Breathing and Hyperventilation
Many people are surprised that very subtle shifts in breathing can cause anxiety symptoms ranging from muscle tension to migraines, panic attacks and high blood pressure. The highly respected researcher and physician Chandra Patel sums it up:
"Behind the simple act (of breathing) lies a process that affects us profoundly. It affects the way we think and feel, the quality of what we create, and how we function in our daily life. Breathing affects our psychological and physiological states, while our psychological states affect the pattern of our breathingÖHyperventilation causes not only anxiety but also such a variety of symptoms that patients can go from one specialty department to another until a wise clinician spots the abnormal breathing pattern and the patient is successfully trained to shift from maladaptive to normal breathing behavior.
"It has long been known that slow, rhythmic, diaphragmatic breathing can soothe our inner storms and make us feel calm and composed. It is difficult to apportion the benefit contributed by breathing exercise, but I now believe it is likely to be larger than I had originally imagined."
Hyperventilation is seen in many, and perhaps most, people with anxiety disorders. It accounts for many visits to primary-care physicians and most of the calls for ambulances.
What Exactly is Hyperventilation?
Hyperventilation, or overbreathing, means that you expel carbon dioxide (CO2) faster than your body is producing it. This usually occurs with rapid, shallow "chest" breathing, but can also occur with deep breathing.
Why Is It A Problem?
When blood CO2 drops, at least two major changes occur in the body. First, certain blood vessels constrict causing less oxygen to reach the brain, heart and extremities. Secondly, the blood acidity changes, causing less oxygen to reach the tissues and certain ions to flood body tissues. These changes account for a wide array of symptoms that are virtually identical to the symptoms of anxiety (see Table 6.1). The change in blood acidity is thought to play a role in sensitizing the nerves.
The author wishes to express appreciation to Dr. Ronald Ley, University of Albany, for reviewing this section, which has drawn much from his work: Timmons, B.H., & Ley, R. (Eds.). (1994) Behavioral & Psychological Approaches to Breathing Disorders. New York: Plenum.
Signs and Symptoms of Hyperventilation
(breathlessness and chest pain are most common)
Cardiovascular: palpitations, missed beats, tachycardia, sharp or dull atypical chest pain, "angina", vasomotor instability, cold extremities, Raynaudís phenomenon, blotchy flushing of blush area, capillary vasoconstriction (face, arms, hands)
Neurological: dizziness, unsteadiness or instability, faint feelings (rarely actual fainting), visual disturbance (occasional blackouts or tunnel vision), headache (often migrainous), parethesiae (i.e., numbness, deadness, uselessness, heaviness, pins and needles, burning, limb feeling out of proportion or "donít belong"), commonly of hands, feet, or face, sometimes of scalp or whole body, intolerance of light or noise, large pupils (wearing dark glasses on a dull day)
Respiratory: shortness of breath (typically after exertion), irritable cough, tightness or oppression of chest, "asthma", air hunger, inability to take a satisfying breath, excessive sighing, yawning, sniffing
Gastrointestinal: difficulty in swallowing, globus, dry mouth and throat, acid regurgitation, heart burn, "Hiatus hernia", flatulence, belching, air swallowing, abdominal discomfort, bloating
Muscular: cramps, muscle pains, (particularly occipital, neck, shoulders, between scapulae; less commonly, the lower back and limbs), tremors, twitching, weakness, stiffness or tetany (seizing up)
Psychic: tension, anxiety, "unreal feelings", depersonalization, feeling "out of the body", hallucinations, fear of insanity, panic phobias, agoraphobia, catastrophizing
General: weakness; exhaustion; impaired concentration, memory and performance; disturbed sleep, including nightmares; emotional sweating (axillae, palms, sometimes whole body); wooly head
Source: From personal communication from Dr. L.C. Lum, 1991, in B.H. Timmons & R. Ley (Eds.), Behavioral and Psychological Approaches to Breathing Disorders (p. 4). NY: Plenum
What Causes It?
