Stress, anxiety and panic disorder in adults and children

Stress is a fact of modern life. We enjoy unprecedented levels of convenience and technological advancement, but our daily lives are full on, high pressure and, thanks to social media, lived more publicly than ever before.

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 caused by crowded commutes, presentation deadlines and software updates, when only a few hundred years ago these things simply didn’t exist. It’s easy to end up with our fight, flight or freeze button jammed in the ‘on’ position. The result is chronic stress and emotional exhaustion.

It’s well recognized that events, which might on an individual basis be considered non-traumatic, can compound to become significant. Faced with sustained periods of stress, family problems such as divorce or care giving, and challenging work environments, we struggle to cope. It’s hardly surprising then, that we develop mental health problems such as anxiety and panic disorder, and a catalogue of related negative health outcomes¹.

One three-year study of anxiety disorder in the general population found that 11.4% of people were dealing with ‘subthreshold’ anxiety disorder – their anxiety was not chronic enough to produce symptoms, but it was a constant factor in their lives. By the time these patients were reassessed at the end of the three year trial, the condition had progressed to full-blown anxiety disorder in 13.8% of those with anxiety². Meanwhile, Mind, the Mental Health Charity reports that 5.9% of people in England suffer from generalized anxiety disorder, and nearly 8% have mixed anxiety and depression³.

Research has found that: “Anxiety is common in children and adolescents.”⁴ Naturally this is a cause for concern amongst parents and carers. Wouldn’t it be great to find a practical way to support young people with anxiety? Spoiler alert, the Buteyko Breathing Technique can help…

It’s also well known that anxiety frequently occurs alongside other health conditions. For example, people with sleep apnea are more likely to have anxiety disorders than those without⁵, and one review of patients with chronic COPD found that 40% of those with the respiratory illness had clinical anxiety⁶. Another similar study found that clinical anxiety was present in between 10% and 55% of COPD in-patients and 13% and 46% of outpatients⁷. Disorders ranged from generalized anxiety, which affected as many as 33% of those studied, to social phobia, which was reported in up to 11% of patients. Women were more likely to suffer from clinical anxiety disorders such as panic disorder than men⁷.

In another paper, scientists reported that 45% of people with bipolar disorder suffer from anxiety⁸. Treatment of anxiety can be difficult when it co-exists with bipolar, as common antidepressant medications can trigger mania and other symptoms.

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. Patients with panic disorder have much higher lifetime rates of cardiovascular, respiratory, gastrointestinal, and other medical problems⁹, and anxiety can even lead to suicidal thoughts. When you’re constantly on the brink of a panic attack, it becomes difficult to function, socially, at work or at home.

So what can you do about it?

Buteyko Breathing instructor Patrick McKeown offers two hour online clinics for panic disorder, anxiety and stress. The cost of this 2 hour clinic and video recording costs 95dollars. Click here to find out more.

Take a deep breath

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^10,11. The normal reaction when instructed to take a deep breath is to inhale a big gulp of air straight into the upper chest. This leads to over-breathing and perpetuates hyperventilation.

It’s important to understand what hyperventilation is, because it’s not quite what most of us think. Chronic hyperventilation happens subtly, with not 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. Hyperventilation, as defined by scientists in the 1930s, is fast, upper chest breathing, where more air is taken into the lungs than is needed, causing a loss of carbon dioxide and disrupting the blood chemistry¹². This can create a series of reactions, including muscle tension. And if there isn’t enough CO₂ in the blood, less oxygen reaches the heart and the brain.

Many studies have shown a negative feedback loop between hyperventilation and anxiety in which poor breathing patterns are a central factor₁₃. But it’s important to understand the difference between short-term over breathing and a long-term habit. It’s normal, for example, for breathing volume and speed to increase during exercise, or if you’re suddenly stressed out. The real problem occurs when over breathing continues and becomes your normal way of breathing.

What causes panic attacks?

The Diagnostic and Statistical Manual of Mental Health Disorders (DSM) defines panic attacks as: “an abrupt surge of intense fear or discomfort”⁹. These episodes can be really scary, because panic attacks peak within just a few minutes. Symptoms include palpitations, a pounding heart or accelerated heart rate, trembling or shaking, feelings of choking, sweating, dyspnea (breathlessness) or a feeling of suffocating, chest pain, nausea or abdominal distress, dizziness or light-headedness, chills or heat sensations, fainting, numbness or tingling sensations, derealization (feelings of unreality) or depersonalization (being detached from oneself), fear of losing control or ‘going crazy’, and even fear of dying.

