Verification of the Psychometric Characteristics of the Nijmegen Questionnaire for the Diagnosis of Dysfunctional Breathing During the COVID-19 Pandemic on a Russian Sample

The purpose of the study was to check the psychometric properties of the Nijmegen questionnaire (NQ) (Van Dixhoorn, Duivenvoorden, 1985), aimed at diagnosing the presence of signs of dysfunctional breathing (DВ) according to self–reports of respondents in the conditions of the COVID-19 pandemic in a Russian-speaking sample. The study sample consisted of 1 362 respondents (1 153 women and 209 men) aged 18 to 88 years (mean age 38.3±11.4) who filled out an online questionnaire from April to December 2020 during the COVID-19 pandemic. The following methods were used to test the construct validity of the Russian version of the NQ: 1) Perceived Stress Scale-10 (PSS-10; Ababkov et al., 2016); 2) State-Trait Anxiety Inventory (STAI, Khanin, 1976), the scales of which were modified to measure the level of anxiety during a pandemic (State anxiety) and before the pandemic (Trait anxiety) (Pervichko et al., 2020); 3) The Symptom Check List-32 (SCL-32) (Mitina, Gorbunova, 2011); (4) An abridged version of the Six-Factor Personality Inventory HEXACO-24 (Egorova et al, 2019). The study participants also completed a socio-demographic questionnaire (Pervichko et al., 2020). The results of checking the Russian-language version of the NQ for reliability are presented: the value of the internal consistency coefficient α-Cronbach for the integral indicator = 0.877. Four subscales were identified, the indicators of which improved when the questionnaire was reduced to 10 points. Internal convergent and discriminant validity has been verified for the abridged version. The external constructive validity of the questionnaire is proved. High rates of correlation with stress, situational and personal anxiety, as well as other symptoms of psychological distress were revealed. In addition, a high correlation with emotionality has been established. The problem of the "threshold" value of NQ required to identify the formed symptom complex of DB is discussed. The prevalence of DB symptoms before and during the pandemic was compared. A significant difference in the indicators on the scale for men and women was established. Using the obtained Russian-language version of NQ, it was shown that in the conditions of the COVID-19 pandemic, 27.7% of the study participants who were not sick with COVID-19 showed signs of a formed DB symptom complex, which is more than twice higher than the population indicators in the pre-pandemic period. The frequency of occurrence of the holistic symptom complex of DB in women is three times higher than in men: 31.0% vs 9.1% (p<0.001). The results of the study allow us to conclude that NQ is a reliable and valid tool for diagnosing the severity of DB symptoms, which can be recommended for use as an express diagnostic tool for the presence of psychogenically caused respiratory disorders in persons complaining of "difficulty breathing" in the absence of objective grounds.

1. Ababkov V.A., Baryshnikova K., Vorontsova-Venger O.V. et al. Validizatsiya russkoyazychnoy versii oprosnika «Shkala vosprinimayemogo stressa-10» [Validation of the Russian version of the questionnaire “Scale of Perceived Stress-10”]. Vestnik Sankt-Peterburgskogo Universiteta=Bulletin of St. Petersburg University, 2016, ser. 16, vol. 2, pp. 6–15. DOI: 10.21638/11701/spbu16.2016.202 (In Russ., abstr. in Engl.).
2. Vegetativnye rasstroistva: klinika, diagnostika, lechenie [Vegetative disorders: Clinic, diagnosis, treatment] / A.M. Vein (ed.). Moscow: Meditsinskoye informatsionnoye agentstvo, 2003. 752 p. (In Russ.).
3. Vygotskii L.S. Diagnostika razvitiya i pedologicheskaya klinika trudnogo detstva [The Diagnostics of Development and the Pedological Clinic for Difficult Children]. Vol. 5. Moscow, 1983. P. 257–321. (In Russ.).
4. Daragan N.V., Chikina S.Yu. Giperventilyatsionnyĭ sindrom v praktike vracha-pul'monologa: Patogenez, klinika, diagnostika [Hyperventilation syndrome in practical work of a pneumologist: Pathogenesis, clinical features, diagnosis]. Pul'monologiya=Russian Pulmonology Journal, 2011, no. 5, pp. 87–96. DOI: 10.18093/0869-0189-2011-0-5-87-96 (In Russ., abstr. in Engl.).