The causes and maintaining factors of hyperventilation are almost identical to those that cause anxiety symptoms, plus several more:
Worry and Stress. When stressed or worried, we tend to tense the muscles of the neck, throat, chest and abdomen. Especially when we tighten the abdominal muscles, we begin to breathe with rapid, shallow breaths primarily in the upper chest region. As the drop in CO2 causes distressing symptoms, we become afraid of the symptoms. Arousal remains high and a vicious cycle of worry and arousal occurs.
The role of emotions in hyperventilation is suggested by an intriguing case. Charles Darwin was thought to hyperventilate. He suffered from trembling hands, swimming head, and a lifetime of nerve and heart problems. Following his motherís death when he was eight years old, his sisters taught him not to verbalize grief and anxiety. When his ten-year-old daughter Annie died, however, he openly wept, and then showed none of his usual anxiety symptoms. He lived to be 75 years old.
Hyperventilation is more likely when one becomes stressed and remains immobile, such as when driving or watching an upsetting television show. If worrisome thoughts trigger hyperventilation, one might learn to manage such thoughts. Learning to relax while one faces the thoughts will reduce the arousal.
- Notice any disorder of the lungs or airways, even one that goes undetected by a medical examination, such as mild asthma. Look for wheeziness or difficulty breathing during exertions, along with hay fever, allergies, or a family history of asthma. Bronchitis, wheezing, or persistent coughing in childhood might suggest mild asthma. Also, look for bronchitis, interstitial lung diseases, pulmonary emboli (clots), or pulmonary edema. Bronchitis usually occurs in smokers, and is indicated by "smokers cough" and early morning phlegm. Physicians called pulmonologists (chest/lung doctors) can diagnose such problems.
- Certain postures favor hyperventilation. Under stress, some seem to assume an "attack posture" (hunched shoulders, head and neck thrust forward, clenched teeth). Others puff up their hard, firm chests on inhalation, and underinflate during exhalation. Relaxing the body and roughly equalizing the inhalation and exhalation phases of breathing helps.
- Excessive fast, breathless talking and taking large breaths of air can maintain hyperventilation.
- Heat, humidity or a steep fall in barometric pressure can trigger symptoms.
- Blood sugar in the low normal range in combination with hyperventilation can aggravate symptoms. The antidote is multiple meals, avoiding refined sugars.
- Progesterone causes CO2 to drop. Hyperventilation can contribute to PMS or pregnancy symptoms, such as fatigue or headache.
- Strong perfumes or smells.
- Uncontrolled diabetes (acdidosis), kidney or liver failure, heart disease, excessive caffeine, other stimulants and essentially the other causes of anxiety mentioned in Chapter 2 can cause or maintain hyperventilation.
After hyperventilating for about ten days, the body makes certain accommodations to adjust to low CO2 and restore the acid-base balance of the blood. The breathing may
slow, but when it increases (as under stress), the symptoms of anxiety will be even more pronounced. Even a deep breath or sigh can then trigger symptoms. Some people may be symptomatic most of the time. Some are symptomatic only during stress.
How Do I Know If I Hyperventilate?
There is great relief in knowing that hyperventilation is causing your distressing symptoms and that this is treatable.
- Observe breathing rate and other signs. Simply paying attention to your breathing can help you breathe correctly. Notice if any of these indications of hyperventilation exist:
- A rate in excess of 14 breaths per minute usually indicates hyperventilation.
- Breathing is mostly chest (thoracic) breathing. Little use is made of the diaphragm, the muscle below the lungs that normally moves down on the in-breath, pushing the abdomen out. So the chest breather will show little abdominal movement. Instead, the breastbone (sternum) moves up and out, with little lateral expansion. Sometimes, youíll also see the neck, shoulder and clavicles (collar bones) move up and down.
- Once established, low blood CO2 can be maintained by normal breathing plus occasional deep breaths or sighs. So look for other signs: occasional deep breath or sigh, repeated sighs, air hunger, canít take satisfying breath, coughing, frequent yawning, clearing the throat, sniffing, or nasal drip.
