Atlas›Domain X · Body, movement, breath & physical›Guide 150
Guide X-150

Diaphragmatic breathing

A 17 · L 69 · M 1417 interventions in the Trinity explorer
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[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: the low, nose-based, diaphragm-led "breathing re-education" taught in UK NHS respiratory and physiotherapy leaflets for breathing pattern disorder (BPD, also called dysfunctional breathing or hyperventilation syndrome), adapted for psychotherapy as a coping and regulation skill inside CBT for anxiety and panic. Where CBT panic protocols differ (breathing retraining included, as in Craske and Barlow's Mastery of Your Anxiety and Panic, versus breathing deliberately left out in favour of interoceptive exposure), both positions are described and the choice is named in section 2. [source: Leicester BPD leaflet 2023; West Suffolk hyperventilation leaflet; Cambridge (CUH) breathing retraining page 2024; Tolin ADAA slides] [uncertain: the Craske and Barlow workbook content was not verified beyond its title and edition page]

What it is. Diaphragmatic ("tummy", "low" or "abdominal") breathing is a way of breathing at rest in which the diaphragm does most of the work: the lower ribs and belly move gently outwards on the in-breath, the upper chest and shoulders stay quiet, breathing goes in and out through the nose, and the breath is quiet, even and unforced. NHS leaflets describe this as the pattern people are born with and say it can be lost after physical or emotional stress, becoming a habit of upper-chest, faster or deeper-than-needed breathing. [source: Leicester BPD leaflet; West Suffolk leaflet; CUH page]

How change is thought to happen. Two accounts exist, and the therapist should hold both lightly:

  • Physiological account (respiratory physiotherapy and early CBT). Over-breathing "blows off" too much carbon dioxide; the resulting imbalance produces breathlessness, palpitations, tingling, dizziness and anxiety, which feed more over-breathing. Retraining a slower, quieter, lower pattern is meant to break that cycle. [source: West Suffolk leaflet; Leicester leaflet]
  • Psychological account (CBT critics and reviewers). Garssen, de Ruiter and van Dyck (1992) judged hyperventilation theory insufficient and argued that breathing retraining works, but probably through other routes: a relaxation response, a credible explanation for frightening symptoms, a distracting task when panic threatens, and a feeling of control. Meuret and colleagues (2003) found the panic evidence inconclusive and argued that, if low CO2 matters, it should be measured rather than assumed. [source: Garssen et al. 1992 abstract; Meuret et al. 2003 abstract]

Evidence status in brief. A Cochrane review of breathing exercises for dysfunctional breathing/hyperventilation syndrome in adults (Jones et al.; searches to 2013) found only one small, poorly reported trial and no credible evidence either way. In panic disorder, adding breathing retraining to CBT has given mixed results, and in one single-session study of people high in anxiety sensitivity, adding diaphragmatic breathing (and cognitive reappraisal) to interoceptive exposure added nothing. In COPD, diaphragmatic breathing helped some patients but increased breathlessness in those whose chest and belly moved out of step. Present it as a skill that many people find useful, not as a treatment for any physical or mental disorder. [source: Cochrane CD009041; Tolin slides; Deacon et al. 2012 abstract; Fernandes et al. 2011] [uncertain: wider breathwork meta-analyses (e.g. Fincham et al. 2023) not verified here]

Overlap. The Papworth Method (an integrated physiotherapy approach to dysfunctional breathing that includes diaphragmatic breathing, relaxation and education) overlaps heavily with this guide. [uncertain: not verified] HRV biofeedback and resonance-frequency breathing belong to the Domain IX biofeedback guides; holotropic and other intense breathwork belong to Domain VII; Wim Hof is covered separately (167).

2. Framework

Diaphragmatic breathing is a skill, not a therapy with fixed phases. The stages below combine the physiotherapy sequence (awareness, then quiet low nose breathing at rest, then the same pattern in activity, talking and daily life) with the CBT question of when and how to use it. [source: West Suffolk leaflet; Leicester leaflet; CUH page; Tolin slides] [synthesis for the staging and the psychotherapy framing]

Typical dose and format. In psychotherapy it is usually taught in one session and refined over two to four further sessions, a few minutes each time, within a wider treatment. An NHS BPD physiotherapy first appointment lasts about 45 minutes and combines detailed history, observation of the breathing pattern, discussion of triggers and starter exercises; Meuret's capnometry-assisted protocol for panic used four sessions with twice-daily home practice. [source: Southampton (UHS) BPD factsheet 2024; Tolin slides citing Meuret et al. 2008] [synthesis for the psychotherapy dose]

