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The Anti-Drug for Anxiety

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Four years ago, Laura Knight’s 11-year-old son, Matt, died after years of battling severe epilepsy. Although she and her husband had adjusted to living with a chronically ill child and had committed themselves to enjoying their time as a family, it’s not surprising that the stress of seeing her child endure seven seizures a week, spending long hours in the hospital, and receiving insensitive treatment from medical professionals caused many episodes of anxiety. “The stress, anger, and sadness were all interlinked,” she recalls. She also battled bouts of pneumonia and flare-ups of asthma that left her winded after a simple walk.

After Matt passed away, Knight knew she had to quell the constant anxieties that enveloped her and continued to affect her health. While her son was alive, time for yoga was scarce, but when Knight returned to her practice, she discovered that yoga helped her confront her grief. She had an epiphany while practicing extensive Pranayama, or breathwork, during a yoga workshop. “I began to experience how free my breathing could be, and I realized just how much [emotion] I was holding in my lungs,” Knight says. Taking deep, full breaths helped her to embrace her sadness and had a welcome calming effect.

During times like ours, when pending war, a smallpox scare, suicide bombers, and snipers are the dramas that define our daily narratives, people who do not usually experience feelings of anxiety are being gripped by the sudden sensations of an accelerated heartbeat, a rise in blood pressure, a tightness in the chest, or excessive sweating. These feelings can sometimes have a deep psychological impact, where people are afraid to leave their homes for fear of “something bad happening,” or they have trouble sleeping or performing their jobs. At other times, anxiety coexists with mental health illnesses like depression, eating disorders, and substance abuse.

“Anxiety is mostly caused by two emotions: anger and sadness,” says Gay Hendricks, Ph.D., author of Conscious Breathing: Breathwork for Health, Stress Release, and Personal Mastery (Bantam, 1995). “People get anxious about not being able to control their anger or about not knowing how to deal with situations that make them sad. And that is what fear is—the inability to solve the problem that is making you angry or sad.”

At the core of most anxiety attacks, though, is the breath, or the lack of it. When you are anxious, natural breathing is inhibited. The diaphragm freezes, failing to move air downward as you inhale, which means that you don’t let your lungs fully expand and fill with air.

“And when you don’t get enough oxygen, the brain receives a ‘danger’ signal, which perpetuates your mind-body state of anxiety,” explains Jonathan Davidson, M.D., director of the Anxiety and Traumatic Stress Program at Duke University Medical Center. “Your breathing quickens and becomes even more shallow; in an extreme case this can lead to a full-blown panic attack, in which the person begins to hyperventilate.”

To use the breath to combat anxiety, though, is something we know intuitively. Frequently the first words we say to someone who speaks too fast or appears physically distressed are “Calm down and take some deep breaths.” The supremacy of the breath is not lost on yogis.

Prana, which in Sanskrit is defined as the universal life force or energy that surrounds us, is also found in the breath, and the moment-to-moment act of inhaling and exhaling is seen as a powerful way to connect with the world. Or, put in other words, the way that we breathe says a lot about how we live.

The Science of Breath

According to the Anxiety Disorders Association of America, anxiety is now the most commonly diagnosed mental illness in the country. A UCLA survey published in 2001, though, indicates that less than 25 percent of all anxiety sufferers receive treatment for this affliction, which affects approximately 19 million people.

The most common forms of anxiety, in order of prevalence are: Generalized Anxiety Disorder, which is characterized by unnecessary worry and catastrophizing; Obsessive Compulsive Disorder, the inability to control unwanted thoughts or behaviors; Panic Disorder, episodes of intense fear that surface without warning and may result in physical symptoms such as abdominal distress and heart palpitations; Post-Traumatic Stress Disorder, which manifests as fear that persists long after the experience of a traumatic event; and phobias, or irrational fears.

Treatment for anxiety can vary, from medication, talk therapy, and cognitive behavioral therapy (working to eliminate any thoughts and behaviors that may trigger and result from anxiety) to relaxation techniques like diaphragmatic breathing and mindful breathing—or pranayama. Science has shown that pranayama can be just as effective as the other approaches—and in some cases more so—in slowing down the pace of our hectic lives and reinstating the physiological and psychological balance that dispels anxiety.

