Hi Everyone,

I generally choose which articles I read based on my curiosity at that time. (In fact, The Breathing Diabetic has really been me scratching my own itch!) Recently, I came across some papers related breathing and anxiety/panic disorder. Because I suffered from panic attacks during my first year of graduate school, this topic stood out to me. And, I discovered that diabetics generally suffer more from anxiety and panic disorder than non-diabetics. This now makes intuitive sense to me: Blood sugar ups & downs, managing insulin doses, and always having to be prepared “for the worst” (on top of normal life stressors) can add quite a bit of anxiety. So, when I saw scientific studies focusing on the breath and anxiety/panic, I jumped in.

This week, I’m sharing my first two science reviews on this subject:

Controlled breathing reduces the frequency and severity of panic attacks by increasing carbon dioxide levels (full summary below)

Slow, controlled breathing improves anxiety independent of CO2

Both of these papers concluded that controlled, moderately-slow breathing (~12 breaths/min) is an effective therapy for treating anxiety and panic disorder. For example, in the first study, patients experienced less panic attacks after starting breathing training. And, when they did have a panic attack, it was much less severe.

However, there was one major difference in these studies. The first one found that controlled breathing increased CO2, and concluded that this was the cause of the improvements. The second study found that patients’ improved without changes in CO2. Thus, although their patients were breathing slower, they were still breathing too much (that is, hyperventilating). Yet their anxiety/panic improved significantly…that is a pretty big discrepancy.

Out of clutter, find simplicity.” - Albert Einstein

I think these results are actually quite simple to interpret: Slow, controlled breathing reduces anxiety and panic. Combining that with breathing less will help even more.

The act of controlling your breath will immediately make you feel in more control of your body and your emotions, which will be beneficial during episodes of anxiety or panic. When we couple that with the practice of breathing less, we’ll see even better results due to increased CO2, better oxygenation, and better physiological resilience.

Therefore, the goal is to both breathe slower and breathe less. Next week, we’ll look at how biofeedback might help us do just that.

In good breath,

P.S. Feel free to respond directly to this email if you’d like more information of if you’d like to discuss any of these topics further. And, if you missed last week’s email, you can find it here.

Respiratory control in the treatment of panic attacks: Replication and extension with concurrent measurement of behavior and pCO2 - Salkovskis et al. (1986)

Key Points

  • Patients suffering from panic attacks have significantly lower resting carbon dioxide concentrations than matched controls

  • Breathing control reduces frequency and severity of panic attacks

  • Breathing control restores carbon dioxide levels to normal

The Breathing Diabetic Summary

As diabetics, we deal with a lot more stress than the average person.  We have the physiological stress of fluctuating blood sugars, along with the mental/emotional stress of dealing with highs and lows, dosing insulin correctly, planning ahead for everything, etc.  In general, this leads to higher levels of anxiety (https://www.healthline.com/health/diabetes/with-anxiety#research).  Personally, I went through a period in grad school where I experienced panic attacks, which was likely related to poor blood sugar control, poor sleep, and the pressure I was putting on myself.  But regardless of your specific situation, anything that helps reduce anxiety will be beneficial as a diabetic. 

This study looked at the effects of controlled breathing on anxiety and panic attacks.  Panic attacks have similar symptoms to hyperventilation, and previous studies have shown that preventing hyperventilation via controlled breathing has positive results on panic attacks.

One mechanism by which controlled breathing might help panic attacks is through increasing carbon dioxide (CO2).  During hyperventilation, we offload too much CO2 from the blood, increasing pH, and potentially heightening bodily sensations that would strengthen a panic attack.  However, controlled breathing has to potential to level out CO2 and reduce panic attacks.

This research studied 9 patients who suffered from panic attacks.  The study took place over a 6-month period.  The patients were taught to breathe at 12 breaths/min using a tape set.  They were given the tape to use once daily at home.  They were also instructed to practice paced breathing to alleviate anxiety.  Finally, the patients were taught the connection between the breath and anxiety and how hyperventilation potentially worsens/causes panic attacks.  Thus, one could argue that there was also a “white coat” placebo effect in place.  Throughout the experiment, participants used a diary to monitor the frequency & severity of panic attacks along with their general levels of anxiety.  They also received several questionnaires to measure how the controlled breathing protocol subjectively impacted their lives.

The results revealed that controlled breathing reduced general levels of anxiety in the patients.  It also reduced both the frequency and severity of panic attacks.

As for CO2, they found that at baseline, the patients had much lower resting concentrations than those of matched controls.  This indicates that they were in a constant state of mild hyperventilation.  The authors suspect that these low baseline values might make very small changes in CO2 less tolerable, making the patients more vulnerable to physiological stressors (thus exacerbating panic attacks).  Encouragingly, after practice of controlled breathing, the patients’ resting CO2 levels rose to normal, which the authors believe played a role in decreasing the frequency and severity of panic attacks.

Overall, controlled breathing reduced anxiety, reduced both the frequency and severity of panic attacks, and restored CO2 levels to normal. The patients in this study practiced controlled breathing at a moderate pace of 12 breaths/min…I can only contemplate as to how a slower pace (e.g., 6 breaths/min) would further improve these results. The next time our blood sugars send us on an emotional roller coaster, we will be wise to remember this study and Principle 1 and focus on slow, light breathing.