Stage 0: Screening and decision. Goal: decide whether breathing work is safe and useful, and in what role. Rule out or refer physical causes of breathlessness and chest symptoms; screen for BPD features; decide whether in this case breathing is a general regulation skill, a BPD retraining aid alongside physiotherapy, or something to leave out (for example during exposure-based panic treatment). Move on when medical questions are answered and the client agrees to the rationale. [synthesis; see 4.1]

Stage 1: Education and awareness. Goal: the client understands normal breathing, the over-breathing cycle (or the alternative account) and notices their own pattern without changing it. Move on when the client can describe where their breath moves and what it sounds like. [source: West Suffolk; CUH; Leicester]

Stage 2: Quiet low nose breathing at rest. Goal: gentle, quiet, even breathing led by the lower ribs and belly, in a supported lying or half-reclined position, then sitting. NHS leaflets describe normal resting breathing as roughly 10–15 (Leicester), 10–12 (West Suffolk) or 12–16 (Cambridge) breaths a minute; these are descriptions of normal breathing, not targets to count. Move on when the client can produce the pattern comfortably for a short spell without strain or symptoms. [source: Leicester; West Suffolk; CUH]

Stage 3: Generalisation. Goal: the same pattern sitting, standing, walking, on stairs, eating and talking (short phrases with a gentle low breath in pauses), and checking that breathing settles after activity. Move on when it starts to happen without much effort. [source: West Suffolk; Leicester]

Stage 4: Use in the CBT plan. Goal: decide openly how the skill is used. Two named versions:

  • Coping-skill version (breathing retraining included, as in some CBT panic packages and in BPD physiotherapy): breathing is used during early exposure or acute episodes, then faded.
  • Exposure-first version (breathing omitted or confined to general stress management): breathing is not used in feared situations, because it can act as a safety behaviour that blocks learning that the sensations are harmless. [source: Tolin slides; Deacon et al. 2012 abstract] [uncertain: the safety-behaviour theory itself (Clark; Salkovskis) not verified here]

This guide follows the coping-skill version for BPD-type presentations and general anxiety, and the exposure-first version once panic treatment reaches interoceptive and situational exposure. [synthesis]

Stage 5: Ending. Goal: the pattern is automatic, the client can catch and correct a slide into upper-chest breathing, and the use of breathing in feared situations has been faded and replaced by fearless contact with sensations. [source: Leicester (aim of automatic breathing); synthesis for fading]

3. Guiding principles

  • Medical first. Breathlessness, chest pain or palpitations need a medical explanation before they are treated as anxiety; this is the referrer's or GP's job, not yours. [synthesis]
  • Gentle, not deep. The aim is quiet, soft, average-sized breaths, not big ones; NHS leaflets warn against large "recovery" breaths. Practical meaning: praise quieter, smaller, slower, not bigger. [source: Leicester; CUH]
  • Nose by default, without force. In and out through the nose where possible; return to quiet mouth breathing if the nose cannot manage, and suggest a GP or pharmacist for a blocked nose. [source: Leicester; CUH]
  • Low and wide, not a pushed belly. Movement is in the lower ribs and belly, outward in all directions, never forced. [source: RUH Bath diaphragmatic breathing leaflet 2021]
  • Some discomfort is expected and passes. Air hunger and a sense of strangeness are common early on and usually ease with practice. Practical meaning: warn in advance and normalise. [source: Leicester; CUH; West Suffolk; UHS]
  • Awareness before change. Observe the pattern first; change it second. [source: West Suffolk; Leicester]
  • No targets, no performance. In psychotherapy, home practice is framed as brief, frequent, curious practice, not as a number to hit; striving makes breathing worse. [synthesis]
  • Be transparent about mechanism. Offer both the CO2 account and the "sense of control, credible explanation, relaxation" account; do not promise that breathing will stop panic. [source: Garssen et al. 1992; Meuret et al. 2003]
  • Function over form. Ask what the breathing is for in this moment: regulation, or avoidance of a feared sensation. Practical meaning: the same breath can help or hinder. [source: Tolin slides] [synthesis]
  • Fade the crutch. A skill used to escape fear should be phased out before exposure ends. [synthesis, consistent with Deacon et al. 2012]
  • Hands-off teaching. The client places their own hands; the therapist demonstrates on themselves. Any physical cueing needs explicit consent before and during, the right to stop at any moment and a clear non-sexual purpose, and many psychotherapists' codes give no explicit touch guidance, so avoid it. [synthesis; USABP Code VIII; APA Ethics Code]
  • Know the boundary with physiotherapy. Diagnosed BPD, asthma, COPD, voice disorders and pelvic-floor work are led by respiratory physiotherapists or speech and language therapists; the psychotherapist supports and coordinates. [source: UHS factsheet (referral to psychological services); CUH (speech and language therapy)] [synthesis]
  • Never change medicines. Breathing practice never replaces inhalers or other medication; changes are for the prescriber. [synthesis]

4. Intervention inventory

All example language is illustrative wording for a therapist, not text from the leaflets or manuals cited.

