy treatment.

Diet to Protect against Asthma
There is growing evidence that several aspects of the modern Western diet make asthma more likely to develop. Parts of this evidence are very convincing, while other findings are less conclusive as yet. Some people might argue that, until all the facts about diet and asthma are firmly established, no dietary changes should be recommended. However, all the dietary changes that might protect against asthma are also very valuable for general health.
This diet is potentially useful for:
0Atopic families who wish to reduce the chance of their chil- dren developing asthma. Other preventive measures, such as allergen avoidance and exercise (see Chapter 8), are obviously important as well.
•    Anyone who already suffers from asthma – with this diet, their symptoms may diminish.
The main elements of the anti-asthma diet are:
•    A high intake of fresh fruit. Researchers in Britain and the Netherlands have shown that people who eat more fruit have better lung function, and are less likely to develop asthma or bronchitis. Apples have a particularly good effect on the airways, according to one recent study. Many other studies show a link between Vitamin C – the major vitamin in fruit – and asthma prevention. This makes sense because Vitamin C is an antioxidant which inactivates the pro-inflammatory substances (called oxidants) that are found in cigarette smoke and other polluted air. In addition to Vitamin C, many fruits contain beta-carotene (see below) – mangoes and apricots are the richest sources.
•    Regular helpings of carrots, which contain the orange pigment beta-carotene. This is another antioxidant that can help prevent inflammation in the airways. It should be obtained from food, not supplements (see p. 207).
•    A high intake of fresh green vegetables, especially broccoli, spring greens, dark green cabbage, peas, parsley and courgettes. One Australian study has shown that children who eat fewer vegetables are more likely to wheeze. The benefits of vegetables may be partly due to the fact that they contain beta-carotene and (if eaten raw or only lightly cooked) Vitamin C. Dark green vegetables are also a good source of magnesium, and researchers find that people with a higher magnesium intake have healthier airways. Magnesium is believed to protect against asthma by helping the muscles of the airways to relax.
•    Plenty of tomatoes and tomato products, such as tomato juice, tomato sauce, ketchup and paste. The special protective effect of tomatoes is not entirely explained by their Vitamin C or beta-carotene content – another antioxidant, called lycopene, may be the crucial ingredient here. Good news for fast-food fans – the benefits of tomato paste are even seen among pizza eaters who are significantly less vulnerable to asthma.
•    Daily intake of sunflower seeds, or sunflower oil and margarine. These are by far the best natural source of Vitamin E, another antioxidant (see left) which helps to reduce the risk of becoming asthmatic. Vitamin E taken in supplements seems to have much less beneficial effect than natural Vitamin E from food.
•    A good intake of the minerals zinc, manganese and selenium, as well as magnesium (see p. 206). Shortage of any of these minerals may be linked with asthma. It is important not to eat too much wheat bran or unyeasted wholemeal bread, especially with main meals, as these block the absorption of several minerals.
Good sources of zinc include meat, shrimps, clams and oysters, with smaller amounts in cheese and egg yolks. Nuts, lentils and beans are fairly good sources of zinc, while soya protein blocks its absorption.
As well as being found in dark green vegetables, magnesium is plentiful in sardines, peanuts, hazelnuts, walnuts and lentils. Other fish, lean meat, milk, cheese and bananas contain smaller amounts.
Manganese is found in eggs and milk, and though the amounts are small, these are good sources because the mineral in them can be absorbed easily. While green leafy vegetables, whole grains and tea apparently contain more manganese – and are frequently recommended as a source of this mineral – in fact very little can be absorbed from those foods. Lentils are a moderately good source of manganese.
Selenium is most plentiful in fish and meat. It may be scarce in home-grown plant foods in areas of the world (notably Finland and parts of New Zealand) where selenium is lacking in the soil.
•    A limited intake of meat, especially red meat, plus a com-
-    plete avoidance of kidney, liver and other offal meats. An entirely vegetarian diet incurs a risk of mineral deficiencies however (see above). On balance, it is probably best to eat meat once a week or less.
•    A low intake of salt. Researchers in Kenya found that children eating a high salt diet (which equals the average salt intake in Britain and other parts of the developed world) were at greater risk of becoming asthmatic. For existing asthmatics, increasing the amount of salt eaten can make asthma worse, while reducing salt can lessen symptoms. Male asthmatics seem to be more vulnerable than females. Salt probably affects the muscles of the airways, making them more likely to contract.
The role of supplements
You should try to get all the nutrients you need from food rather than supplements. However, there are times when a supplement can be useful. Any asthmatic who has to cope with the effects of high air pollution, especially ozone and sulphur dioxide (see pp. 130-31), may find a supplement of Vitamin C beneficial. However, you should avoid very high doses of Vitamin C (e.g. I g/day) as they can cause disturbed sleep. Use natural sources for Vitamin E (see p. 206) if you can, but taking a supplement is better than nothing.
Vegans should think about taking a multi-mineral supplement, given the difficulties of ensuring an adequate intake of zinc, manganese and selenium from vegetable food (see left). Vegetarians may also benefit from a mineral supplement.
Some supplements, in certain circumstances, can do more harm than good. Omega-3 oils (also called w-3 oils, concentrated fish oils, or EPA and DHA) may make asthma worse for some people (see box on p. 221). Beta-carotene (sold alone and as part of mixed antioxidant supplements) may, according to some studies, promote cancer at the high doses used in many supplements. It should only be obtained from food.
Foods and drinks that bring on asthma attacks
The anti-asthma diet tackles the inflammation of the airways and the underlying tendency of the airway muscles to go into spasm – in other words, it is concerned with the long-term treatment or prevention of asthma. In addition, you should obviously avoid any foods which aggravate asthma in the short term. Various foods and drinks can bring on an asthma attack:
•    Foods and drinks containing sulphur-based preservatives tend to give off the irritant gas sulphur dioxide while being chewed or swallowed. Some asthmatics are more sensitive to sulphur dioxide than others. The foods that most commonly cause problems are dried apricots and other dried fruit (except those labelled ‘unsulphured’), shellfish, french fries, ready-made salads and fruit salads. Sulphur-based preservatives are used widely in the catering industry. On packaged food, look for ’sulphite’ and’metabisulphil or E numbers 220-227. Soft drinks, wine, beer and cider almost always contain sulphur-based preservatives.
•    Foods that cause heartburn (GER – see p.38) can aggravate asthma for some people.
•    Alcoholic drinks may make the airways contract for some asthmatics (see box on p. 160).
•    Some asthmatics need to avoid foods containing histamine (see box on p. 67).
•    A few asthmatics respond badly to the smell of food cooking. The most severely affected can suffer an asthma attack from anyfood aroma. Cromog lycate -type drugs (see p. 148) or anti -choli nerg ics (see p. 156) may block this reaction.
Needless to say, if you have a sensitivity reaction to any food listed for the anti-asthma diet you should not eat this food.

When Leonard Noon reported his first tentative experiments with immunotherapy for hayfever, in 1911 (see p. 164), he believed that pollen contained a toxin. Most people were

‘immune’ to this toxin, he said, in the same way that people might be immune to measles or diphtheria, but hayfever sufferers lacked this immunity. Noon thought that his

steadily increasing doses of pollen, injected just under the skin, were inducing immunity to the pollen toxin, in the same way that a smallpox vaccine could induce immunity to

smallpox.
Noon’s theory was all wrong, as we now know, but the important thing was that the treatment seemed to work. In fact it transformed the lives of some patients, especially those

who were very severely affected by hayfever. One spoke of a ‘marvellous cure’, another of going for walks to kick my old enemy the hay’.
So doctors kept using Noon’s treatment, and in time — when it became clear that Noon’s theory was flawed — medical researchers began trying to figure out how the injections

really worked.
Surprisingly, they have still not succeeded, even though a great deal is now known about the changes that can occur in people undergoing immunotherapy. Despite a wealth of

detailed knowledge (see p. 166), it remains impossible to say exactly how conventional immunotherapy reduces allergic reactions. Surprising discoveries about the effects of

conventional immunotherapy are being made all the time.
New methods of immunotherapy are still being devised today, and there are three different approaches being taken.
Firstly, there are doctors experimenting with modifications of the technique devised by Noon. For example, instead of injecting the allergen extract, some doctors are giving it

to their patients in capsule form. to be swallowed. Others are giving it as a liquid, to be placed under the tongue and held there for a few minutes, then swallowed (see p.

169). Sound scientific trials show that both these methods work well, at least with some allergens.
There are also experiments with speeded-up immunotherapy
(see p. 166), called ultrarush techniques — at the outset, injections are given at hourly intervals, or even more frequently (in hospital, of course, where severe reactions can

be dealt with immediately). Doctors have found that they can induce a remarkably rapid tolerance of the allergen in this way.
The second approach is to apply modern medical knowledge about allergic reactions and so develop entirely new methods of immunotherapy (see p. 168-9). Such research involves

working out, from first principles, novel ways of modifying the immune response in general, or the reaction to one allergen in particular.
This theory-led approach is certainly successful for classical allergies such as hayfever and perennial allergic rhinitis, where there is a good understanding of the basic

mechanism (i.e. the malfunctions of the immune system that produce the disease). But for those diseases where the underlying mechanism is only partially understood, such as

atopic eczema, this approach is not necessarily the best one. And for diseases such as food intolerance, where the cause of the illness remains largely unknown, it is a complete

non-starter.
The third type of approach is to devise a technique by trial and error, and then puzzle out the ‘how’ question later. This is the same sort of path as Noon originally took, and

some believe that this kind of pragmatic experimental approach — practising a method which seems to be effective, even though it’s a mystery how it works — is as valid now as it

was in 1911. Others disagree.
210 complementary therapies The two most widely used methods that have been developed in this way are Provocation-Neutralisation and Enzyme- Potentiated Desensitisation.

Although these techniques are practised by doctors with a conventional medical training, they remain ‘outside the pale’ as far as orthodox medicine is concerned. The

controversies that surround them are discussed below.
Enzyme- Potentiated Desensitisation (EPD)
This technique has been developed by a British doctor, Dr Len McEwen, who began work on it in the 1960s. It is now practised in many parts of the world, as well as Britain,

including the United States, Germany and Italy.
EPD is used for a far wider range of problems than conventional immunotherapy, being given to people with food intolerance and chemical intolerance, as well as to those with

true allergies. This — along with the fact that it is unclear how it works —contributes to the controversies that surround it, because these conditions do not have the same

basic causes.
Dr McEwen began with the observation that, when immune cells are aroused during inflammation — whether caused by allergy or some other stimulus — they release large amounts of

an enzyme called beta-glucuronidase. This enzyme increases the immune response to the allergen or antigen that provoked the inflammation.
Dr McEwen experimented with injecting beta-glucuronidase into the skin, along with very small amounts of allergen, believing that in such circumstances the enzyme might have the

opposite effect, and reduce the immune reaction to the allergen. Eventually he discovered a combination of enzyme and allergen which seemed to have the desired effect.
EPD has been tested, in a rigorous scientific manner, and the results suggest that it can work for hayfever and asthma, as well as for childhood migraine and hyperactivity in

children when these are triggered by foods.
In one trial with hayfever patients, researchers measured the levels of anti-pollen IgE following EPD treatment, and it did not rise during the pollen season as it normally does

in those with hayfever. This kind of finding is impressive because it is unlikely to be due to placebo effect. Not all studies have produced positive results, however.
In addition, doctors using EPD claim that it is very effective for patients with allergies who have not done well on the standard course of immunotherapy injections (see p.

164). This fits in with other studies suggesting that the immune changes brought about by EPD are fundamentally different from those induced by traditional immunotherapy.
Patients with true food allergy have been given EPD, and while it does not enable them to eat their culprit food, it does
seem to reduce their reaction to accidental exposures.
Doctors in the Netherlands are using EPD as a treatment for people with Chronic Fatigue Syndrome (CFS), and report that it helps about 50% of patients.
One point in favour of EPD is that it uses very small amounts of allergen, and is therefore very safe — anaphylaxis has never occurred with this technique.
Provocation-Neutralisation
‘After following conventional methods [of immunotherapy] for thirteen years, I heard Carleton H. Lee deliver a paper on provocative testing in 1965, at a meeting of the American

College of Allergists in Chicago. I was naturally sceptical, but tried his suggestions when I returned to my office. The results can only be described as astounding. Many

patients with unresolved allergic problems responded markedly and rapidly. Many with resistant asthma or perennial allergic rhinitis improved greatly or cleared completely when

food injection therapy was added to their inhalant injection therapy.’ So wrote Dr Joseph B. Miller — a distinguished allergist and paediatrician, and a Professor of Medicine at

the University of Alabama, in 1972.
The technique which he learned from Carleton H. Lee was controversial then and, although Miller developed it with great care and precision during the years that followed, it

remains controversial now.
There are two elements in provocation - neutralisation: testing and treatment. Both are used for a wide range of problems — not just classical allergic diseases, but also food

intolerance and chemical intolerance. As with EPD (see left), this is one of the controversial aspects of the technique.
Although provocation-neutralisation involves an injection technique that looks, superficially, very much like conventional immunotherapy (see p. 164), there are several

important differences. Firstly, the allergen extract used (in the case of true allergies) is a very dilute extract, so that far less of the allergen is injected than in

conventional immunotherapy. Likewise, in the case of food intolerance and chemical intolerance, the extracts of the offending substance are used in highly dilute form.
Secondly, the idea of the neutralising dose — which is the central plank of provocation-neutralisation — is quite different from anything in conventional immunotherapy. Broadly

speaking, the conventional technique (see pp. 165-6) works by slowly reeducating the immune system with a gradually increasing dose of the allergen. Only after a succession of

injections does the immune system start to behave differently on encountering the allergen. By contrast, in provocation-neutralisation treatment, the neutralising dose is

claimed to have an instantaneous and direct effect on the body, ‘turning off’ symptoms that have already begun. This is the neutralisation aspect of the technique. The doctors

who practise this technique do not claim to know how the neutralising dose might work.
According to the theory of provocation-neutralisation, the strength of the extract that acts as a neutralising dose is specific for a particular allergen and a particular

person. It can only be worked out by a rather slow procedure involving a series of injections. These are intradermal injections – they place the allergen extract in the skin, at

a slightly deeper level than a skin-prick test. (For treatment, rather than testing, subcutaneous injections are used – these go deeper than intradermal injections, placing the

allergen extract just underneath the skin. Neither hurts very much.)
Ideally, the neutralising dose should be decided on by measuring the size of the wheal (a raised area of skin around the injection site), and whether it grows, stays the same

size, or disappears. The doctor or nurse carrying out the procedure can, in theory, work out the neutralising dose just by careful examination of the skin wheals.
However, it is part of the tradition of provocation-neutralisation techniques that verbal feedback from the patient is also taken into account – so if the patient says that an

injection has turned off the symptoms, that reinforces the belief that the neutralising dose has been found.
The problem with this aspect of provocation-neutralisation is that expectations, and the power of suggestion, can become involved. So if the doctor or nurse says ‘you may find

that this next injection makes the symptoms go away’, that is often exactly what happens – because the forces of placebo effect (see p. 233) come into play. Unfortunately,

verbal interactions such as this are a key aspect of the provocation-neutralisation procedure in many clinics.
Just the same hazard besets provocation - neutralisation if it is used to test for the existence of allergy or intolerance, because it is quite common for practitioners to tell

patients which allergen (or other offending substance) is being injected and to ask if any symptoms are provoked by the injection. This is not good practice – if someone expects

to react to a particular substance, they are quite likely to produce symptoms through purely psychological mechanisms (see pp. 232-3).
Quite apart from this, the question of allergy testing with provocation-neutralisation techniques is contentious, because the pioneers of the technique, such as Professor