5. Egorova M.S., Parshikova O.V, Mitina O.V. Struktura Rossiiskogo varianta Shestifaktornogo lichnostnogo oprosnika HEXACO-PI-R [The structure of the Russian version of the Six-factor personality questionnaire HEXACO-PI-R]. Voprosy psikhologii= Psychology Issues, 2019, no. 5, pp. 33–48. (In Russ., abstr. in Engl.).
6. Zinchenko Y.P., Pervichko E.I. Postneklassicheskaya metodologiya v klinicheskoi psikhologii: Nauchnaya shkola L.S. Vygotskogo – A.R. Luriya [Postnonclassical methodology in clinical psychology: Vygotsky–Luria school]. Natsional'nyi psikhologicheskii zhurnal= National Psychological Journal, 2012, no. 2, vol. 8, pp. 32–45. (In Russ.).
7. Mitina O.V. Razrabotka i adaptatsiya psikhologicheskikh oprosnikov: uchebnoe posobie [Development and adaptation of psychological questionnaires: A Study guide]. Moscow: Smysl, 2011. 235 p. (In Russ.).
8. Mitina O.V., Gorbunova A.I. Ispol'zovanie oprosnika «Perechen' simptomov-32» v tselyakh ehkspress-monitoringa sostoyaniya psikhicheskogo zdorov'ya [The use of the questionnaire "List of symptoms-32" for the purpose of express monitoring of the state of mental health]. In Yu. S. Pivovarov (ed.), Rossiya v sovremennom mire. Sbornik nauchnykh trudov = Russia in the Modern World. Collection of scientific papers, Institute for Scientific Information on Social Sciences of the Russian Academy of Sciences, 2011, vol. 9, pp. 228–236. (In Russ.).
9. Organizatsionnaya psikhologiya: uchebnik dlya studentov vysshikh uchebnykh zavedenii, obuchayushchikhsya po napravleniyu podgotovki FGOS VPO 030300 "Psikhologiya" [Organizational Psychology: A Textbook for students of higher educational institutions studying in the direction of training of the Federal State Educational Standard HPE 030300 "Psychology"] / A.B. Leonova (ed.). Moscow: INFRA-M. 2013. 429 p. (In Russ.).
10. Pervichko E.I., Konyukhovskaya Yu.E. Ehmotsional'noe blagopoluchie naseleniya i patsientov v usloviyakh pandemii COVID-19: obzor zarubezhnykh issledovanii [Emotional well-being of the population and patients in the context of the COVID-19 pandemic: A review of foreign studies]. Psikhicheskoe zdorov'e. = Mental Health, 2021, no. 5, pp. 29–42. DOI: 10.25557/2074-014X.2021.05.29-42 (In Russ., abstr. in Engl.).
11. Pervichko E.I., Mitina O.V., Konyukhovskaya Yu.E. et al. Lichnostnye determinanty predstavlenii o pandemii i svyazannykh s nei perezhivanii u ne bolevshikh COVID-19 zhitelei Rossii [Personal determinants of the pandemic perceptions and related experiences in non-COVID-19 residents of Russia]. Voprosy psikhologii = Psychology Issues, 2021, vol. 67, no. 3, pp. 104–117. (In Russ., abstr. in Engl.).
12. Pervichko E.I., Mitina O.V., Stepanova O.B. et al. Vospriyatie COVID-19 naseleniem Rossii v usloviyakh pandemii 2020 goda [Perception of COVID-19 by the Russian population in the context of the 2020 pandemic]. Klinicheskaya i spetsial'naya psikhologiya = Clinical Psychology and Special Education, 2020, vol. 9, no. 2, pp. 119–146. DOI: 10.17759/cpse.2020090206 (In Russ., abstr. in Engl.).
13. Savkina N.P. Osobennosti funktsional'nykh narushenii dykhaniya pri neirotsirkulyatornoi distonii i ikh verifikatsiya: diss. … kand. med. nauk. [Features of functional breathing disorders in neurocirculatory dystonia and their verification. PhD (Medicine) Dissertation]. Ryazan, 2003. 117 p. (In Russ.).