4.1 Screening, contraindications and medical clearance

  • Purpose / when: before any breathing work, and again before any exercise that deliberately changes breathing (for example over-breathing in interoceptive exposure).
  • Steps:
    1. Ask about breathlessness at rest, chest pain, palpitations, fainting, wheeze, cough, recent illness or surgery, and whether symptoms have been medically assessed. New, worsening or unexplained physical symptoms go to the GP or referrer first. [synthesis]
    2. Ask about diagnosed lung disease. In one NHS respiratory service most people with BPD also have asthma, COPD or another respiratory condition, so BPD and lung disease often coexist. With asthma or COPD, coordinate with the respiratory team, and keep all medicines exactly as prescribed. [source: UHS factsheet] [synthesis for coordination]
    3. COPD: diaphragmatic breathing increased breathlessness in patients whose chest and abdomen moved out of step; the authors suggest it suits patients with preserved respiratory mechanics and note earlier reports that it may not suit people with marked hyperinflation. Leave COPD breathing technique to the respiratory physiotherapist. [source: Fernandes et al. 2011]
    4. Deliberate over-breathing (only relevant if your panic protocol uses it as interoceptive exposure): a UK clinical neurophysiology guideline for hyperventilation during EEG lists as absolute contraindications stroke or heart attack in the past 12 months, significant heart disease such as unstable angina, lung disease causing breathlessness at rest, sickle cell disease or trait, and moyamoya disease; and as relative contraindications stable cerebrovascular disease, ischaemic heart disease and asthma. It notes that over-breathing can provoke seizures (mostly absences in its audit) and that pregnancy or frailty may limit it. Treat these as minimum medical screening; get medical clearance where any applies, and do not use over-breathing exercises with clients with epilepsy without neurological advice. [source: ANS/BSCN hyperventilation guideline 2013] [synthesis for transfer to psychotherapy]
    5. Other cautions often listed for breathwork (pregnancy, psychosis or bipolar disorder, glaucoma or retinal problems, recent surgery, cardiovascular disease, uncontrolled blood pressure) apply mainly to forceful, rapid or breath-holding practices, not to gentle diaphragmatic breathing; check with the client's doctor when in doubt. [uncertain: not verified for diaphragmatic breathing specifically]
    6. Psychological screening: panic disorder (breathing focus can at first increase fear of sensations), health anxiety, trauma histories where attention to the body or lying down feels unsafe, and dissociation. Offer sitting, eyes open, and client control of pace. [synthesis]
    7. Setting rules: never practise breathing exercises while driving, operating machinery, or in or near water; any breath-holding or over-breathing in water carries a risk of shallow-water blackout. [synthesis]
    8. Stop rules for every exercise: stop and breathe normally if the client feels faint, has chest pain, marked dizziness, tingling or cramping of hands or mouth, or wants to stop. [source: ANS/BSCN guideline (stop on chest pain or wish to stop); CUH (shorten a pause if faint)] [synthesis]
  • Example language (illustrative): "Before we try anything with your breathing, I want to be sure a doctor has looked at the chest symptoms you mentioned. If they have, we can treat this as a skill to practise. Whatever we do, you keep using your inhalers exactly as prescribed."
  • Watch for: symptoms that do not fit anxiety (exertional chest pain, breathlessness lying flat, wheeze, fever); a client who wants to stop medicines; refusal to see a doctor. It is working when medical questions are settled and the client knows the stop rules.

