The latest research is definitive regarding the link between breathwork and anxiety disorders: the way we breathe matters for our physical health and more specifically for our mental health.
“There is a strong a bi-directional relationship between anxiety disorders and the way we breathe. The findings of this meta analysis shine a light on breathwork as a successful treatment for anxiety. As this research shows, breathwork has been the subject of study for many decades and has been clinically proven to be a safe, effective and accessible therapy – we propose that breathwork could be a fundamental part of the solution to the explosion in anxiety that we are seeing worldwide” says Johannes Egberts, Breathwork Pioneer, Biohacker and co-author of a recent study entitled “Breathwork Interventions for Adults with Clinically Diagnosed Anxiety Disorders: A Scoping Review.”
The study was published last month in Brain Sciences, an international, peer-reviewed open access journal on neuroscience and was co-authored by experts from the fields of medicine, pharmacotherapy, psychiatry, psychology, neuroscience, wellness, literacy and breathwork.
“We can say that nothing in science is perfect, but this is as close as it is going to get. This meta-analysis of controlled trials has been filtered through rigorous standards, and provides the best scientific analysis on breathwork and its application to anxiety disorders to date” says Egberts.
25% RISE IN ANXIETY WORLDWIDE
Anxiety ranks number 1 out of all mental health disorders and is on the rise globally. In the first year of the COVID-19 pandemic, the global prevalence of anxiety and depression increased by a massive 25%, according to a scientific brief released by the World Health Organization (WHO) on March 2, 2022.
Despite the anxiety epidemic we are facing, anxiety disorders remain hugely underdiagnosed and underfunded; more money is spent funding drug development and pharmaceutical research than on investigating and developing safe and non-drug natural solutions.
The WHO’s latest Mental Health Atlas showed that in 2020, governments worldwide spent on average just over 2% of their health budgets on mental health, with many low-income countries reporting having fewer than 1 mental health worker per 100, 000 people.
It’s perhaps no surprise then, that despite ranking number 1 out of mental health disorder groupings, anxiety disorders often go unrecognised and undertreated in primary care; the whole arena of mental health is completely underfunded.
“Too many people remain unable to get the care and support they need for both pre-existing and newly developed mental health conditions. Unfortunately, the situation underscores a chronic global shortage of mental health resources that continues today” according to the WHO.
The 2023 research paper published in Brain Sciences has also highlighted that current drug-psychotherapy protocols for the treatment of anxiety disorders are falling short and more often than not completely missing the mark for several reasons. It found there’s a real and pressing need for non-drug therapies that can be self-administered and used by large populations, easily and without great expense, to reduce the stress and anxiety that people are facing.
“It seems a little crazy given the bi-directional relationship between anxiety and respiration, that treatments focusing at least in part on the breath are not already gold standard. The breath is the most readily available tool worldwide for anyone alive today. Regardless of race, religion or social class, we all breathe, and in the modern world, that means we can all learn to breathe a little better”, says Egberts.
It would seem that breathwork ticks all the boxes – its effectiveness is clinically proven, it is relatively easy to learn, it comes without the serious downsides of pharmacological approaches, and it’s cost effective. It also comes without many of the barriers that limit accessibility to standard treatments; it can be effective as well as accessible online when face to face treatment is inaccessible to patients. There are no unwanted drug side effects, as experienced with pharmacologic interventions which the study shows can cause problems with compliance.
THE LOW DOWN ON RESEARCH FINDINGS
In a nutshell, the study, which was a meta-analysis of clinical trials spanning the past four decades, looked at how breathwork could be applied as a solution to the rise in anxiety disorders, as well as the effectiveness of the current approaches being used.
It found that in psychiatric research, breathwork has been clinically shown to diagnostically improve symptoms of:
The research has shown that dysfunctional breathers are more prone to anxiety and mental health issues; and that certain health issues can be a precursor to dysfunctional breathing:
“People who do not breathe well and who exhibit breathing dysfunction are more susceptible to anxiety and depression, and patients with health conditions such as asthma or chronic obstructive pulmonary disease for example, will have subsequent breathing problems. Furthermore, comorbid anxiety and depression is an independent predictor of the future risk of asthma.”