14. Safronova N.S., Fomenko A.V., Mustafaeva L.A. Proyavleniya disfunktsional'nogo dykhaniya i vozmozhnost' ego korrektsii u predstavitelei deportirovannykh narodov Kryma [Manifestations of dysfunctional breathing and the possibility of its correction in representatives of the deported peoples of Crimea]. Uchenye zapiski Tavricheskogo natsional'nogo universiteta imeni V. I. Vernadskogo. Biologiya. Khimiya. = Scientific Notes of Taurida V.I. Vernadsky National University. Series: Biology. Chemistry, 2011, vol. 24 (63), no. 4, pp. 261–267. (In Russ., abstr. in Engl.).
15. Tetaniya [Tetany]. In B.V. Petrovskii (ed.), Bol'shaya Meditsinskaya Ehntsiklopediya = The Great Medical Encyclopedia. 3rd ed. URL: https://xn--90aw5c.xn--c1avg/index.php/%D0%A2%D0%95%D0%A2%D0%90%D0%9D%D0%98%D0%AF?ysclid=l8scv5l6t7251001350 (Accessed: 22.09.2022). (In Russ.).
16. Tokareva N.A. Giperventilyatsionnyĭ sindrom pri somaticheskoi patologii (na primere bronkhial'noi astmy, gipertonicheskoi bolezni) i organnom nevroze — osobennosti techeniya i lecheniya: dis. … kand. med. nauk. [Hyperventilation syndrome in somatic pathology (for example, bronchial asthma, hypertension) and organ neurosis — features of the course and treatment. PhD (Medicine) Dissertation]. Moscow, 2004. 137 p. (In Russ.).
17. Trushenko N.V., Chikina S.Yu., Lukashenko E.P. Verbal'nye kharakteristiki odyshki u patsientov s khronicheskoĭ obstruktivnoĭ bolezn'yu legkikh i bronkhial'noĭ astmoĭ [Verbal descriptions of dyspnea in patients with chronic obstructive pulmonary disease and bronchial asthma]. Pul'monologiya = Russian Pulmonology Journal, 2011, no. 3, pp. 70–80. DOI: 10.18093/0869-0189-2011-0-3-70-80 (In Russ.).
18. Khanin Yu.L. Kratkoe rukovodstvo k primeneniyu shkaly reaktivnoi i lichnostnoi trevozhnosti Ch.D. Spilbergera [A brief guide to the use of the scale of reactive and personal anxiety Ch.D. Spielberger]. Leningrad, 1976. 18 p. (In Russ.).
19. Ashton M. C., Lee K. Empirical, theoretical, and practical advantages of the HEXACO model of personality structure. Personality and Social Psychology Review, 2007, vol. 11, no. 2. pp. 150–166. DOI: 10.1177/1088868306294907
20. Baumann N., Kaschel R., Kuhl J. Affect sensitivity and affect regulation in dealing with positive and negative affect. Journal of Research in Personality, 2007, vol. 41, no. 1, pp. 239–248. DOI: 10.1016/j.jrp.2006.05.002
21. Boulding R., Stacey R., Niven R. et al. Dysfunctional breathing: A review of the literature and proposal for classification. European Respiratory Review, 2016, vol. 25, no. 141, pp. 287–294. DOI: 10.1183/16000617.0088-2015
22. Brashear R.E. Hyperventilation syndrome. Lung, 1983, vol. 161, pp. 257–273. DOI: 10.1007/BF02713872
23. Broche-Pérez Y., Fernández-Fleites Z., Jiménez-Puig E. et al. Gender and fear of COVID-19 in a cuban population sample. International Journal of Mental Health and Addiction, 2020, vol. 20, no. 1. pp. 83–91. DOI: 10.1007/s11469-020-00343-8
24. Cannito L., Di Crosta A., Palumbo R. et al. Health anxiety and attentional bias toward virus-related stimuli during the COVID-19 pandemic. Scientific Reports, 2020, vol. 10, no.1, article 16476. DOI: 10.1038/s41598-020-73599-8
25. Chaitow L., Bradley D., Gilbert C. Recognizing and treating breathing disorders:
    A multidisciplinary approach. 2nd ed. Elsevier, 2014. 320 p.
