Stress, Anxiety and Panic Attacks

Anxiety is a feeling of unease, worry, fear, or dread and it can range in intensity and severity. We all experience anxiety from time to time, however, when it becomes persistent and strong enough to interfere with daily activities it is diagnosed as an Anxiety Disorder, and at its most severe, as a Panic Disorder. Left untreated, anxiety can negatively affect mental and physical health, reduce quality of life, productivity, and ability to function; and impact the sufferer and society at large.

Fortunately, there is a simple way forward – by taking control of your breathing and addressing the biochemical imbalances in your body, you can reduce anxiety and moderate the frequency and severity of panic attacks. Later we will share 10 general guidelines and 4 breathing exercises for panic attacks, anxiety attacks, and general anxiety. First, however, we will take a deeper look at Anxiety Disorders, panic attacks, the stress response, and how the breath is a key modulator of all 3.

TYPES OF ANXIETY

Anxiety Disorders affect all races, genders, and age categories and are one of the most common mental health disorders affecting nearly 30% of the population at some point in their lives. Anxiety Disorders cause physical and psychological discomfort and symptoms such as nervousness, tension, fear, avoidance, restlessness, irritability, fatigue, disturbed sleep, memory problems, muscle tension, rapid heartbeat, poor focus, and panic attacks. There are 5 major types of Anxiety Disorders and they include: Generalized Anxiety Disorder (GAD), Obsessive-Compulsive Disorder (OCD), Post-Traumatic Stress Disorder (PTSD), Social Anxiety Disorder (SAD), and Panic Disorder (PD).

PANIC DISORDER & PANIC ATTACKS

The Diagnostic and Statistical Manual of Mental Health Disorders (DSM) defines panic attacks as: “an abrupt surge of intense fear or discomfort”. These episodes typically occur without any real danger or apparent cause, come on suddenly, and are incredibly scary. Panic attacks can happen to people without a Panic Disorder or other type of Anxiety Disorder, however, when a person experiences recurrent episodes, a persistent fear of a potential recurrence, and there are no other medical causes of the attack, they are diagnosed with Panic Disorder.

Most panic attacks peak within just a few minutes and subside within 5 to 20 minutes. They are accompanied by symptoms such as a pounding heart, rapid heart rate, trembling, feelings of choking or suffocation, sweating, breathlessness, chest pain, nausea, dizziness, light-headedness, chills or heat sensations, numbness, tingling sensations, or fainting. There may also be derealization (feelings of unreality) or depersonalization (being detached from oneself), fear of losing control or ‘going crazy,’ and fear of dying.

ANXIETY ATTACKS

The symptoms of anxiety attacks are similar to panic attacks but not as intense. In contrast to Panic Disorder, anxiety attacks are not a documented mental illness and there is usually a clearly identifiable trigger. Also, unlike panic attacks which happen abruptly, anxiety attacks typically build up gradually over time and follow a period of excessive worry.

SUBCLINICAL ANXIETY

You can suffer from anxiety’s negative consequences and not have a diagnosable disorder. One 3-year study of Generalized Anxiety Disorder (GAD) in the general population found that 11.4% of people were dealing with a ‘subthreshold’ Anxiety Disorder. This means that their anxiety was not severe enough to be clinically diagnosed, but it was a constant factor in their lives. By the time these patients were reassessed at the end of the trial, the condition had progressed to a full-blown Anxiety Disorder in 13.8% of those with anxiety. Fortunately, no matter where your anxiety lies on the spectrum – the breath can be harnessed to manage it.

ANXIETY & STRESS

Anxiety and stress often get confused as the same thing and while the symptoms can be similar, stress is a reaction to an outside trigger, whereas anxiety is a person’s specific reaction to stress; which means its origin is internal. While the causes differ, both anxiety and stress trigger the same response in the body. More specifically, they activate the Sympathetic Nervous System (SNS), which is a branch of the Autonomic Nervous System (ANS). The other branch of the ANS is the Parasympathetic Nervous System (PNS), and both operate unconsciously and automatically without our control.