4.2 Assessing the breathing pattern

  • Purpose / when: at the start, to see whether a BPD-type pattern is present and to get a baseline.
  • Steps:
    1. Watch quietly while the client talks and then sits still: nose or mouth; upper chest and shoulders versus lower ribs and belly; rate (fast or slow), size, rhythm (even or irregular); frequent sighs, yawns, throat clearing or gulping breaths; neck and shoulder tension. [source: West Suffolk (breathing awareness); Leicester (good breathing features)]
    2. Self-check: the client lies or sits with one hand on the chest and one on the belly and notices which moves more. [source: CUH; West Suffolk]
    3. Symptom history: tingling fingers, dizziness, palpitations, chest or throat tightness, difficulty getting a satisfying breath, dry mouth, cold hands, tiredness. [source: Leicester; UHS]
    4. Screening questionnaire: the Nijmegen Questionnaire is a free, self-completed 16-item frequency checklist of hyperventilation-related complaints from Nijmegen in the 1980s, taking about five minutes; a total above 23 out of 64 is commonly treated as a positive screen. A critical review rates its content validity as poor and its criterion validity and reliability as only fair, the evidence for the cut-off as unclear, and responsiveness as untested; use it as a symptom checklist and conversation-starter, not a diagnosis, and confirm with a physiotherapist. Other measures named in that review: the Self Evaluation of Breathing Questionnaire and the Rowley Breathing Self-Efficacy scale. [source: Ogilvie and Kersten review] Obtain the instrument from a legitimate source; it is not reproduced here.
    5. Diagnostic testing (for example a hyperventilation provocation test or capnography) is for respiratory clinicians. [source: Ogilvie and Kersten (HVPT as criterion)] [synthesis]
  • Example language (illustrative): "I'm going to notice your breathing for a minute while we chat, not to judge it, just to see what it's doing. Then I'll tell you what I saw and you can tell me if that fits."
  • Watch for: the client changing their breathing because they are being watched (normalise it); high Nijmegen scores with marked lung disease (refer); signs that need medical review. It is working when you and the client share a description of their usual pattern.

4.3 Psychoeducation

  • Purpose / when: after assessment, to give a credible, non-frightening account of symptoms.
  • Steps:
    1. Normal breathing: in through the nose, the diaphragm moves down so the belly and lower ribs move out; on the out-breath it relaxes and rises; neck and upper-chest muscles are for hard exercise. [source: West Suffolk; CUH]
    2. Over-breathing: breathing more than the body needs lowers carbon dioxide; this can cause tingling, dizziness, palpitations, breathlessness and anxiety, which drive more over-breathing; the original trigger may be long gone or forgotten. [source: West Suffolk; Leicester; UHS]
    3. Offer the second account honestly: the practice may also help by calming the body, explaining the symptoms and giving a sense of control. [source: Garssen et al. 1992]
    4. Say what to expect: some discomfort and air hunger at first that usually eases with practice; improvement takes time. [source: Leicester; UHS; West Suffolk]
  • Example language (illustrative): "When we breathe a bit more than we need, the gas balance in the blood shifts, and that can make your fingers tingle and your head swim. It feels dangerous, but it's a known, reversible effect. Practising a quieter, lower breath is one way to break that loop."
  • Watch for: the explanation being heard as "I am damaging myself" (correct it); a client who takes it as proof the sensations must be stopped at all costs (panic risk; see 4.15). Working when the client can retell the cycle in their own words.

4.4 Breathing awareness

  • Purpose / when: first practical step; also a check-in at the start of later sessions.
  • Steps: supported half-lying or comfortable sitting, head and neck supported, loose clothing; one hand on the belly, one on the lower chest; notice size, speed, rhythm, which area moves, and tension in head, neck and shoulders; no attempt to change anything yet. Leicester adds listening to the sound the breath makes. [source: West Suffolk; Leicester]
  • Example language (illustrative): "Just notice. Is the breath mostly under the top hand or the bottom one? Is it noisy or quiet? You don't need to fix anything yet."
  • Watch for: rising anxiety when attention goes to the breath (shorten it, eyes open, shift attention to the hands or the chair). Working when the client can report what they noticed.

4.5 Release of upper-body tension

  • Purpose / when: before and during breathing practice, when shoulders, neck, jaw or hands are tense.
  • Steps: let the shoulders drop, lengthen the back of the neck, loosen fingers and thumbs, let the head rest on the support, let the jaw go loose. Other relaxation methods (music, imagery, progressive tensing and releasing) can be added. [source: West Suffolk; CUH]
  • Example language (illustrative): "Let your shoulders slide down away from your ears. Unclench your jaw a little. Let the chair take your weight."
  • Watch for: relaxation-induced anxiety in some clients (keep eyes open, short spells). Working when visible shoulder lift on the in-breath lessens.

