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Slow voluntarily regulated breathing practices are noninvasive, easy to learn, and generally safe for treating patients with symptoms of anxiety, insomnia, depression, stress- and trauma-related disorders, ADHD, schizophrenia, and substance abuse.
Autonomic nervous system dysfunction is associated with most disorders seen in pediatric and adult psychiatric practice, including anxiety disorders, depression, PTSD, hostility and aggression, attention deficit disorders, and autism spectrum disorder. Increasing the underactivity of the parasympathetic branch and correcting the erratic or overactivity of the sympathetic branch can improve stress resilience and ameliorate psychological and physical symptoms.
Although prescription medications (eg, anxiolytics, antidepressants, antipsychotics) can dampen overactivity of the sympathetic nervous system (SNS), they cannot correct underactivity of the parasympathetic nervous system (PNS). Most parasympathetic pathways are contained in the vagus nerves, the 10th cranial nerves, whose extensive branches innervate all internal organs and glands. The development of measures (respiratory sinus arrhythmia, and heart rate variability) of SNS and PNS activity made it possible to assess the effects of interventions such as breathing practices on autonomic activity and to document the association between improvements in sympatho-vagal balance and reduction in psychiatric symptoms.1 The Polyvagal Theory, articulated by Stephen Porges,2 proposes that the vagal nerves are major conduits for bidirectional communication between the brain and the body.
Studies have shown that voluntarily regulated breathing practices (VRBPs) can significantly improve symptoms of anxiety disorders, trauma- and stressor-related disorders, depressive disorders, and other conditions.3 VRBPs can also be used to restore feelings of meaningful connection, bonding, and love for patients who experience states of disconnection or emotional numbing-common sequelae of trauma and loss. Certain breathing practices can facilitate the psychotherapeutic process by reducing anxiety and defensiveness.4 Patients with long-standing psychological and somatic PTSD symptoms responded to VRBPs after years of no response to traditional psychotherapy and psychoanalysis.5,6 Their sexual function, body perceptions, sense of self, pain syndromes, and other symptoms normalized.
Furthermore, clinicians can use VRBPs to reduce their own level of stress and to enhance empathic abilities.
Neuroanatomic substrate for effects of VRBPs on sympatho-vagal balance
In 2005, we proposed a neurophysiological model to account for the observed clinical effects of VRBPs on sympatho-vagal balance and psychological symptoms.7 Specific VRBPs entail changing the pattern of breathing, thereby changing the interoceptive messages sent through vagal afferent pathways (from the peripheral to the CNS), via brainstem nuclei to the limbic system, hypothalamus, thalamus, prefrontal cortex, insular cortex, and networks involved in perception, interpretation, emotion regulation, and cognitive function (Figure). The respiratory system is rich in stretch receptors (eg, inside alveolar walls, thoracic musculature, diaphragm), bronchial airways, chemoreceptors, and baroreceptors. Two-way neural pathways between the respiratory system and the brain are of necessity strong and rapid. Interoceptive information derived from breathing patterns has global effects on brain function with the potential to rapidly change how we feel and think.
The polyvagal theory and social engagement systems
According to polyvagal theory, the hierarchical organization of the autonomic stress response system contains 3 evolutionary levels of development. The oldest, evolutionarily, are the unmyelinated vagal fibers, which carry signals that induce defensive states associated with death feigning, freezing, or dissociation. The second level of development, the sympathetic system, orchestrates fight or flight (approach or avoid) responses. The third and highest evolutionary level is the myelinated vagus found only in mammals. A mere 3% of vagal fibers, the myelinated vagus, enables the social engagement system, bonding, group cooperation, communication, and love. According to Porges,8 any stimulus that increases feelings of safety can recruit neural circuits that support the social engagement system and inhibit defensive limbic structures. Physiological states characterized by increased vagal influence on heart rate variability support social bonding.
The vagal-GABA theory
Streeter and colleagues9 hypothesized that slow breathing practices (through vagal afferent stimulation) could increase gamma amino-butyric acid (GABA) transmission from the prefrontal cortex (and possibly the insular cortex) to the central nucleus of the amygdala. The inhibitory transmitter, GABA, could modulate the overactivity known to occur in the amygdala in individuals with PTSD, depression, and epilepsy (Figure). In a recent phase 1 mass resonance spectroscopy randomized controlled trial (RCT) of 30 patients with MDD, participation in a 12-week program of Iyengar yoga and coherent breathing resulted in significant increases in thalamic GABA levels and heart rate variability, which correlated with significant reductions in depression.10
Slow breathing practices increase vagal influence on heart rate variability
Hundreds of breathing practices are described in ancient and modern texts. In brief, they can be divided according to respiratory rate, relative ratio of the length of 4 breath phases (inhalation, pause, exhalation, pause), and forcefulness of breathing. In general, slow, gentle breathing is calming and increases parasympathetic tone; rapid, forceful breathing is activating and increases sympathetic tone. The Table summarizes breath practices commonly used in the US. The characteristics of VRBPs that increase vagal influence on heart rate variability and that tend to induce calm, relaxed states; reduce defensive reactions; and activate the social engagement system are slow rate, prolonged expiratory phase, and airway resistance. Three of the most clinically useful slow VRBPs (3 to 10 breaths per minute, cpm) are Qi Gong breath 4-4-6-2, coherent breathing, and breath moving.