Throughout human evolution, we have relied on the immediate bodily responses of the SNS whenever we were confronted with danger. Known as the ‘fight or flight’ response, the automatic reactions of the SNS result 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 our evolutionary past, the SNS was typically only activated for short periods of time in response to fleeting danger e.g. a predator attack. However, modern-day living subjects us to unprecedented stressors which are much more insidious and enduring. On top of worrying about finances, relationships, and work, many of us have to cope with traffic, crowded communities, and a jam-packed schedule. Technology compounds this stress by keeping us constantly ‘online’, on the lookout for the next message or task, and preventing us from fully shutting off and resting.

Our body’s Autonomic Nervous System has sophisticated mechanisms to deal with moments of stress and danger. But it would be an evolutionary miracle if these autonomic processes had developed fast enough to manage the constant influx of stressors we experience today, when only a few hundred years ago these things simply didn’t exist. As a result, many of us have our ‘fight or flight’ button jammed permanently in the ‘on’ position. This prevents the Parasympathetic Nervous System (PNS) from activating, and we need the PNS to rest, digest, repair, and rejuvenate.

Living under chronic stress creates emotional and physical exhaustion. Once we’re in this depleted state, the effects of stress become compounded, and our ability to copy becomes depleted. This can lead to several mental health problems including Anxiety Disorders such as Generalized Anxiety Disorder and Panic Disorder.

UNTREATED ANXIETY CONSEQUENCES

If you’ve ever experienced anxiety, you’ll know that it can have an extremely debilitating effect on your quality of life. It’s damaging to physical health too. Whether you have a diagnosable Anxiety Disorder or not, if you regularly experience anxiety, your body is being impacted by chronic stress. Chronic stress compromises the immune system and makes you more prone to infections, respiratory illnesses, and autoimmune diseases. It also increases inflammation, and inflammation is an underlying cause of nearly every chronic disease. Anxiety is additionally linked with a greater risk of several mental health disorders including Bipolar Disorder, Depression, and Substance Abuse Disorder.

The effects of a Panic Disorder are even more profound than anxiety on its own. When you’re constantly on the brink of a panic attack, it becomes incredibly difficult to function, socially, at work, and at home. Patients with Panic Disorder have much higher lifetime rates of cardiovascular, respiratory, and gastrointestinal disorders; major depressive disorder; and suicide. Fortunately, by addressing breathing pattern dysfunctions it is possible to relieve symptoms of anxiety and Panic Disorder and notably improve quality of life.

RELATED & CO-OCCURING HEALTH CONDITIONS

Anxiety frequently occurs alongside other health conditions. For example, people with Sleep Apnea are more likely to have an Anxiety Disorder than those without. Chronic Obstructive Pulmonary Disease (COPD) is also frequently co-occurring, and one meta-analysis showed 40% of COPD patients had clinical anxiety. In another paper, scientists reported that 45% of people with Bipolar Disorder suffer from anxiety.

THE LINK BETWEEN STRESS, OVERBREATHING, ANXIETY, AND PANIC ATTACKS

Chronic stress and anxiety have serious implications on a person’s physical health, the most damaging of which is habitual hyperventilation (overbreathing). Increased breathing is a perfectly normal response to temporary stress or anxiety as a rise in heart rate and breathing rate are necessary to prepare the body to fight or flee. But this natural response becomes abnormal when stress is sustained over the long term and breathing volume does not have an opportunity to normalize leading to chronic hyperventilation.

It’s important to understand what hyperventilation is because it’s not quite what most of us think. Chronic hyperventilation happens subtly, without a single paper bag in sight, and much of it is habitual – we’re breathing too much air on a constant and long-term basis. A direct link has been found between hyperventilation, anxiety, and panic attacks. To understand how the breath can trigger these states, you must first understand the effects of breathing on carbon dioxide (CO2) levels in the blood.

