How to Reduce Anxiety with Breathing Exercises and HRVB

Anxiety, insomnia, post-traumatic stress disorder, depression, attention deficit disorder: there are so many symptoms that breathing exercises can help to alleviate. More and more studies are providing evidence for the benefits of a therapy that has been around for centuries. And heart rate variability, measured by smartphone, can be combined with breathing exercises, providing a convenient way to take back control of one’s mental state.

How prevalent is anxiety in our societies? As an example, the January 2021 “Stress Snapshot”, conducted by The Harris Poll on behalf of the American Psychological Association, showed an average reported stress level of 5.6 during the preceding month. On this scale, “10” means “great stress”. 84% of the adults reported feeling at least one emotion associated with prolonged stress in the preceding two weeks. Factors contributing to that significant level included the pandemic.

Studies reflect a rise of anxiety levels in adults and the youth

The pandemic, and measures taken to control the spread of the virus, are key contributors to the deterioration of mental health. Children and adolescents are also affected: recent meta research looks at 29 studies which focused on depressive and anxiety symptoms during COVID-19. Based on results from more than 81,000 young people globally, the analysis found estimates of clinically child and adolescent depression and anxiety elevated at 25.2% and 20.5%, respectively. Authors say the prevalence of depression and anxiety symptoms during COVID-19 have doubled in comparison with pre-pandemic estimates. Prevalence rates were higher when collected later in the pandemic, in older adolescents, and in girls.

Lockdowns may be necessary to protect community health, according to one of many studies from Europe. On the other hand, physical isolation may have long-lasting negative consequences, especially for mental health. The Portuguese authors call for strategies which foster mental health

Approaches to combat anxiety – during and beyond the pandemic 

In this situation of raised anxiety levels, breathwork can help calm one’s nervous system. This approach encompasses a group of exercises geared towards teaching individuals to manipulate the rate and depth of their breathing. The aim is to bring awareness to one’s breath, and ultimately provide the same benefits one might reap from meditation. Whereas this is rather new to people in the Western world, the Eastern world shows a history of practicing breathwork spanning thousands of years. Zandra Palma, MD, describes the following breathing exercises

  • Box Breathing involves focusing on a square shape, and breathing in for a count of four, holding one’s breath for a count of four, and exhaling for a slow count of four. 
  • Diaphragmatic Breathing: taking a breath from between one’s chest and abdomen. This can help individuals achieve deeper and more expansive breathing. 
  • 4-7-8 Breathing is another way to calm and ground oneself by counting inhales and exhales. 
  • Alternate Nostril Breathing involves breathing through one nostril at a time. A study demonstrates that this approach helps to reduce anxiety. One nostril at a time is covered with the thumb, directing inhale and exhale through the other nostril. 

The effects behind these methods

Different from deep breathing, which can lower blood pressure and cortisol levels and increase parasympathetic tone, formal breathwork practices exert some even more impressive positive effects on the body and work in a different and almost opposite way. This is Dr. Palm’s outline:

  • Alkalizing blood PH. Hyperventilation induces “respiratory alkalosis” which means we get rid of more CO2 – of acid in the blood – and shift to a higher, or more alkaline pH. 
  • Increasing muscle tone. With the blood becoming more alkaline, calcium ions bind to albumin. In this short-term low-calcium state, increased firing in sensory and motor neurons. The artificially low blood calcium now manifests in the neurological system as tingling sensations, smooth muscle contractions, and increased muscle tone. Exercising the diaphragm muscle supports one’s breathing also for sports such as long-distance running.
  • Anti-inflammatory effects are induced by neurons in the autonomic nervous system firing more during hyperventilation. This releases epinephrine (also called adrenaline), causing the innate immune system to increase its anti-inflammatory activity.
  • Blood pressure and circulation are improved, reducing the risk factor for hypertension. 
  • Elevating one’s mood and reducing stress. Increased blood pH decreases oxygen delivery to tissues; within one minute of hyperventilation, the vessels in the brain constrict, reducing blood flow and oxygen delivery to the brain by 40 percent. This is probably why breathwork practitioners experience feelings of wellbeing. 

Dr. Palm describes further benefits to breathwork. She mentions a study conducted by Yale University: students who participated in a yoga and breathwork program self-reported improvements in stress, depression, positive affect, mindfulness, and social connectedness. The study compared the breathwork program to an emotional intelligence program, for which students reported only mindfulness as a benefit, and a mindfulness-based stress reduction program, which didn’t show any changes. The breathwork program, Dr. Palm summarizes, is what seemed to have the most positive effect on participants’ overall mental health.

The benefits of HRVB

For anyone interested in using breathing exercises to reduce anxiety, there are numerous apps available. They include Calm, Liberate, and MyLife. Smartphone users can conveniently measure their heart rate variability (HRV): the time interval between the heartbeats of a healthy heart is constantly fluctuating. It indicates how well one’s body handles stress. Intervals over a given time period are referred to as HRV. A high HRV indicates that one’s body can cope well with stress, whereas a low HRV can be a symptom of, e.g., anxiety. 

