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.


Table 6.1

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.

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.

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.

Breathing Retraining

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:

  1. Loosen your clothing (belts, ties, collars, around waist and abdomen). Remove contact lenses or glasses if you wish.
  2. Lie on your back or in the half-lying position with pillows under back and knees to relax the abdominal muscles.
  3. 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.
  4. 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.
  5. 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.
  6. Practice. It might take a few weeks until abdominal breathing becomes automatic.

Here are suggested guidelines:

Tips for Breathing Retraining:

Trouble Shooting:

Physical Activity

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.