When a person breathes too rapidly from their upper chest it leads to hyperventilation and a greater volume of air being taken in than the body requires. This, in turn, causes levels of CO2 in the blood to lower. CO2 is not just a waste gas, it is required for oxygen to be delivered to the cells and organs, so when CO2 levels drop, less oxygen reaches the brain and body. It’s somewhat ironic that the brain receives less oxygen during the very time when alertness and concentration are most required, but this is exactly why it’s so difficult to think clearly when stressed or anxious.

The drop in blood CO2 and oxygen delivery that occurs from overbreathing triggers feelings of air hunger akin to suffocation. This causes compensatory overbreathing and perpetuates hyperventilation. Studies show, in people who are susceptible to panic attacks, this feeling of suffocation provokes a very strong fear response and sends them into a state of panic, deep air hunger, and more hyperventilation, which further fuels panic.

Compounding this negative snowball effect is the fact that emotions such as fear which accompany anxiety cause an increase in adrenaline and noradrenaline. This makes the body around 30% more sensitive to CO2, and CO2 is the alarm bell to breathe. Because of this, when you are more sensitive to CO2, you tend to breathe more, and this fuels overbreathing and worsens anxiety symptoms. This creates a negative feedback loop in which shallow, fast, upper-chest breathing (hyperventilation), increases CO2 sensitivity and feelings of anxiety, and increased anxiety leads to more hyperventilation. This is not a hypothesis, countless studies have confirmed anxious people are more sensitive to changes in CO2, and higher CO2 sensitivity increases both the rate of breathing and symptoms of anxiety.

Research has also proven that people with Anxiety Disorders will panic and hyperventilate when their levels of blood CO2 rise, as the feeling of air hunger prompts them to react fearfully. These biochemical triggers are really interesting. They indicate that the balance of CO2 is integral to susceptibility to anxiety and panic attacks. And this means you can do something about anxiety and panic attacks in a way that will achieve tangible results, and allow you to feel more in control. This will feed back to your brain, and the feeling of control will lessen the psychological aspects of the problem – perpetuating a positive feedback loop this time.

Worth noting here is that sighing can also contribute to anxiety because it promotes hyperventilation, and increases both the stress response and blood CO2 sensitivity. 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 we have seen the detrimental effects that habitual sighing can have on a person’s health, and the habit must be eliminated if dysfunctional breathing patterns are to be addressed.

CONVENTIONAL TREATMENT VS THE BUTEYKO METHOD

Current conventional treatments for anxiety and Panic Disorder include prescription drugs and psychological interventions such as Cognitive Behavioral Therapy (CBT). Noteworthy is that when scientists compared the effects of CBT to breath retraining in people with Panic Disorder, they found both had similar positive outcomes. However, breath retraining had the additional benefit of increasing low CO2 levels, thereby addressing the underlying biochemical cause of anxiety and panic.

BUTEYKO BREATHING FOR ANXIETY

Evidence shows that people who are prone to anxiety and panic attacks tend to have dysfunctional breathing patterns, the most common of which is overbreathing. Research also shows that different emotions are associated with different forms of breathing, and changing how we breathe can change how we feel. When it comes to anxiety, panic attacks, and depression, the practice of reduced breathing exercises that modify CO2 sensitivity have been found particularly therapeutic. Before outlining how to do these exercises, it’s helpful to first understand what breathing patterns fuel the SNS stress and anxiety response, and what breathing patterns fuel the PNS rest and relaxation response:

SNS STRESS ACTIVATION BREATHING:

• Fast breathing
• Frequent sighing
• Breathing from the upper chest
• Breathing through the mouth
• Breathing in a more noticeable or louder way
• Erratic breathing

If you suffer with panic attacks or anxiety, chances are, you already breathe in the ways described above. This type of breathing becomes even more pronounced in moments of high anxiety or panic creating a negative, self-perpetuating cycle.

