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)