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Breathing and Panic Disorder

Much has changed in the field of psychology in the last fifty years, including a proliferation of research and treatments. This has led to an increase in public access to, and choice of, an expanding list of effective therapies. Dismantling studies have enabled the microanalysis of specific treatment components to determine the most effective mechanism of action. From this, we can determine what interventions are helpful, unhelpful, or non-essential. One such example is the role of breathing retraining in Panic Disorder Treatment.


Breathing retraining was once a central component in the treatment of panic disorder. This is due in part to the high incidence of patients reporting symptoms of hyperventilation being like their panic attack symptoms, and that diaphragmatic deep breathing initially appeared to be an effective method to target respiratory distress. Breathing retraining involves training the individual to take slow breaths from the diaphragm, over the course of several minutes, to help decrease rapid breathing (hyperventilation), which for many is an integral part of a panic attack. Breathing retraining can also be combined with Progressive Muscle Relaxation, resulting in a 5-30 minute intervention for daily use.


Despite favorable patient reviews about breathing retraining, researchers queried whether it was an active ingredient in symptom improvement. The results were mixed. Some studies determined that breathing retraining provided direct benefit, while other studies concluded that it was a non-essential ingredient. One study even found it to be harmful. Interestingly, although many patients report difficulty with hyperventilation, only 50% of patients have been shown to have corresponding problematic hyperventilation physiology. Stated another way, a patient’s subjective experience of the cause of their panic is not necessarily the objective reality. As a result, some researchers have concluded that the active change ingredient in the use of breathing retraining does not come from changes in breathing physiology, but rather results from refocused attention and control. These studies have been influential in modifying the role of breathing retraining in the treatment of panic disorder.


Breathing retraining is no longer considered a central component of CBT for panic disorder. However, some clinicians and clients alike continue to use it, begging the question: if the value of breathing retraining is unclear, does it have a role in panic disorder treatment? I believe the answer is yes.


I am in favor of the judicious inclusion of breathing retraining for some clients, in some situations. Although these specifics are best determined through individual case formulation for each client, breathing retraining can be useful as a means to help clients tolerate and cope with unwanted panic symptoms. The goal is for the client to learn to cope with, and tolerate, their sensations, rather than misunderstanding that breathing is meant to control or stop their sensations. Emphasizing this distinction is critical. When clients learn panic sensations are harmless and time-limited, they also learn that there is no need to control or stop them. Thus breathing can be a useful tool to pass the time and get through an unpleasant experience (i.e. a panic attack). This is comparable to how one might use humming to cope with getting a vaccination, and thereby reduce unnecessary suffering. However, for other clients, breathing retraining may serve as a distraction, or worse, as an avoidance tactic. Clients may use breathing to control, eliminate, or avoid panic attacks, rather than to tolerate and cope. For these clients teaching and reinforcing use of other interventions will be more effective.


Although far from exhaustive, the following are a few examples of when breathing retraining might be considered:

  • For clients with other anxiety disorders, such as generalized anxiety disorder (GAD) or post-traumatic stress disorder (PTSD). For some individuals with GAD or PTSD, breathing retraining and progressive muscle relaxation are effective treatment components. Thus, if they have comorbid panic disorder, it makes good clinical sense to discuss how to use the breathing retraining for panic, given they already are using it for GAD or PTSD.

  • For young clients, or clients with concrete thinking. These clients may respond better to behavioural interventions, and thus are more apt to benefit from judicious breathing retraining than cognitive restructuring.

  • For clients who do not report hyperventilation as a primary panic attack symptom. Such clients will be at lower risk to misuse breathing retraining as a form of escape or control.


Ultimately it is important to help clients recognize that stress and anxiety are embedded in our everyday lives. Rather than fall victim to the illusion of control, it is far more effective to provide clients with the tools to tolerate and cope with their symptoms, rather than to control and escape. Breathing retraining is only beneficial for clients when it is used in this format. Thus, by encouraging clients to stay with their sensations, akin to “floating with panic,” or, “riding the wave,” they benefit from a more efficacious treatment plan.