26. Chand T., Khan M. Sigh syndrome: An emerging issue in the healthy population amid the COVID-19 pandemic. EC Pulmonology and Respiratory Medicine, 2020, vol. 9, no.11, pp. 43–45.
27. Cohen S., Kamarck T., Mermelstein R. A global measure of perceived stress. Journal of Health and Social Behavior, 1983, vol. 24, no. 4, pp. 385–396.
28. Courtney R., Greenwood K.M., Cohen M. Relationships between measures of dysfunctional breathing in a population with concerns about their breathing. Journal of Bodywork and Movement Therapy, 2011, vol. 15, no. 1, pp. 24–34. DOI: 10.1016/j.jbmt.2010.06.004
29. Derogatis L.R. BSI, Brief Symptom Inventory: Administration, scoring, and procedures manual. 4th ed. Minneapolis, MN: National Computer Systems, 1993. 85 p.
30. Derogatis L.R. Symptom Checklist-90-R (SCL-90-R) Administration, scoring, and procedures manual. 3rd ed. Minneapolis, MN: National Computer Systems, 1994.
31. Derogatis L.R. The SCL-R-90 Manual I: Scoring, administration and procedures for the SCL-90. Baltimore, MD: Clinical Psychometric Research, 1977.
32. Fornell C., Larcker D.F. Evaluating structural equation models with unobservable variables and measurement error. Journal of Marketing Research, 1981, vol. 18, no. 1, pp. 39–50. DOI: 10.2307/3151312
33. Gavriatopoulou M., Korompoki E., Fotiou D. et al. Organ-specific manifestations of COVID-19 infection. Clinical and Experimental Medicine, 2020, vol. 20, no. 4, pp. 493–506. DOI: 10.1007/s10238-020-00648-x
34. Grammatopoulou E.P., Skordilis E.K., Georgoudis G. et al. Hyperventilation in asthma: A validation study of the Nijmegen Questionnaire – NQ. Journal of Asthma, 2014, vol. 51, no. 8. pp. 839–846. DOI: 10.3109/02770903.2014.922190
35. Han J.N., Stegen K., Schepers R. et al. Subjective symptoms and breathing pattern at rest and following hyperventilation in anxiety and somatoform disorders. Journal of Psychosomatic Research, 1998, vol. 45, no. 6, pp. 519–532. DOI: 10.1016/s0022-3999(98)00044-0
36. Henseler J., Ringle C.M., Sarstedt M. A new criterion for assessing discriminant validity in variance-based structural equation modeling. Journal of the Academy of Marketing Science, 2015, vol. 43, no. 1, pp. 115–135. DOI: 10.1007/s11747-014-0403-8
37. Islam M.S., Ferdous M.Z., Potenza M.N. Panic and generalized anxiety during the COVID-19 pandemic among Bangladeshi people: An online pilot survey early in the outbreak. Journal of Affective Disorders, 2020, no. 276, pp. 30–37. DOI: 10.1016/j.jad.2020.06.049
38. Jungmann S.M., Witthöft M. Health anxiety, cyberchondria, and coping in the current COVID-19 pandemic: Which factors are related to coronavirus anxiety? Journal of Anxiety Disorders, 2020, no. 73, article 102239. DOI: 10.1016/j.janxdis.2020.102239
39. Koniukhovskaia J., Pervichko E. Psychological mediation of dysfunction and hyperfunction of respiratory regulation. Behavioral Sciences (Basel, Switzerland), 2020, vol. 10, no. 1, article 5. DOI: 10.3390/bs10010005
40. Li Ogilvie V., Kayes N.M., Kersten P. The Nijmegen Questionnaire: A valid measure for hyperventilation syndrome. New Zealand Journal of Physiotherapy, 2019, vol. 47, no. 3, pp. 160–171. DOI:10.15619/NZJP/47.3.04
41. Motiejunaite J., Balagny P., Arnoult F. et al. Hyperventilation: A possible explanation for long-lasting exercise intolerance in mild COVID-19 survivors? Frontiers in Physiology, 2021, vol. 11, article 614590. DOI: 10.3389/fphys.2020.614590
42. Ng K. H., Kemp R. Understanding and reducing the fear of COVID-19. Journal of Zhejiang University. Science. B, 2020, vol.21, no. 9, pp. 752–754. DOI: 10.1631/jzus.b2000228
43. Osatuyi B. Personality traits and information privacy concern on social media platforms. Journal of Computer Information Systems, 2015, vol. 55, no. 4, pp. 11–19. DOI: 10.1080/08874417.2015.11645782
44. Qiu J., Shen B., Zhao M. et al. A nationwide survey of psychological distress among Chinese people in the COVID-19 epidemic: Implications and policy recommendations. Journal of General Psychiatry, 2020, vol. 33, no. 2, e100213. DOI: 10.1136/gpsych-2020-100213
45. Ravanbakhs M., Nargesi M., Raji H. et al. Reliability and validity of the Iranian version of Nijmegen questionnaire in Iranians with asthma. Tanaffos. 2015, vol. 14, no. 2, pp. 121–127.  