BREATHWORK FOR ANXIETY DISORDERS
The authors propose that breathwork has the potential to solve the problem of finding a cost effective and accessible solution to treating anxiety for the following reasons:
- Respiratory abnormalities, specifically hyperventilation (rapid, irregular over-breathing), are a hallmark of anxiety.
- The amygdala, the part of the brain responsible for the fear response, is smaller in people with anxiety. In these people the amygdala is more sensitive to the gas CO2, which can lead to an increased state of CO2 induced fear. Breathwork techniques, including “breath retraining” can be used to increase tolerance to CO2 sensitivity and therefore decrease the sensitivity threshold.
- Breathing has a bi-directional effect on the autonomic nervous system (ANS), which controls the “fight or flight” reflex that is responsible for putting people into a state where they experience anxiety or panic. Likewise, breathing has a strong effect on and can stimulate the “rest and digest” response, which as the name suggests, elicits a state of rest, ease and calm.
- Voluntarily changing the rate, depth and pattern of respiration affects both cardio and cortical activity(heart and brain).
You can learn some specifics of how to use breathwork for anxiety here:
THE COST OF ANXIETY DISORDERS WORLDWIDE
When it comes to mental health, research shows that more people suffer from anxiety than any other disorder. The WHO has named anxiety and depression the biggest epidemic of the 21st century, stating that anxiety disorders are now the 9th most common cause of health-related disabilities.
The consequences of anxiety can be debilitating and far reaching. A 2019 study entitled the ‘The Global Burden of Disease Study’ calculated that anxiety disorders account for 28.68 million years of healthy life lost due to disability or premature death.
ANXIETY IN AUSTRALIA
An international study led by researchers from the University of Queensland looked at the massive increase in anxiety disorders worldwide in 2020, the increase in cases believed to be spurred on by the global pandemic. In August of 2021, mental health crisis lines received record numbers of calls from Australians needing support. In its busiest day ever, Lifeline received 3,345 calls, a rise of over 220 per cent. Anxiety now affects twice as many Australian women as it does men, with one in three women affected, and one in five men.
THE GAP IN CARE
When those who are actually diagnosed are treated, the quality of care is often poor, leaving patients feeling substantially dissatisfied – and as though their needs have not been met. Of the 80% of adults with anxiety disorders who sought help from their doctors, less than 20% received appropriate treatment with medication, and less than 10% received appropriate counselling, leaving the majority untreated and having to fend for themselves.
SHORTFALLS IN CURRENT TREATMENT APPROACHES
The mainstays of treatment for anxiety disorders are integrated approaches combining drugs and psychotherapy, however there are several issues that raise questions around whether this approach is really the best option:
- Drug Side Effects
Medications in the benzodiazepines and paroxetine groups are poorly tolerated due to the side effects patients experience, which results in patients who don’t want to stay on their medication.
- Prohibitive Cost of Treatment
The cost of current treatment protocols is absolutely staggering. Many patients simply cannot afford treatment, or have other practical limitations such as limited access to providers, or problems with the side effects of the drugs prescribed. The financial burden of these interventions is predicted to weigh in at USD 56 billion from 2016 to 2030.
BREATHWORK AS A SOLUTION TO ANXIETY
The study showed that patients had a preference to manage their condition themselves, and identified that there is a need for cost-effective, non-pharmacologic, and self-administered therapies “that can be utilised by large populations to relieve stress and anxiety”.
Although dysfunctional breathing is a hallmark of anxiety disorders, the study found that the mainstays of patient treatment protocols do not tackle breathing in patients who are suffering anxiety.