Miller, never advocated using provocation - neutralisation in this way. Using it as a routine test for sensitivity reactions was a later development, and there are many doctors

today who, while they practise provocation-neutralisation as a treatment, say that it does not work well as a test for sensitivity reactions. While they agree that injecting a

dose
which is either stronger or weaker than the neutralising dose may provoke actual symptoms (this is the provocation aspect of the technique) they don’t think the reaction is

reliable enough to form the basis of a test for allergies. Nor do they think that using skin-wheal measurements alone (i.e. silent testing) turns the technique into an accurate

test for allergies. That is not what the provocation-neutralisation technique was designed for – it is about treatment, not testing.
The evidence from research
Recent research from the Nova Scotia Environmental Health Centre in Canada confirms that testing by provocation injections is not reliable. The subjects in this study were all

suffering fr= multiple chemical intolerance, a condition which – for one reasor or another – makes patients liable to develop symptoms at an,, time. No less than 70% of these

patients experienced symptoms in response to a dummy injection which contained none of the offending substance. Indeed, 15% of patients also produced a skin wheal in response to

some of the dummy injections, confirming that even this reaction may be subject to the power of suggestion (see pp. 232-3).
Looking just at the patients who did not react to the placebo injection (i.e. those least susceptible to suggestion) the test still did not yield any reliable result – a person

might react to one injection with a particular substance, but fail to react to a subsequent injection with the same substance. The authors concluded that their patients were ‘in

a state of heightened sensitivity as the result of the chronic irritation by various environmental components and other external and internal stressors’. In this state of

sensitivity. patients are so close to the brink all the time that the smallest thing can trigger symptoms. So the apparent reactions to the test injections were actually

determined by other factors – some psychological factors (including a psychological response to the prick of the needle) and some external ones, such as exposure to smells or

very small amounts of airborne chemicals.
Another recent research study, carried out by scientists at the University of California, confirmed the finding of the Nova Scotia team as regards testing. Although this study

did not set out to look at the use of the neutralising dose for treatment, some of the patients were given neutralising doses during the testing process and the researchers

observed that ‘in most cases a single neutralising injection relieved the symptoms’. This casual observation clearly needs to be confirmed by more rigorous testing. Oddly

enough, despite this positive observation about the neutralising doses, the overall conclusion of the researchers was to completely dismiss all aspects of

provocation-neutralisation as ‘the result of suggestion and chance’. This conclusion has been widely publicised in the United States as part of a general campaign against

provocation-neutralisation and doctors who practise it.
Other researchers have looked at treatment with neutralising doses, using stringent scientific methods (a double-blind placebo-controlled trial — see p. 90), and found that they

do work. In one such trial, patients with asthma. and allergies to dogs or cats, were treated with injections of the neutralising dose. They showed a reduction in the

sensitivity of their airways, as measured by objective tests. In another experiment, patients with perennial allergic rhinitis and an allergy to house-dust mite were studied,

and the neutralising dose was given as drops of allergen extract placed under the tongue (sublingual drops) – an alternative to injections. The blockage of the nose, as measured

by scientific tests, was reduced by the neutralising dose.
A great many more trials of this kind would be required to convince most doctors that provocation-neutralisation works.
Furthermore, the recent study from California – which observed a number of practitioners of provocation-neutralisation at work with their patients — showed that these

practitioners need to be a lot more rigorous and objective in their approach. However, the fact that provocation-neutralisation is often practised badly does not necessarily

mean that the basic technique is without any value. There are a great many level-headed doctors and patients who, while initially very sceptical about

provocation-neutralisation, have found it surprisingly effective – just as Professor Miller did back in 1965.
Deciding for yourself
So is provocation-neutralisation an option that is worth trying for your condition?
As regards testing, the answer is probably ‘no’. The most reliable tests are skin-prick tests or FAST blood tests for true allergies (see pp. 91-2), an elimination diet for food

intolerance (see p. 194), and avoidance followed by re-exposure (a challenge test) for chemical intolerance.
As regards treatment for true allergies, conventional immunotherapy has been far more thoroughly tested and, if you can get it (not easy in Britain — see p. 164), is probably a

better bet. It is definitely the best treatment for allergy to insect stings.
The major advantage that provocation-neutralisation has over conventional immunotherapy, in the case of true allergies, is that it is far safer. Because such small amounts of

allergen are used, anaphylactic reactions (see p. 58) don’t occur.
When it comes to treatment for food intolerance, complete avoidance of the problem food(s), for a period of a year or two, is usually a very effective treatment (see p. 77).

Other forms of treatment are only needed for people who find that they have
intolerance to a great many different foods (on the basis of an elimination diet, not kinesiology, blood tests and the like — see p. 93) and cannot devise an adequate diet from

the foods they are able to eat. For such people, provocation-neutralisation may be worth a try. Many patients feel that they have gained considerable help from this treatment.

They report suffering fewer symptoms and being able to return to a more nutritionally balanced diet.
In the case of chemical intolerance, the first line of treatment should be to avoid the substances concerned as far as possible, eat a good balanced diet, and take a vitamin and

mineral supplement if nutritional deficiencies are suspected. Treating any underlying hyperventilation (see pp. 226-9) can also help considerably. Only if there are persistent

symptoms, and you are sure these are not due to psychological causes, might provocation-neutralisation be worth a try. Some people with chemical intolerance do find it is

helpful, but whether this is a real effect, or simply placebo, remains uncertain.
If you decide to give provocation-neutralisation a try, find a practitioner who has good medical qualifications, who seems objective and sensible in their approach, and who

doesn’t make implausible claims for the technique. Take note of what other treatments the practitioner offers, and whether these seem rational or not – this is often a good

guide to the care and objectivity with which provocation - neutralisation is carried out.
Ask the doctor how he or she assesses the neutralising dose. and avoid anyone who does not use the traditional method of a series of injections combined with wheal measurement.

When the neutralising dose is being assessed, say that you would like it to be done ’single-blind’ – that is, you don’t want to be told anything about what is being injected.

Reporting how you feel to the doctor or nurse during the assessment is fine, but only mention really significant symptoms, or a very definite clearance of the symptoms, if this

occurs. These precautions will help you to be sure that you are getting something which is of genuine benefit, rather than just a very expensive form of placebo treatment.
I always wanted to be a doctor, and I enjoyed
medical school immensely, but once I became a
ell GP, I no longer felt quite so sure about what I was doing. It seemed clear to me that there were a lot of people coming to my surgery who I couldn’t do much for. And there

were others who, while I could treat their obvious medical problems with some success, remained distressed and were not coping well with life. Once I became a senior partner in

this practice, I experimented with having a counsellor come in for one session a week, and then an osteopath for the bad backs. It was popular with the patients, and I saw some

people improve enormously. Now we have stress-management classes too, and one of my colleagues has trained in acupuncture, which he uses for selected patients. We also use

elimination diets for patients with a lot of long-term problems like migraine. Overall, I think of it in terms of having more tools at our disposal - being able to tackle things

from a different angle when standard medicine isn’t hitting the spot.’
Geoffrey, a GP in the north of England, is typical of the reconciliation that is now beginning to occur between conventional medicine and alternative medicine. But he also has

plenty of criticisms to make of the alternative scene. ‘The idea that alternative medicine is “holistic” while conventional medicine isn’t, really raises my hackles. Most GPs

could be magnificently holistic if they had an hour with each patient as alternative therapists usually do. We have just 15 minutes, on average, and we have to pack a lot into

that - including our basic duty to eliminate the possibility of serious organic disease such as cancer. Time pressure is everything now, and it has squeezed the humanity out of

medicine, to a very large extent. But the potential for a holistic approach is there - most doctors have a tremendous store of wisdom and life
experience at their disposal, which could form the basis of a holistic approach to treatment if only there were more time to spend with each patient.’
It is in search of a more unhurried and all-embracing approach to treatment that many people turn to alternative medicine. Frequently, what they get out of the therapy has less

to do with the actual methods used, and still less with the theories behind those methods, but everything to do with spending a quiet hour with someone supportive and caring who

listens to all the complex concerns that surround any illness, gives reassurance or advice, or just offers a `safe space’ in which to talk about life’s difficulties.
Other people turn to alternative therapies due to a more serious disillusionment with orthodox medicine. When patients with inscrutable medical problems -such as persistent

unexplained diarrhoea, joint pain or chronic urticaria - are given a succession of different diagnoses by different doctors, they often lose faith entirely in modern medicine

and reject orthodox treatment in favour of alternatives. This is a great mistake. Modern medicine isn’t perfect, but that is only to be expected, because it is not a fixed body

of knowledge but a process - a continuing journey of questioning, investigation, discovery and improvement. Scientific medicine has come a tremendously long way from the state

of ignorance that prevailed two centuries ago, and it will undoubtedly go farther.
Conventional medicine has a great deal going for it - ask anyone over 50, with severe life-long asthma, what they think of treatment now compared to treatment in the 1950s or

early 1960s. You will hear a hymn of praise to the improvements in both drugs and drug delivery systems. Asthma is just one example -conventional medicine has a lot to offer for

all the classical allergic diseases. Alternative medicine should always be regarded as an adjunct to conventional treatment, not a replacement. That is why many doctors prefer

the term complementary medicine.
A third reason for using alternative medicine is a more philosophical one, a need to understand illness in some larger sense, often part of a general search for meaning in life.

Some types of alternative treatment attempt to offer metaphysical reasons for allergy -rather than the mundane explanations of antibodies and immune cells that are given in this

book - and this can be attractive to some people. There is no harm in this approach, which can prompt you to make a critical review of your life, look at unresolved emotional

issues, or reassess choices that are making you unhappy.
But not all illness, or worsening symptoms, can be explained by emotional causes, and the rigid belief that every illness must have a meaning can be damaging. It easily

degenerates into the wholesale psychologisation of illness, the kind of blame-the-victim mentality which can attribute hayfever to ‘Emotional congestion; fear of the calendar; a

belief in persecution; guilt’ and asthma in babies to ‘Fear of life; not wanting to be here’. Both these diagnoses are taken from the best-selling You
can Heal your Life by Louise Hay, which is very influential among some alternative therapists. This compulsive psychologisation of illness can be profoundly damaging, and if

your complementary therapist is preoccupied by ideas of this kind, you could find yourself on a very long guilt trip indeed.
Apart from the psychological aspects of alternative medicine, there is the question of whether it actually works in a practical sense - whether it provides more than just

emotional support and placebo effect (the benefit that comes from any treatment which you believe in). This is always the central question for scientific medicine in relation to

its own treatments,
and conventional doctors naturally apply the same criteria to alternative medicine. Most of this chapter is concerned with trying to answer that question.
Unfortunately, there are so many different kinds of alternative therapy available today that it is impossible to cover all of them in this book. To complicate matters further,

many complementary therapists now practise two or more different techniques, mixing them to
produce their own unique cocktail of diagnosis and treatment. This eclectic approach can span a remarkable range - you may find a therapist doing distinctly whacky stuff such as

iridology (looking at the eye to diagnose all illness - it has been tested and definitely doesn’t work), combined with something perfectly rational such as an elimination diet.

(The elimination diet might be presented as a ‘detox diet’, but it is actually being used to detect food intolerances.)
With new forms of therapy springing up all over the place, a healthy scepticism is a distinct asset for the consumer. Be sceptical about any diagnostic test or treatment that is

only being practised by one person in the country, or in the world - when doctors hit on something that works, they want other doctors to try it out. World exclusives in

medicine are usually suspect.
Avoid any practitioner who tells you to stop using your drugs without your doctor’s consent. Likewise, avoid those with a messianic gleam in their eye, an evident disregard for

logic or reasonable discussion, or an amazing cure that fixes everything from acne to AIDS. Very few of those who sell bogus cures and phoney diagnostic tests are complete

rogues. Most are nice people who are quite genuinely convinced that they have indeed found the answer to people’s problems. The powers of placebo effect (see p. 233) can sustain

such a conviction for a very long time.