4.6 Core teaching: quiet low nose breathing at rest

  • Purpose / when: the central skill, taught once awareness and tension release are in place.
  • Steps:
    1. Position: lying with pillows under head and knees, or half-reclined, then sitting; shoulders relaxed, mouth closed. [source: CUH; West Suffolk]
    2. Hands: one on the belly and one on the upper chest, or both on the sides of the lower ribs. [source: CUH; RUH]
    3. Let the upper chest go quiet and breathe gently in through the nose so the belly and lower ribs move outward under the hands, in all directions, without pushing. [source: CUH; RUH; West Suffolk]
    4. Let the out-breath happen passively, through the nose, or released softly. The West Suffolk leaflet describes letting the breath go with a soft sigh; the Leicester and Cambridge leaflets keep the out-breath through the nose. [source: West Suffolk; Leicester; CUH] Choose one and name it; for clients who sigh a lot, prefer the quiet nose out-breath. [synthesis]
    5. Keep the breath small to average, quiet and even. [source: Leicester; West Suffolk; CUH]
    6. Demonstrate on yourself first; the client copies; you give brief feedback on what you see (shoulders, sound, where the hands move). [synthesis]
    7. Practise a short spell, then return to ordinary breathing and debrief. [synthesis]
  • Example language (illustrative): "Let the top hand stay still, almost lazy. Breathe in gently through your nose and let the bottom hand be moved outwards, like the breath is widening you rather than lifting you. Now just let it go. Smaller than you think, quieter than you think."
  • Watch for: belly pushing with no rib movement, breath-holding, larger and larger breaths, light-headedness or tingling (sign of over-breathing: make breaths smaller and quieter), and frustration. Working when the lower hand moves more than the upper, the breath is quiet, and the client feels at least neutral.

4.7 Quietening the breath

  • Purpose / when: for noisy, effortful or over-large breathing; a simple first change for anxious clients.
  • Steps: sit or lie comfortably; listen to the breath; make it quieter by using less effort; then introduce slow, quiet nose breathing; return to quiet mouth breathing if the nose cannot keep up; avoid big recovery breaths. The Leicester leaflet also asks clients to time how long they can nose-breathe and extend it gradually; in psychotherapy, frame this as noticing rather than a target. [source: Leicester] [synthesis for the framing]
  • Example language (illustrative): "See if you can breathe so quietly that I couldn't hear you across the room. Less effort, not more."
  • Watch for: the client restricting breathing until air hunger becomes distressing (see 4.10). Working when breathing is audibly quieter without distress.

4.8 Slowing and lengthening the out-breath

  • Purpose / when: once low nose breathing is comfortable, to slow the rate and support calming.
  • Steps:
    1. Slow the breath slightly and let the out-breath be a little longer than the in-breath. [source: CUH; RUH]
    2. Published patterns differ and are given here only as the sources state them: the Bath (RUH) diaphragmatic-breathing leaflet describes an in-breath of about 4 seconds and an out-breath of about 5 seconds; the Cambridge (CUH) page describes short counts with the out-breath longer than the in-breath, guided by a "breathing rectangle", and later an optional short, unforced pause after the out-breath that is shortened if the person feels more breathless or faint. [source: RUH 2021; CUH 2024] Do not lengthen, add to or progress these patterns; any pause or count is optional and is dropped if it produces strain. [synthesis]
    3. If counting raises anxiety, drop counting and use the hand movement as the guide. [synthesis]
  • Example language (illustrative): "Let the breath out take a little longer than the breath in. No need to count unless counting helps. If you feel any strain, let it go back to whatever is easy."
  • Watch for: breath-holding, dizziness, forcing long exhales, perfectionism about counts. Working when the breath slows on its own and the client reports calm or neutrality.

4.9 Feedback aids and alternative positions

  • Purpose / when: when the client cannot feel or produce lower-rib and belly movement.
  • Steps:
    1. Hands on lower ribs or belly (the client's own hands). [source: RUH; CUH]
    2. Mirror: watch upper-chest movement and reduce it. [source: Leicester]
    3. Belt: a belt wrapped around the lower torso, crossed at the front and held firmly; breathe gently against its light pressure. [source: RUH]
    4. Child's pose (kneeling, folded forward), directing the breath into the back of the lungs; use only if the client can kneel comfortably and has no relevant joint, abdominal or pregnancy issues, and not with clients for whom the posture feels exposing. [source: RUH] [synthesis for the cautions]
    5. Lying with pillows under head and knees often makes belly movement easier. [source: CUH; West Suffolk]
  • Example language (illustrative): "Try holding the belt ends yourself and breathe so the belt gets slightly snugger as you breathe in. Nothing dramatic."
  • Watch for: any aid that makes the client self-conscious or triggers trauma memories (offer another, or seated work with eyes open). The therapist does not place hands on the client. Working when the client reports feeling movement low down.