PNS RELAXATION BREATHING:

• Slow breathing
• Breathing from the tummy (as opposed to the upper chest)
• Suppressing sighs (if possible)
• Breathing through the nose
• Quiet breathing
• Gentle, light, and calm breathing 

10 BUTEYKO GUIDELINES FOR REDUCING ANXIETY & PANIC ATTACKS:

1. SWITCH TO NASAL BREATHING

If you have a tendency to breathe through your mouth (and most of us do without even realizing it), it’s important that you retrain yourself to breathe through your nose and keep your mouth closed. If your nose is blocked, use the nose-unblocking exercise to clear it. Mouth taping at night will ensure to keep your mouth shut while you’re sleeping. You can also use MyoTape during the day if you have downtime at home. It’s additionally beneficial, to practice gentle walking daily while breathing through your nose with your mouth closed.

2. BUILD A TOLERABLE AIR HUNGER

The first thing we do with clients who come to the clinic with panic attacks is work on building a tolerance to light air hunger and on reducing sensitivity to CO2. We achieve this by having them practice breathing exercises that create a slight accumulation of CO2 (see below section ‘4 Buteyko Breathing Exercises for Panic Attacks & Anxiety’). This, in turn, conditions the brain to tolerate higher concentrations of the gas, thereby reducing CO2 sensitivity.

3. REDUCE BREATHING VOLUME

The technique of observing and slowing down the breath has been shown to calm the mind and improve resilience in stressful situations. While many breathing techniques aim to slow down breathing, the Buteyko Method is the only breathing exercise to our knowledge that also 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 anxiety symptoms. This reduces the body’s fear response and helps the person 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, we have also witnessed vast short-term improvements in people who suffer regularly from panic attacks – sometimes in as little as 2 hours after the commencement of breathing exercises.

Ideally, you will spend a cumulative 60 minutes per day practicing reduced breathing exercises. It’s also recommended that you work on reducing your breathing from the moment you wake up in the morning. For example, while lying in bed for a few minutes, reduce your breathing and create a slight air hunger. While driving to work, reduce your breathing by relaxing your chest and tummy and ensuring that your chest remains still. And while doing daily tasks such as showering, reduce your breathing by holding your breath after the exhale until you feel a tolerable hunger for air.

4. STOP BREATHING LOUDLY & SIGHING

Breathing loudly and sighing both fuel overbreathing. As such, it’s important that you ensure that your breathing is quiet 24/7 and that you stop sighing if you have a tendency to do so. If you notice a sigh is on the way, swallow or hold your breath. If a sigh slips out, compensate by exhaling through your nose and holding your breath for 5 to 10 seconds after the exhalation – this will rebalance your blood gases.

5. EXTEND YOUR EXHALES

Aim to make your out-breath approximately 1.5 times longer than your in-breath in your everyday life. This way of breathing activates the PNS and research shows that a longer exhale is helpful for reducing anxiety, as well as physical and mental stress.

6. BREATHE INTO YOUR DIAPHRAGM

When things are stressful, we’re often told to ‘take a deep breath’. Ironically, contrary to everything you might think, this can be exactly the wrong thing to do. This is because many people equate taking a deep breath with taking a giant gulp of air into their upper chest and this leads to overbreathing and perpetuates hyperventilation. Breathing lightly, slowly, and deeply into the diaphragm on the other hand, has been shown to induce a state of calm, effectively reduce anxiety and its symptoms, and alleviate negative emotions such as depression and anger.

7. USE BREATHING EXERCISES FOR ANXIETY ATTACK & PANIC ATTACKS

In addition to addressing hyperventilation (overbreathing) 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. This is why it’s vital to address your breathing at the first sign of an anxiety or panic attack. If you notice symptoms coming on, practice either the ‘Many Small Breath Holds,’ ‘Cupped Hand Rescue Breath,’ or ‘Breathe Slow & Deep Breath’ immediately (exercises are outlined below).