‘I get ill if I do a long coach journey - six or seven hours say. I usually feel sick by the end of the journey, and have a headache. The funny thing is, if I’m walking along

the street and I happen to see a coach of the kind that I do long trips on, I feel a bit sick then too, just for a short while. It seems crazy, but I get ill just from seeing

the coach.’
What Jake is observing is the powerful effect of the mind on the body, in the reaction known as conditioning. Some people are more susceptible to it than others, but no one is

completely immune.
The Russian scientist Ivan Petrovich Pavlov first demonstrated conditioning in 1889, with his famous dog-and-dinner-bell experiment. Pavlov rang a bell every time he fed the

dog, and eventually the dog would salivate each time it heard the bell, whether dinner was being served or not. Its stomach would also begin to secrete acid, in anticipation of

the meal, simply on hearing the bell.
Modern-day experiments have shown that conditioning works with immune reactions too. For example, rats can be conditioned by repeatedly giving them an immunosuppressive drug and

always adding saccharin to their drinking water on the day the drug is given. Subsequently, just the taste of saccharin in the water is enough to- suppress their immune

responses.
This surprising discovery is partially explained by the finding that there are nerves running to the lymph nodes – key areas where the immune responses are coordinated. In other

words, the immune system and the nervous system, once thought of as completely separate domains, are in conversation with each other. In fact this is a three-way discussion,

because the hormones are also involved. The study of these complex interactions,
which we are only just beginning to understand, is known as psychoneuroimmunology.
Even before Pavlov carried out his classic experiment, Dr John MacKenzie of Baltimore had discovered that an artificial rose, in the vase on his desk, would bring on an attack

of rhinitis and asthma in one of his patients who believed that she was allergic to roses. (In fact such an allergy is unlikely –see box on p. 127. It is usually the strong

scent that triggers symptoms, the allergy being to something else, often grass pollen, which is in the air when roses flower.)
Much more recently, something similar happened – this time unintentionally – when a boy with severe hayfever and pollen asthma was undergoing hypnosis aimed at helping him

relax. Part of the hypnotist’s standard technique was to describe an idyllic scene in an alpine meadow, and ask the subject to imagine being there. For this boy, it worked all

too well – the thought of the grass pollen in the meadow brought on a severe asthma attack. The hypnotist, with great presence of mind, asked him to imagine a helicopter

suddenly appearing in the sky and rescuing him from the meadow – and the asthma attack subsided. How allergies affect the mind
In studying the psychological aspects of allergy, researchers have discovered that some patients frequently have thoughts that catastrophise the situation. In the case of atopic

eczema, these thoughts might go along the lines of ‘this terrible itching will never end’ or ‘none of the treatment really makes much difference’.
Such thoughts may be just below the surface of the conscious mind most of the time, and it is only by developing the ability to notice what is going on internally that the

allergy sufferer can become aware of them.
Researchers have also found that, when negative thoughts such as these arise, eczema sufferers are far more likely to scratch their skin and so make the eczema worse. Thus the

thought becomes a reality – a self-fulfilling prophecy.
The tendency to catastrophise difficult situations is something that most people develop (or acquire from others) at a very young age, and it may take some effort to even become

aware of this mental habit, let alone change it. Yet it is possible to start thinking about illness, and about life in general, in a different way – for example, as a difficult

challenge but one that can usually be overcome.
Allergies are in no sense unique. Any long-term disease that causes intense discomfort, makes life unpredictable or limits your activities, is bound to have profound effects on

the personality. However strong a person you are, it affects your life, and influences you in a very deep way – shaping you as a thinking and feeling individual. This is

especially true if illness begins at an early age, becoming part of your formative interactions with your parents (see box on p. 233) or marking you out as different from other

children.
This shaping can have both positive and negative aspects, and it is important to recognise that there is a choice about which aspect you emphasise. It is never too late to try

to change the emphasis. Counselling or psychotherapy (see p. 225) may help with this, especially if the counter-productive attitudes to the illness are deeply rooted in family

experiences.
The role of the mind in asthma
The diagnosis of intrinsic asthma has long since been abandoned. This diagnosis, which was commonplace in the 1950s and 1960s, technically meant ‘asthma with no external cause’.

But the widespread assumption was that the cause was psychological. As older asthmatics will tell you, this made their lives particularly miserable, because they were held

responsible for their disease. Families were often ashamed of having an asthmatic child.
The injustice of this sweeping assumption is clear today. Modern research shows that an external stimulus which initiated the asthma, such as an allergen, can usually be found.

Among asthmatic children, an allergic cause exists in 80-90% of cases. Even where no specific stimulus can be found, there is still a clear-cut state of inflammation in the

airways. No one with any knowledge of asthma would now claim that it is an entirely psychosomatic disease, nor even that it is predominantly psychosomatic.
Nevertheless, once asthma has begun, the mind may play an important role in bringing on attacks, or making them worse, as many asthmatics know from their own experience. This is

entirely understandable when you think how closely breathing is tied up with our emotional lives – fear, sadness, excitement and anger all alter the usual breathing pattern in

different ways, and any of these reactions may trigger an asthma attack.
The interactions between the mind and the airways are complex in the extreme, and vary from one person to another. Anxiety and tension can make asthma a great deal worse for

some people, while others only suffer an asthma attack when the stress is over. A few people actually have less trouble with their asthma when under stress and, oddly enough,

this is the reaction that is easiest to explain. Stress activates the sympathetic nervous system (see box on p.235), which produces adrenaline, and the adrenaline opens up the

airways.
For stress to make asthma worse, as it frequently does, there must be some other reaction going on which overrides the effect of the adrenaline. Doctors don’t know exactly what

this is, but asthmatics who get worse when stressed could be hyperventilating (see p. 226) just a little – not enough for it to be obvious, but enough to make their airway

muscles contract.
Breathing through the mouth, rather than the nose, can also occur under intense stress, and this is bad for the airways because the air they receive tends to be drier, dustier

and possibly colder, for not having passed through the nose first. This raw air may irritate the sensitive airway linings of an asthmatic, and so make the airway muscles

tighten. Small local nerves, that run directly from the airway linings to the airway muscles, could cause this reaction.
Scientific tests, carried out in a laboratory, back up these casual observations. For example, many people who are allergic to grass pollen will suffer an asthma attack if the

experimenter says they are inhaling grass pollen through a mouthpiece – even though they are actually inhaling fresh air.
It can work the other way as well. Telling the same asthmatics that they are now inhaling a reliever drug will stop the attack, even though they are still breathing the same air

as before. This is the basis of placebo effect, the benefit that tends to occur with any treatment, even a dummy pill, as long as patients believe that the treatment will work.
Note that it is not necessarily the immune system producing all these reactions. There are also direct effects of the mind on the skin, in atopic eczema, on the airway muscles,

in the case of asthma, and on the nose, in rhinitis. Some of these are due to the autonomic nervous system (see box on p. 235) while others are much less well understood.
The findings described above should be reassuring for anyone who has noticed that their allergy or asthma symptoms are sometimes affected by their thoughts and feelings. There

is no need to feel bad about this, and it certainly doesn’t mean that your allergies are ‘all in the mind’. Conditioning, and other psychological responses, are an entirely

natural reaction to a very real illness.
However, if you suspect that psychological reactions are making a big contribution to your symptoms, you could try to address the problem directly. Hypnotherapy (see p. 223) can

be particularly useful in this regard, because those who are most susceptible to conditioning are also very responsive to hypnotic suggestion – which can counteract the

conditioning messages. Hypnotherapy can also help those asthmatics who
become psychologically dependent on their inhalers – something that happens quite often, especially in people with severe asthma. In the words of one asthmatic ‘If I found that

I’d left my Ventolin at home, that would sometimes start me off wheezing straight away. I was so afraid of being without it.’ Of course, it is important to carry your reliever

inhaler with you at all times, but this kind of excessive psychological dependence is distinctly unhealthy. At worst, it can lead you to over-use your reliever inhaler, which

can increase your risk of a life-threatening asthma attack (see pp. 153-4).
Sometimes the psychological effects involved in allergies and asthma are far more complex and deep-rooted than this, not just a matter of simple conditioning. It is not uncommon

for asthma attacks, in particular, to be provoked by family tensions and anxieties, or by suppressed memories from childhood. This can occur even though the asthma also has a

clear-cut physical cause, such as an allergy to house-dust mite. Some people find that their asthma always gets worse when they are in a certain place, with a certain person, or

in a particular situation. These problems are usually helped by psychotherapy (see p. 225).
While hypnotherapy and psychological treatments can sometimes be valuable, it is vital to remember that the mental factors in allergic reactions are always operating in

combination with purely physical responses – such as the triggering of mast cells by allergens (see box on p.12). Using psychological treatments alone is as much of a mistake as

ignoring the mental and emotional dimension of ill-health completely. The two aspects of treatment – physical and psychological – should always go hand in hand. Be very wary of

alternative therapists who overemphasise the psychological aspects (see p. 209).
Under the skin
To see a baby with severe eczema is heart-breaking for any parent – tormented by something it cannot understand, the child often experiences touch, not as a comforting and

pleasurable contact, but as a further irritation. According to some psychologists who have studied eczema in depth, suffering from severely itchy skin in the early years of life

may create long-lasting psychological problems. They believe that the discomfort associated with the skin, and especially with being touched, interferes with normal processes of

relating to the world and developing loving relationships with others. That is why it is so important to get the skin symptoms under control, with the proper use of steroid

creams, skin care, dietary changes if appropriate, and an anti-scratching programme (see p. 47).
Psychological symptoms from sensitivity reactions
‘People thought that because the hospital couldn’t find anything wrong with me, and because I wasn’t terminally ill, there was nothing wrong with me at all. No one could

understand how I was feeling, or even believed me. My friends and family lost patience with me. I overheard one member of my family saying they thought I was just

attention-seeking. This hurt me so much. I hated being ill all the time. I wanted to go out and enjoy myself and do the things I’d always done, but I couldn’t because I felt so

bad.’
Josey, who is now 27, was ill in this way for seven years, and her symptoms were so incapacitating that she had to give up work and abandon any sort of social life. Now, as she

puts it, ‘I have my life back again.’
The cause of her symptoms – dizziness, confusion, panic attacks, depression, shortness of breath, and a conviction that she was dying – turned out to be a sensitivity to

caffeine which was inducing hyperventilation (see p. 226). Giving up tea, coffee
and cola drinks restored her to normality very promptly, and she has not relapsed since, except on one occasion, when she unwittingly took a headache remedy that contained

caffeine.
What is clear from Josey’s story is how much the disbelief of those around her added to her problems. She felt trapped by her symptoms, which she could not overcome, while

everyone around her assumed that the whole problem was in her head, and that she could ’snap out of it’ if she chose to.
The suffering of patients like Josey could easily be avoided if more GPs knew how to recognise hyperventilation. This is one of those conditions that is well described in the

medical literature, but does not always get onto the curriculum in medical schools. As a result, many hyperventilating patients go through a lot of expensive and time-wasting

investigations, and may not get a proper diagnosis even then. This is especially sad when hyperventilation is so easy to diagnose and treat (see p. 228).
While the symptoms of hyperventilation are easy to spot, once you know what to look for, this is certainly not true of all
The autonomic nervous system
The autonomic nervous system is a kind of ‘auto-pilot’ – a set of controls that generally keeps you well adjusted to your external circumstances without you having to think

consciously about the situation at all.
The autonomic nervous system controls all the involuntary muscles – those in the heart, around the digestive system, and around the airways. It also controls the state of the

blood vessels, including those in the skin. The autonomic nervous system does its work by issuing two different sets of signals – one set that gears the body up for action and

one set that calms the body down.
Two completely separate nerve networks, the sympathetic nervous system and the parasympathetic nervous system, issue these different signals. The target organs – the airways,

heart, skin, and so on – all receive input from both networks.
The ‘get active’ signals are issued by the sympathetic nervous system, which comes into play at times of stress, excitement, fear or anger. When you can hear your heart pounding

or feel your pulse race, that is your sympathetic nervous system at work. It also makes your nasal passages and airways open up, because extra oxygen is needed for intense

physical activity, and it tightens the muscles around the blood vessels, which raises your blood pressure.
‘Chill out’ messages are delivered by the parasympathetic nervous system. This network comes on-stream when you know you can afford to relax. It slows down the heart, lowers the

blood pressure, encourages the digestive system to do its work, and makes the airways grow narrower because less air is needed when you are less active.
Adrenaline (epinephrine) is the messenger substance released by the sympathetic nervous system. Its action in tightening the muscles around the blood vessels allows adrenaline

to be employed as a drug, which saves the lives of people affected by anaphylaxis (see p. 150). During anaphylaxis, there is a massive fall in blood pressure produced by

histamine (see box on p. 12), but an injection of adrenaline can reverse this.
Both adrenaline and its derivatives, the beta-2 relievers such as Ventolin (see p. 152), also help in asthma attacks. They do this by making the muscles around the airways

relax.
The messenger substance of the parasympathetic nervous system is acetylcholine. Drugs which oppose its action – the
anti-cholinergics – can also help relieve an asthma attack (see p. 156) by blocking the airway-narrowing action of the parasympathetic.
One of the ways in which acupuncture appears to work is by adjusting the activity of the autonomic nervous system. When
acupuncture is used to deal with the immediate symptoms of an asthma attack, this is probably how it makes the airways open up.
sensitivity reactions. Food sensitivity can occasionally cause some unexpected psychological symptoms, such as bouts of hysterical crying (see p. 80) that no conventional doctor

would ever associate with food.
Inevitably, patients with sensitivity problems such as these will initially be diagnosed as having a psychological illness rather than a physical one. It may be a very long time

before the correct diagnosis is established.
Even if the patient works out the link between eating the food and experiencing the psychological response, the doctor may well remain unconvinced. What complicates matters for

doctors is that quite a few people with genuine psychological problems would prefer to think that these have a non-psychological cause, such as a sensitivity to food. (In the

opinion of most doctors, patients of this kind are far more common than patients with psychological problems that are genuinely caused by food or chemical intolerance.) For such

patients, accepting that their problems have a psychological cause means thinking about what that cause might be – and it is often something deeply distressing which the person

would rather forget.
Unfortunately, for people who get into this situation, the phoney explanation doesn’t actually help at all, though it can provide a temporary distraction. Ignoring unpleasant

hidden memories is not the answer – the problem does not go away, it just festers. Facing up to the real underlying problem is the only way to get rid of the distress (see p.