4.10 Managing air hunger

  • Purpose / when: when the client feels they cannot get a satisfying breath, sighs, yawns or gulps during practice or in daily life.
  • Steps:
    1. Explain that air hunger is common early in retraining, temporary, and usually eases with practice. [source: Leicester; CUH]
    2. Options published by the Leicester leaflet: take a slightly deeper breath, then pause briefly, breathe out slowly or pause before the next breath; later, use only a small deeper breath when air hunger comes; or swallow to ease the urge for a big breath. [source: Leicester] (Any pause is brief and unforced; no timing is given.)
    3. Avoid big recovery breaths and repeated deep sighs. [source: Leicester; CUH]
    4. If needed, shorten practice to one or two slow breaths at a time and build gradually. [source: CUH]
  • Example language (illustrative): "That 'I can't get a full breath' feeling is really common at this stage and isn't a sign of danger. Try a swallow, or one slightly bigger breath and then let the next ones be small again."
  • Watch for: air hunger turning into panic (move to 4.13 or 4.15); compulsive sighing. Working when air hunger becomes less frequent and less alarming.

4.11 Generalising to activity, talking and daily life

  • Purpose / when: once the pattern is reliable lying and sitting.
  • Steps:
    1. Practise standing, walking, bending, on stairs, eating and talking. [source: West Suffolk; Leicester]
    2. Expect breathing to speed up with activity; afterwards check it returns to a steady rhythm. [source: West Suffolk; CUH]
    3. Talking: short phrases with a gentle low breath in the pauses. [source: West Suffolk]
    4. Activity: the Cambridge page describes keeping nose and low breathing at a slow pace with a longer out-breath, linked to steps while walking; not holding the breath while lifting or climbing; breathing out on effort; pacing tasks. [source: CUH]
    5. Psychotherapy additions: link practice to everyday cues (sitting down at a desk, waiting at a light as a passenger, before a meeting), and practise in session while discussing mildly stressful material. [synthesis]
  • Example language (illustrative): "Let's try talking about something mildly annoying from this week and see whether you can let a small low breath in between sentences."
  • Watch for: breath-holding on effort, rushed speech without pauses. Working when the client notices and corrects upper-chest breathing in daily life.

4.12 Breathlessness flare-ups and positions of ease

  • Purpose / when: acute episodes of breathlessness in clients with BPD or medically assessed breathlessness.
  • Steps: use relaxed sitting, forward-lean sitting (forearms on thighs or a table), relaxed standing or forward-lean standing to let the upper chest relax; once settled, return to low quiet breathing with a longer out-breath; cool air on the face (a fan, an open window, cool water) may ease the sensation of breathlessness. [source: CUH] Pursed-lip breathing is taught by respiratory physiotherapists and speech and language therapists; leave it to them. [source: CUH] [synthesis for the boundary]
  • Example language (illustrative): "Lean forward and rest your arms on your knees. Let the fan blow on your face. When it settles a bit, we'll let the breath come low and slow again."
  • Watch for: any red-flag symptom (chest pain, blue lips, confusion, breathlessness not easing): stop and seek medical help. [synthesis] Working when the episode settles and the client feels more in control.

4.13 In-session practice and coaching

  • Purpose / when: every session while the skill is being learned.
  • Steps: brief check-in on home practice (curious, not evaluative); a short breathing-awareness check; one or two short practice spells with feedback; a spell during mildly emotive conversation; debrief on what the client noticed; agree what to try at home. Keep the total short so it supports, not replaces, the main therapy. [synthesis]
  • Example language (illustrative): "What did you notice when you practised this week, including the times it didn't seem to work?"
  • Watch for: sessions becoming breathing classes; the client performing for the therapist. Working when the client needs less coaching each time.

4.14 Home practice without targets

  • Purpose / when: between sessions, to make the pattern automatic.
  • Steps:
    1. Short, frequent, comfortable practice at rest, including on good days, then in everyday activities. NHS leaflets stress regular practice over time and say conscious effort is needed at first, with the aim of breathing becoming automatic again. [source: Leicester; CUH; RUH]
    2. Agree with the client when and where they might practise (for example after waking, during a break), framed as an experiment, without a required number of repetitions, minutes or counts. [synthesis]
    3. An optional simple log of when they practised and what they noticed (not a score). [synthesis]
    4. Physiotherapy patients should follow their physiotherapist's practice plan; the West Suffolk leaflet says to do the exercises only after a physiotherapist has shown you and to let them advise when and how often. [source: West Suffolk]
  • Example language (illustrative): "There's no quota. Try it a few times a day when it's easy, and write down anything you notice. If you miss days, that's information, not failure."
  • Watch for: turning practice into a test, checking breathing all day (hypervigilance), or avoiding practice because it brings on symptoms. Working when the client reports catching and correcting their breathing without thinking hard.