Barlow, D. H., & Craske, M. G. (2014). Panic Disorder and Agoraphobia. In D. H. Barlow (Ed.), Clinical Handbook of Psychological Disorders: A step by step treatment manual. (pp. 1-61). New York, NY: Guilford Press (2014)


Separation Anxiety Disorder—School Refusal

Separation Anxiety Disorder-School Refusal
by Jacquelyn Weatherall.. M.Ed

For most children attending school is an enjoyable and exciting experience. For some, however, attending school may be overwhelming and is endured or avoided. These children may suffer from Separation Anxiety Disorder (SAD) which manifests as School Refusal. Avoidance is a key component of SAD and can take the form of school refusal, reluctance to interact with other children without close proximity of parents or caregivers or refusal to sleep alone.

It is important to understand that separation fears are common at 8 months, 12 months and between 18 months and 3 years of age. Also it is typical for children to have separation fears when first entering day care or preschool. SAD however, is characterized by excessive and developmentally inappropriate anxiety about being separated from home or significant caregiver.

Symptoms of SAD are physical, cognitive and behavioral. Physical symptoms may include stomach distress, (aches, nausea, diarrhea, vomiting), headaches, over heating, fatigue, crying, inability to speak, tantrums/ occasional aggression and stubbornness/"entrenched" response. Cognitive symptoms include excessive, worrisome thoughts befalling either one's self or caregivers. These may include getting lost or kidnapped, fear of illness or worry that the caregiver may be involved in a dangerous or fatal accident and thus not return home. The connection among these varying thoughts is the fear that one will ultimately become separated from the primary caregiver. Behaviorally, the most common and disruptive symptom is school refusal. This may look like complete refusal to attend, attending but leaving early, starting late and tantruming upon arrival, attending but experiencing a high degree of distress. Other symptoms include refusal or reluctance to be alone or without caregivers, repeated nightmares with separation themes and avoidance of situations, which may result in separation from caregivers.

SAD is treatable and manageable when properly diagnosed. Parental involvement in treatment is critical, as the child needs to be rewarded with parent attention for success. The parents also need to be fully supported in keeping with the treatment plan, despite increasing pressure from the child to go back to the "old" ways of interaction.

The ideal length of time for treatment of SAD is about twelve sessions, although studies show that children who have as few as six sessions do show improvement. As with the treatment of other anxiety disorders it is recommended that each session stand alone and incorporates the core components of Cognitive Behavioral Therapy.

Treatment begins with educating the child about anxiety and normalizing its experience. Anxiety is a normal response experienced by all and helps to alert one to danger. Using the analogy of a faulty car alarm or smoke alarm that goes off at the slightest signal is helpful in having the child or youth realize when anxiety is no longer a useful tool in personal safety. Education also involves assisting the child to understand why anxiety develops. An ideal way to explain anxiety is to use the A (affect) B (behavior) C (cognition) triangle so the child can understand the relation ship between their thoughts ( C ), feelings (A) and behaviors (B).

For example a child may think (C ), "my dad is going to have a car accident if he goes to work", the feelings (A) are nausea and head- ache; the behaviors (B) are tantrums and complaints of illness so dad will stay home. Understanding this relationship ultimately empowers the child to take more control of the anxiety provoking situation.

The next core component of treatment is to help the child recognize the bodily sensations of anxiety, the feelings (A), and how to manage them. Learning to use the body sensations as a clue or warning sign of anxiety helps the child know when to use utilize effective management strategies such as progressive muscle relaxation or deep and controlled breathing.

Another core component of treatment is cognitive challenging or assisting the child to gain the ability to diffuse overwhelming and exaggerated thoughts (C ). Learning to identify unhelpful thoughts and externalizing them as "worry monsters", empowers the child to confront them. Other cognitive strategies help the child to replace disruptive thoughts with more helpful ones or realistically estimate the probability of the thoughts actually coming true. Identifying and then challenging faulty thinking patterns helps to minimize the hold anxiety can have and increases the likelihood of participation versus avoidance.