225).
If you have psychological symptoms of any kind, bear in mind that psychological causes are by far the most likely. Such causes can include difficult life circumstances, damaging

experiences during childhood, loss of close relationships, or extremely traumatic incidents in the more recent past. Where there are longstanding problems, neurological factors

(damage to the nerves or brain) or metabolic factors (something affecting the balance of chemicals in the brain), might also play a part, or sometimes be the sole cause.
For a busy doctor, without much time to spare, it is immensely difficult to distinguish patients who really do have psychological symptoms due to food or chemical intolerance,

from patients with psychological problems that they have mistakenly attributed to an intolerance reaction.
What adds to the difficulty is that, with time, psychological causes can sometimes be grafted onto a straightforward intolerance problem. This occurs because illness of any kind

can produce some psychological problems of its own, especially if the person affected cannot lead a normal life. The psychological effects of the illness invariably get worse if

the person concerned has been treated with disbelief by doctors, family or friends – as
is frequently the case when a person has indefinite long-term symptoms that are due to food or chemical intolerance. Separating the secondary psychological reactions to the

illness (or to the scepticism of others) from the primary psychological symptoms that are genuinely produced by the intolerance reactions is far from easy.
Hyperventilation and chemical intolerance
Hyperventilation (see pp. 226-9) and chemical intolerance (see p. 84) often go hand in hand. A person who is sensitive to airborne items which they cannot avoid inhaling, such

as perfume or petrol fumes, may well feel apprehensive when they catch a whiff of these, and unconsciously alter their breathing in response. They may hyperventilate.
If they do, this can both aggravate the sensitivity symptoms, and increase their anxious feelings – because one key symptom of hyperventilation is anxiety (see p. 227). In this

way the problem begins to feed upon itself, and can spiral out of control.
Hyperventilation, pure and simple, may also masquerade as chemical intolerance. In these cases, a deep underlying anxiety probably exists in the person concerned, and one way in

which this expresses itself is as a fear of synthetic chemicals. The person’s fear triggers hyperventilation, which is the initial cause of symptoms. That is not how the person

interprets those symptoms however – because the person was anticipating a reaction to synthetic chemicals, the symptoms seem to confirm that a reaction has occurred. Again, a

vicious circle has been started which is hard to break.
Another possible scenario is that someone with a few sensitivity reactions – for example, a reaction to perfume and cigarette smoke – starts to feel concerned about other

chemical sub-
‘ and to suspect that these might also cause problems. If an anxious reaction to the presence of these substances develops into hyperventilation, symptoms will ensue from the

hyperventilation. These symptoms will appear to confirm the person’s fears about yet more sensitivity reactions. In this way, people with relatively mild chemical intolerance

can begin to believe that their chemical intolerance reactions are far more extensive and disabling than they actually are.
Where the symptoms of hyperventilation are all tangled up with symptoms due to genuine chemical intolerance, opinions tend to split. Some doctors will interpret all the symptoms

as psychological, while other doctors will attribute them all to the intolerance. Both are over-simplifying the problem, and missing a crucial ingredient – hyperventilation.

Recognising and treating hyperventilation (see p. 228) can help a great deal to alleviate the illness.
The psychologisation of illness
‘From the moment Joanna was born, she was never hungry’ Sandra recalls. ‘It took all day to force an ounce of milk down, and she seemed to have terrible stomach pains. At six

months old, after countless trips to the doctor, she was admitted to hospital. The hospital doctors couldn’t work out what was wrong, and in the end they said that she was just

very independent and that she wouldn’t eat until she could feed herself. I couldn’t believe my ears – what a thing to say about a six-month-old baby!’ But as far as the doctors

were concerned, that was that.
As Joanna got older, the symptoms got worse. She developed severe constipation, opening her bowels only once every four weeks. Because her over-full bowel put so much pressure

on her bladder, she wet herself several times a day.
‘She hated school, because the other children teased her, saying she smelled. And she had such awful stomach pains that she couldn’t bend down to tie her shoelaces. When she was

six she was admitted to hospital for a second time.
‘Again they said there was nothing physically wrong with her and it was all in her head, and this time they decided that it must be because something traumatic had happened at

home. They wanted her to see a psychiatrist. It was terrible. I knew nothing like that had happened to her at home, but it was impossible to convince them.’ There was talk of

Joanna being taken away from her parents, because of suspicions about child abuse.
Two weeks before seeing the psychiatrist, something happened to change Joanna’s life. Sandra saw an item on television about a book on food allergies. She bought the book and,

remembering how fiercely Joanna had rejected milk as a baby, she hazarded a guess that milk was the problem. She immediately took all dairy products out of Joanna’s diet.
The effect was astonishing. ‘Within 12 hours her tummy ache had gone, and after six weeks she began opening her bowels almost every day. She stopped wetting herself, and was so

much happier and healthier.’ In fact, all of Joanna’s symptoms went away. and she has remained well on a milk-free diet.
Psychologisation is most frequently encountered by patients %vith medical problems that are unrecognised by conventional medicine – Joanna is a typical example of such a

patient. Occasionally, however, those with true allergies find themselves in the same situation. Take, for example, someone who has collapsed after being stung by a wasp but

gives a negative skin-test result to wasp venom. In the case of insect-sting allergy, skin-tests are supposed to give very few false negatives – so the doctor may be sceptical

about the patient’s observation of what happened. A PAST test (see p. 92) may be ordered, but sometimes this too gives a false negative.
Doctors are – not unreasonably – more inclined to believe that the patient is an unreliable witness (there was never any insect involved), or that the patient has a

psychological problem that has led to this consultation, than that both these tests gave a false-negative result. A patient in this position may need to be quite persistent to

get proper treatment. The same goes for anyone else with unusual allergic reactions that are initially labelled ‘psychological’ by their doctor. In such cases, good

communication is everything.
Good communication with your doctor
Given the intense pressure under which they work, doctors often react badly to symptoms that don’t fit into a neat diagnostic pigeonhole, or don’t respond to standard treatment.

They simply do not have the time for unravelling complex problems and there is a common tendency to ‘psychologise’ such symptoms automatically. This often does great damage to

the patients concerned, boxing them into a corner from which it is impossible to escape – the more they try to convince the doctor their symptoms are genuine, and request

further tests or treatment, the more the doctor views them as difficult, demanding patients with psychological problems. Unfortunately, it is part of the dogma about

psychosomatic illness that patients affected by it will object vehemently to such a diagnosis. So the more you insist that the symptoms are not psychological, the more this

confirms the diagnosis as far as many doctors are concerned.
The psychologisation of illness becomes a real nightmare where the patient is a child, and parents are accused of actually causing the symptoms in some way (see Joanna’s story,

left). This has happened more than once to children with unusual sensitivity reactions.
Good communication skills may stop you from sliding into this situation with your doctor. Firstly, whatever else you do, stay very very calm. Getting emotional, agitated or

angry always causes doctors to suspect a psychological cause for your symptoms.
Secondly, be very open with the doctor, and don’t conceal anything. Be clear about describing symptoms, and accurate about times, the intensity of the reaction and any other

details. Never, ever exaggerate. If you are given to describing things quite colourfully in everyday life, tone it down as much as possible for your doctor’s benefit.
Thirdly, don’t make your own diagnosis – doctors are taught to believe that patients who diagnose themselves may well be suffering from hypochondria. Present any medical

knowledge you have acquired from books or the Internet as tactfully as possible. Finally, it will probably help a lot to use the appropriate words to describe your illness when

talking with the doctor.

Acupuncture
Acupuncture shot to fame in the West in 1972, when James Reston, a correspondent for the New York Times, fell ill with appendicitis while covering President Nixon’s historic

trip to China. Following the removal of his appendix, he received acupuncture treatment for pain, and was highly impressed with its effects.
His Chinese doctor invited Reston to witness the use of acupuncture in anaesthesia, and he reported the remarkable fact that patients undergoing surgery could be free from pain

with just a few tiny needles inserted into carefully chosen points on the body. They remained alert and talkative throughout the operation.
Traditional Chinese medicine has enjoyed a good reputation in the West ever since, but what few people realise is that acupuncture anaesthesia is a very new invention. Surgery

was not traditionally practised in China and it was only in the 1950s, after Chairman Mao had urged Chinese doctors to unify Western and Chinese medicine, that the anaesthetic

potential of acupuncture was discovered.
The remarkable effects of acupuncture anaesthesia made a huge impression on doctors in the West – a high-profile success that has had both good and bad results. On the positive

side, conventional medicine has been prepared to take acupuncture seriously, and to undertake some research into its effects. On the negative side, most
of that research has concerned pain control – the effects of acupuncture on the endorphins. These are natural painkilling compounds produced by the body (their effects are

mimicked by opiate drugs such as morphine and heroin).
Western researchers have paid little attention to how acupuncture affects most other aspects of health, including the immune system and allergic diseases. One exception to this

is asthma, where certain nerves do play a large part in producing the symptoms (see box on p. 235).
Treating the person
Diagnosis and treatment are far more orientated towards the individual patient-, in traditional Chinese medicine, and diagnostic labels such as ‘allergy’ or `hayfever’ are less

important than the particular character of a person’s Qi (see box on p. 215), as detected by the acupuncturist. A traditional Chinese acupuncturist pays great attention to the

quality of the different pulses and takes them at the start of every appointment, and at intervals during treatment, to check how the Qi flow has changed. Each treatment session

is unique and tailored to the individual’s condition at that particular moment.
This makes it very difficult to carry out conventional scientific research into traditional acupuncture.
In an effort to make acupuncture accessible to research, a more Westernised and formulaic approach has been developed, using orthodox medical diagnosis and needling a set of

acupuncture points that are prescribed for that medical condition. Experts in traditional acupuncture feel that this approach – first name the disease, then apply a standard

remedy – will often fail, and is missing the whole point of acupuncture.
That is not the only problem with Westernised acupuncture, as Dr David Eisenberg of Harvard University, a leading expert on acupuncture, points out. He describes a typical

acupuncture session in China: ‘Each time the acupuncturist inserts a needle, he or she asks the patient, “Do you have it or not?” referring to the patient’s “obtaining the Qi”

(de Qi). The question asks whether the patient has felt a sensation of fullness, distension, pins and needles, or the like, from the insertion of the needle in the spot being

used… Most Chinese have experienced acupuncture and they understand the phenomenon of de Qi… By contrast, most Western patients seeking acupuncture therapy know nothing of

the phenomenon of de Qi. Not knowing what sensations they should anticipate, they cannot tell the acupuncturist whether a needle is in the right place. When both therapist and

patient know little about de Qi, as frequently occurs in Western acupuncture clinics, the result is bound to be disappointing.’ Fortunately it is possible to find acupuncturists

who have been properly trained, and the sensation of ‘obtaining the Qi’ is perfectly detectable, even to a sceptical Westerner, so look for someone who pays attention to this.
There can be emotional and psychological reactions to acupuncture, so make sure that you also feel relaxed with your acupuncturist and that there is a certain empathy between

you.
Does acupuncture work for allergies?
According to Chinese theories, acupuncture can have some benefits in any illness – if you are ill, your flow of Qi must be disturbed, and it will help to put that right. Indeed,

most people do feel a sense of well-being after an acupuncture session.
To look at this from a Western scientific perspective, acupuncture can stimulate your body to increase its production of endorphins (see p. 214). This gives you a mild high,

similar to that you’d get from running for a couple of hours. Feeling relaxed and confident helps most people to cope better, and gives them a new perspective on life’s

problems. Since the mind plays some part in almost all illness (if only to aggravate the effects of an underlying physical problem), inducing a more positive state of mind can

be of benefit.
As regards more specific effects, several studies show that acupuncture can have a small, short-term effect in opening up the airways of asthmatics. This is not surprising

because acupuncture affects the autonomic nervous system, the ‘auto-pilot’ section of the nervous system (see box on p. 235) which can tighten or relax the muscles around the

airways. A short-term effect is just that – it doesn’t treat the real problem. What matters more in asthma is the long-term impact of any treatment on the underlying

inflammation of the airways (see p. 36). Although some studies of acupuncture treatment have found a reduction in inflammation, other studies have not. However, only one study

to date used an individualised approach to acupuncture, as opposed to a same-for-everyone formula. It is interesting that this study did find good long-term effects on airway

inflammation.
The larger picture
Acupuncture is just one element of Chinese medicine, which has several other techniques available. In China (and in some Chinese clinics in the West) these techniques are used

together, as different ways of tackling the same problem. No traditional Chinese doctor would dream of trying to treat every patient with acupuncture alone and, in the case of a

patient with allergies, herbal remedies would usually be a central part of the treatment.
A recent and very careful scientific study from Germany took this combined approach with hayfever, and showed some benefit. The patients were treated with both acupuncture and

herbal treatment, using a standardised regime but with additional acupuncture points and herbs chosen to suit the individual. Those treated reported a substantial improvement in

how they felt generally –but not in the specific symptoms of hayfever.
The flow of energy
Acupuncture is rooted in ancient Chinese ideas of the human body. which are radically different from those of Western medicine:
•    Vital energy. called Oi or Chi (and always pronounced ‘thee’). is what distinguishes living bodies from dead ones. It should flow easily and harmoniously thrOLIC11011i

the body nourishing and protecting the organs. When the flow of Qi is blocked, or becomes unbalanced. then illness develops. - Channels called meridians are the conduits for Qi

in the body. They mostly run vertically (i.e. from head to toe) and the points where acupuncture needles are inserted all lie on these meridians.
•    The flow of Qi can be measured by carefully taking pulses — not just one pulse as in Western medicine, but several different kinds of pulse.
•    By detecting disturbances in the flow of Qi, and correcting them, existing illness can be cured, and incipient illness prevented, before there are any obvious symptoms.
The nature of the meridians and the acupuncture points remains a mystery to Western doctors. Some parts of the meridians run roughly along the lines of certain nerves or blood

vessels, but they do not follow them exactly. The acupuncture points have no anatomical reality — there is nothing to see either on the surface or under the skin. However, many

are located near major nerve endings or over deep pressure receptors.

