REDUCE STRESS, ANXIETY AND PANIC ATTACKS
Stress and breathing
Many vital functions of the human body operate on an unconscious level; you don’t need to tell your heart to beat or your lungs to take in air, your body takes care of it for you. These basic functions are the responsibility of the autonomic nervous system (ANS) which controls heart rate, digestion, respiratory rate, salivation, perspiration, pupillary dilation, urination, and sexual arousal. Most autonomous functions are involuntary, but some are also under some degree of conscious control, such as breathing, swallowing and sexual arousal.
The ANS is classically divided into two subsystems, known as the parasympathetic nervous system (PSNS), which is responsible for rest and relaxation, and the sympathetic nervous system (SNS), which is responsible for stress responses.
Throughout human evolution, we have relied on our immediate bodily responses whenever we are confronted with danger – whether it’s fleeing from a charging elephant, panicking about an interview, or being dragged up by your friends to sing karaoke in public. Known as the fight or flight response, this automatic reaction of the sympathetic nervous system was first described by American doctor Walter Bradford Cannon, who lived from 1871 to 1945. Cannon noted that a perceived threat aroused the SNS and resulted in certain physical reactions, including an increase in blood pressure and rate of breathing, and a release of adrenaline to help us run faster or fight harder.
In prehistoric times, when confronted by a predator, immediate and intense physical exercise would have been required to fight it or run from it. In this situation, the stress was short term, lasting just a few minutes. Once out of danger, breathing and heart rate would quickly normalise, allowing operating systems to revert to regular function.
Today’s stresses are different in a number of ways. Firstly, they are not usually accompanied by physical exercise, which is required to help the body’s operating systems revert to normal. Secondly, and more importantly, modern stresses often last longer, or are spread over a prolonged period of time. Modern life includes a myriad of worries and anxieties – finances, relationships, work, sometimes all three combined – and this constant state of stress can have serious implications on a person’s health.
Humans are well-adapted to cope with short term stresses, but long term stress, in my opinion, exerts more harm on the body than anything else. You can probably get away with eating a relatively poor diet or doing very little physical exercise for as long as twenty years, but twenty years of stress will almost certainly make you ill. My own father exercised regularly, ate a good diet, didn’t smoke, and drank very little alcohol throughout his life. He was, however, a worrying man, and I am in no doubt that his stress levels caused his early passing at the age of sixty-four.
The most damaging of long term stress symptoms is habitual over-breathing. Increased breathing is a perfectly normal response to temporary stress as a rise in heart rate and breathing rate are necessary to prepare the body for a potentially sudden burst of action. But this natural response becomes abnormal when stress is sustained over the long term and breathing volume does not have an opportunity to normalise. As a result, the habit of breathing a volume of air greater that the body requires is developed, causing levels of carbon dioxide in the blood to lower. Too little carbon dioxide in the blood limits blood flow, reducing oxygenation of the heart and brain. It’s somewhat ironic that the brain receives less oxygen during the very time when alertness and mental concentration are acutely required, but this is exactly why it’s so difficult to think clearly under stress – how can a brain that is deprived of oxygen be expected to work properly?
The first accounts of the effects of stress on breathing were documented during the 1870s by military doctor De Costa after he observed an array of symptoms amongst soldiers returning from the front line. These soldiers had endured heavy stress over many months which altered their breathing habits and caused a biochemical change, resulting in symptoms such as:
- Fatigue upon exertion
- Excessive sweating
- Chest pain
Even when the soldiers returned to civilian life they faced a long and arduous process to regain their health. In 1937, scientists Kerr and colleagues coined the term hyperventilation syndrome to describe the main cause of these symptoms. In other words: over-breathing.
