Respiratory feedback for treating panic disorder - Meuret et al. (2004)

Key Points

  • Slow breathing is not enough in panic disorder; CO2 also must be monitored to prevent hyperventilation

  • Biofeedback improves CO2 levels and reduces respiratory rate, while providing patients with visible evidence of their improvement

  • Breathing training helps patients with panic disorder even if they do not have respiratory problems to begin with

The Breathing Diabetic Summary

This is our third paper on breathing as a treatment for anxiety and panic attacks.  As we have seen in the first two papers (here & here), hyperventilation can cause or exacerbate panic attacks.  Here, I think it’s important to pause to reflect on what hyperventilation is.  We often think of it as uncontrolled, fast breathing (which it can be).  However, as this paper points out, hyperventilation is simply breathing more than your body requires at any given moment.  Thus, we can hyperventilate without it being noticeable.  This precise definition of hyperventilation leads to the uniqueness of this paper.

In this study, biofeedback was used not only to help patients breathe slowly, but to also help them breathe less (that is, eliminate hyperventilation).  They educated their patients on the importance of proper breathing and carbon dioxide (CO2) (See more about CO2 here).  Their aim was to reverse dysfunctional breathing, increase resting CO2, and ultimately eradicate panic attacks.

An interesting aspect of this paper is that they used a composite case study (representing many patients they have treated with their approach) rather than a statistical analysis.  Although it felt less scientific, I actually found it easy to read and easy to relate to. 

They describe the case of “Jane”, who has panic disorder and overbreathes.  They hook her up to a nasal cannula so she can see her CO2 levels in real time.  They advise her to breathe less by placing one hand on her chest, one her stomach, and gradually reducing her airflow while breathing into her abdomen (sounds like Breathe Light!).  After a few minutes, she feels breathless.  However, the monitor reveals that her CO2 levels are still below normal, indicating that she is still overbreathing. 

Jane is given a tape recording that guides her to breathe slowly at home.  She is also given the CO2 monitoring device to wear while she practices.  She finds that the tape recording helps her feel more comfortable while breathing less.  A tape or recording would probably help a lot of patients…I know that I personally love using an app to pace my breathing (see “Practice Principle 1” section here).

Over the next 12 months, Jane’s CO2 levels rose to normal, even when she was not performing the paced breathing exercise.  She experienced fewer panic attacks and fewer physical symptoms of anxiety.  The treatment was a success.

The authors point out that this worked for many patients like “Jane.”  Even patients who displayed normal breathing patterns still showed improvements.  This might be related to a placebo effect, or to the general feeling of relaxation that accompanies slow breathing.

Overall, this study showed that slow breathing coupled with biofeedback is a powerful tool for treating panic disorder. By giving patients visible evidence of their improvement, it gave them confidence to reduce their breathing while increasing their CO2. In my opinion, using CO2 biofeedback likely would be beneficial in many disease states, not just panic disorder.

Abstract from Paper

Panic disorder patients often complain of shortness of breath or other respiratory complaints, which has been used as evidence for both hyperventilation and false suffocation alarm theories of panic. Training patients to change their breathing patterns is a common intervention, but breathing rarely has been measured objectively in assessing the patient or monitoring therapy results. We report a new breathing training method that makes use of respiratory biofeedback to teach individuals to modify four respiratory characteristics: increased ventilation (Respiratory Rate x Tidal Volume), breath-to-breath irregularity in rate and depth, and chest breathing. As illustrated by a composite case, feedback of respiratory rate and end-tidal pCO2 can facilitate voluntary control of respiration and reduce symptoms. Respiratory monitoring may provide relevant diagnostic, prognostic, and outcome information.

Journal Reference:

Meuret, A.E., Wilhelm, F.H., and Roth, W.T., (2004) Respiratory feedback for treating panic disorder, Journal of Clinical Psychology, 60 (2), 197 – 207,