Controlled Breathing Exercises as an Adjunctive Treatment for Insomnia

New research suggests deliberate control of breathing could help regulate autonomic function in patients who have insomnia.

Controlled breathing exercises can be a solution or an adjunctive treatment for some people who have primary insomnia. Insomnia is a common problem, affecting most adults at some point in their lives. Chronic insomnia and temporary bouts of insomnia can both affect total sleep time, restorative sleep, mood, and daytime sleepiness. These issues can also lead to disrupted sleep schedules—with unwanted daytime naps, erratic sleep patterns, decreased productivity, and a feeling of being unrested.

A Nonpharmacological Approach

Many patients who cannot fall asleep or stay asleep will report their symptoms to their primary care doctor, and those who have idiopathic insomnia may be referred to a psychiatrist or a sleep specialist when first line and second line therapies are ineffective. As more patients are learning about the harms of chronic use of various sleeping pills, some are asking for nonpharmacological therapies to aid in the treatment of insomnia or will agree to try a nonpharmacological management approach when it is suggested by their doctor. While dysregulated breathing is a key component of obstructive sleep apnea and central sleep apnea, breathing irregularities have not been widely considered a significant component of primary insomnia and idiopathic insomnia.

Research Review

Attempts at using controlled breathing techniques to help patients with insomnia is based on several underlying issues: the role that the autonomic nervous system plays in sleep and the relationship between insomnia and depression or anxiety. Breathing exercises are considered an adjunct in management anxiety and depression, which are common comorbidities of insomnia. Researchers have proposed that hyperarousal and chronic sympathetic hyperactivation and/or parasympathetic hypoactivation could disrupt a number of sleep features, such as normal sleep onset latency, sleep quality, and sleep duration.1 A large review study noted that people who had insomnia were found to have a range of different alterations in their autonomic activity.2 This subclinical autonomic dysfunction is one of the potential explanations for why breathing exercises may have a beneficial impact on insomnia.

A few studies have examined the effects of controlled breathing on insomnia. One study, for example, assessed the effects of presleep breathing exercises on a small group of participants who had self-reported insomnia. During the study, the participants learned how to do slow paced breathing exercises for 20 minutes before going to sleep. After implementing the exercises, participants experienced a number of positive outcomes.3 Sleep onset latency, number of awakenings, and awakening time during sleep were decreased, and sleep efficiency was increased. Based on these observations, the researchers proposed that people who have insomnia may have disordered autonomic function, suggesting that deliberate control of breathing could help regulate autonomic function in patients who have insomnia, and that this could have potentially played a role in the observed symptom improvement.

Another experiment assessed the effect of a yoga breathing technique on healthcare professionals during the COVID-19 pandemic. Participants initially rated their sleep through a series of questionaries before learning breathing techniques that are part of a specific type of yoga practice.4 After using the breathing techniques on a regular basis, the participants experienced improvements in self-reported sleep and quality of life measures.

While these and other similar studies are generally small, a variety of different types of breathing exercises with varying schedules (during the day or right before sleep) seem to have a positive impact on sleep, without side effects. Controlled breathing and deep breathing may help to promote sleep initiation.1 The effect on sleep initiation would not, however, explain the benefits of deep breathing exercises that are done during the day. There seems to be a positive effect of breathing exercises on insomnia that reaches beyond sleep initiation. Sympathetic hyperactivation is generally associated with rapid, shallow breathing, while the parasympathetic state is associated with slower, deeper breathing, and the interplay between these aspects of the autonomic nervous system is generally expected to have effects that last several hours.

Concluding Thoughts

Breathing exercises can be a safe and useful adjunct in the treatment of insomnia. People can learn to use controlled breathing on a regular basis or can add these techniques to a more comprehensive sleep regimen as a way to help manage bouts of insomnia. For patients who want to gain a sense of personal control over their sleep, such exercises may provide a good way to take part in their own management. Patients can learn breathing techniques by working with a therapist or by using videos or apps recommended by their doctor. Because deep breathing techniques have also been shown to help alleviate anxiety, which is both a cause and an effect of insomnia, these types of exercises can reduce insomnia and its effects with a multipronged approach.

Dr Moawad is Associate Editor Humanities in Neurology, Clinical Assistant Professor Case Western Reserve University School of Medicine, Div. of Medical Education, and Editor in Chief Emeritus of Neurology Times (2017-2019).

References

1. Jerath R, Beveridge C, Barnes VA. Self-regulation of breathing as an adjunctive treatment of insomnia. Front Psychiatry. 2019;9:780.

2. Nano MM, Fonseca P, Vullings R, Aarts RM. Measures of cardiovascular autonomic activity in insomnia disorder: a systematic review. PLoS One. 2017;12(10):e0186716.

3. Tsai HJ, Kuo TB, Lee GS, Yang CC. Efficacy of paced breathing for insomnia: enhances vagal activity and improves sleep quality. Psychophysiology. 2015;52(3):388-96.

4. Divya K, Bharathi S, Somya R, Darshan MH. Impact of a yogic breathing technique on the well-being of healthcare professionals during the COVID-19 pandemic. Glob Adv Health Med. 2021;10:2164956120982956.