Breathing Exercises
Breathing is a delicate art, and it is possible to get it wrong, in a variety of ways and for a variety of reasons. A poor breathing pattern can gradually become habitual,

without the person concerned being aware that his or her breathing is at all abnormal.
Allergy and sensitivity reactions sometimes play a part in causing abnormal breathing, and the symptoms produced by a poor breathing pattern may then augment the symptoms of

sensitivity, creating a vicious circle. Correcting an abnormal breathing pattern, by means of breathing exercises and re-training, can produce remarkable improvements in health

for some people.
Breathing too much
Taking in too much air, often called over-breathing or hyperventilation, is the most common breathing disorder. It can produce a variety of rather strange symptoms (see p. 227)

that are sometimes diagnosed correctly, and treated appropriately, but often get overlooked or misdiagnosed.
The primary purpose of breathing is to obtain oxygen from the air and absorb it into the blood. The lungs are a crucial interface here, a trading post for gases that are

exchanged between the bloodstream and the external air. The delicate, moist membranes that cover the inner surface of the lungs are accessed by millions of tiny thread-like

blood vessels known as capillaries. Oxygen from the air seeps into the blood through the thin walls of these capillaries. At the same time, the lungs clean the blood of carbon

dioxide, a waste gas produced by the body’s metabolism. As oxygen seeps into the blood, carbon dioxide seeps out.
That is the school-textbook view of breathing, and it is correct up to a point. But it is over-simplified and misleading if it simply portrays oxygen as totally
good and carbon dioxide as totally bad. In fact, there is a correct level in the blood for both gases, and too little or too much of either can cause problems.
Carbon dioxide plays an important role in the equilibrium of the blood because, when dissolved in any liquid, carbon dioxide makes a weak acid. So the amount of carbon dioxide

present is crucial in deciding the acidity of the blood. Given that the blood reaches every part of the body, it is not surprising that any changes from its normal composition

have far-reaching effects.
Normally, blood is very slightly acidic, and that is what the body is accustomed to. While some body parts can cope with small changes in the acidity of the blood, other parts

respond very badly. The nerve cells are particularly vulnerable to changes in acidity.
Hyperventilation, or over-breathing, has relatively little effect on the level of oxygen in the blood, which is carefully controlled, but it can lower the level of carbon

dioxide in the blood, thus making it less acid. More commonly, hyperventilation just makes the level of carbon dioxide vary a great deal.

When the carbon dioxide levels in the blood yo-yo about all the time, this has some unpleasant effects. In particular, it disrupts the smooth running of the nerve cells, which

is why many of the symptoms of hyperventilation involve the senses, feelings or behaviour.
The symptoms of hyperventilation can include:
•    numbness or pins-and-needles in the hands and feet, occasionally affecting the lips and tongue as well
•    difficulty in swallowing
•    aching muscles, cramps, tremors and twitches
•    sudden loss of strength in the muscles
•    dizziness, confusion, unreal or spaced-outfeelings
•    blurred vision, ringing in the ears
•    headache, migraine
•    breathlessness
•    aching in the chest
•    abnormal heart rhythm
•    sensitivity to bright lights and loud noises.
There may also be some severe psychological symptoms:
•    panic – a brief but intense state of anxiety
•    prolonged anxiety or depression
•    hallucinations, although this is rare
•    mood swings and phobias, most frequently a fear of dying. The irrational conviction that death is imminent can be overwhelming, even in someone who is young and

apparently in good health.
Each of these symptoms can, of course, be caused in several other ways, but when this whole cluster of symptoms – or a large number of them –occurs together in an individual,

that person is very likely to be a hyperventilator.
When there are short self-contained bursts of hyperventilation, the effects are often described as a panic attack. Doctors usually have no trouble recognising this problem, but

– not surprisingly – are often misled by the sustained psychological symptoms of chronic (long-term) hyperventilation. Many people with chronic hyperventilation are diagnosed as

having some kind of mental illness, and they may go for years without getting the right diagnosis.
Hyperventilation and sensitivity reactions The link between sensitivity reactions and hyperventilation seems to be a complex one. Unfortunately, very little research has been

done in this area, so what follows is based on the case-histories of patients, and the collective experience of doctors, not on hard scientific data.
In some cases, a sensitivity reaction may
directly provoke a change in breathing pattern. This
is what appears to happen for some people with
caffeine sensitivity. Cutting out all caffeine-con-
taining drinks (coffee, tea and colas) seems to put a
stop to the hyperventilation symptoms, because the
multiple symptoms promptly disappear (see p. 235).
In other cases, a severe sensitivity problem such
as multiple chemical intolerance results in an anxious
state of mind, and the anxiety leads to hyperventi-
lation. Hyperventilation, pure and simple, may also
masquerade as chemical intolerance (see p. 236).
Wheezy as a mountain breeze
Ionisers — devices that supposedly turn indoor urban air into a fresh mountain breeze — are often promoted as alternative devices that can clear allergens from the air. They do

remove some allergens, but in the case of asthma, research shows that some ionisers can actually make symptoms worse, by generating ozone which irritates the airways. It is

usually the cheaper ionisers that do this. More expensive models are less likely to produce ozone, but they are unlikely to help either. Several scientific trials show that

ionisers have no significant benefits when used by asthmatics.
Hyperventilation and asthma
While hyperventilation can develop in anyone, asthmatics are particularly vulnerable. During an asthma attack, especially a severe one, developing an abnormal breathing pattern

is an entirely understandable reaction. In an attempt to get more air, you may start breathing more rapidly and taking air into the upper chest, using the accessory muscles of

breathing (see p. 230). These muscles should not normally be used when you are at rest — they exist to give you extra breathing capacity when running fast.
As long as the asthma attack lasts, this forced breathing does no harm, because its effects are cancelled out by the narrowing of the airways. But if this over-breathing

persists after the attack has ended, then too much air is going in and out of the lungs, so carbon dioxide levels in the blood begin to fall.
Simply feeling anxious can also trigger off rapid upper-chest breathing. If you get very worried when an asthma attack starts, you may begin hyperventilating just out of

anxiety.
For asthmatics, in addition to the usual symptoms of hyperventilation (see p. 227) there are some subtle effects of hyperventilation that can make asthma worse:
•    The airway muscles (and all other muscles that are not under voluntary control) contract slightly when carbon dioxide levels in the blood fall.
•    Mast cells are quicker to degranulate (see box on p.12) when
there is less carbon dioxide, and this triggers allergic symptoms. Just to complicate matters, one of the symptoms of hyperventilation is breathlessness. Sometimes this is the

most prominent symptom in non-asthmatic hyperventilators, and the doctor overlooks the other symptoms and gives a diagnosis of asthma. In such cases, people are told they have

asthma when they are actually suffering from hyperventilation alone.
Testing for hyperventilation
You can do two simple tests for hyperventilation at home, if you think that it could be playing a part in your symptoms. (If you are asthmatic, only do these tests when you have

no asthma symptoms and your peak-flow reading is good. Make sure your reliever inhaler is nearby, in case of a bad reaction to the test.)
The first test should be done when you have some symptoms that might indicate hyperventilation (see p. 227).
Find a clean paper bag and hold it over your nose and mouth while breathing normally. Any symptoms that are due to hyperventilation should clear up, because, by re-Inhaling the

air that you have just breathed out, you will increase the level of carbon dioxide in your blood.
The second test is done when you don’t have any of the symptoms listed for hyperventilation.
Speed up your breathing, and inflate your upper chest with each breath. Do this for a few minutes. Do any of your usual symptoms appear? If they do, this suggests that they may

be caused by hyperventilation.
If either of these tests indicates hyperventilation, make an appointment to see your doctor. It is important that you should have a proper medical diagnosis, so that you get the

right professional treatment.
Treating hyperventilation
If you hyperventilate, you could be taught a more healthy breathing pattern by a physiotherapist — ask your doctor for a referral. Certain complementary therapists, such as

osteopaths and Feldenkrais practitioners, can also teach good breathing patterns, and so can experienced yoga teachers (see p. 224). A teacher or therapist who works at a

relaxed pace, is not too dogmatic, and helps you to find your own way to healthy breathing, is preferable to one who tries to impose a regimented breathing pattern on you.
On the assumption that most hyperventilators don’t just over-breathe, but also breathe with their upper chest and under-use the diaphragm (see pp. 229-230), all these different

practitioners will take a combined approach — tackling both sides of the problem at once. This represents an important difference from the Buteykc, method (see below).
The Buteyko method
The stated aim of the Buteyko method (also called the Buteyko treatment) is to stop people from hyperventilating. However, Buteykc, practitioners do not work with people who

have the symptoms of hyperventilation, as recognised by conventional medicine (see p. 227). Instead they work with asthmatics — any asthmatics, not just those whose symptoms

suggest that they might be hyperventilators.
The rationale for this is the claim, by the originator of the exercises, Professor Konstantin Buteyko, that asthma is actually caused by hyperventilation. (What is more,

Professor Buteyko cites hyperventilation as the cause of no fewer than 150 different diseases, including allergies, eczema, migraines, insomnia, bronchitis, high blood pressure

and haemorrhoids. However, his treatment is only marketed for asthma.)
The claims made for the success of the Buteyko method in treating asthma are startling. According to one training centre, it can get 97% of asthmatics off most of their drugs

and able to control attacks within a week of starting.
Not surprisingly, this is a bit of an exaggeration. But the real achievements of the Buteykc, method are still quite impressive: an Australian research study showed that during

the course of Buteyko lessons, the overall use of reliever inhalers (e. g. Ventolin) fell substantially and remained relatively low three months later. However, the patients’

average peak flow stayed the same, and 15% of those studied were admitted to hospital with a severe asthma attack during the trial. In the eight months that followed, 30% needed

a course of steroid tablets – indicating a substantial worsening in their condition. In other words, the Buteyko method can give some help to many asthmatics, but the claim that

it can get almost everyone off asthma drugs and free of asthma is just hype.
Professor Buteyko’s claim to have discovered the fundamental cause of asthma is clearly untrue. What he seems to have discovered is that there are many more hyperventilators

among asthmatics than was widely realised, and that they generally show no obvious symptoms of hyperventilation. His other important contribution is to suggest that

mouth-breathing may create a lot more problems for asthmatics than previously recognised.
The Buteyko method has three aspects:
•    unblocking the nose
•    training to breathe through the nose, not the mouth
•    training to take fewer breaths and pause between breaths. Unlike other treatments for hyperventilation (both conventional and alternative), the original Buteyko method

pays no attention to teaching asthmatics to breathe with the diaphragm. However, a few Buteyko practitioners are now beginning to incorporate this aspect of treatment.
If you decide you would like to try the Buteyko method, there are several different options. Classes are the most expensive route, with very high fees being charged. There are

video cassettes you can buy, which are less expensive. Alternatively, there are various books, which are much less costly, and which explain how to do the exercises (see p.

255).
Whichever option you choose, it is vital that you get your doctor’s permission before starting. Ensure that your reliever inhaler is in your pocket while doing the exercises,

because they could provoke an asthma attack. Keep taking your preventer drugs regularly throughout the treatment. If you start to feel much better and want to reduce your dose

of preventer, you must talk to your doctor first.
Don’t follow the Buteyko method blindly, because some of the advice given is dangerous. For example, some Buteyko publications advise you to refuse oxygen if you are taken to

hospital with a severe asthma attack. They claim that oxygen levels in the blood are not reduced during a severe asthma attack, but this is just not true. Measurements clearly

show that the level of oxygen
gets very low, and this is frequently the cause of death.
Another very peculiar Buteyko idea is that you should not try to shift mucus from your airways because mucus ‘protects you’ against losing too much carbon dioxide. This too is

dangerous advice. Accumulated mucus narrows the airways, adding to your asthma symptoms, and it can even block a small airway completely. The part of the lung served by that

airway then collapses – a serious complication that no asthmatic would want.
Using the right muscles
Hyperventilation is often linked with an abnormal way of breathing, in which the wrong muscles are used. This is one common pattern that conventional doctors recognise for

hyperventilators:
•    The main muscle of breathing – the diaphragm (see below) is not used fully
•    The muscles of the upper chest become involved in breathing, even at rest, when they should not be needed
•    There are lots of rapid, shallow breaths
•    The breathing is quite irregular, with deep, sighing breaths from time to time, or frequent yawning.
Even in those who do not hyperventilate, breathing with the upper chest, and/or neglecting the diaphragm, can become a problem. This pattern of breathing is sometimes linked to

anxiety and emotional problems (see p. 230).
To understand what goes wrong, you need first to know about the healthy way to breathe.
The rib-cage and the diaphragm are the work-horses of breathing. You can feel your rib-cage through your skin, and feel its movements, but the diaphragm is far more

inaccessible. It lies below the lungs, but above the stomach and intestines.
In its contracted state, the diaphragm becomes a thick slab of muscle, with a slight curve, like an inverted saucer. When it relaxes, it becomes far more curvaceous, changing to

a shape like an inverted bell. In this shape, there is less space for the lungs above the diaphragm.
If you are breathing correctly, the diaphragm contracts when you breathe in and relaxes when you breathe out. The contraction lowers the dome of the diaphragm, pulling the base

of the lungs downwards and so making them expand.
Breathing out requires no muscular force whatever, as long
as you are just sitting or walking about (and therefore not breath-
ing hard). The lungs are naturally elastic, like balloons, so they
automatically contract and force out the air, once the diaphragm
relaxes into its bell-like shape and stops pulling them downwards.
While you cannot feel the diaphragm itself, you can feel the
effect of its in-breath contraction. As it contracts, the diaphragm
pushes down on the stomach and intestines, so that your abdomen bulges out a little with each breath. Western women, conditioned to admire an unnatural flat-bellied body shape

(unnatural for a woman, that is), often breathe badly because they are trying to ‘hold the tummy in’. This steely tightening of the muscles across the front of the abdomen

opposes the contraction of the diaphragm, and prevents a natural and relaxed in-breath.
The diaphragm should do virtually all the work of breathing in, when you are not exerting yourself much. The upper part of the rib-cage should hardly expand at all and the

muscles that run between the ribs, the intercostal muscles, should not be working.
When you become more active, and therefore need more oxygen, the upper chest automatically starts to expand with each in-breath. At this point the intercostal muscles become

involved, along with a whole team of other muscles in the chest region —these are known as the accessory muscles of breathing.
The effects of an asthma attack
In the grip of a severe asthma attack, you may well start using the accessory muscles of breathing to try to take in more air. If you have frequent attacks, or if this way of

breathing gets to be a habit and goes on between attacks, then the chest may be distorted by the constant use of the accessory muscles, plus the over-inflation of the lungs.