4.15 Using breathing within CBT for panic: the safety-behaviour decision

  • Purpose / when: whenever the client has panic attacks or fear of bodily sensations, before deciding whether breathing is taught for use in feared situations.
  • What the sources say:
    • Breathing retraining aims to slow breathing and reduce breath size, raising end-tidal CO2; Meuret's capnometry-assisted respiratory training (CART) for panic, a four-session protocol with twice-daily home practice, outperformed a waitlist, and changes in CO2 mediated changes in anxiety sensitivity. [source: Tolin slides citing Meuret et al. 2008, 2009, 2010] CART uses capnometry feedback and is a specialist protocol; it is not described here. [synthesis]
    • Adding breathing retraining to CBT has given mixed results (Craske et al. 1997; Schmidt et al. 2000), and breathing used in anxiety-provoking situations may act as a safety behaviour that limits what exposure teaches; integrating breathing with exposure is described as problematic. [source: Tolin slides]
    • In a single-session study of 58 people with high anxiety sensitivity, adding cognitive reappraisal and diaphragmatic breathing to interoceptive exposure did not improve outcomes, which questions the routine combination. [source: Deacon et al. 2012 abstract]
    • Meuret and colleagues (2003) warn that claims breathing training should be rejected in favour of cognitive or other interventions are "premature". [source: Meuret et al. 2003 abstract]
  • Steps (decision procedure): [synthesis]
    1. Map the client's safety behaviours, including any "breathing to stop a panic", and ask what they fear would happen without it.
    2. Agree a role openly: (a) general stress-regulation skill practised at calm times; (b) temporary coping aid that helps the client approach exposure, with a plan to fade it; or (c) not used during exposure at all.
    3. If interoceptive exposure (for example deliberate over-breathing to bring on sensations) is part of your protocol, apply 4.1 screening first and follow the protocol's own instructions; do not use breathing to cut the exposure short.
    4. Behavioural experiment: compare a feared situation with and without the breathing strategy, and look at what the client learns about the sensations.
    5. Fade: reduce use in feared situations as confidence grows, until the sensations themselves are no longer treated as dangerous.
  • Example language (illustrative): "There are two ways people use breathing. One is like practising calm. The other is like a rescue: 'if I don't breathe right I'll pass out.' The second can keep the fear alive, because you never find out the sensations would pass anyway. Which way are you using it?"
  • Watch for: rigid rules ("I must breathe properly or I'll faint"), checking the breath constantly, refusing exposure without the breathing, or breathing used to escape the session's exposure task. It is working when the client can let sensations rise and fall with or without the breathing, and their belief that the sensations are dangerous drops.

4.16 Supporting physiotherapy-led and other specialist uses

  • Purpose / when: when the client is also being treated by a respiratory physiotherapist, pelvic health physiotherapist or speech and language therapist.
  • Steps:
    1. BPD and respiratory disease: ask the client to bring their physiotherapy exercises; reinforce, do not alter, them; share anxiety formulation with consent. NHS BPD services refer on to psychological services where underlying mental health needs support, so expect joint work. [source: UHS factsheet] [synthesis]
    2. Pelvic health: the Bath leaflet links diaphragmatic breathing with coordinated pelvic floor function and suggests it may help calm an overactive pelvic floor and reduce pelvic or abdominal pain, with an individual assessment often needed. This work is assessed and taught by pelvic health physiotherapists; the psychotherapist supports the anxiety and pain-coping side. [source: RUH 2021]
    3. Gut conditions (for example IBS or rumination): diaphragmatic breathing is used in gastroenterology and gut-directed psychological care. [uncertain: not verified] Coordinate with the treating team.
    4. Voice and throat symptoms: speech and language therapists may teach specific breathing methods such as pursed-lip breathing to ease throat tension. [source: CUH]
  • Example language (illustrative): "Could you show me what your physio gave you? I'd rather we practise their version than invent a different one."
  • Watch for: conflicting instructions between professionals (agree one version), or the client using therapy to avoid medical follow-up. Working when everyone is reinforcing the same pattern.