Qi Gong breath 4-4-6-2. Paces breath cycle: 4 counts on the inhale, 4 to pause, 6 on the exhale, and 2 to pause. This calming practice activates the PNS. It can be used in combination with a Qi Gong posture to rapidly reduce anxiety, rage, and suicidal thoughts.
Coherent breathing or resonant breathing. Gentle natural breathing in and out through the nose with equal length of inspiration and expiration at a rate that optimizes sympatho-vagal balance (heart rate variability), between 4.5 and 6 cpm for most adults. For more sedative effects at bedtime, the length of exhalation is doubled. This is the most clinically useful practice because it is easy to learn, safe for most people, and induces a mental state of emotional calmness with mental alertness and enhanced cognitive processing. It can be done unobtrusively with eyes open walking, during everyday activities (eg, reading, writing, working), and in public. Consequently, it can be used throughout the day without attracting attention. Also it creates a relaxed alert state that is optimal for daytime functioning.
Adverse reactions are rare. However, in patients with severe symptomatic asthma, initiating slow breathing may cause narrowing of the airways and may exacerbate breathing problems. We found that teaching asthmatics to do breath moving prevents this temporary bronchiolar constriction during slow breathing practices.
Breath moving is an advanced practice in Qi Gong and other traditions, wherein one uses the imagination to move the breath and attention to different parts of the body in circuits.11 Breath moving can augment the benefits of coherent breathing in the treatment of psychological conditions, physical injuries, and pain. It also prevents transient bronchiolar constriction during slow breathing practices in patients with respiratory problems such as severe asthma.
Clinical research review
The studies of vagal nerve stimulation, paced breathing, and VRBPs that support the proposed neurophysiological model for the effects of VRBPs on the brain were reviewed in 2005.7 Subsequently, a review of VRBPs by Brown, Gerbarg, and Muench12 in 2013, which included multi-modal mind-body programs wherein breath practices were a major component of the intervention, identified 5 RCTs in persons under stress but without a psychiatric diagnosis. All 227 participants showed significant improvements in perceived stress, insomnia, anxiety, depression, and anger. In one of these studies, paced breathing at 8 cpm before an electric shock increased parasympathetic tone (high-frequency heart rate variability), but pacing at 15 cpm decreased heart rate variability.
In studies of patients with anxiety and insomnia, 4 RCTs (N = 190) and one nonrandomized controlled trial (N = 91) found significant improvements in anxiety, fear, and insomnia. Three RCTs (N = 152) and one nonrandomized controlled trial (N = 183) showed highly significant improvements on standardized measure of PTSD (P < .007 - <.001). The groups studied were survivors of mass disasters (tsunami and war), victims of intimate partner abuse, and disabled veterans with chronic treatment-resistant PTSD. Two RCTs (total N = 127) documented significant improvements in patients with diagnosed depression.
A review by Telles and Singh13 included one study of kapalabhati and one of alternate nostril breathing that showed benefits in ADHD. Since these reviews, an RCT of 21 veterans with PTSD found significant improvements in PTSD, anxiety, and hyperarousal symptoms.14 This study replicated the methods (with additional biomarkers) and findings of an earlier 6-month RCT of 31 Vietnam veterans with severe treatment-resistant PTSD, who responded to a similar intervention with an effect size of 0.9 for change on the Clinician Administered PTSD Scale (CAPS) at week 6.15
Combining breathing techniques with conventional treatments
Breathing practices enhance conventional treatments. The following are a few examples. Many people have difficulty learning mindfulness and other meditation-based techniques because their level of anxious ruminations is so high that they cannot focus productively on anything else. One advantage of breath practice is that it does not matter what the mind is doing. If the person simply paces his or her breathing to 5 cpm using a sound track, the anxious ruminations will quiet down and cognitive functions will improve. Once the mind is quiet and calm, it is much easier to focus on mindfulness, meditation, and psychotherapy.