Severe asthmatics often have high shoulders and a `barrel-chested’ look as a result of this. Hyperventilation may also start in this way.
Observing how you breathe
To discover whether you are breathing with your diaphragm or your upper chest, lie on your back with your left hand on your belly, and your right hand on your upper chest. Just

lie still for a few minutes, let your arms relax, then start to pay attention to your hands. When you breathe in, which hand rises? It should be the left hand, with little or no

movement in the right.
Alternatively, bend over and hold the back of a chair with your hands. Your back, head and arms should form a straight horizontal line, at right angles to your legs. Just stay

quietly in this position for a while. It is very difficult to breathe with the upper chest in this pose, whereas breathing with the diaphragm is easy. If you feel fine in this

position, then you are probably breathing well normally.
Correcting upper-chest breathing
Learning to breathe with the diaphragm is often an important part of correcting hyperventilation (see p. 228). It should also be taught to anyone who has the kind of chest

deformities that develop in severe asthma (see above).
Diaphragmatic breathing, or abdominal breathing as it is sometimes called, should help make you feel more relaxed
because the in-breath can disperse tensions in your abdomen. This is where many people ‘hold on to’ their fears, with chronically tense abdominal muscles. When you start

breathing into this area of tension, it is important to take things gently and not force the breath downwards. Be aware of any resistance to the in-breath in the abdomen, and of

any emotional reactions that occur when you challenge this resistance.
Sometimes breathing in this way for the first time can bring up emotional difficulties that may need careful handling. That is why it may be better to learn abdominal breathing

from someone who has time to deal with such issues, and with whom you feel very comfortable and relaxed — for example, a yoga teacher or an alternative therapist who you like

and trust. Physiotherapists tend to take a very brisk and practical approach to breathing, which may not be entirely appropriate or helpful when habitual ways of breathing are

tied up with emotional problems.
When learning to breathe with the diaphragm, be careful not to get carried away and become a ‘belly breather’, whose every in-breath sends the abdomen bulging out like a

mainsail. The abdominal muscles should oppose the downward movement of the diaphragm to some extent, without being too tense.
Clearing the nose
Breathing through the nose, rather than the mouth, is beneficial for asthmatics, because it cleans and warms the air. It can also help those with chronic sinusitis because it

oxygenates the air in the sinuses, which discourages some of the more troublesome microbes responsible for sinus infections.
This technique for clearing a blocked nose, part of a set of breathing exercises for opera singers, is based on a time-honoured yoga exercise called alternate nostril breathing:
•    Sit with your mouth closed.
•    Press your right nostril against your nose to close it, using the thumb of your right hand.
•    Breathe out through your left nostril.
•    Press your left nostril against your nose with the index finger of your right hand, to close it. (The hand makes only a very small movement from side to side.)
•    Breathe in through your right nostril.
•    Repeat the sequence.
Once you have got the hang of this, do ten fairly rapid breaths, with no pause between out-breath and in-breath. Pause and rest.
Repeat using your left hand, and reversing the flow of the breath: out through the right nostril and in through the left. Again, do ten breaths and then rest.
Alternatively, try the following exercise, which is recommend by Buteyko practitioners for unblocking the nose. This technique has not been tested scientifically, but the

reports of asthmatics who have used it suggest that it often works wonders, even with children who could never breathe through their noses previously:
•    Have your reliever inhaler to hand, just in case the exercise brings on an asthma attack.
•    Breathe as you do normally, and at the end of a normal out-breath, close your mouth and hold your nose
•    Stay like this, without inhaling, for as long as you can without discomfort. Walk around the room while you are doing this or, if you are young and fit, do something

more strenuous – either walk upstairs or squat-then-stand several times.
•    When you need to breathe in, keep your mouth shut but release your nose
•    Breathe in slowly through the nose
•    Repeat the exercise if your nose becomes blocked again.
Special exercises for asthma
In addition to tackling the problem of hyperventilation, if one exists, asthmatics can use other breathing exercises to tackle specific aspects of their asthma.
Clearing mucus from the lungs A physiotherapist can teach methods of clearing mucus from the airways which are suitable for asthmatics. Ask your doctor for a referral. You could

also try the following exercises:
Huffing Take an in-breath, then tighten your abdominal muscles very sharply, to push the air out. Imagine there is a candle in front of you, and you are trying to extinguish it,

but using your belly muscles only. Your out-breath should make a short soft ‘huff’ sound – if it is more of a loud ‘w000sh’, you are contracting the muscles in your chest as

well as those in the belly. Try again, and focus your attention on your belly as you make the out-breath.
The in-breath should be effortless with this exercise – it just bounces back in. Do as many huffs as you can without feeling breathless. Rest and repeat. The aim is to build up

stamina until you can do 30 or more huffs in succession.
Pursed-lips breathing Take a fairly deep in-breath, then purse your lips together. As with huffing, your belly muscles have to do all the work of the out-breath, but in this

exercise they are working against the muscles of the lips. The aim is to divide the out-breath into as many fragments as possible – to push the air out through the lips in a

succession of tiny, forceful blasts.
One objective of these exercises is to encourage mucus to start moving up to the top of the airways. From there, it can be cleared with a little throat-clearing cough. Note that

the mucus will probably take a while to reach the throat – this may happen some time after you do the exercise. For maximum effect, repeat these exercises several times each

day.
Coping with asthma attacks
The crucial thing during an asthma attack is to focus on your out-breath, not your in-breath. Of course this goes against the grain, because you feel so desperate for air, but

remember that the central problem is stale air from your last in-breath, now trapped in your lungs by the narrow airways. If you can focus on exhaling this used air, you will

have more space for fresh air to come in with the next in-breath.
At times when you are not suffering from an asthma attack, it is worth doing some exercises that improve the strength of your out-breath. The key problem during an asthma attack

is that the natural elasticity of the lungs, which should power the out-breath, is not equal to the challenge of pushing out all that air through narrowed airways in a short

space of time. In this situation, contracting your abdominal muscles so that they push upwards and assist in emptying the lungs is helpful.
The two exercises described above for clearing mucus –huffing and pursed-lips breathing – also strengthen those abdominal muscles which can assist you with your out-breath

during asthma attacks.
Strengthening exercises
Several different exercises or pursuits that strengthen the breathing muscles seem to produce an improvement in asthma. The reasons for this are not understood.
Asthmatics who take up a wind instrument, such as the flute, often report that their asthma improves considerably. The same effect has regularly occurred with asthmatics who

undertake classical training in singing. One set of exercises, taught to aspiring opera singers and designed specifically to strengthen the diaphragm, has been scientifically

tested and shown to improve asthma and reduce the need for drugs. These exercises can be learned at home (see p. 255). There are also some mechanical devices which can

strengthen the breathing muscles (see p. 255).

Allergy and Your Immune System
`The summer used to be such a miserable time for me because I’m allergic to grass pollen. For most of

my life I have had dreadful hayfever, and my asthma would get worse during the summer as well.

Antihistamines knocked me for six, and although there were nose drops that helped a little, they

certainly did not resolve the problem completely. Exam time was always a nightmare when I was a student

- then, as now, it coincided exactly with the pollen season.’
‘Getting a job in Chicago was a turning point in my health. My colleagues were amazed to see me

snuffling through the summer and just accepting that nothing could be done to improve matters. The

whole approach to treating allergies is different there. Eventually someone marched me off to see her

allergist, who said that I should have “allergy shots” and that my health insurance would cover it. The

process was very time-consuming at first, and it took a while to work, but the change is remarkable.

I’ve never regretted having the treatment. Summer is a time I can actually enjoy now.’
Not everyone responds this well to immunotherapy, but for those allergy sufferers who do benefit, this

is an excellent treatment. It tackles allergies right at their source, by teaching the immune system to

react differently to the allergen.
Also known as Specific Immunotherapy (SIT), Incremental Immunotherapy (11T) or simply as

hyposensitisation, this form of treatment was devised by two English medical researchers, Leonard Noon

and John Freeman, who reported their successes with hayfever patients in 1911. Ironically, their

treatment is now less readily available in Britain than in any other industrialised nation. Only a

small minority of British allergy patients receive immunotherapy. The cause of this strange situation

is a ruling made in 1986 by the Committee on the Safety of Medicines (CSM). This states that

immunotherapy must only be given where there is resuscitation equipment available, and that all

patients must wait for an hour after each injection, in case of
side effects. In addition, immunotherapy cannot be used for severe asthma.
The requirement for resuscitation equipment rules out most GP surgeries, and this effectively puts

immunotherapy beyond the reach of many allergic individuals in Britain, owing to the extreme shortage

of allergists and hospital allergy clinics (see p. 89). (In the past, the lack of allergy specialists

meant that most immunotherapy in Britain was given by GPs.)
The CSM ruling was triggered by a number of deaths due to immunotherapy: there were eleven fatalities

between 1980 and 1986, with five of these in the eighteen months just before the report. But almost all

these deaths were due to very basic errors in the way the injections were given – tragic as the deaths

were, the official response to them was inappropriate. Fatal reactions to immunotherapy can be avoided

with close attention to ordinary safeguards (see p. 166-7).
Allergen immunotherapy is still freely available elsewhere in the world, and is regarded as a key part

of allergy treatment. Britain is now out of step with all other developed countries, and most doctors

feel that British restrictions are far too strict.
There are hopes that this situation may change within the next few years, and that more allergy

sufferers may be able to take advantage of this valuable treatment. This could be achieved, in part, by

investing more National Health Service money in allergy clinics and allergy specialists. In addition,

there should be a relaxation of the regulations, so that properly trained GPs can give immunotherapy to

patients who are not at high risk of a fatal reaction. For people whose lives are affected by

allergies, the reintroduction of this treatment (with appropriate safeguards) would be a huge boon.
The uses of immunotherapy
Immunotherapy is mainly used for airborne allergens such as pollen, house-dust mite and mould spores.

Allergies to animals can also be treated with immunotherapy, but the treatment cannot work miracles –

if a cat-allergic person decides to keep the cat, the high dose of allergen inhaled every day limits

the impact of immunotherapy treatment.
People with straightforward allergic reactions affecting the nose and eyes (allergic rhinitis and

conjunctivitis) respond well to immunotherapy. In patients with hayfever, for example, the success rate

(patients showing some degree of improvement) is about 80-90%. When nasal allergies are complicated by

chronic sinusitis or nasal polyps, the chance of success is a little lower.
Some studies of the long-term effects of immunotherapy suggest that, if it is given to children with

hayfever or perennial rhinitis, those children are less likely to develop asthma.
The benefits of using immunotherapy to treat established asthma are less certain. Asthma is a more

complex disease than hayfever, and allergies are only one factor among many (see p. 36), which may

limit the impact that immunotherapy can make. Experience suggests that immunotherapy can be a great

help for an asthmatic with a strong allergic reaction to a single airborne allergen, such as grass

pollen or house-dust mite, but not for other asthmatics. Asthmatics with aspirin sensitivity or chronic

sinusitis are unlikely to benefit.
The value of immunotherapy to children with asthma is a subject of great debate among doctors in the

United States. Some studies suggest that it is of little real benefit, while others are more positive.

One interesting study, that followed asthmatic children for 15 years or more, found that if they were

given a full five-year course of immunotherapy when young, they tended to have fewer asthma symptoms

and need less medication in their late teens and early twenties.
Chronic urticaria (nettle rash) is occasionally due to airborne allergens, in which case immunotherapy

may help. However, immunotherapy is not recommended for atopic eczema. When people with both eczema and

rhinitis try immunotherapy for their nasal allergies, some find that their eczema gets worse.
Insect-sting allergy is a prime candidate for immunotherapy (see pp. 167-8) but food allergy is a

different matter, and is not treated with immunotherapy at present (see p. 168).
Who can get immunotherapy?
As a result of the CSM ruling (see p. 164) remarkably few allergy sufferers in Britain receive

immunotherapy.
Those with insect-sting allergy, who have suffered anaphylaxis (see p. 58), are the most likely to be

offered this treatment. However, even with this frightening and life-threatening problem, which can be

treated with almost 100% success by immunotherapy (see p. 167-8), such treatment is not automatically

available.
A few people with severe hayfever that does not respond well to drug treatment may also be given

immunotherapy. It is worth asking your doctor about such treatment if you feel you would benefit.
How immunotherapy works
Immunotherapy consists of a series of small injections, just under the skin. The liquid that is

injected contains an extract of the offending allergen, for example house-dust mite. The injections are

given at regular intervals, usually once a week, although other schedules are possible (see p. 167-8).
At the outset, a very dilute version of the allergen extract is used, way below the threshold for an

allergic reaction. People who seem highly sensitive, on the basis of their skin tests, start on an

extract that is even more dilute.
For the next injection, a slightly higher concentration of the allergen extract is used, and the

concentration goes on increasing with each successive injection. The idea is to habituate the immune

system to the offending allergen, by very gradually raising the dose. Eventually, when the dose reaches

a level which generally gives beneficial effects, no further increases are made.
If an allergy sufferer reacts badly to immunotherapy injections (see p. 166) on several successive

occasions, the dose may be levelled off before the ideal maximum dose is reached. However, a good

allergist will persist for some time in trying to increase the dose because stopping at a lower level

often results in the treatment being ineffective.
The first stage of immunotherapy, when the concentration of allergen is being increased week by week,

is referred to as the build-up stage. The second stage, when the dose is being kept at the same level,

is called maintenance therapy, and the dose used is the maintenance dose.
There is sometimes an obvious improvement by the time the build-up stage is complete, but not always.