8. PRACTICE MIND & BODY AWARENESS

Watch your thoughts and observe the antics of your mind. Pay attention to what is going through your mind and determine how your thoughts create your mood and how your mood creates your thoughts. Watch out for repetitive thought processes, especially the recurrent thoughts that take so much of your time, reach no conclusion, create anger, tension, and anxiety, and drain you of energy.

It’s also important to relax your body. If your tummy or chest are tense, encourage them to relax through mental commentary. Keep your breathing calm at all times and keep your chest still while breathing. When faced with confrontation, bring your attention immediately to your inner body. If you need to challenge somebody, wait until your anger has passed and approach the individual while keeping most of your attention on your inner body.

9. IMPROVE YOUR CONTROL PAUSE (CP)

Your Control Pause (CP) is the number of seconds that you can hold your breath on an exhalation before the impulse to breathe in, and it’s an indicator of blood sensitivity to CO2. By working to increase your CP, you will gradually reduce your sensitivity to blood CO2. This will have a positive impact on your breathing during rest, sleep, and exercise, and increase your resilience to stress.

10. TRACK YOUR PROGRESS

You can measure your progress by using the CP score. If your CP is below 25 seconds, your breathing is likely to be problematic. Ideally, your CP will increase by 4 seconds each week, and if it is not increasing by that much, pay more attention to your breathing or do more of the breathing exercises outlined below. You can also tell whether your breathing pattern is becoming healthier just by the way you feel. If you’re breathing optimally your brain and body will be getting all the oxygen it needs, your sleep will be better, and you’ll feel more energetic, alert, and focused.

4 BUTEYKO BREATHING EXERCISES FOR PANIC ATTACKS & ANXIETY

Below are 4 breathing exercises that will help to balance your biochemistry so you experience less anxiety and panic attacks. Exercises #1-3 can be used at the first signs of anxiety or panic to stop it in its tracks. Exercises #2-4 can be used when you are not on the verge of a panic attack to increase your CP and reduce anxiety levels in general.

EXERCISE #1: CUPPED HAND RESCUE BREATH

Do this exercise immediately if you’re feeling symptoms of panic coming on. This exercise will allow you to breathe a higher concentration of CO2 into your lungs and more oxygen into your cells. By normalizing CO2 levels, it will calm your breathing and your mind..This exercise produces similar results to the old brown paper bag routine but it’s much safer, as it allows you to maintain your oxygen levels. It is suitable for everyone, except those with serious health concerns or those in the first trimester of pregnancy.

Instructions

• You can do this exercise lying down on your back or sitting up straight.
• Cup your hands over your face. Make sure there are no big gaps between your fingers.
• Take a short, soft inhale and exhale through your nose.
• Breathe in softly through your nose and allow a calm, gentle, prolonged breath out.
• Don’t hold your breath or restrict your breathing. Just gently soften your breathing.
• You can time your breathing to breathe in for 3 seconds and out for 3 seconds.
• As you breathe in, imagine your lower ribs gently moving outwards.
• As you breathe out, feel your lower ribs gently moving inwards.
• Continue to breathe into your cupped hands for 2 minutes.

You should not feel any air hunger during this exercise. If your breathing rhythm becomes fast or chaotic, or you experience a need for air, take a rest for around 30 seconds and start again. 

EXERCISE #2: MANY SMALL BREATH HOLDS

Do this exercise frequently throughout the day to balance your biochemistry, and also when you experience the first symptoms of stress, anxiety, or a panic attack. Don’t wait until the symptoms worsen, as getting your breath under control will be a lot more difficult. If you wake up during the night with attacks, then sit up in bed and do this exercise. It is gentle, suits everybody, and will dramatically reduce your symptoms. The main objective of this exercise is to keep your breathing calm.

Instructions

• Breathe in, breathe out, and hold your exhale for 2 to 5 seconds. Do not attempt to hold your breath for longer than this, as this will only increase your breathing and possibly aggravate your symptoms. Your maximum breath hold should be no greater than half your Control Pause. For example, if your Control Pause is 4 seconds, then do small breath holds for only 2 seconds.
• After each breath hold, breathe normally for 10 to 15 seconds. Don’t interfere with your breathing.
• Continue to do a small breath hold followed by normal breathing for 10 to 15 seconds until your symptoms have passed.
• You can repeat this exercise hundreds of times per day and into the night.

