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(p. 85) Breathing Skills 

(p. 85) Breathing Skills
Chapter:
(p. 85) Breathing Skills
Author(s):

Michelle G. Craske

and David H. Barlow

DOI:
10.1093/med:psych/9780195311402.003.0009
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date: 03 August 2020

(Corresponds to chapter 6 of the workbook)

This chapter is divided into four sections.

Materials Needed for All Sections

  • Breathing Skills Record

Section 1 Education and Diaphragmatic Breathing

Outline

  • Educate the client about overbreathing

  • Conduct a forced hyperventilation test

  • Introduce diaphragmatic breathing skill

Therapist Behaviors

After reviewing the basic concepts of respiratory physiology and overbreathing, the therapist may model the method of hyperventilation before asking clients to hyperventilate, or the therapist may hyperventilate along with the client. This type of participant modeling is especially helpful for clients who are self-conscious or highly anxious about the exercise, and it can be used to validate the normalcy of symptoms experienced (p. 86) as a result of hyperventilation (i.e., therapists can indicate the symptoms that they experience from the exercise). Also, the therapist may demonstrate the diaphragmatic breathing techniques for the client to imitate. Then, the therapist can observe the client practice the exercise of diaphragmatic breathing and give corrective feedback. Of course, generalization from the clinic to the home setting occurs by having clients practice the exercises on a regular basis in their own environments.

Overbreathing

The main goals of this section are to introduce the physiology of overbreathing as something that may contribute to the physiological sensations during panic attacks and to recognize that hyperventilatory sensations are not harmful. It is important that the client not misconstrue the discussion of overbreathing as an indication that panic and fear are a direct result of primarily physiological irregularities. That is, the role of hyperventilation is placed within the context of the interactions that occur among the three response components (i.e., behavioral, physiological, and subjective). The experience of overbreathing in isolation from catastrophic misinterpretations of bodily sensations or from learned fear of bodily sensations is unlikely to result in a panic attack.

Breathing Skills

In this treatment, breathing skills training is intended to regulate breathing, but more importantly, it is also intended to interrupt the panic cycle and provide a tool to help clients face their fear, anxiety, and anxiety-producing situations. Although breathing skills training may result in a reduction in symptoms of overbreathing, this is not the primary goal. The goal is to use breathing skills training to encourage the client’s continued approach toward anxiety and anxiety-producing situations. It is important that clients do not attempt to use breathing skills to prevent dire consequences from occurring (e.g., to prevent oneself from fainting or dying) and that they do not view the skills as “magical” cures. (p. 87)

The breathing skills are first practiced in relaxing environments for two reasons: first, as a way of enhancing skill development and to permit concentration on the breathing; second, to deemphasize the use of breathing skills as an immediate tool for the reduction of fear or symptoms.

Diaphragmatic Breathing Exercise

The purpose of this exercise is to teach clients a method of regulating breathing that will help them to directly deal with the physical symptoms and situations that currently make them anxious. Diaphragmatic breathing has two components: (i) a breathing component, in which clients learn to slow their breathing and to breathe using their diaphragm muscles as opposed to their chest muscles; and (ii) a meditation component. Detailed instructions for diaphragmatic breathing are included in the workbook (chapter 6, section 1). The client should practice this skill twice a day for 10 minutes each time and record the exercises on the Breathing Skills Record. A blank record is included in the workbook, and multiple copies can be downloaded from the Treatments ThatWork™ website (http://www.oup.com/us/ttw).

An example of a completed Breathing Skills Record is shown on page 88.

Figure 9.1. Example of completed Breathing Skills Record

Figure 9.1.
Example of completed Breathing Skills Record

Case Vignettes

Case Vignette 1

C: Will I pass out if I hyperventilate?

T: It is rare to pass out from hyperventilating for short periods of time. Even hyperventilating for long periods of time rarely leads directly to loss of consciousness. You may stop the hyperventilating exercise when you wish, although I would encourage you to go for the specified period of time.

(p. 88)

(p. 89) Case Vignette 2

C: The symptoms are similar to what I experience when I panic, but somehow, it feels different because you are here.