- Other possible indications: Moistening lips (excessive breathing dries out the airways), occasional spasmodic twitching of facial muscles, tenderness of chest wall, or irregular inhale/exhale ratio.
- Provocation Test. An expensive, but useful test in a lung function laboratory or other specialty clinic, this involves intentionally breathing fast (30-60 times per minute) and deeply or thoracically for 2-3 minutes. The appearance of symptoms or the inability to complete the test indicates that hyperventilation is the cause. Determination of low blood CO2 and decreased acidity of the blood confirms the diagnosis. By demonstrating to the person that symptoms are only the result of breathing and that they are safe and reversible, this test can be very reassuring. In some cases, as little as 12 rapid breaths while standing will produce symptoms.
- The Think Test is often used along with the Provocation Test. Sometimes just thinking about and recalling a stressful time when great physical distress was experienced will bring on hyperventilation and anxiety symptoms. After the provocation test, persons close their eyes and recreate the situation at the time of a panic attack. That is, they think about circumstances (such as disturbing topics they were thinking about at the time of the attack), feelings, sensations, and symptoms. The combination of the two tests is more likely to create hyperventilation symptoms, thus confirming the diagnosis.
How Do I Treat It?
The effects of stress-induced hyperventilation can be reversed by altering the breathing so that CO2 is conserved, or by increasing through exercise the amount of CO2 produced by the body. The first approach is called breathing retraining, a most important skill, which weíll discuss next.
Normal breathing is slow, effortless, regular, fluid and quiet with virtually no movement above the diaphragm. Some master breathing retraining quite rapidly, while others may require months of practice. The goals are to change from erratic breathing to slow, regular, rhythmic abdominal breathing and to make this kind of breathing automatic. This shift in breathing results in long-term changes in the nervous system and anxiety symptoms. Here are the steps:
- Loosen your clothing (belts, ties, collars, around waist and abdomen). Remove contact lenses or glasses if you wish.
- Lie on your back or in the half-lying position with pillows under back and knees to relax the abdominal muscles.
- Relax your entire body. Especially warm and relax the abdomen. Also release tension in the chest, shoulders, neck, face and jaw. Using the upper bodyís muscles to breathe wastes energy.
- Place a telephone book over the abdomen (the area below the diaphragm down to the pelvis; practically, this means putting the book below the ribs and over the navel). The book provides resistance to strengthen the diaphragm and encourages abdominal movement.
- Bring your lips together. Breathe comfortably and rhythmically, not deeply, through your nose. As you breathe in, let you stomach rise slowly, gradually, quietly. Think of your stomach as a balloon easily filling gently with air. Move smoothly into the exhalation without pause. Expiration is quiet, passive and relaxed. The in-breath and the out-breath are approximately equivalent in time, the out-breath perhaps a little longer. Transition smoothly between the out-breath and the in-breath, with little pause between phases. Keep all of your body above your diaphragm relaxed and still, moving only your abdomen. Youíll see the book gently rise as you breathe in and fall as you breathe out, while the upper body remains still.
- Practice. It might take a few weeks until abdominal breathing becomes automatic.
Here are suggested guidelines:
- Practice twice a day or more, for 5-10 minutes each time
- For the first few days, just breathe at your regular rate. If at any point you feel dizzy or faint, or if your diaphragm cramps, stop immediately. You might need to build up gradually to 5-10 minutes over the course of days or seeks, beginning with only a few seconds of practice. Generally, dizziness and faintness result from improper breathing. These symptoms will disappear if you get up and walk (e.g., up stairs) to increase the bodyís CO2 production. When you resume practice, be sure that you are not breathing fast or deeply, only slowly and regularly.
- After about a week, begin to gradually slow your breathing rate. Perhaps youíll eventually reach a rate of 6-10 breaths per minute (i.e., about 6-10 seconds for each breath cycle). However, donít worry about the rate. Focus on achieving a rate that is comfortable.