Although cognitive behavioral therapy is beneficial in many cases, it has some limitations. A top-down cognitive approach is not always able to control anxiety. It takes many sessions and considerable effort to control intense fears and other emotions. Coherent breathing, as a bottom-up approach, is more effective because it bypasses intellectual processing and utilizes more rapid and powerful pathways between the brainstem and the emotion regulatory circuits.
Once coherent breathing has shifted a patient out of the sympathetically driven defense mode and into the more parasympathetic social engagement mode, it becomes easier to engage in any form of therapy, to be more open and trusting, and to cognitively process whatever is discussed in treatment. In addition, if overwhelming emotions arise, the breath practice can be used for self-regulation during sessions.
There are no known adverse interactions between slow therapeutic breath practices and medications. The only adverse medication interaction we are aware of can occur with rapid breath practices that increase urinary output and therefore can lower lithium levels. Breathing practices can augment the benefits of medication and, in many cases, reduce the dose of medication needed (eg, sedative hypnotics, anxiolytics).
Alex, a 20-year-old college junior, consulted a psychiatrist for help with anxiety, limited symptom attacks, insomnia, and inability to focus on preparing for final exams. He appeared to be on the verge of tears, and his right leg jiggled up and down continuously. The history revealed a pattern of low-grade anxiety with increased severity in reaction to academic pressures.
Previous treatments included benzodiazepines and sertraline. Alex did not like to take medication and was eager to learn a breathing practice that was offered as an alternative. He was taught coherent breathing paced at 5 cpm with a CD chime track. Within 5 minutes, he appeared physically relaxed and his leg stopped shaking. After another 15 minutes, he resumed normal breathing and opened his eyes. Alex said that the anxiety was gone, the worry thoughts stopped, and he felt calmer and more relaxed than he had in a very long time. He agreed to practice the breathing for 20 minutes twice a day during stressful times and otherwise once a day.
The psychiatrist also encouraged him to do shorter periods of coherent breathing whenever he felt stressed, such as waiting for a test to begin. She also advised him that doubling the length of his exhale when he practiced at bedtime would help him fall asleep. The following week Alex came to the office smiling. He had downloaded a breath-pacing app on his iPhone and used coherent breathing to manage stress and quickly fall asleep.
Current and future research
Breathing practices are being studied for the treatment of depression, anxiety, trauma, and schizophrenia. One current trend-when funding is available-is to include biological markers (eg, inflammatory markers, heart rate variability, oxytocin, cortisol), brain imaging (eg, functional MRI, mass resonance spectroscopy), and EEG data that provide more information about the underlying psycho-neuro-immuno-endocrine processes involved in the clinical changes that occur with mind-body techniques. The use of breathing practices in the treatment of stress-related and immune-related medical conditions (eg, cardiovascular disease, inflammatory bowel disease, diabetes, dementia) is developing. Breath practices for children is an area with tremendous potential for improving emotion regulation, behavior, learning, and social/interpersonal development.
To date, although the number of yoga programs in schools is growing, the research on mind-body programs for children has received relatively little support. Most of the studies show positive results, but they are small and preliminary. We have observed that children learn breathing practices very easily and are eager to use them because they like to feel calmer, to control their emotions and behaviors, to put themselves to sleep, and to reduce their anxiety when taking tests or performing in arts or sports. They also enjoy teaching the breathing practices to their friends and family (see Chemung County Project at www.Breath-body-mind.com).
Slow VRBPs are noninvasive, easy to learn, and generally safe for treating patients with symptoms of anxiety, insomnia, depression, stress- and trauma-related disorders, ADHD, schizophrenia, and substance abuse. A small but growing literature supports the benefits of VRBPs as solo or adjunctive treatments. Significant improvements in emotion regulation and stress response have been attributed to the effects of afferent signals from the respiratory system, transmitted by vagal afferents to the hypothalamus, limbic system, thalamus, and prefrontal and frontal cortex. Reduced sympathetic activity and defensive reactions, in tandem with increased activity of the parasympathetic and social engagement systems, have been implicated. Breath practices have the potential to open a portal to correct imbalances of the stress response systems and to facilitate emotion regulation, social engagement, bonding, and recovery from trauma.
Dr. Gerbarg is Assistant Clinical Professor of Psychiatry, New York Medical College, Valhalla, NY. Dr. Brown is Associate Clinical Professor of Psychiatry, Columbia University College of Physicians and Surgeons, New York, NY. Drs. Gerbarg and Brown are co-editors and chapter co-authors with Dr. Philip R. Muskin of the upcoming Complementary and Integrative Treatments in Psychiatric Practice from the American Psychiatric Association Press. The authors report that they are consultants on NCCAM Grant RO1 AT007483, they teach breath-body-mind workshops, and they receive royalties for books on this topic.
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