All the components of Cognitive Behavioral treatment of anxiety disorders are important to successful intervention. However, exposure, or having the child face their fears is critical. Exposure is best done gradually, rather than an all or none, sink or swim approach. A hierarchy or fear ladder is constructed so that the child can gradually face the least fearful situation to the most fearful situation. As the child works through the fear hierarchy the length of exposure can also increase from brief to prolonged. Each hierarchy will be as individual as the child. For example, playing at a friend's house without a parent present may be precluded by having the parent in the house for all of the playtime, half of the playtime, or waiting outside in the car with cell phone access only.

Although SAD can be a stubborn disorder, it is treatable. Part of the core components of treatment includes understanding the likelihood of relapse. Often a child will do well for a period of time and then suddenly regress. This may occur when schedules and expected routines change. Knowing this is normal will help in reestablishing prior gains.

Research has shown that the Cognitive Behavioral anxiety management skills and exposure strategies are effective in the treatment of Separation Anxiety Disorder. School like work for adults, is a vital part of a child's experience and growth. Learning to manage the debilitating symptoms of SAD empowers children and families to face their fears and lead more enjoyable lives.


Anxiety Canada's President's Address


APRIL 22 - 24, 2010



              On behalf of Anxiety Canada I would like to welcome everyone to the Anxiety Disorders Association of Canada 2010 Scientific and Academic Conference. 

              The Anxiety Disorders Association of BC (now known as Anxiety Canada) became a reality in 1999 due to a small group of hard working and tenacious individuals.  Drs. Peter McLean and Maureen Whittal, from the UBC Anxiety Disorders Unit, formed Anxiety Canada.  At that time, people with anxiety and their family members were experiencing difficulty accessing information as well as treatment resources. It was decided that the needs of people troubled by anxiety symptoms would be better served if awareness of anxiety increased in the larger population.  These two psychologists recruited several people with broad expertise and an interest in anxiety to form Anxiety Canada.

              It is an honor for me to serve in the capacity of President of the Board, but Iam equally proud of having overcome an anxiety disorder.  Prior to being diagnosed with Generalized Anxiety Disorder, and receiving treatment, it was a struggle for me to make a telephone call, and it would have been out of the question for me to appear before you today.

              I consider myself very lucky to have had a GP who recognized that I was struggling with anxiety and referred me to the UBC Anxiety Disorders Unit.   After a wait of a few months I was called in for an assessment and received the diagnosis of G.A.D.   Again, I was fortunate that a group for G.A.D. was beginning shortly, and in late 2004 I began a 15 week treatment program using cognitive behavioural therapy. 

At the conclusion of treatment I asked whether there were any volunteer opportunities available.  It was then that I learned of Anxiety Canada, and discovered that they were looking for persons to peer-lead groups of others suffering from panic disorder.  In 2005 I co-lead my first group, and since then have co-led four other groups.   Research has shown that peer modeling is one of the most effective ways by which individuals can acquire new skills.   

              As a leader, I have been inspired by the changes I have seen in group members. I have also come to realize that teaching anxiety management skills to others has allowed me to keep my own anxiety in check.  By demonstrating self-management skills to them I am reminded of what I must do.  In short, everyone benefits:  the participants, the group leaders, and the health care system.  I mention the health care system because individuals with panic disorder also generate significant economic costs, and peer-lead groups are a very cost-effective way to help them before they become more severe and begin to access the health care system much more frequently, by, for example, showing up at doctors' offices or even hospital emergency rooms with unexplained symptoms, frequently those similar to a heart attack.

In a best case scenario, the panic disorder groups would be ongoing and numerous.  Many of those able to overcome their anxiety issues through treatment, such as myself, would be willing to volunteer as peer-leaders, allowing the number of groups to expand and more people to be helped.  Sadly, Anxiety Canada has not been able to offer these groups for the past two years due to a lack of funding.