The benefits of the treatment generally appear within six months of reaching the maintenance dose, but

some people have to wait a year or even two before things improve. As the immunotherapy begins to take

effect, symptoms decline and there is often less need for drugs.
A great deal of research effort has gone into finding out what lies behind these changes – in other

words, what is actually happening to the immune system when immunotherapy is effective. The answer is

that a surprising number of different changes may occur and no two allergy sufferers react to

immunotherapy in quite the same way. Frequently there is a shift in the kinds of antibodies the body

produces against the offending allergen. Levels of IgG antibodies (which help to block the allergic

reaction) go up, while levels of the allergy antibody, IgE, tend to stabilise and eventually go down.

The numbers of mast cells (see box on p. 12) may also decline, and they can become less responsive to

the allergen. The balance of power between Th1 cells and Th2 cells may also shift, with the pro-allergy

Th2 cells (see p. 11) becoming less influential.
What can go wrong
The secret of safe immunotherapy is to go at exactly the right speed for the immune system of the

individual being treated. The doctor should look for feedback from the immune system – signs that show

how well it is coping with the steadily increasing dose of allergen – and use these to pace the

immunotherapy schedule.
Going too fast – getting ahead of the immune system’s ability to cope – is hazardous. A major allergic

reaction, called anaphylaxis (see p. 58), can occur, and this is the cause of deaths during

immunotherapy. However, as long as there is injectable adrenaline (see p. 150) and resuscitation

equipment available, even such an extreme crisis can be dealt with safely.
Serious reactions to immunotherapy usually occur:
•    during the initial build-up phase; maintenance therapy is much safer
•    during the pollen season, for those with pollen allergy
•    when a new vial of allergen extract is first being used, because of variations in concentration

(see p. 168-9).
Those most vulnerable to severe reactions are:
•    people with asthma, especially severe or unstable asthma
•    those who have experienced systemic allergic reactions in the past
•    anyone who appears to be extremely allergic, on the basis of skin tests
•    anyone taking beta-Mockers (see box on p. 150).
With care, these fatalities can be avoided. Patients who are given immunotherapy can ensure their own

safety by being well informed about the procedure (see p. 167).
The timing of immunotherapy
There are various different approaches to the timing of immurotherapy. The basic method (which has a

good safety record in the United States where it is very commonly used) starts with injections once a

week. After the maintenance dose has been reached, maintenance injections are given once every 2-4

weeks. The frequency of these may be increased during the pollen season, for people with pollen

allergies.
It is the regularity of the injection schedule that gradually creates, and then sustains, immune

tolerance, so the treatment is only of value to patients who can reliably keep their appointments.
When immunotherapy is successful, it can eventually be discontinued without any reappearance of the

allergic reaction. It usually takes 4-5 years of regular therapy, from the time of the first injection,

to get to this point. The benefits then persist for many years, perhaps indefinitely in some people,

even without any further injections.
Rush immunotherapy
Trying to speed up the process of immunotherapy greatly increases the risk of a severe reaction

(anaphylaxis). However, there are some situations where fast results are needed, and in such cases rush

immunotherapy, also called accelerated immunotherapy, may be used.
During the build-up stage of rush immunotherapy, injections are given every day, or even several times

a day. All the usual safety procedures (see below) are observed with particular care, to reduce the

chance of a severe reaction.
In semi-rush immunotherapy, the build-up injections are given twice a week, and the risks are lower

than with daily injections, but still higher than with weekly injections.
Minimising the risks
If you are lucky enough to be offered immunotherapy treatment under the National Health Service, you

should not feel concerned about accepting the offer. There is very little risk of a bad reaction

because safety procedures are now so stringent.
To minimise the risk of suffering a severe reaction, the doctor will ask you, at each visit, about any

reactions that occurred after your previous injection. Reactions might include redness, itching or

swelling around the injection site, or (more seriously) symptoms elsewhere on the body, such as nettle

rash (urticaria), itchy skin, sneezing, a runny nose, red or itchy eyes, tightness in the throat or

chest, coughing or wheezing. Always make a note of such symptoms, so that you don’t forget to mention

them at the next visit. This is crucially important, as such reactions can indicate that the immune

system is being hurried along too fast.
The doctor will also ask if you have an infection of any kind, as this can alter your reaction. You

should also tell the doctor about any new medicines being taken, as some, such as betablockers (see box

on p. 150), can make a bad reaction to the injection more likely to occur.
Asthmatics can expect the doctor to ask about current asthma symptoms, and to check their peak flow

both before and after an injection. If there are any symptoms, or if the peak flow is less than 70% of

the best-ever value, the injection won’t be given.
Severe reactions can sometimes begin several hours after the injection, so stay within reach of a phone

for about 24 hours. Among United States allergists (who don’t require their patients to wait after the

injection for more than 20-30 minutes) there are some who believe that everyone undergoing

immunotherapy should carry an adrenaline (epinephrine) auto-injector (see p. 150) on the day an

injection has been given, for use in the event of a severe reaction. Anyone who has suffered

anaphylaxis in response to an insect sting will probably have an adrenaline auto-injector anyway, and

this can certainly be used to treat anaphylaxis following immunotherapy. Note, however, that using the

adrenaline is just the first step in treating anaphylaxis (see p. 98) and you must then go back to your

allergist, or to the nearest hospital emergency department, without any delay.
It is sensible to avoid exercise for two hours after an injection. Be extra-cautious during the pollen

season if you are receiving immunotherapy for pollen allergies.
Immunotherapy for insect-sting allergy
`Our daughter has had two really bad reactions from being stung by a wasp. After the second one, the

doctor at the accident and emergency department told us that she nearly died. We got so anxious about

it that we worried every time we left the house in the summer, and it was even worse if she went out

without us. My wife got so upset about it that she wasn’t sleeping well. It was affecting the whole

family badly.
‘Then we heard about desensitisation treatment, and asked our GP, but he said he couldn’t do it.

According to him, they might be able to do it at the hospital, but it might not work, and it was risky

too. We accepted that at first, but then I started doing some research on the Internet, and discovered

that in America and Germany this treatment is absolutely standard – someone like our daughter would

automatically be given it. We felt very angry when we found this out, and went back to the doctor.

Eventually Ann was referred to the allergy department at a hospital, and now she is getting this

desensitisation treatment. I’m pleased about that, obviously, but I still think it shouldn’t have been

such a fight to get it.’
Immunotherapy provides highly effective protection for those with insect-sting allergy, and should be

given to anyone who has had a severe systemic reaction (see p. 60). Some United States allergists also

recommend it for adults who have had a cutaneous systemic reaction (see p. 60), on the basis that they

may well progress to a severe systemic reaction with the next sting.
Studies of people who have suffered severe systemic reactions, and are then treated with immunotherapy,

show that 97% have no systemic reaction to future insect stings. For the 3% who are not fully

protected, the severity of the reaction is much reduced and far less likely to be life-threatening. In

other words, this is an excellent treatment which can save lives.
Targeting the treatment
Choosing the right venom for immunotherapy can sometimes be difficult. Not everyone with insect-sting

allergy sees the insect that caused the reaction. Skin tests may not give the answer either, because

there are often positive reactions to several different venoms. Some of these may be false positives

(see box on p. 91) and it is impossible for the allergist to say which one(s) are actually relevant.

Most allergists will recommend immunotherapy for all of them, using a mixture of venom extracts.
Where the guilty insect was seen and identified, but other venoms also give positive skin tests, a more

difficult decision has to be made. Many allergists carry out immunotherapy for all the venoms that gave

a positive skin test, on a ‘better safe than sorry’ basis. Since there are cross-reactions between

venoms (see box on p. 113), there is some sense in this. Other allergists just give immunotherapy for

the insect that did the deed.
Will immunotherapy against one insect protect against a related insect? With two closely related

insects such as wasps and hornets, which have many allergens in common, it might do – but there is no

guarantee. The problem is that, as well as the shared allergens, each venom also has its own unique

ingredients. It’s impossible to say, with the kind of tests available at present, if an allergic

reaction was to shared allergens or unique ones. So immunotherapy against wasp venom may give

protection against hornet venom, but it will not necessarily do so – and vice versa.
In the case of bumblebee allergy (seen almost exclusively in those, such as horticulturalists, whose

work involves handling bumblebees) a more definite answer can be given – honeybee immunotherapy does

not work. Immunotherapy with bumblebee venom does work, fortunately. The bumblebee extract has to be

obtained from specialist sources.
Injections are given weekly during the build-up phase, unless protection is needed urgently, as with

work-related sting allergy, in which case rush immunotherapy may be used. Once the maximum dose has

been reached, a maintenance injection is needed every four weeks. After a year, this maintenance dose

can be given every 6-8 weeks.
After 3-5 years of immunotherapy, skin tests with insect venoms are usually tried again. If the results

are negative, the immunotherapy will stop. Research now shows that, even if skin tests are still

positive when immunotherapy ends, there’s an 8090% chance that no systemic reaction will occur to

future stings. Some people are not reassured by this, and prefer to continue with immunotherapy for

their own peace of mind. Indeed, research shows that a near-fatal systemic reaction has a long-lasting

psychological impact, and that many people continue to feel anxious despite completing immunotherapy

and reacting negatively to skin tests.
At one time, challenge stings with live insects were given to check whether immunotherapy had actually

worked. Few doctors do this now, but your allergist may be prepared to do a challenge test if you ask.

Adrenaline and resuscitation equipment would be available if a challenge test were used, so any severe

reaction could be dealt with promptly and effectively. The fact that the psychological consequences of

insect-sting allergy are so persistent suggests that challenge tests with live insects may have a

particular value, in demonstrating that immunotherapy has worked. Challenge tests are also helpful for

those who work with stinging insects, such as honeybees and bumblebees, and who need to be sure that

they can go back to work safely.
Immunotherapy for food allergy?
Attempts to use standard immunotherapy for food allergy have been made repeatedly, but without success.

The process of giving the injections is nerve-racking because of the constant risk of a severe

reaction. The risks prevent the dose of allergen being increased very much, so the beneficial effects

are small. While there may be some reduction insensitivity, it is not enough – or not reliable enough –

to be of any practical value.
What doctors are aiming for here, incidentally, is simply to protect against the effects of

accidentally eating a tiny amount of the food – no one is expecting that someone with peanut allergy

will be able to eat peanut butter sandwiches as a result.
Some of the new developments in immunotherapy may be useful for food allergy, as described in the next

section.
The future of immunotherapy
Many different research teams are working on ways of improving immunotherapy – making it more

effective, safer to give, and less time-consuming.
One approach involves altering the allergen, so that it only interacts with those parts of the immune

system whose job is to control allergic reactions (and therefore bring about tolerance). The changes

made to the allergen are designed to make it ‘invisible’ to the parts of the immune system that

actually attack the allergen. The idea is to inject something that can’t cause a bad reaction, and is

therefore 100% safe.
The modified allergens are called allergoids. Another term often used is peptide immunotherapy – this

describes a technique in which the allergens are chopped up into small pieces to make them safe

(allergens are proteins, and a fragment of a protein is called a peptide).
Already, researchers in Germany have made an allergoid from birch pollen that can reduce hayfever

symptoms with a series of just seven injections given before the pollen season.
Meanwhile, a research team in London is working on peptides made from cat allergen, with encouraging

results so far. In a group of asthmatics who were allergic to cats, a series of 4-10 injections, over a

period of 2-8 weeks, produced benefits in about half those treated. The researchers believe that they

can improve on this and help the majority of people with cat allergy, at least enough to survive

temporary exposure to cat allergen (when visiting cat-owning friends, for example). They hope to refine

the treatment sufficiently to enable some cat-allergic people to keep their pet, rather than finding it

a new home. This is a relatively safe treatment that might be given by a GP, rather than only by

specialists. The research team hopes the treatment will be available by about 2009.
Could this kind of technique work for food allergy? Doctors believe that it can, and a great deal of

research work is being done, in both Britain and the United States. A major focus of this effort is

peanut allergy, since this puts so many young lives at risk. Even if the research is successful, It

will be several years before such treatments become available.
Researchers are also working hard to produce standardised allergen extracts – in other words, allergen

extracts that always contain a standard amount of the allergen. The aim is not only to reduce the

number of treatment failures (which can occur if the extract does not contain enough allergen) but also

to avoid mishaps when a new vial of allergen extract is used (differences in strength, between one vial

and another, are sometimes a cause of anaphylactic reactions).
Standardisation is difficult, because the starting materials –skin particles from horses, for example,

or dust-mite droppings –are natural materials and therefore variable. Some samples contain far more of

a particular allergenic ingredient than others.
One way around this problem is to develop accurate methods of measuring the amount of allergen in the

extract. Another approach is to abandon the whole business of making extracts, and produce allergens

artificially, in a laboratory. This is done by inserting the gene for the allergen – the gene for the

Der p1 allergen of house-dust mite, for example – into bacteria. These bacteria then act as production

units, manufacturing large amounts of the allergen every day. With this high-tech approach, the exact

content of the allergen preparations can be controlled.
These high-tech allergen preparations are extremely pure, and therefore very effective – as long as the

person receiving immunotherapy really is sensitised to the particular allergen that is included.

Unfortunately, most natural allergenic materials contain two, three or even more separate allergens. In

house-dust mite droppings, for example, while Der p1 is the allergen that affects most people, there is

also an allergen called Der p2, and a few people are more sensitive to this than to Der pl.
Artificially produced allergen preparations usually include the main allergen only. For the minority of

people who are more severely allergic to one of the other allergens, this extract will not work.

