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 (  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.

Abstract from Paper

A case series is reported in which nine patients who experienced phobic and/or nonphobic panic attacks were given a cognitive-behavioural treatment based on the supposition that catastrophic interpretations of sensations produced by hyperventilation played an important role in their attacks. Large and rapid reductions in panic attack frequency and questionnaire report of fear were observed. Patients' resting pCO2 was significantly lower than controls and rose to normal levels during treatment.

Journal Reference:

Salkovskis PM, Jones DR, and Clark DM, (1986) Respiratory control in the treatment of panic attacks: Replication and extension with concurrent measurement of behavior and pCO2, British Journal of Psychiatry, 148, 526 – 532.