T: Do you mean that the symptoms are less anxious for you when we do the exercise together?

C: Yes, it feels as if the symptoms won’t get any worse, and they are not as intense as when I panic.

T: This shows the influence of your thinking; that is, my presence is leading you to think differently about the symptoms. Remember our panic cycle?

Atypical and Problematic Responses

The breathing skills exercise may, for some clients, become a form of exposure to feared sensations (as described in chapter 10) because the exercise either forces attention on bodily sensations or induces new, unfamiliar bodily sensations. Clients who become anxious during breathing skills training for these reasons should be encouraged to continue with the exercises in the same way as would occur during interoceptive exposure practices.

Notably, the research on the role of breathing skills training within cognitive behavioral therapy for panic disorder is not clear. There is some indication that it does not add significantly to the effect of exposure alone and that the combination of cognitive restructuring, in vivo exposure, and breathing skills is slightly less effective than the combination of cognitive restructuring, in vivo exposure, and interoceptive exposure. However, the studies to date have not clearly framed breathing skills as a tool for continuing to face anxious situations and instead have emphasized breathing skills as a way of reducing symptoms. As noted earlier, the program in this workbook focuses away from the immediate reduction in symptoms and fear and toward toleration of symptoms and fear. Thus, if breathing skills training is done in the way framed above, it may have more beneficial effects than when it is used as a means for controlling symptoms. If it appears that a client is using breathing skills as a control strategy, consider minimizing their use. (p. 90)

Some clients find that the breathing exercises lack credibility. They point out that if they could simply tell themselves to breathe slowly or to relax, they would have no need for treatment, and thus, the exercise seems like a gimmick. Remind clients that the goal of breathing skills training is not to relax or calm down but to facilitate movement forward to face fear, anxiety, and anxious situations.

Homework

  • The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

  • At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

  • Instruct the client to practice the diaphragmatic breathing exercise twice a day, 10 minutes each time, for seven days and to record practices on the Breathing Skills Record form.

  • The client should read chapter 6, section 2, in the workbook.

Section 2 Slowed Breathing

Outline

  • Review the client’s practice of breathing skills over the past week

  • Introduce slowed diaphragmatic breathing technique

Therapist Behaviors

The therapist is to review the client’s practice of breathing skills over the past week and brainstorm ways of overcoming problems with the breathing skills practice (e.g., noncompliance or anxiety). In addition, the therapist (p. 91) can model slowed diaphragmatic breathing and then provide corrective feedback as the client practices this skill.

Slowed Breathing

The purpose of this exercise is to teach clients how to slow their breathing rate by matching their breathing to their counting. Detailed instructions for slowed breathing are included in the workbook (see chapter 6, section 2). The client should practice this skill twice a day for 10 minutes each time and then record the exercises on the Breathing Skills Record.

Case Vignettes

Case Vignette 1

C: I feel really dizzy when I focus on the breathing, and I feel as if I have to take a deep breath.

T: This suggests that you may habitually overbreathe—that is, your normal style is to overbreathe—and, therefore, trying to institute a new method of breathing is exacerbating some of your hyperventilation tendencies. However, it is important that you continue the exercise, because it will gradually get easier. If you really feel like you have to take in a deep gulp of air, hold the air in a little bit longer after you in-hale and before you exhale.

Case Vignette 2

C: I haven’t had time to practice. It seems like an extra burden to have to do these exercises.

T: In a sense, you are right, because there is a definite time and effort commitment involved. Does it help to realize that you are probably exerting (p. 92) as much effort trying to ward off feeling anxious and panicky as you would in practicing these exercises?

Case Vignette 3

C: Should I be taking big breaths?

T: What you are trying to change during these exercises is not the amount of air but, rather, the rate and depth at which you breathe. Breathe in the normal amount, but do it slowly, and draw the air deeply into your lungs.

Atypical and Problematic Responses

Occasionally, clients view these exercises as “magic pills” that they must use in order to prevent dire consequences from happening. For example, “I could pass out if I don’t slow down my breathing.” This is when cognitive restructuring is so essential in helping clients to realize that no calamity will result, even if their breathing cannot be slowed.