Eventually this problem will no doubt be circumvented by means of more precise skin testing before

immunotherapy begins – skin tests with individual allergens, rather than with allergen extract

containing a mix of allergens.
A third approach is to change from injections to oral immunotherapy – giving the allergen extracts by

mouth. The best results are obtained when the allergen is held under the tongue for a while and then

swallowed. This is known as Sub-lingual immunotherapy or SLIT, and has become very popular in Italy and

France, where it is a common treatment for hayfever. A recent pilot trial among GPs in Britain suggests

that it may be useful, but is not a miracle cure. Overall, the group treated with SLIT had fewer

symptoms during the pollen season, but antihistamines were still needed. There is some evidence from

Italy that SLIT might reduce the likelihood of children with hayfever going on to develop asthma, and

reduce the chance of new sensitivities.
Side effects are unusual with this treatment, and those that do occur are mostly mild – itching in the

mouth, for example. The treatment is safe enough for routine use in children.
Might oral immunotherapy work for food allergy? Other Italian studies suggest that it could. The

objective of these studies is to reduce the risk to children with cow’s-milk allergy from accidental

encounters with ‘hidden milk’ in prepared food or drink. The immunotherapy treatment begins with

miniscule amounts of milk – the doctors start with a single drop diluted in water, each day for a week

– and increase the dose extremely slowly. Antihistamines are given to minimise the risk of a reaction.
The whole process requires enormous patience, but after seven months, the majority of the children

involved can tolerate some milk – between three tablespoonfuls and a small cupful each day.
This is a very encouraging study that should be repeated by doctors in Britain. Because of the risks of

anaphylaxis – which can, of course, be fatal – it does require full medical supervision, and you should

not attempt it at home. Whether this method would work for allergens other than milk is something that

nobody has yet investigated.
A great many other approaches to immunotherapy are currently being tried for food allergy. Many of the

new techniques are highly experimental, and some show great promise, but it will be many years before

they are in use.
One innovation that is closer to being in general use in the United States involves giving the anti-IgE

drug omalizumab (see p. 149) alongside immunotherapy injections. The drug maximises the benefits from

the immunotherapy, and may make the build-up stage (see p. 165) safer, by lowering the risk of

anaphylaxis. For British allergy sufferers, who cannot yet get omalizumab, and whose chances of getting

immunotherapy are vanishingly small, it may seem unkind even to mention such treatments, but we can

only hope that things will improve here in the near future. You might take some comfort from the

thought that, by the time immunotherapy is available again in Britain, there will be a whole host of

highly effective new techniques available for doctors to try.
All the methods described above are forms of specific immunotherapy – they treat an allergy to dust

mites or to grass pollen or some other specific allergen.
A far more radical and ambitious approach to immunotherapy is now the aim of some medical researchers:

blocking the tendency to allergies as a whole.The underlying idea here is to reverse the basic shift in

the immune response, from Th1 cells to Th2 cells. It is this shift to Th2 cells which produces the

allergic tendency (see pp. 11 –13).
Some interesting findings have already been made in this area, including the surprising discovery that

the balance of Th1 cells and Th2 cells can be adjusted even in people with longstanding allergies.

Inspired by discoveries about hygiene and allergy (see p. 21), British researchers have made a vaccine

containing inactivated cells of a harmless bacterium found in the soil, Mycobacterium vaccae. This is

given as a single injection just under the surface of the skin. It has been used for adult patients

with asthma, and for children with severe atopic eczema, with some improvement in both groups. If the

treatment proves as useful as the preliminary studies suggest, this could be a common treatment in a

few years’ time.

Using inhalers
The value of using an inhaler rather than taking tablets or syrup is explained on p. 141 for steroids. The same principle applies to all drugs.
The oldest type of inhaler is the ‘puffer’ or aerosol inhaler, properly called a ‘pressurised metered-dose inhaler’ or MDI. It delivers the drug as a fine, moist, spray. In addition, there are now many devices that deliver drugs in dry-powder form.
If you or your child find the aerosol inhalers difficult, you may do better with a dry-powder inhaler. Your doctor should have several different inhalers available for you to try out, to see which one suits you best.
When you are given an inhaler you must be shown how to use it by a doctor or asthma nurse. A great many asthma patients have a ‘poor inhaler technique’, and get too little of the drug as a result. This often leads to their asthma getting out of control. The advice given here for using inhalers is no substitute for proper training, and should only be used to supplement what your doctor or asthma nurse has told you.
When using an aerosol inhaler or MDI, remember to shake the inhaler well or you will not get the right dose. Your in-breath must coincide exactly with pressing the canister down: this is the part that many people find difficult. You must breathe in slowly and deeply, otherwise you do not get much of the drug into your airways.
Many asthmatics stop inhaling the moment the
spray from the aerosol inhaler hits the back of the
throat. The spray contains a propellant, which
makes it very cold, and there is a natural reflex
response to this cold liquid which stops inhalation.
This response may be impossible to control. If so,
you need a dry-powder inhaler (see right), or a
spacer to use with your aerosol inhaler (see p. 162).
Breath-operated aerosol inhalers such as the
Autohaler can be useful for those who find ordinary
aerosol inhalers too hard to use. With these devices, you do not have to push the canister down because your in-breath triggers the release of the drug. Take care not to block the air-intake holes with your hands and don’t stop breathing when you hear the inhaler click. (If there is no click, start again and breathe in more forcefully this time.)
One hazard with aerosol inhalers is that, when almost empty, they produce no drug – just the propellant. Although they still ‘puff’ normally, they are not effective. It may be hard to tell when your inhaler is running low. Ask your doctor or asthma nurse for advice about this.
Many asthmatics find dry-powder inhalers such as the Spinhaler, Rotahaler, Diskhaler, Accuhaler, Clickhaler and Turbohaler are the easiest to use. They have no aerosol device, so none of the problems associated with the coldness of the propellant.
On the other hand, nothing pushes the drug into your mouth and lungs with a dry-powder inhaler: you have to do all the work yourself. This means you have to breathe in quite hard and fast. During a severe asthma attack you may not be able to breathe in hard enough to get a good dose of the drug. Some asthmatics have an aerosol inhaler as well, often combined with a spacer (see p. 162), for use during severe attacks.
For the parents of asthmatics, who want to keep an eye on how much of a drug is being used, most of the dry-powder inhalers allow you to do so.
Arthritis and inhalers
Those who suffer from arthritis in their hands often find inhalers difficult to use. There are several aids now available to help with this problem – ask your doctor or asthma nurse about these.
Do hold your breath
Whichever type of inhaler you use, it is important to give the drugs a chance to do their work. After inhaling, and when your lungs are full, you should hold your breath for at least ten seconds. Then breathe out, but wait at least another 30 seconds before breathing in again.
Side effects from non-drug ingredients
There are other ingredients in inhalers, besides the drug, and they occasionally cause side effects.
Aerosol inhalers are the worst offenders. They can contain up to five non-drug ingredients, such as propellants and surfactants. Some asthmatics are sensitive to one of these, and respond with coughing or bronchospasm when they inhale them.
If inhaled in large amounts, the propellants in aerosol inhalers can give a mild ‘high’, and asthmatic teenagers and their friends may - very rarely - begin abusing inhaled beta-2 relievers. Parents should be alert for the possibility of such problems, but not worry unduly.
Dry-powder inhalers do not need propellants or surfactants, so they are suitable for anyone who develops a sensitivity to these. However, they may contain lactose, or milk sugar, in addition to the drug. Enough lactose is deposited in the mouth and swallowed to provoke symptoms, such as diarrhoea and wind, in people who suffer from severe lactose intolerance (see box on p. 79). Trace amounts of milk proteins in the lactose may be a problem for people with severe milk allergy.
CFCs and inhalers
Aerosol inhalers have long contained CFCs, which are very inert gases (at ground level) and perfectly safe to inhale. Unfortunately, they cause serious damage when they reach the ozone layer high above the earth, so they are being phased out in asthma inhalers, as they are in all aerosols. Other propellants, called hydrofluoroalkanes (HFAs), are being introduced to take their place. The spray from an HFA inhaler may taste and feel different, but it should do exactly the same job as a CFC inhaler: the drug it contains remains the same. Research suggests that these new propellants are very safe, but tell your doctor if your reaction to your inhaler seems to change suddenly.
These new propellants deliver medication more efficiently into the lungs, so that usually only half the previous dose is required. Unlike CFC-type inhalers, they will deliver a constant dose until empty. In addition, they are not affected as much by below-freezing temperatures.
Inhale - then clean your teeth
Asthmatic children are more prone to dental decay than other children, and inhalers are suspected of causing the problem. No one knows, as yet, exactly which ingredient of the inhalers is the culprit - it could be a drug, or a non-drug additive such as a propellant. Alternatively, the fact that the spray from some inhalers is slightly acidic could explain this side effect. Brushing the teeth after using the inhaler, or just rinsing out the mouth with water, is recommended as a preventive measure.
Using spacers
A spacer is a large empty chamber that can be fitted to an aerosol inhaler (a puffer or MIDI). to make it more effective and easier to use. The aerosol spray goes into one end of the spacer, and the asthmatic breathes it in from the other end.
When using a spacer, you can breathe normally: you don’t have to take all the drug in at once. or hold your breath after you’ve inhaled. But you should try to breathe as deeply as possible, and hold your breath for up to ten seconds if you can.
Note that spacers are for use with aerosol inhalers only. Spacers allow the aerosol propellant (see p. 161) to evaporate, leaving tiny airborne droplets of the drug to be inhaled. Once the propellant has evaporated, these droplets are no longer cold, so the reflex response that stops inhalation is avoided.
During an asthma attack, spacers are immensely valuable because they allow you to get some of the drug into your airways even though you are unable to take a deep breath. There is a collapsible spacer, called the E-Z Spacer, which folds up into a plastic case small enough to be slipped into a pocket. In a severe asthma attack, having such a spacer could save your life.
In an emergency, if no spacer is available, you can improvise one (see p. 100).
Babies and small children, who cannot yet coordinate the in-breath with pushing the aerosol canister down, need spacers for everyday use. There are spacers designed for children under two years, with masks that fit over the nose and mouth.
When using a spacer, shake the inhaler and then spray it into the spacer once only. Inhale within five seconds. During an asthma attack, you can add another dose from the inhaler every ten seconds, until the attack begins to subside, but keep a count of how many puffs you use (see p. 100).
For a young child, shake the inhaler well, and fit it to the spacer. Put the mouthpiece into the child’s mouth, or put the mask on. Tell the child to breathe in and out steadily. Listen for the clicking of the valve on the spacer - this shows that it is opening and closing. When the child’s breathing is regular, puff a single dose into the spacer. The child should breathe in and out 5-8 times.
Priming a spacer
Prime a new spacer, or one that has been washed, by firing the inhaler into it about five times. Do this before you actually need to use the spacer.
The drug will coat the spacer walls, due to an electrostatic charge on the plastic. You won’t be able to see the drug as it forms a very thin coating.
When you come to use the spacer, no more of the drug will stick to the spacer walls, because they are already coated, so the full dose will be available for you or your child to inhale.
Priming new spacers is particularly important when the asthmatic is a young child, because there may be some delay between firing the inhaler and the child actually getting a proper lungful of the drug. The longer the delay, the more chance the drug has to stick to the unprimed spacer walls.
A spacer can be used on a baby while it is asleep, which may make life easier for you both. If you need to use the spacer while the baby or toddler is awake, stroke the mask against the child’s cheek first. Keep smiling and talking so that the situation doesn’t seem so frightening. If the baby does start to cry, keep the mask in place: crying will bring on a deep in-breath which is just what is needed.
For an older child, decorating the spacer with coloured stickers can make it appear less daunting. Try to make using the spacer seem like a game. If this fails, don’t get into a battle with the child – leave it a while and try again later.
Playing with the spacer when feeling well will help the child to see it as something familiar, not as a frightening piece of equipment associated with asthma attacks.
Nebulisers
A nebuliser delivers high doses of asthma drugs in an easily inhaled form. It is generally used for severe asthma only, or in an emergency to relieve asthma attacks.
A nebuliser can be attached to an oxygen cylinder, which enriches the air–drug mixture with oxygen. This is useful in severe asthma.
The only people who need to have a nebuliser at home for emergencies are those with brittle asthma, whose condition can deteriorate very suddenly and sharply.
For routine use, only a very small minority of asthmatics require a nebuliser. They include:
• Those with such severe asthma that they depend on large doses of drugs to control their symptoms
• Very small children or elderly people with severe asthma, who have difficulty using inhalers. For them, a nebuliser may be the easiest way to take their drugs.
The fact that the hospital’s nebuliser is so effective in an emergency gives it a special mystique for many people, who assume that nebulisers are a magical cure for asthma. Nebulisers are widely advertised in specialist publications for asthmatics and, while they are expensive, they can look like the answer to a prayer. Many asthmatics, or their parents, mistakenly believe that owning a nebuliser would be the answer to all their problems. In fact the nebuliser only works so well because it delivers a much higher dose of the reliever drug – a dose which also carries a higher risk of side effects. This high-dose treatment should not be used on a regular basis unless it is absolutely essential. No one should buy a nebuliser without first discussing the matter with their doctor.
Asthmatics who own a nebuliser should have detailed written instructions from a doctor about when and how to use it, and how much of the drug to put in. One hazard of owning a nebuliser is that it may give you a false sense of security during emergencies, and delay you from getting expert medical help when you need it. If the nebuliser is for emergency use you should be told the exact signs that indicate a need to use it and – no less important – the signs that show the attack is out of control and needs hospital treatment.
Take care, when using a nebuliser, not to allow the mist to escape and settle on the face or eyes. Regular exposure to steroid mist can cause cataracts in the eyes, and thinning of the skin on the face. Anti-cholinergics (see p. 156) can cause glaucoma if they come into contact with the eye. The mask must fit very tightly. As an additional precaution, place a scarf around the upper edge of the mask to cover any gaps. Wash the face after using the nebuliser for steroids.
Keep off the cough mixture
Coughing can be a useful reaction in asthma, evicting mucus from the lungs. But in some asthmatics the cough does not produce mucus and seems to be no more than a reflex reaction to the airway inflammation. This type of cough can be debilitating, but it is not a good idea to treat it with cough mixture which has no benefit and may mask the seriousness of the asthma. Tackling the airway inflammation with preventer drugs such as steroids is the best course. Simple expectorants, which loosen mucus, may be of value – ask your pharmacist about these.