4.17 Ending and relapse prevention

  • Purpose / when: final sessions.
  • Steps: review what the client noticed about their breathing at the start and now; list early signs of slipping into upper-chest or fast breathing (sighing, yawning, throat tightness, tingling); write a personal plan (awareness check, quiet low breath, position of ease, when to contact GP or physiotherapist); for panic clients, confirm that breathing is no longer needed as a rescue. [synthesis; early-sign list from Leicester and UHS symptom lists]
  • Example language (illustrative): "If the old pattern comes back under stress, what will you notice first, and what's your first step?"
  • Watch for: a plan built entirely on breathing to stop panic (revisit 4.15). Working when the client can describe their plan without prompting.

5. Handling problems

  • Symptoms get worse when starting (dizziness, tingling, more breathlessness). Likely over-breathing while "trying" (breaths too big or fast) or effortful belly pushing. Make breaths smaller and quieter, shorten spells, switch to sitting with eyes open, stop if symptoms persist. Some discomfort as the body adjusts is described by NHS services and usually eases with practice. [source: UHS; Leicester; CUH] [synthesis for the response]
  • Air hunger dominates. Use the 4.10 options (a small deeper breath, then small breaths again; a swallow); start with one or two breaths at a time; reassure that it is temporary. [source: Leicester; CUH]
  • Persistent chest breathing; cannot feel the belly move. Try lying with knees supported, both hands on the lower ribs, a mirror, or the belt; for some, child's pose. [source: CUH; Leicester; RUH] If nothing works after a few sessions, refer to a respiratory physiotherapist. [synthesis]
  • Breath focus triggers panic. Normalise; use eyes-open, seated, short spells; shift attention to external anchors; reconsider whether breathing is the right tool, and consider moving to interoceptive exposure under your panic protocol (with 4.1 screening). [synthesis; Deacon et al. 2012 for the exposure option]
  • Breathing as a safety behaviour. Signs: rigid rules, refusal to enter situations without it, belief that failure to breathe properly causes fainting or suffocation. Discuss the two uses, run a behavioural experiment, fade. [source: Tolin slides] [synthesis for the response]
  • Trauma-related distress (lying down, closing eyes, attention to the belly or chest). Offer full control: sitting, eyes open, door side, short practice, permission to stop; teach without any touch; ground before ending. [synthesis]
  • Dissociation or depersonalisation during practice. Stop, re-orient (name the room, feet on floor, open eyes), shorten spells, keep breathing work small and secondary. [synthesis]
  • Non-adherence. Explore what gets in the way (forgetting, boredom, symptoms during practice, perfectionism, belief it will not work); attach practice to existing routines; remove targets; review the rationale. [synthesis]
  • Over-adherence and hypervigilance. Constant monitoring of breathing can maintain symptoms; set limited practice times and encourage ordinary attention to life in between. [synthesis]
  • "It doesn't work, I still panic." Reframe: the aim is not to stop all sensations; review whether the skill is being used as a rescue; move to exposure. Be honest that evidence in panic is mixed. [source: Tolin slides; Meuret et al. 2003] [synthesis]
  • Rupture: the client feels dismissed ("you think it's all in my head"). Validate that the symptoms are real and physical; explain that breathing patterns involve body and mind; reconnect with the medical findings; offer joint working with the physiotherapist. [synthesis]
  • Client with asthma or COPD wants to cut inhalers. Do not agree; direct them to the prescriber; record the discussion. [synthesis]
  • COPD client more breathless with belly breathing. Stop; this has been documented in patients with uncoordinated chest-abdomen movement; refer back to the respiratory physiotherapist. [source: Fernandes et al. 2011]
  • Pregnancy. Belly movement and positions change; use comfortable sitting, avoid lying flat for long if uncomfortable, avoid any over-breathing exercises without medical advice, and coordinate with maternity care. [synthesis; ANS/BSCN guideline notes pregnancy as a limit on over-breathing]
  • Epilepsy. Gentle diaphragmatic breathing is not over-breathing, but deliberate hyperventilation can provoke seizures; do not use over-breathing exposures without neurological advice, and stop if the client becomes confused or unresponsive. [source: ANS/BSCN guideline] [synthesis]
  • Red flags during a session (chest pain, fainting, blue lips, breathlessness not settling). Stop the exercise and follow your setting's medical emergency procedure. [synthesis; ANS/BSCN guideline stop rule]
  • Practising in unsafe settings. Remind clients never to practise while driving or in water; relaxation-style practice with eyes closed belongs in safe, seated or lying settings. [synthesis]

Sources

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