One study that was published in the Journal of the American Medical Association (May 17, 2000), coming out of Boston University’s Center for Anxiety Related Disorders, found that slow diaphragmatic breathing (similar to the pranayama technique Deergha Swasam, or Three-Part Breathing, from the Integral Yoga tradition) proved just as effective in reducing anxiety as the antidepressant drug imipramine.

While some practitioners, like Alfred Kleinbaum, Ph.D., a New York City cognitive behavior therapist, believe medication is an option for some patients, others use breathwork and biofeedback. “With breath,” Kleinbaum explains, “I can help to change these pathological breathing patterns and then teach people to relax. It helps them reduce fear and get back to a balanced state.”

In the 1970s Herbert Benson, M.D., founder of the Mind/Body Medical Institute at Harvard Medical School, found that practicing Transcendental Meditation, a simple meditation developed by Maraishi Mahesh Yogi, could lower blood pressure, improve heart health, and reduce stress levels. His research spawned |a whole field of science that explores the therapeutic efficacy of meditation and the idea that our mind can relax our body.

Then, in 1992, John Kabat-Zinn, Ph.D., founder of the Center for Mindfulness at the University of Massachusetts Medical School, published a study in The American Journal of Psychiatry (July 1992) concluding that mindfulness meditation was also an effective way to reduce panic and anxiety symptoms.

In addition, a follow-up study three years later showed that those in the original group who had continued to practice this meditation were still effectively controlling their anxieties. With Kabat-Zinn and Benson providing evidence for the anti-anxiety effects of meditation, other scientists have subsequently looked even closer at how effective the breath can be as a tool to calm both body and mind, and ultimately to help curb anxiety.

For example, a 1990 study in Biofeedback and Self Regulation (September 1990) looked at the effects of slow-breath training on alcoholics with anxiety disorders. The participants who were asked to slow their breath to 10 cycles per minute (the average is 14 to 16) felt less anxious at the end of the exercise than those who were simply told to relax on their own, without any specific technique provided. Another study in 1996, at Tokai Central Hospital in Japan, concluded that subjects who practiced slow-paced breathing were less apt to respond to electric shock with anxiety than subjects who were instructed to breathe quickly or at a regular rate.

“The breath and mind go together,” explains Swami Karunananda, a senior teacher at Yogaville in Buckingham, Virginia, who specializes in using pranayama to deal with fear, anger, and depression—conditions that often accompany anxiety. “If the breath is calm, steady, and even, so are we. If the breath is shallow, agitated, and arrhythmic, the mind won’t be able to concentrate.”

Although this may sound like common sense, those who manifest their anxiety with abnormal breathing patterns sometimes can lose the ability to monitor their own breath. “Some individuals even get relaxation-induced anxiety, which means they get anxious when they relax because it’s such an alien state of being,” explains Kleinbaum. Thus the breaking down of breathing patterns that exacerbate anxiety is key to the success of pranayama as an intervention.

The ‘Fight or Flight’ Response

In order to learn how to breathe better, it’s important to understand the physiology of the breath. The respiratory system is part of the autonomic nervous system, which means breathing happens without our even thinking about it. This response comes in handy in times of crisis, when we need to activate the “fight or flight” response. When our brain senses any danger, our heart rate increases, the endocrine system begins pumping out adrenaline and cortisol that give us that additional “oomph” we may need in times of turmoil, plus the digestive system shuts down, and the breath quickens, flooding the body with oxygen.

The fight or flight response is warranted in times of legitimate crisis. But when this heightened state is induced unnecessarily, it can trigger panic and anxiety attacks. In some cases the individual begins to hyperventilate. Rapid breathing then causes more carbon dioxide to be expelled at a greater rate. The low levels of carbon dioxide make the body more alkaline, which leads to even more hyperventilation. The result is a vicious cycle that not only prevents the body from slowing down but also interferes with the blood’s ability to release oxygen to the tissues.

Trying to break this breathing pattern can be a challenge because it’s a chicken-or-egg dilemma, according to Robert M. Goisman, M.D., an assistant professor of psychiatry at Harvard Medical School, who is affiliated with the Harvard/Brown Anxiety Disorders Program. “People will begin to hyperventilate because they’re anxious, and then as the carbon dioxide levels drop, the hyperventilation makes the anxiety worse,” he explains. “It causes a lot of fear. They feel like they’re having a heart attack or a stroke, and unless a person understands that slowing down the breath will help, instinct is going to tell him or her to keep up the fast-paced panting.”