A direct link has been proven between anxiety, panic attacks and levels of blood carbon dioxide. Rapid breathing, which is common in people with anxiety, causes a drop in blood CO2, which means less oxygen reaches the brain. This triggers feelings of air hunger akin to suffocation, which cause compensatory over-breathing, perpetuating hyperventilation. In one study, the relationship between childhood anxiety disorders and breathing was examined in children aged 9-17 years. Researchers concluded that anxiety in the children was determined by increased sensitivity to carbon dioxide. Correlations were found between sensitivity to blood CO2, increased speed of breathing and symptoms of anxiety¹⁴.

Emotions such as fear also cause an increase in adrenaline and noradrenalin. This makes the body around 30% more sensitive to carbon dioxide¹⁵, with the same result: Hyperventilation. If you’re already prone to panic attacks, you may have experienced a strong reaction to the sense of suffocation, without realizing that it was caused by over-breathing. Research has proven that people with anxiety disorders will panic and hyperventilate when their levels of blood carbon dioxide rise, as the feeling of air hunger prompts them to react fearfully.

This biochemical trigger is really interesting. It indicates that the balance of your blood gases is integral to your susceptibility to panic attacks. And this means you can do something about your panic attacks in a way that will achieve tangible results, and allow you to feel more in control of your anxiety. This will feed back to your brain, and the feelings of control will lessen the psychological aspects of the problem – a positive feedback loop this time.

The first thing I do with any client who comes to me with panic attacks and anxiety is to begin work to address the underlying breathing pattern disorders. I look at each aspect of breath re-training in turn. First, I work to balance the biochemistry, building tolerance to light air hunger and reducing sensitivity to carbon dioxide. Then I introduce diaphragm breathing, and finally work to slow down the breath.

Alongside a gentle program of breathing exercises, it’s also important to look at the following factors:

• Good quality sleep really helps with your quality of life and your ability to cope, whatever your current state of health. I recommend reduced breathing exercises for 15 minutes before bed, and ensuring nasal breathing during sleep to address sleep-disordered breathing such as sleep apnea. You can use MYOTAPE to tape the mouth while re-introducing habitual nasal breathing during sleep
• It’s good to build awareness of physical tension and unhelpful thought patterns. If you notice the physical and psychological signs that may trigger feelings of anxiety and/or panic, you can gently slow down your breathing to relax
• By working to increase your control pause, you will gradually reduce your sensitivity to blood CO₂. This will have a positive impact on your breathing during rest, sleep and exercise, and give you greater resilience to stress.

Breathing exercises vs. cognitive behavioral therapy

Current treatments for panic disorder include psychological and pharmacological interventions. Of the psychological interventions, cognitive behavioral therapy (CBT) is the most commonly used⁹. According to one report, “Panic disorder has no cure, and its course is unpredictable. The currently available pharmacological therapy and cognitive behavior therapy do work in about 80% of patients, but relapses are common. About 20% of patients continue to have symptoms that lead to poor quality of life.”⁹

However, a 2010 study from scientists in the US, shares a much more positive view when it comes to treatment options and outcomes. This study examined patients with panic disorder and agoraphobia. The participants were randomly placed into two groups, and over the course of four weeks they were given either capnometry-assisted respiratory training or panic-related CBT¹⁷. The breathing group practiced exercises that gradually reduced their rate of respiration from 13 breaths a minute in week 1 to 6 breaths a minute in week 4. Severity and symptoms of panic thinking improved in all the patients, as did their perceived levels of control. However, the biochemical results were different. In the group who received the respiratory training, blood CO₂ levels went from too low (hypocapnic) to normal. This change was not replicated in the CBT group. The results indicated that the breath training created biochemical changes that produced body-to-brain feedback. The breathing exercises addressed the panic disorder from a physiological point of view, whereas the main improvement for the CBT group was due to the fact they believed themselves to be more in control of their condition¹⁷.

It’s thought that many of the benefits of psychosocial therapy are gained from feelings of being more in control of the onset of attacks. While the value of this approach is unquestionable, it’s interesting to note that breath re-training addresses the symptoms from a chemical perspective. If hyperventilation (in terms of the reaction to carbon dioxide) rather than mental stress is the initial trigger for panic attacks, symptoms and frequency will decrease when carbon dioxide levels are corrected. While previous studies have interpreted the drop in CO₂ to be a result of the increased feelings of control, this study concluded that it was the therapeutic change in carbon dioxide that reduced the sensations and intensity of panic, not the other way around – the biochemical change was responsible for the positive outcomes.