- After the second week, progress to the seated position, then to standing and leaning against a wall, standing unsupported, slow walking and fast walking. Remember, first relax your entire body, warm and relax your abdomen, then breathe slowly, regularly, abdominally.
- Try rebreathing in a variety of situations (e.g., in bed as you wake up or before sleeping, walking down the hall, jogging, watching TV, on the train).
- As you gain confidence, try consciously rebreathing in slightly stressful situations, before anxiety symptoms appear (e.g., in a traffic slowdown). Then try it in situations where anxiety symptoms have already begun to appear. Just notice the symptoms. Think, "My breathing is causing this. Iím not going mad or having a heart attack. These symptoms are harmless and reversible. I know how to breathe." Then relax your body, warm your abdomen, and breathe slowly and regularly. Watch your symptoms come and watch them subside, like a scientist watching an experiment.
- Do not attempt breathing retraining if you have diabetes, kidney disease or other disorders which might cause metabolic acidosis, without first discussing this with your doctor. In such cases, breathing may have become rapid to normalize the metabolic acidosis, and slowing down the breathing could be dangerous.
Tips for Breathing Retraining:
- If you can, breathe through your nose, which increases resistance and helps to slow breathing. If you canít, breathe through pursed lips.
- Donít be too concerned with technique. Just be aware of your breathing and attempt to breathe in a way that is restful for you. Simple awareness of how youíre breathing is often all that is needed to slow down and to encourage abdominal breathing.
- Visualizing air being drawn through the toes into the abdomen and pelvis helps to slow down. As you practice think, "Low and slow".
- Some find it helpful to visualize being on the beach, breathing in refreshing air and likening the breath to the easy rhythm of the waves.
- While fist practicing, use a mirror to check for tension or movement in the face, jaw, shoulders or chest. Insure that the abdomen, or belly, is moving up and down rhythmically.
- Wear looser clothes around the neck, chest and abdomen.
- When you feel confident, move on to Progressive Muscle Relaxation to learn how to further relax.
- Donít sigh or yawn, which expel more CO2; suppress coughs and sniffs. Instead of sighs or yawns, swallow. Or hold the normal breath for a count of five, breathe out slowly, hold to five, then resume easy abdominal breathing.
- Learn ways to express feelings constructively. You might have learned to smother your feelings. This can be unlearned. We can school our feelings, giving them constructive outlets.
- When speaking, relax your muscles. Go more slowly and smoothly. Use short sentences with gentle breathing through your nose; no gasping or gulping air. Seek natural pausing places to breathe gently.
- If you canít relax the abdominal muscles while seated, Weiss advises putting your fists on the back of your hips and trying to bring your elbows together behind you. Someone behind you can assists. Getting on all fours with the abdomen relaxed is another way to learn to relax and move only the abdomen.
- If rebreathing frightens or frustrates you, and you find that anxiety increases or you tune into the physical symptoms:
- Relax into the symptoms. Let them happen. Keep practicing until the nervous system is desensitized. Remind yourself that the symptoms are harmless. Or consider enlisting the help of a mental health professional specializing in anxiety and breathing retraining.
- In an emergency, if all else fails, hold a paper bag over your nose and mouth with thumbs and forefingers of both hands. Take 6-12 easy natural breaths, then breathe abdominally. Breathing into and from a bag recaptures CO2. The bag should have a capacity of about one liter.
Recall that fight or flight is designed for activity. When the muscles move, more CO2 is produced. The breathing increases just enough to expel the appropriate amount of CO2. So hyperventilation does not usually occur with exercise. Regular, moderate exercise is recommended to decrease arousal. This type of exercise also decreases resting heart and breathing rates. However, those with a pattern of hyperventilation need to first learn to breathe abdominally before engaging in exercise. Warning: Slow down gradually after exercise. Suddenly stopping can produce acute hyperventilation. Cool down, then, for several minutes with walking, perhaps followed by stretching.
Yoga is a form of exercise that improves the physical condition of people of all ages and promotes breathing control. However deep breathing that fills the entire lungs, holds the inspired air and then emphasizes long exhalations should be avoided for overbreathers.