As an important measure of health and wellbeing, HRV is significantly impacted by mood and mental health. Combined with breathing exercises, HRV biofeedback (HRVB) provides a simple and cost-effective way to take control of body functions – and of one’s mental state

Does HRV Biofeedback Work as Treatment for PTSD?

In the United States, post-traumatic stress disorder (PTSD) affects approximately 3.5 percent of adults every year; an estimated one in 11 people will be diagnosed with PTSD in their lifetime. As a non-invasive treatment of various stress-related disorders, heart rate variability biofeedback (HRVB) has been gaining significant attention from researchers in recent years; will it prove to be efficient in trauma treatment settings?

It is a condition that develops in some people who have experienced a shocking, scary, or dangerous event: PTSD. During and after a traumatic situation, fear comes naturally. In order to help our bodies defend themselves against, or to avoid, danger, fear triggers a “fight-or-flight” response, explains the UK’s National Institute of Mental Health. Following a trauma, most individuals will experience a range of reactions; however, the majority of cases is characterized by natural recovery from symptoms. Individuals who continue to feel stressed or frightened, even when they are not in danger, may be diagnosed with PTSD.

Symptoms usually begin within about three months of the traumatic incident; in some cases, they only emerge after years. In order to be considered PTSD, symptoms must last more than a month and be severe enough to interfere with relationships or work. Whereas some people recover within six months, others experience longer-lasting symptoms. In some patients, the condition becomes chronic.

Diagnosing PTSD

To be diagnosed with PTSD, adults will, for a minimum of one month, need to have at least: one re-experiencing symptom; one avoidance symptom; two arousal and reactivity symptoms; as well as two cognition and mood symptoms. Anyone can develop PTSD at any age; children and teens can also have extreme reactions to trauma, but some of their symptoms may be different from adults. 

Researchers are looking into risk factors which include experiencing dangerous events, getting hurt, and mental illness or substance abuse. Support from friends and family and coping strategies are among the factors which may promote recovery. Thanks to research going on in genetics and neurobiology, it may be possible at some time in the future to predict who is likely to develop PTSD and how to prevent it. 

Treatments and Therapies

PTSD treatment aims at helping individuals regain a sense of control over their lives. While primary treatment is psychotherapy, it is often combined with medication. Combining these treatments can help improve your symptoms by teaching patients useful skills to address symptoms, induce positive thinking, communicating ways to cope if symptoms return, and treating other problems often related, in particular depression, anxiety, or misuse of alcohol or drugs. 

Psychotherapeutic approaches include cognitive therapy. This talk therapy helps individuals recognize the ways of thinking that are keeping you stuck, e.g. negative beliefs about themselves and the risk of traumatic things recurring. 

Exposure therapy helps patients safely face situations as well as memories they find frightening so that individuals can learn to cope with them effectively. This behavioral therapy has been particularly helpful in cases of flashbacks and nightmares. 

Eye movement desensitization and reprocessing (EMDR) is a further treatment option. It combines exposure therapy with guided eye movements, aiming to help patients process traumatic memories and change how they react.

Heart Rate Variability Enabling a Treatment Option

Heart rate variability (HRV) is measured by the variation in time between each heartbeat. Greater variability indicates greater ability of the autonomic nervous system to regulate itself. This measure of the functioning of the autonomic nervous system reflects an individual’s ability to adaptively cope with stress. As a non-invasive treatment, heart rate variability biofeedback (HRVB) helps patients to self-regulate a physiological dysregulated vagal nerve. 

In an example, a study analyzed whether veterans with combat-related PTSD would show significantly different HRV prior to an intervention at baseline compared to controls. It aimed at determining whether the HRV among veterans experiencing PTSD is more depressed than that among veterans without PTSD. The study also assessed the feasibility, acceptability, and potential efficacy of providing HRVB as a treatment for PTSD. The findings suggest that implementing an HRV biofeedback as a treatment for PTSD is effective, feasible, and acceptable for veterans. 

Somewhat more recently, researchers looked into the efficacy of HRVB as an additional psychophysiological treatment for depression and PTSD. A selection from 789 studies showed that, despite an obvious popularity of HRV in literature, HRVB had not really been reviewed systematically. According to the researchers, significant outcomes from six randomized studies indicate there may be a clinical improvement when HRVB training is integrated into treatment of PTSD and depression. This holds true in particular when combined with psychotherapy. More research, study authors underline, needs to be done with larger groups, and further efforts are needed to integrate HRVB into treatment of stress-related disorders. Future research also needs to focus on the psychophysiological mechanisms involved.

The debate about efficacy may be ongoing. Already today, however, patients can use their smartphones to measure HRV. This convenient option provides innovative support of HRVB therapy as an additional psychophysiological treatment for PTSD.