The researchers also concluded that the breathing exercises and CBT worked via different pathways within the body. People who suffer with anxiety and panic attacks have an imbalance in their body biochemistry that means they are constantly on the brink of a panic attack. In order that their problem is fully resolved, it is necessary to use breathing techniques alongside psychological interventions to ensure that symptoms are managed both emotionally and physically. This gives the best chance of that elusive ‘cure’.

Addressing breathing pattern disorders for greater resilience against stress

Have you ever noticed what happens to your breathing when you are stressed? It may not be uppermost on your mind in the middle of a crisis, but it’s likely that a few things happen. These are:

• Your breathing speeds up
• You breathe from the upper chest
• You might sigh more often
• You breathe through your mouth
• Your breathing becomes irregular, erratic, or noticeable because it’s louder

Equally, it is possible to create feelings of stress by adjusting your breathing to replicate these habits.

If you suffer with anxiety and panic attacks, the chances are, you already breathe in the ways described above. You can start addressing this just by becoming aware.

• If breathing is fast, gently slow it down
• If breathing is fast, gently slow it down
• If you notice yourself sighing, hold the breath for 10 seconds after the sigh to rebalance your blood gases
• If you’re mouth breathing, switch to nasal breathing
• If your breathing is noisy or erratic, quieten it, and practice slow, light, deep breaths

Buteyko Breathing exercises for anxiety and panic disorder

When beginning Buteyko breathing exercises for anxiety and panic disorder, it’s important to remember to go gently. If you rush in full steam ahead, intense feelings of air hunger may trigger a panic attack.

Here are some things you can do:

• Switch to nasal breathing both day and night
• Stop sighing. If you notice a sigh is on the way, swallow. If a sigh slips out, compensate by exhaling through your nose and holding your breath for five to ten seconds after the exhalation
• Try the Breath Hold Walk exercise (below) – a beginner exercise that’s really effective for anxiety
• Improve your control pause

The Breath Hold Walk

1. Take a normal breath out through your nose

2. Hold your breath and hold your nose with your fingers so that no air creeps in

3. While holding your breath, walk five to ten steps

4. Stop walking and let go of your nose

5. Begin breathing again, through your nostrils

6. Breathe normally for 30 to 60 seconds and repeat. Practice four sets of five repetitions during the day

Reduced breathing exercises will help you to increase your control pause – the number of seconds for which you can hold the breath on an exhalation before the impulse to breathe in, and an indicator of blood sensitivity to carbon dioxide. Your breathing rate will slow and the amount of air you take in with each breath will reduce to match the metabolic needs of your body. Your in-breath will be lighter, your out-breath slightly longer – in healthy breathing patterns, the out-breath is about 1.5 times longer than the in-breath – and the pause between your inhalation and exhalation will increase. Research has shown that an inhalation to exhalation ratio where the out-breath is longer is helpful for reducing physical and mental stress during confrontation¹⁸.

Breathing exercises to stop panic in its tracks

You can measure your progress by using the control pause score. If your control pause is below 25 seconds, your breathing is likely to be problematic. You can also tell whether your breathing pattern is becoming healthier just by the way you feel. If you’re breathing nasally, your sleep will be better, and your brain and body will be getting all the oxygen it needs. If you do feel a panic attack coming on, it’s useful to know these two exercises, which can be used to prevent the onset of symptoms:

1. Practice a series of short breath holds (on the exhalation) of between 3 and 5 seconds each

2. Cup your hands across your mouth to re-breathe the exhaled carbon dioxide

If you suffer with anxiety and panic disorder, there is a simple way forward. By taking control of your breathing, and addressing the biochemical imbalance in your body, you can moderate the frequency and severity of panic attacks and reduce your anxiety for good.

Avail of Patrick McKeown online clinics for panic disorder, anxiety and stress. 2 hour online face to face training and video recording of the training costs 95dollars. Click here to register for Patrick’s next clinic for anxiety.

References:

1. Matosin, Natalie, Cristiana Cruceanu, and Elisabeth B. Binder. “Preclinical and clinical evidence of DNA methylation changes in response to trauma and chronic stress.” Chronic stress 1 (2017): 2470547017710764.

2. Bosman, Renske C., Margreet ten Have, Ron de Graaf, Anna DT Muntingh, Anton JLM van Balkom, and Neeltje M. Batelaan. “Prevalence and course of subthreshold anxiety disorder in the general population: A three-year follow-up study.” Journal of affective disorders 247 (2019): 105-113.