Yoga teacher Barbara Benagh knows firsthand what it feels like when the fight or flight response gets out of control and causes panic or fear. For years her chronic asthma made her feel like a swimmer caught in a whirlpool. “Anxiety was a huge part of my asthmatic life,” she recollects. “When I realized this was about panic and lack of control, I began to address the anxiety by understanding when and why my body jammed into the fight or flight response without the proper context. I learned [from breath-control work] that I could change that chemical response with my breath.”

Anyone who has ever experienced panic or anxiety knows that it builds on itself. And repatterning the breath to overcome the cycle can be an easy solution, which Benagh says will take patience and trust. “Anxiety builds up over years, so by the time it blossoms into panic, it’s going to take some time to deconstruct.”

Out on the Eighth Limb

Traditionally, yogis have emphasized the practice of pranayama over that of asana. Pranayama is one of the eight limbs of yoga and emphasizes using the mind to control the breath and the universal energy that unites us and also feeds our souls.

Pranayama is able to give you a feeling of higher consciousness, and that can reduce anxiety,” says Dharma Singh Khalsa, M.D., Kundalini yogi and coauthor with Cameron Stauth of Meditation As Medicine (Fireside, 2002). “If you look at it spiritually, people who are anxious may lack a connection with their deeper selves. We remember what we had for breakfast, but we forget we are spiritual beings who are connected to God.”

The beauty of the breath is that even though it’s an automatic response, we do have the ability to control it. That knowledge alone, says Singh Khalsa, empowers people to take control of their health and to reduce their anxiety. Yogis also believe that breathing can increase the amount of prana that enters our body, which, in turn, heightens our awareness as well as strengthens our ties to the world. Finally, Singh Khalsa notes in his book that proper breathing is a great way to increase mindfulness of the moment, which ultimately helps retrain the old patterns that spawn anxiety.

“You can use your newfound expertise in breathing to gain greater effectiveness and enjoyment even in very simple things in life,” Singh Khalsa writes. He continues with the suggestion that “whenever you get the chance, stop, inhale deeply, bring the energy up, and then exhale again through the nose. This will keep you calm, centered, relaxed, and at peace.”

Follow Your Nose

There are many methods of pranayama, some more complex than others. But a few of the more common types are Nadi Sodhana, alternate nostril breathing; Kapalabhati, rapid inhalation and exhalation (also called the Breath of Fire); Ujjayi Pranayama, nostril breathing with an audible breath; Antara Kumbhaka, retention of the breath after inhalation; and Bahya Kumbhaka, retention of the breath after exhalation.

One of the simplest ways to start a pranayama practice is to pay attention to the sound of your breath while sitting in a comfortable position. “I tell my students to just let the breath relax them, then to listen to its rhythms and to hear its soothing ocean sounds,” says Benagh. “Once you surrender to the natural sounds of your inhalation and exhalation, you begin to invite a breath that is not fearful, that begins to calm the body and to lower the heart rate and blood pressure.”

Laura Knight’s pranayama practice has not only enabled her to work through her grief but also to control the subsequent anxiety. It has also helped her to overcome other fears—despite her fear of heights, she enrolled in trapeze camp, and although she has asthma, she decided to take up mountain climbing. “If I would have had access to these tools when I was dealing with my son, it would have helped a lot,” she states. “There was a time when I was very anxious, but now I do not get anxiety in situations that in the past would have induced my fears.” That’s not to say she no longer has the normal stress of everyday life. Recently, she enrolled in a yoga teacher training program.

Before Knight taught her first class, she practiced alternate nostril breathing to help calm her nerves. “Now I can ease into things and work through them,” she says. “Sure, the breathwork is a great tool; however, I really think it’s all about the intention. If you want to breathe better, that’s more powerful than doing the actual exercises.” n

Stacie Stukin is a contributing editor to Yoga Journal. Her last story, “Yoga for Your Dosha,” appeared in the January/February 2003 issue.