When working with clients, I often ask them how their breathing changes when they are stressed. The response is almost always the same: breathing becomes faster and more noticeable. I then ask the client to take a deep breath, to which they respond with a quick breath, often through the mouth, and with obvious movement from the upper chest. Finally, I ask them how they would feel if they continued to breathe that way. Invariably, the response is that they would begin to feel light headed or dizzy. Stress causes us to breathe more, so taking a deep breath to calm yourself down just doesn’t make any sense, and only serves to keep you in a continued state of stress. Instead, the opposite is needed – slow, quiet, calm breathing that allows blood gases and operating systems to restore to normal. The following responses will give you an idea of the correct way to deal with symptom of stress:
- Breathing becomes faster
- More frequent sighing
- Breathing from the upper chest
- Breathing through the mouth
- Breathing becomes more noticeable
- Breathing becomes erratic
- Slow down breathing
- Suppress sighs if possible
- Breathe from the tummy
- Breathe through the nose
- Quieten and silence breathing
- Take slow, gentle, calm, quiet breaths
There is much-documented research to demonstrate that people who are prone to panic attacks and anxiety tend to have dysfunctional breathing patterns, including breathing irregularity and sighing frequently (1). Few healthcare professionals would pay much attention to the habit of sighing every few minutes, but to anyone trained in the Buteyko Method, it immediately sets alarm bells ringing. Time and time again I have seen the detrimental effects that habitual sighing can have on a person’s health, and there is no doubt that the habit must be eliminated if dysfunctional breathing patterns are to be addressed.
Professor Donald Klein from the Department of Psychiatry at Columbia University College claims that the feeling of suffocation caused by over-breathing provokes a very strong reaction in people who are susceptible to panic attacks, sending them into a state of panic and hyperventilation. Other studies have confirmed this, reporting that patients with panic disorders tend to hyperventilate and panic in response to an increase of carbon dioxide, triggering the fear response (2) and a feeling of air hunger
(3). Evidence also shows that the practice of reduced breathing exercises which modify carbon dioxide tolerance are therapeutic (4) to those who suffer from anxiety, panic attacks and depression (5). The technique of observing and slowing down the breath has been shown to calm the mind and improve resilience in stressful situations. Practicing breathing exercises that create a slight accumulation of carbon dioxide conditions the brain to tolerate higher concentrations of the gas. Gently subjecting the body to the feeling of air hunger for short periods of time will also reduce the body’s fear response, reducing the risk of panic and hyperventilation. After all, the sensation of air hunger is a natural occurrence that we experience several times a day, especially during physical exercise, and there is no need for the body to respond to the feeling with panic.
While many breathing techniques aim to slow down breathing, the Buteyko Method is the only breathing exercise to my knowledge that intentionally reduces breathing volume in order to create a tolerable need for air. In essence, the theory works like a vaccine – reducing breathing to create an air hunger is similar to giving the body a very small, controlled dose of symptoms, which can be a useful strategy to overcome the fear of the sensations that accompany a full-blown panic attack. While the long term goal is to reset the respiratory center towards normal breathing volume, I have also witnessed vast short term improvements in people who suffer regularly from panic disorders – sometimes as little as two hours after the commencement of breathing exercises. Noticeable breathing, frequent sighing, and breathing from the upper chest are all habits that can be easily addressed by re-education the breath and reducing breathing volume to a healthy amount.
In addition to addressing hyperventilation over the long term, it is also very important to learn to control breathing during the early stages of an attack. A central feature of a panic attack is that the symptoms are cyclical, feeding back in on themselves and perpetuating the attack. If symptoms continue for several minutes, the increase to breathing volume serves to disturb blood gases, reducing the delivery of oxygen to the brain and causing the attack to become even more intense. Practicing many small breath holds of 3-5 seconds each, or cupping the hands across the face to re-breathe exhaled carbon dioxide are two effective strategies to employ at the first signs of symptoms. The sooner you take control of your breathing, the better chance you have of stopping the attack before it takes hold.