When there is such a strong relationship between breathing practices and symptom improvement in anxiety disorders, why is breathing not targeted in gold standard treatments? Targeting respiratory abnormalities through breathwork in patients with anxiety disorders has been shown to directly improve physiological, psychological, and behavioural outcomes:
The application of breathwork across all 16 studies in the meta analysis found significant improvement in all measures of anxiety compared with the control including Improved heart rate variability (HRV) and panic symptoms, significant improvement in anxiety measures including at post-treatment and follow-up, significant improvement in panic severity maintained and at 6-month follow-up, significant improvement in panic symptoms, panic-related cognitions and perceived control.
DETAILED FINDINGS FROM THE 16 CLINICAL TRIALS ON BREATHWORK AND ANXIETY
While anxiety disorders differ in their symptomatology, commonly shared features include maladaptive attention bias to a threat, even when the threat is irrelevant.
Heightened anxiety over extended periods can lead to a wide variety of physical symptoms and behavioural changes, such as shortness of breath, palpitations, insomnia, and restlessness. These can have severe implications for overall health and well-being.
Slow diaphragmatic, deep, or controlled breathing regimens revealed a significant reduction in anxiety in five (31%) of the studies.
Number of studies per style of breathwork with relative outcome on anxiety improvement (significant or not significant). Abbreviations: breathing retraining cognitive restructuring (BRCR), Surdashan Kriya Yoga (SKY), and heart rate variability-biofeedback (HRV-BF).
One study specifically showed marked improvement in the frequency of panic attacks as well as other psychophysiological scores in patients diagnosed with agoraphobia
(AG) compared with controls, which was maintained at the six-month follow-up.
Other studies demonstrated significant improvement in panic attack frequency and severity, panic in patients with panic disorder and severe AG, daily life complaints and state anxiety, and percent vital capacity (%VC) and diaphragmatic breathing in panic disorder.
Although there was a robust reduction in overall anxiety in both treatment groups, in two of the five aforementioned studies, the two groups (hyperventilators versus non-hyperventilators and self-exposure to internal and external cues versus external cues only) did not differ significantly in anxiety symptoms between them.
All four studies that included respiratory (or capnometry) biofeedback-assisted therapy showed significant improvement in panic disorder severity and measurements (e.g., pCO2), maintained at the 12-month follow-up. In two of these studies with controls, marked reductions in all measures occurred only in the capnometry-assisted respiratory training group. This included corrections from hypocapnic to normocapnic levels. Similarly, Herhaus et al. found that panic disorder or agoraphobia patients receiving heart rate variability-biofeedback(HRV-BF) training significantly improved their HRV and panic symptoms compared with controls. Given the physiological connection between the breath and the heart, both HRV-BF and CART (capnometry-assisted respiratory training) showed positive outcomes in panic disorder.
The effects of hyperventilation on panic disorder were assessed in three (19%) studies. Two studies compared the effects of hypoventilation with hyperventilation by lowering or increasing pCO2, respectively. However, the findings were contradictory. Kim et al. found that both breathing methods effectively reduced the severity of panic disorder, sustained at the six-month follow-up. Patients also learned how to alter their pCO2 and respiratory rate (RR). In contrast, Wollburg et al. showed that despite hypercapnic and hypocapnic breathing associated with higher and lower baseline pCO2 levels, this did not correspond to changes in RR or VT.
One study compared the sensitivity to anxiogenic effects of CO2 between panic patients and healthy individuals by assessing the inhalation of 5% CO2 and 7% CO2 and room-air hyperventilation. They found that room-air hyperventilation caused panic attacks in fewer patients and that CO2 was a more potent anxiogenic stimulus, with 7% CO2 discriminating best.
Conrad et al. showed that paying attention to breathing significantly reduced respiratory and autonomic measures more than anti-hyperventilation instructions. Breathing more slowly, shallowly, or both failed to raise end-tidal pCO2 above initial baseline levels for any of the groups. Breathing retraining cognitive restructuring (BRCR), which uses a combination of hyperventilation and slow breathing, led to robust improvement in symptomatology on all self-report measures, except panic frequency and lowered RR. Two (13%) studies demonstrated significant increases in both anxiety and depression by implementing Surdashan Kriya Yoga(SKY) or respiratory biofeedback-assisted therapy training.