46. Shrestha N. Factor Analysis as a Tool for Survey Analysis. American Journal of Applied Mathematics and Statistics, 2021, vol. 9, no. 1, рр. 4–11. DOI: 10.12691/ajams-9-1-2
47. Spielberger C.D., Gorsuch R., Lushene R. et al. Manual for the State-Trait Anxiety Inventory (Form Y1 – Y2). Palo Alto, CA: Consulting Psychologists Press, 1983.
48. Taverne J., Salvator H., Leboulch C. et al. High incidence of hyperventilation syndrome after COVID-19. Journal of Thoracic Disease, 2021, vol. 13, no. 6, pp. 3918–3922. DOI: 10.21037/jtd-20-2753
49. The Writing Committee for the COMEBAC Study Group. Four-month clinical status of a cohort of patients after hospitalization for COVID-19. JAMA, 2021, vol. 325, no. 15, pp. 1525–1534. DOI: 10.1001/jama.2021.3331
50. Thomas M., McKinley R.K., Freeman E. et al. The prevalence of dysfunctional breathing in adults in the community with and without asthma. Primary Care Respiratory Journal, 2005, vol. 14, no. 2, pp. 78–82. DOI: 10.1016/j.pcrj.2004.10.007
51. Tsang S., Royse C.F., Terkawi A.S. Guidelines for developing, translating, and validating a questionnaire in perioperative and pain medicine. Saudi Journal of Anaestesia, 2017, vol. 11, suppl. 1, pp. S80–S89. DOI: 10.4103/sja.SJA_203_17
52. Van Dixhoom J. Hyperventilation and dysfunctional breathing. Biological Psychology, 1997, vol. 46, pp. 90–91.
53. Van Dixhoorn J., Duivenvoorden H.J. Efficacy of Nijmegen questionnaire in recognition of the hyperventilation syndrome. Journal of Psychosomatic Research, 1985, vol. 29, no. 2, pp. 199–206. DOI: 10.1016/0022-3999(85)90042-X
54. Van Dixhoorn J., Folgering H. The Nijmegen Questionnaire and dysfunctional breathing. European Respiratory Journal Open Research, 2015, vol. 1, no. 1, article 00001-2015. DOI: 10.1183/23120541.00001-2015
55. Vidotto L.S., de Carvalho C.R.F., Harvey A. et al. Dysfunctional breathing: What do we know? Jornal Brasileiro de Pneumologia, 2019, vol. 45, no. 1, e20170347. DOI: 10.1590/1806-3713/e20170347
56. Voorhees C.M., Brady M.K., Calantone R. et al. Discriminant validity testing in marketing: An analysis, causes for concern, and proposed remedies. Journal of the Academy of Marketing Science, 2016, vol. 44, no. 1, pp. 119–134. DOI: 10.1007/s11747-015-0455-4
57. Wilhelm F.H., Rattel J.A., Wegerer M. et al. Attend or defend? Sex differences in behavioral, autonomic, and respiratory response patterns to emotion–eliciting films. Biological Psychology, 2017, vol. 130, pp. 30–40. DOI: 10.1016/j.biopsycho.2017.10.006
58. Wilson C. Hyperventilation syndrome: Diagnosis and reassurance. Journal of Paramedic Practice, 2018, vol. 10, no. 9, pp. 370–375. DOI: 10.12968/jpar.2018.10.9.370