3. “Mental Health Facts and Statistics.” Mind, Published April 2017, www.mind.org.uk/information-support/types-of-mental-health-problems/statistics-and-facts-about-mental-health/how-common-are-mental-health-problems/ (accessed, February 13th 2020)

4. Klaufus, Leonie, Eva Verlinden, Marcel van der Wal, Mia Kösters, Pim Cuijpers, and Mai Chinapaw. “Psychometric evaluation of two short versions of the Revised Child Anxiety and Depression Scale.” BMC Psychiatry 20, no. 1 (2020): 47.

5. Rezaeitalab, Fariborz, Fatemeh Moharrari, Soheila Saberi, Hadi Asadpour, and Fariba Rezaeetalab. “The correlation of anxiety and depression with obstructive sleep apnea syndrome.” Journal of research in medical sciences: the official journal of Isfahan University of Medical Sciences 19, no. 3 (2014): 205.

6. Panagioti, Maria, Charlotte Scott, Amy Blakemore, and Peter A. Coventry. “Overview of the prevalence, impact, and management of depression and anxiety in chronic obstructive pulmonary disease.” International journal of chronic obstructive pulmonary disease 9 (2014): 1289.

7. Willgoss, Thomas George, and Abebaw Mengistu Yohannes. “Anxiety disorders in patients with COPD: a systematic review.” Respiratory care 58, no. 5 (2013): 858-866.

8. Pavlova, Barbara, Roy H. Perlis, Martin Alda, and Rudolf Uher. “Lifetime prevalence of anxiety disorders in people with bipolar disorder: a systematic review and meta-analysis.”The Lancet Psychiatry 2, no. 8 (2015): 710-717.

9. Cackovic, Curt, Saad Nazir, and Raman Marwaha. “Panic Disorder (Attack).” In StatPearls [Internet]. StatPearls Publishing, 2019.

10. Craske, Michelle G., Melissa Rowe, Michael Lewin, and Rosanna Noriega‐Dimitri. “Interoceptive exposure versus breathing retraining within cognitive‐behavioural therapy for panic disorder with agoraphobia 1.” British Journal of Clinical Psychology 36, no. 1 (1997): 85-99.

11. Schmidt, Norman B., Kelly Woolaway-Bickel, Jack Trakowski, Helen Santiago, Julie Storey, Margaret Koselka, and Jeff Cook. “Dismantling cognitive–behavioral treatment for panic disorder: Questioning the utility of breathing retraining.” Journal of consulting and clinical psychology 68, no. 3 (2000): 417.

12. Kerr, William J., Paul A. Gliebe, and James W. Dalton. “Physical phenomena associated with anxiety states: the hyperventilation syndrome.” California and western medicine 48, no. 1 (1938): 12.

13. Schleifer, Lawrence M., Ronald Ley, and Thomas W. Spalding. “A hyperventilation theory of job stress and musculoskeletal disorders.” American journal of industrial medicine 41, no. 5 (2002): 420-432.

14. Pine, Daniel S., Rachel G. Klein, Jeremy D. Coplan, Laszlo A. Papp, Christina W. Hoven, Jose Martinez, Pavel Kovalenko et al. “Differential carbon dioxide sensitivity in childhood anxiety disorders and nonill comparison group.” Archives of General Psychiatry 57, no. 10 (2000): 960-967.

15. Heistad, Donald D., Robert C. Wheeler, Allyn L. Mark, Phillip G. Schmid, and Francois M. Abboud. “Effects of adrenergic stimulation on ventilation in man.” The Journal of clinical investigation 51, no. 6 (1972): 1469-1475.

16. Sardinha, Aline, Rafael Christophe da Rocha Freire, Walter Araújo Zin, and Antonio Egidio Nardi. “Respiratory manifestations of panic disorder: causes, consequences and therapeutic implications.” Jornal Brasileiro de Pneumologia 35, no. 7 (2009): 698-708.

17. Meuret, Alicia E., David Rosenfield, Anke Seidel, Lavanya Bhaskara, and Stefan G. Hofmann. “Respiratory and cognitive mediators of treatment change in panic disorder: Evidence for intervention specificity.” Journal of consulting and clinical psychology 78, no. 5 (2010): 691.

18. Cappo, Bruce M., and David S. Holmes. “The utility of prolonged respiratory exhalation for reducing physiological and psychological arousal in non-threatening and threatening situations.” Journal of Psychosomatic Research 28, no. 4 (1984): 265-273.