Breathing Retraining for Individuals Who Fear Respiratory Sensations: Examination of Safety Behavior and Coping Aid Hypotheses

By Lickel, James J.; Carruthers, Billy R. et al. | Journal of Cognitive Psychotherapy, July 1, 2013 | Go to article overview

Breathing Retraining for Individuals Who Fear Respiratory Sensations: Examination of Safety Behavior and Coping Aid Hypotheses


Lickel, James J., Carruthers, Billy R., Dixon, Laura J., Deacon, Brett J., Journal of Cognitive Psychotherapy


Cognitive behavioral theorists have suggested that breathing retraining may be used as a safety behavior. Safety behaviors are acts aimed at preventing or minimizing feared catastrophe and may maintain pathologic anxiety by hindering resolution of maladaptive cognitive processes. An opposing position is that breathing retraining is an effective coping aid. This study examined the safety behavior and coping aid hypotheses as they apply to breathing retraining. Individuals high in fear of respiratory sensations were randomly assigned to a psychoeducation control condition (EDU; n 5 27) or a psychoeducation plus breathing retraining condition (EDU1BR; n 5 30). As compared to psychoeducation alone, the addition of breathing retraining neither limited improvement of cognitive processes (e.g., anxiety sensitivity) nor added to the gains observed on measures of coping (e.g., perceived control). The findings are evaluated in light of the available literature regarding breathing retraining and the safety behavior and coping aid hypotheses.

Keywords: breathing retraining; diaphragmatic breathing; safety behavior; coping aid; anxiety sensitivity

Modern cognitive behavioral therapies (CBTs) for panic disorder typically include multiple treatment components including psychoeducation, cognitive restructuring, in vivo exposure, interoceptive exposure, and breathing retraining. Psychoeducation, cognitive restructuring, and exposure exercises allow for correction of inaccurate beliefs about feared stimuli (for a more detailed description, see Antony & McCabe, 2002). In contrast, patients are taught breathing retraining to purposefully reduce anxious arousal (Barlow & Craske, 2007). Theorists have cautioned that the use of breathing retraining to reduce anxiety-related body sensations among individuals who fear such sensations may limit the effectiveness of CBT by inhibiting correction of maladaptive cognitive processes (Barlow, 2002; Schmidt et al., 2000; Taylor, 2001).

Individuals taught breathing retraining do report reductions in panic attack frequency and severity (Clark, Salkovskis, & Chalkley, 1985; Rapee, 1985; Salkovskis, Jones, & Clark, 1986); however, results from the only placebo-controlled trial suggest that the effects of breathing retraining on panic attack frequency and severity do not exceed those produced by a credible placebo (Hibbert & Chan, 1989). Although a growing line of research supports that a particular form of respiratory control, capnometry-assisted respiratory training, shows promise (e.g., Meuret, Wilhelm, Ritz, & Roth, 2008), relatively little is known about the effects of more commonly employed forms of breathing retraining.

Despite theoretical concerns about breathing retraining, empirical investigation of its effects within multicomponent CBT protocols has been limited. The three studies available in this regard provide inconclusive evidence regarding the value of combining breathing retraining with other cognitive behavioral techniques. Bonn, Readhead, and Timmons (1984) reported the first trial comparing a 10-session exposure-based treatment for panic disorder without breathing retraining to an exposure-based treatment that was preceded by breathing retraining. No significant differences in outcome were observed at posttreatment. However, significant betweengroup differences favoring the breathing retraining plus exposure condition occurred at 6-month follow-up on measures of panic attack frequency, resting respiration rate, global phobia scores, somatic symptoms, and agoraphobia scores. Conclusions drawn from Bonn and colleagues' findings should be made with caution owing to the small sample size for finding reliable differences between two active treatment conditions (n 5 7 in breathing retraining condition; n 5 5 in exposure only condition).

A more rigorous study conducted by Schmidt and colleagues (2000) examined the use of breathing retraining in the context of multicomponent CBT. …

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