EXERCISE #3: BREATHE SLOW AND DEEP

The objective of this exercise is to help alleviate air hunger and feelings of suffocation, by slowing down your breathing with lateral expansion and contraction of the lower ribs. You can use this exercise at the first signs of a panic attack and you can also practice it regularly to lower overall anxiety and stress levels.

Instructions

• Lie flat or sit up straight.
• Breathe into your diaphragm lightly to a count of 3.
• Place your hands on your sides to feel the ribs gently expanding and contracting as you breathe.
• Breathe out lightly to a count of 3 and notice your ribcage contracting.
• Continue this exercise for at least 5 minutes.
• If the feeling of air hunger becomes quite strong, breathe in slowly for 2 to 3 seconds and out slowly for 3 to 4 seconds. If this feels okay, you can slow down your breathing a little more, inhaling for 5 seconds and exhaling for 5 seconds.

EXERCISE #4: BREATH RECOVERY WALK

The objective of this exercise is to add small breath holds to physical exercise. This exercise is not meant to be used at the onset of a panic attack, instead, use it daily to calm your breathing whenever you are feeling anxious or stressed. You can also practice this exercise once per hour if you want to get your breathing under control. This will increase the buildup of CO2 in the blood, improve your Control Pause score, open up your airways, improve oxygenation of the cells, and gently reduce your breathing volume. Please note, this exercise is not suitable if you are pregnant or have a serious health condition.

Instructions

• While walking at a normal pace, take a normal breath in through your nose and out through your nose.
• Pinch your nose to hold your breath.
• Walk with your breath held for 5-10 steps.
• Let go of your nose and breathe normally through it.
• Stop walking, rest, and let your breathing settle for about 30 seconds.
• Between the breath holds, breathe low and slow through your nose and avoid interfering with your breathing muscles.
• Repeat the breath hold 5 times making sure you are breathing through your nose at all times.
• Rest in between each repetition and aim to do this exercise 4 times throughout the day.

ADDITIONAL SUPPORTIVE PRACTICES

Alongside a gentle program of breathing exercises, it’s also important to look at lifestyle factors. Getting enough high-quality sleep really helps with your quality of life and your ability to cope with stress. It’s also important to build awareness of physical tension and to slow down your breathing if you notice tension arising. Try to connect to and feel your inner body during many five-minute pockets throughout the day. You can also use the Buteyko breathing belt for assistance with learning diaphragmatic breathing.

Moving your body is additionally important and mindful movement exercises such as walking and yoga are particularly beneficial (try to do these with your mouth shut). Limiting sugar, alcohol, and caffeine, and balancing blood sugar by consuming a wholefoods-based diet and eating small meals spaced out throughout the day is also recommended. Finally, speaking to a therapist can be helpful because it will allow you to gain awareness around unhelpful thought patterns and belief systems which fuel anxiety.

GET YOUR COMPLETE BUTEYKO ANXIETY GUIDE

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CLOSING THOUGHTS

The breathing exercises and techniques outlined above are to be used in conjunction with normal day-to-day treatments. Given the sensitive nature of anxiety and panic attacks, 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. Instead, begin with focusing on switching to nasal breathing and eliminating the habit of sighing. After a few days, when you are comfortable with nasal breathing, begin to incorporate gentle relaxation and the above-reduced breathing exercises.

Finally, if you are serious about taking control of your mental health and reducing anxiety and panic attacks naturally, we recommend getting the Oxygen Advantage app. This FREE breathing app offers breathwork coaching, exercises, and guided meditations to help you take control of your mind/body health and it has a special section for supporting people with anxiety and Panic Disorder.

*For more help, speak to your medical doctor or find a certified Breathing Instructor.

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