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The Best Breathing Exercise for Reducing Stress and Anxiety

Anxiety spelled out using Scrabble letters

Since 2020 there has been a 26% rise in anxiety disorder cases globally (1). Anxiety and chronic stress have well documented impacts on physical and mental health, increasing the risk of a range of diseases including heart attack, stroke, diabetes, fatty liver disease, cancer, neurodegenerative disease, mental illness, and all-cause mortality, leading to the “cumulative ‘wear and tear’ on the brain and body that erodes resiliency and health” (2).


Currently, the two main treatments for anxiety disorders are psychotherapy (e.g. CBT, MBT and other ‘talk therapies’) and medications, which have been shown to be moderately effective or are not without side effects. However, more recently, research into breathing practices has shown them to be effective treatments to help reduce stress and anxiety.


However, a quick search of “breathing practices” on PubMed yields 18,721 results, more than half of which have been published since 2010.


With so many practices and so many variables to consider, it can be difficult to get a consensus on what ‘best practice’ looks like when it comes to using breathing techniques to help reduce stress and anxiety and “no singular effective protocol has been established and supported by scientific analyses.” (2)


Thankfully a 2023 study, led by the Health and Human Performance Foundation (HHPF), investigated just that. Here's a description of the study in their own words “Although existing literature confirms the widespread benefits of slow breathing practices for stress/anxiety reduction, null or negative results are reported in some studies, [so] discerning the distinguishing features between effective and ineffective interventions is of interest.” (2)



TL;DR


Short on reading time? Here’s what they found:


Summary chart of the study discussed in the article
Bentley et. al. 2023

In summary,

  • Practise slow paced breathing (or a mix of slow & fast paced with breath holds)

  • Breathe for longer than 5 mins per session

  • Get guidance from someone at the start

  • Practise regularly (ideally daily) and consistently

  • Choose a simple, easy-to-follow breathing technique


[Scroll to the bottom for 3 breathing exercises that meet this criteria]



The Study


Clinical studies that used voluntary, regulated breathing practice as a standalone intervention (not those that combined breathing & yoga or meditation) and those that used visual or audio cues for guiding the breathing pace (not those that used a device to provide real-time feedback) were included in the final review of 58 studies.


They also included studies from across the world, included various age groups and both healthy and high anxiety populations, totalling 5,407 participants and included 72 breathing interventions (fancy word for techniques), making this an exciting and significant piece of research in helping to treat anxiety disorder.



The Results


To help determine what the ‘best’ breathing practice for helping to lower stress and manage anxiety looks like, the interventions were classified based on 5 parameters; breathing pace, session duration, human-guided training, multiple sessions and long-term practice.


Below are my key takeaways from each of the parameters:


Breathing Pace


  • Incredibly, the specific breathing pace may not matter (provided its not fast and is potentially slower than normal) when it comes to effective stress/anxiety reduction

  • Fast-only breathing techniques were less effective compared to any other pace

  • However, fast breathing when paired with a slower pace or holding your breath is effective


Slower breathing activates the parasympathetic nervous system which can “counterbalance the high sympathetic activity intrinsic to stress and anxiety” (2). Within brain activity, slow breathing has been shown to increase alpha and decrease theta power, leading to increased comfort, relaxation, and pleasantness… and reduced symptoms of arousal, anxiety, and depression (5).


The researchers hypothesised that paired fast and slow breathing may work by training the autonomic nervous system to switch back to the parasympathetic branch quicker, or it may teach people to better self-soothe after a stressful situation.


There was a caveat regarding fast breathing due to low study numbers and poor study design. There is the potential for fast-only breathing to help lower stress by acting as an acute stressor that builds resilience over time, or by providing agency in our ability to regulate our internal state through our breathing.


Important note: There’s more to consider when using fast breathing methods, as one of the ways they work is by inducing transient hypofrontality - the progressive downregulation of areas of the brain like the prefrontal cortex, that support high cognitive tasks (6) - which can lead to feelings of dissociation. If someone’s internal awareness is lacking, this dissociation can feel like stress relief. It’s why I caution about the rise in popularity of hyperventilation breathwork styles. The jury is definitely still out on this one.


Session Duration


  • Any session duration beyond 5 min can be effective

  • Simply engaging in a breathing practice (> 5 mins) provides benefits

  • Sessions < 5 mins were ineffective, likely relying too many parameters for successful implementation


There is a general assumption of a dose-response relationship, with longer sessions seen as better. Interestingly, this has also been shown in mindfulness practices (7).


Human-Guided Training


  • Having human guidance during initial sessions contributes to the effectiveness of the practices

  • Human guidance does not guarantee stress reduction benefits, nor does a lack of human guidance reduce the effectiveness

  • More human guidance may be needed for high-anxiety populations, when learning more technical practices (like alternate nostril breathing) or in higher stress settings


Receiving live or pre-recorded instructions can help ensure proper breath mechanics, diaphragmatic engagement, and breathing pace. When live it also allows people to ask questions and/or get feedback, which may help them stick at it and therefore improve the outcomes.


Multiple Sessions


  • Multiple sessions alone appears to support breath practice effectiveness, with a longer intervention duration being more beneficial

  • Multiple sessions may help overcome a lack of human-guided training

  • Multiple sessions help people become more familiar with the practice and help build consistency


Long-Term Practice


  • A minimum of 6 sessions over at least 1 week significantly increased the effectiveness in reducing anxiety

  • Having one initial guided session greatly improved the ‘stickability’ of the practice and improved the effectiveness



What Breathing Exercises Should You Practise?


Here are 3 breathing exercises you can start practising today to help you lower stress and anxiety. Start with 5-10 mins daily, and gradually work your way up to 15 mins twice a day (if you like). Ideally keep the breathing nasal only. If that’s too challenging use a mouth exhale through pursed lips.


Balanced Breathing

6 breaths per min

  1. Sit or lie in a comfortable position

  2. Inhale for 5 sec, exhale for 5 sec

  3. Make your breathing nice and smooth

  4. Don’t pause at the top or bottom

  5. If this is too challenging, dial it back to 4 seconds


Box Breathing

5 breaths per min

  1. Sit or lie in a comfortable position

  2. Inhale for 4 sec, hold for 4 sec, exhale for 4 sec, hold for 4 sec

  3. Make your breathing nice and smooth

  4. If this is too challenging, dial it back to 3 sec for all parts


Extended High Triangle Breathing

4 breaths per min

  1. Sit or lie in a comfortable position

  2. Inhale for 4 sec, hold for 8 sec, exhale for 4 sec

  3. Make your breathing nice and smooth

  4. Don’t pause at the bottom

  5. If this is too challenging, make the hold 4 sec


 

References



 

Learn more about the important work of The Health and Human Performance Foundation


You can find more breathwork resources including accounts to follow, books & more at My Top Breathwork Content


Interested to learn more about the breath or want to learn how to go deeper? Join me at an upcoming workshops or explore my coaching program


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