Breathing skills training can be very hard for the true chronic hyperventilator, the person whose typical breathing pattern is shallow and rapid, who sighs and yawns frequently, who experiences chronic chest tightness, and who is very vulnerable to shortness of breath and paresthesia. Such a client may feel short of breath after the 10-minute exercise and take deep gulps of air between the slow breaths during the exercise. Our experience tells us that learning breathing skills takes a lot longer with these individuals, but it can still be a valuable tool for them.

As mentioned above, breathing skills exercises may elicit panic. In these cases, the panic is occurring in response to a heightened focusing of attention on feared sensations (in contrast to the typical pattern of trying to keep one’s mind occupied to avoid noticing the sensations), an increased experience of atypical sensations, or both. Under these conditions, help clients understand the reasons why they panicked, and instruct them to continue to practice. In this way, repeated practice of breathing becomes an exposure.

(p. 93) Homework

  • The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

  • At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

  • Instruct the client to practice the slowed breathing exercise twice a day, 10 minutes each time, for 7 days and to record practices on the Breathing Skills Record form.

  • The client should read chapter 6, section 3, of the workbook.

Section 3 Breathing Skills as a Coping Technique

Outline

  • Teach the client to use breathing skills in distracting environments

Therapist Behaviors

Now that slow and diaphragmatic breathing have been practiced sufficiently in relaxing environments, these skills are now ready to be used in distracting environments and in anxious situations. It is time to practice in different places. The therapist could have the client practice the breathing skills in session while providing a deliberate distractor (such as a noise). Also, the therapist can encourage the client to role play the use of breathing skills as a coping tool in an imagined anxiety-provoking situation.

Coping Application

Encourage clients to use breathing skills as a coping technique to help them face fear, anxiety, and anxiety-provoking situations. A coping template is provided for use of breathing skills in combination with thinking (p. 94) skills as tools for facing fear and anxiety rather than avoiding or retreating.

Case Vignettes

Case Vignette 1

C: When I panicked during the week, I tried to use the breathing, but it didn’t work. It made me feel worse.

T: It sounds as if you might have attempted to use the breathing exercise as a desperate attempt to control the feelings that you were experiencing.

C: Yes, that’s right.

T: Remember that the breathing skills training is not only intended to regulate your breathing but, more importantly, is to encourage you to face whatever it is that is making you anxious. This means that you do not have to control your anxious feelings or your symptoms; instead, you have to learn to continue in your activities despite the symptoms and the feelings, because these symptoms are not dangerous.

Atypical and Problematic Responses

As noted before, the biggest problem is when clients begin to use breathing skills as a safety signal or a safety behavior. In other words, they believe that they will be at risk for some mental, physical, or social calamity if they do not breathe correctly. For clients who are using breathing skills in this way, discontinuation of the breathing skills may be the most effective choice. That is, design exposure exercises without the use of breathing skills so that clients learn that what they are most worried about happening either does not happen or can be managed without using the breathing skills.

(p. 95) Homework

  • The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

  • At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

  • Instruct the client to practice breathing skills in different distracting environments and when anxious.

Section 4 Review of Breathing Skills

Outline

  • Review breathing skills as a way of facing anxious feelings and situations

Therapist Behaviors

Therapists are to inquire about the way in which the breathing skills are being implemented in anxious situations and to provide corrective feedback and encouragement. If appropriate, therapists can have clients role play their use of breathing skills in an anxious situation.

Atypical and Problematic Responses

As noted above, overreliance on breathing skills as a means for immediate fear reduction or immediate symptom alleviation, or to prevent a “catastrophe,” indicates that breathing skills are being used as a safety behavior. In these situations, remind clients of the purpose of breathing (i.e., a tool for regulating breathing and a tool for facing fear and anxiety despite physical symptoms and despite anxiety).

(p. 96) Homework

  • The client should continue to record anxiety and panic using the Panic Attack Record and the Daily Mood Record.

  • At the end of each week, the client should add the number of panic attacks and daily average anxiety to the Progress Record.

  • Instruct the client to continue practicing breathing skills techniques.