As I said at the outset, I was fortunate.  Although effective treatments for anxiety disorders have been established, evidence-based interventions are received by only a minority of individuals who seek treatment, while many others do not have access to appropriate treatment resources. Unfortunately, many practitioners do not have the appropriate training to deliver evidence-based treatments for the successful management of anxiety disorders. Moreover, evidence-based programs for anxiety disorders are not widely available.

Given these facts, it is astounding to me that the UBC Anxiety Disorders Clinic, where I received my diagnosis and treatment in 2004, was closed by Vancouver Coastal Health approximately one year ago.  The clinic was a tertiary service that provided assessments and treatment province-wide. In their last year of operation the ADC recorded over 3000 patient visits. Most of these visits were one-hour therapy appointments (group or individual) with the remainder, medication consultations or checks.

In addition to providing high quality evidence-based treatment, the staff members of the ADC were heavily involved in training and research. A number of federally and provincially funded research studies were carried out in the clinic. A number of these research projects involved investigations of novel treatments, which meant that the people with anxiety disorders were getting cutting edge treatment. ADC staff were also centrally involved in training and teaching of CBT, both to pre-doctoral interns, post-doctoral fellows and psychology graduate students. With the closure of the ADC there is no longer an internship program in CBT in Vancouver. 

            While we remain hopeful that things will change, Anxiety Canada in the meantime has done as much as we can within our limited funding to advance our goals of increasing awareness, promoting education and improving access to programs that work.   We have developed a website which has been recognized throughout the world by both consumers and professionals, and provides substantial information and practical self-help strategies that can be used by those affected by anxiety.  We have within the past month added a section on CBT, and this too is being widely viewed and we have received much positive feedback.   Interestingly enough, our website statistics indicate that the most frequent visitors are the B.C. government and the U.S military.

We have embarked on a continuing program to develop educational DVDs on both childhood and adult anxiety.  Two DVDs have been completed:  the first on separation anxiety in children, and the second on panic disorder in adults.  On Saturday, the two finished DVDs will be screened during the lunch break, with Dr. Michael Catchpole providing some comments.  The third DVD is in production and will be on Social Anxiety in older children and teens.  Our goal is to develop a library of DVDs on all anxiety disorders affecting both adults and childen.  The DVDs are being widely distributed throughout British Columbia, through child and youth and other government agencies, libraries, hospitals and the like. 

Over the years Anxiety Canada has offered several parent information nights throughout the province to assist parents with anxious children, and has developed an in-depth one day parenting workshop that is now being offered.  These have been well received and, funding permitting, will be continued.

            It is obvious, however, that much more remains to be done and that not-for-profit organizations such as Anxiety Canada and ADAC can only do so much.  What will be required is leadership, policy direction and support from all levels of government, to ensure access to a high standard of care for individuals with anxiety disorders, irrespective of their place of residence.  I mentioned earlier that I considered myself very "lucky" to have received treatment for my anxiety disorder; I look forward to the day when "luck" will play no part at all and everyone in need will have access to evidence-based treatment.


Shelly Jones,

President - Anxiety Canada



Ask The Doctor (Spring 2011) by - Ron Norton, PH.D - PTSD

Dear Proud Vet,

Thank you for your question and service to our country.  No there is absolutely nothing wrong with you.  Recent research by neurobiologists and psychologists has shown that humans are very resilient to the horrors we sometimes experience.  When we are faced with danger our bodies react in ways that prepare us to face the danger by either fighting or fleeing the situation.  When the danger is prolonged and/ or intense as in combat, some people are unable to recover from these bodily and psychological events, but most do.  The reason why some people develop serious problems such as PTSD and others don't is not totally clear, but genetics and previous life experiences seem to play important roles.  For example, people who have suffered previous psychological problems are more vulnerable to developing PTSD following horrific events than are those who did not have prior psychological problems.  I would suggest that you read Richard McNally's article in a previous edition of Strides.  It provides an excellent overview of PTSD.


The Doctor