Kathleen Kawamura, PhD Clinical Psychologist

Anxiety and the Breath

When our mind perceives danger, we begin to breathe rapidly and shallowly from our upper lungs in preparation for physical exertion. This style of breathing is normal when we are running or fighting, but if our bodies are idle, this style of breathing can lead to hyperventilation, or breathing more than is necessary.

When hyperventilating, we are dumping out carbon dioxide, which lowers the carbon dioxide levels in our blood, which leads to symptoms such as:

Dizziness
Shortness of breath
Chest pain
Lump in throat
Tingling in extremities
Nausea
Confusion

These breathing patterns can further contribute to uncomfortable symptoms of anxiety, which can lead to anxious thoughts about the symptoms, which can then lead to more anxiety.

In addition, when we experience chronic stress, we may be consistently hyperventilating on a small scale, leaving our bodies vulnerable to a panic attack.

A study by Meuret et al (2011) showed that for those who experienced "out of the blue" panic attacks, significant changes in their breathing and heart rate occurred a full hour before their panic attack, and that these symptoms were largely outside of conscious awareness.

Wilhelm and Trabert (2011) also showed that individuals with panic disorder evidenced instability in measures of respiration even at rest. These findings point to the importance of stabilizing respiration in those who suffer from panic attacks.

Because of the relationship between breathing and anxiety, many treatments for anxiety disorders involve breathing retraining. Breathing retraining refers to teaching clients how to breathe from their diaphragm, or from their bellies, vs their chest.

Breathing retraining also involves learning how to slow the breath cycle to about 6 breaths per minute, or 10-second breaths. Often, this can be done by imagining breathing through the nose (smelling the flowers) and then breathing out through pursed lips (blowing out the candles) and imagining that you are breathing into your belly, filling up a balloon that expands and pushes up your belly.

There have been mixed findings regarding the efficacy of breathing retraining in the treatment of panic disorder. This may be because "correct" breathing becomes another source of anxiety or the breathing is used as a way to stop or control a panic attack that has already been triggered.

The key to treating panic disorder is learning to tolerate the uncomfortable physical symptoms associated with anxiety and to learn that they are not harmful, can be tolerated, and will pass.

Therefore, when implementing this strategy, it is important to use it as a preventative measure that decreases overall physiological arousal to reduce the likelihood of panic attacks, but once a panic attack is triggered, the breathing should be used as way of sitting with the anxiety and allowing it to pass.

Use Breathing Retraining to:

Produce physiological changes that promote relaxation
Increase awareness of the mind and body
Help sit with feelings of anxiety

How breathing affects you physically:

1) Chest or thoracic breathing

Associated with sympathetic “fight or flight” experience of stress, anxiety, emotional distress
Shallow, rapid, uneven breaths into top of lungs
Shoulders rise up and down
Can lead to imbalance in blood levels of oxygen and carbon dioxide which contributes to hyperventilating, or overbreathing which leads to symptoms such as light headedness, heart palpitations, numbness, agitations, tingling, weakness, shortness of breath
Chronic stress and chronic over breathing are not imminently life threatening but can lead to feeling on edge or exhausted making it difficult to cope with stressful situations

2) Abdominal or diaphragmatic breathing

Associated with parasympathetic “rest and digest” experience of relaxation, calm
Full, slow, regular breaths deep into lungs
Abdomen rises and falls
Can lead to balance in blood levels of oxygen and carbon dioxide which can slow and regulate heart rate which further promotes the relaxation response
Regular practice of breathing exercises throughout the day can shift your normal breathing back to a regular pattern so that you feel calm and focused helping you feel prepared to deal with stressful situations

How breathing affects you mentally:

Breathing retraining or mindfulness breathing exercises can:

Help train your mind to focus its attention. With consistent practice, the mind can be trained to focus its attention on where you direct it
Help you sit with the thoughts associated with anxiety. Focusing on your breath is much easier to do than “don’t worry.” Focusing on your breath can help cultivate an attitude of gratitude as you begin to appreciate your breath and body, putting your stress into perspective. Balance and perspective can help you sit with your emotions and see past your distress rather than being carried away by your emotions.
Help you slow your mind down. By taking a step back and shifting your mind away from your distress and towards your breath, you may be able to think more creatively and flexibly to see new options. By slowing your mind and body, you may be able to make decisions based on clarity and perspective rather than raging emotions.

3-minute Breathing Exercise

Find a comfortable position sitting up or lying down.

Inhale, pause, then exhale all the way, emptying your lungs, allowing your body to go loose and limp. This full exhalation will create a vacuum that will pull a deep breath into your abdomen.

Imagine that your abdominal area is a balloon, and as you inhale, you are filling it in with air, and as your exhale you are just letting the air flow out. Imagine that you are filling your lung first from near your abdomen, to your middle chest, then to your upper chest. Filling the balloon from bottom to top.

Allow yourself to breathe through your nose (smelling the roses) and out through slightly pursed lips (blowing out the candles).

Notice your breath. Notice each inhalation and exhalation, notice the pause in between. Be aware of the sound and feeling of your breath against your lips and nostrils. Notice the rise and fall of your body with each inhalation and exhalation. Observe your body breathing itself naturally and automatically.

Notice the thoughts that come to mind. Notice the wandering mind, then gently but firmly bring your focus back to your breath. No matter how many times your mind wanders, simply bring it back to your breath each time. You can label your thought, as in “thinking, planning, judging, noticing, resisting….” Or you can imagine your thoughts floating away or sitting next to your mind.

Notice the steady rhythm of your breathing. Experiment to see what works best for you:
- Imagine that you are breathing in relaxation and breathing out tension. Inhaling relaxation, exhaling tension.
- Center your mind on the movements and sensations of your body.
- Count your breath cycles – inhale 1, relax (with outbreath), inhale 2, relax, inhale 3, relax….

Practice for 3 minutes, 3 times a day (3x3). The goal is not necessarily to achieve relaxation (though this may be a welcome side effect) but rather to retrain your brain and body to breathe in this way on a regular basis. It is important to try to catch yourself throughout the day, notice your breathing, and shift it to regular, calming abdominal breaths so that this becomes your new normal.

TIP: Do NOT use this as a way of making anxiety go away. If your sympathetic nervous system is already triggered, the chemicals that have been released into your body need to dissipate on their own. Your job is to not sustain the alarm. Breathing can be used as a way to sit through the initial false alarm until the anxiety dissipates on its own.

TIP: Do NOT use this as a way to distract from anxiety. It is important to recognize anxiety with all of its thoughts, feelings, and behaviors and learn to not react with alarm. Breathing can be used as part of mindfulness exercise where you notice and sit with your anxious thoughts, feelings, and urges.

Guided Meditations:

Breathe Calm down Meditate App: Free app for Android and iPhones. This app has options for visuals and sounds to help you with breathing exercises. To practice 3-minute breathing, select "Coherent Breathing: anti anxiety and depression" and it preselects 5-second inhale and 5-second exhale. You can set the timer for 3-minutes.

Mindfulness Meditation: 3-minute Breathing Space: Teik Yen Ko