Given the sensitive nature of panic disorders, breathing exercises should be introduced very gently. It’s essential to avoid creating too strong of an air shortage during reduced breathing – or even during measurement of the Control Pause – as this could bring about sensations similar to the beginning of a panic attack (6). Instead, begin with focusing on switching to nasal breathing and eliminating the habit of sighing. You can stop a sigh by swallowing or holding your breath anytime you feel one coming. If you miss a sigh, then simply exhale through your nose and hold your breath for five seconds to compensate afterward. After a few days, when you are comfortable with nasal breathing, begin to incorporate gentle relaxation and reduced breathing exercises. Start by creating a mild feeling of air hunger for very short periods of thirty seconds at a time, practicing ten times throughout the day. As you become more comfortable with the sensation of air hunger, lengthen the duration of the exercise from thirty seconds to up to two minutes. The most important point to remember is that your breathing volume reduces through relaxation. During each reduced breathing exercise, pay attention to whether you are tensing your body, or restricting your breathing by force. If so, abandon the exercise for a minute or so and focus on bringing a feeling of relaxation to your body, gently and gradually allowing your breathing to become quieter and calmer. Some people find it uncomfortable to observe their breathing, as the attention causes breathing rate to increase and become erratic. If you find this happening, concentrate on practicing Many Small Breath Holds and relaxation.
1.Abelson J L., Weg J G, Nesse R, Curtis M. (2001). “Persistent respiratory irregularity in patients with panic disorder.” Biological Psychiatry 49: 588-595.
2.J Bras Pneumol. 2009 Jul;35(7):698-708. Respiratory manifestations of panic disorder: causes, consequences and therapeutic implications.[Article in English, Portuguese] Sardinha A1, Freire RC, Zin WA, Nardi AE.
3.Respir Physiol Neurobiol. 2009 May 30;167(1):133-43. doi: 10.1016/j.resp.2008.07.011. Epub 2008 Jul 25.Panic disorder and control of breathing. Nardi AE, Freire RC, Zin WA.
4.Int J Psychophysiol. 2005 Nov-Dec;58(2-3):190-8. Epub 2005 Aug 30.Physiological markers for anxiety: panic disorder and phobias. Roth WT1. Meuret A , Wilhelm F, Ritz T, Roth W. (2008). “Feedback of end-tidal pCO2 as a therapeutic approach for panic disorder.” J Psychiatric Research 42(7): 560-568. J Psychiatr Res. 2008 Jun;42(7):560-8. Epub 2007 Aug 3.
5.Ley 1999; Ley and Timmons 1999; Brown and Gerbarg 2005
Tweedale P , Rowbottom M I, McHardy G I. (1994). “Breathing Training: effect on anxiety and depression scores in behavioral breathlessness.” Journal of Psychomatic Research 38(1): 11-21. J Psychosom Res. 1994 Jan;38(1):11-21.
Br J Psychiatry. 1976 Nov;129:457-64.Respiratory ventilation and carbon dioxide levels in syndromes of depression.
Mora JD, Grant L, Kenyon P, Patel MK, Jenner FA. J Psychosom Res. 1994 Jan;38(1):11-Breathing re-education: effect on anxiety and depression scores in behavioral breathlessness.Tweeddale PM1, Rowbottom I, McHardy GJ.
6.Depress Anxiety. 2006;23(4):236-44.
35% Carbon dioxide and breath-holding challenge tests in panic disorder: a comparison with spontaneous panic attacks.
Nardi AE1, Valença AM, Mezzasalma MA, Lopes FL, Nascimento I, Veras AB, Freire RC, de-Melo-Neto VL, Zin WA.
Psychiatry Res. 2006 Jun 15;142(2-3):201-8. Epub 2006 Apr 25.
Comparison between hyperventilation and breath-holding in panic disorder: patients responsive and non-responsive to both tests.
Nardi AE, Valença AM, Mezzasalma MA, Levy SP, Lopes FL, Nascimento I, Freire RC, Veras AB, Zin WA.