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Running head: BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY

Running Head: Breathing Retraining and High Anxiety Sensitivity

Breathing Retraining for Individuals who Fear Respiratory Sensations:

Examination of Safety Behavior and Coping Aid Hypotheses

James J. Lickel, Ph.D.1*

William S. Middleton Memorial Veterans Hospital

Billy R. Carruthers, B.S.2

Laura J. Dixon, M.S.2

Brett J. Deacon, Ph.D.2

University of Wyoming

1 William S. Middleton Memorial Veterans Hospital, Mental Health Clinic, 2500 Overlook Terrace, Madison, WI 53705, USA

2 University of Wyoming, Department of Psychology, Dept. 3415, 1000 E. University Ave., Laramie, WY 82071, USA

*Corresponding author, Tel: 1-307-399-6630,

E-mail address:


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BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY

Abstract

Cognitive behavioral theorists have suggested that breathing retraining may be utilized 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 (n = 27) or a psychoeducation plus breathing retraining condition (n = 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.

Breathing Retraining for Individuals who Fear Respiratory Sensations:

Examination of Safety Behavior and Coping Aid Hypotheses

Modern cognitive behavioral therapies (CBT) 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 for the utility/detriment 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 post-treatment. However, significant between-group 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 among two active treatment conditions (n = 7 in breathing retraining condition; n = 5 in exposure only condition).

A more rigorous study conducted by Schmidt and colleagues (2000) examined the utility of breathing retraining in the context of multicomponent CBT. Seventy-seven individuals with panic disorder were randomly assigned to 12 sessions of CBT with breathing retraining (CBT+BR), CBT without breathing retraining (CBT alone), or waitlist control (WL). At post-treatment, CBT alone outperformed WL on 11 of the 12 outcome measures and CBT+BR outperformed WL on 8 of the 12 outcome measure. No differences between the active treatments were observed on the majority of outcomes. However, as compared to the CBT+BR, there were trends for the CBT alone condition to show greater improvements on panic frequency, anticipatory anxiety, avoidance, and overall disability by the 12 month follow-up. Additionally, Craske, Rowe, Lewin, and Noriega-Dimitiri (1997) compared the addition of either breathing retraining or interoceptive exposure to a treatment consisting of cognitive restructuring and in vivo exposure and reported that at both post-treatment and 6-month follow-up, participants receiving interoceptive exposure reported fewer panic attacks and less overall severity and distress than did those receiving breathing retraining.

In light of mixed findings (Bonn et al., 1984; Schmidt et al., 2000), the basis for cautioning against the use of breathing retraining within CBT remains largely theoretical. Theoretical arguments center on the proposition that individuals who fear physiologic arousal (i.e. those with high anxiety sensitivity) may use breathing retraining as an avoidance strategy or safety behavior (Salkovskis, 1991). Several empirical studies support the notion that identification and elimination of safety behaviors improves treatment response (e.g., Morgan & Raffle, 1999; Salkovskis, Clark, Hackmann, Wells, & Gelder 1999; Schmidt, Richey, Maner, & Woolaway-Bickel, 2006; Wells et al., 1995); thus, concerns that breathing retraining may be used as a safety behavior among individuals with high anxiety sensitivity warrants further investigation.

A number of hypotheses have been offered to explain how safety behaviors interfere with the resolution of maladaptive cognitive processes. For example, the use or presence of a safety aid/behavior may increase the perception that exposure to anxiety-related body sensations is dangerous (Telch et al. 2008). When individuals who fear anxious arousal are taught by experts to dampen their anxiety via breathing retraining, they may infer that anxious arousal is dangerous if left uncontrolled ("These body sensations must be dangerous if my therapist is teaching me how to dampen them"). Safety behaviors are also predicted to maintain pathologic anxiety by promoting or maintaining hypervigilance toward threat. Considerable evidence suggests that efforts to avoid a particular stimulus (e.g., specific numbers) paradoxically increases attention toward that stimulus (e.g., Lavy & van den Hout, 1994; Purdon, 1999). Lastly, use of safety behaviors may result in misattribution of safety (Powers, Smits, Whitley, Bystritsky, & Telch, 2008; Salkovskis, 1991). Individuals utilizing breathing retraining in the face of physiologic arousal may erroneously attribute the nonoccurrence of catastrophe (e.g., passing out) to the use of diaphragmatic breathing ("I did not pass-out because I was able to control my breathing").

It has yet to be determined if breathing retraining is commonly used as a safety behavior. If the addition of breathing retraining to other cognitive behavioral interventions is not detrimental and results in significant improvements in any domain, it may simply be an effective coping aid (Thwaites & Freeston, 2005). The available evidence suggests that breathing retraining could be an effective intervention for reducing anxious arousal (Clark et al., 1985; Meuret et al., 2008; Rapee, 1985; Salkovskis et al., 1986). Further, breathing retraining may prove to be a useful if it increases perceptions of control (Sanderson, Rapee, & Barlow, 1989). The distinction between safety behaviors and coping aids in clinical practice is difficult (Thwaites & Freeston, 2005), but in experimental settings differentiation is possible. The safety behavior hypothesis predicts that breathing retraining in conjunction with other cognitive behavioral interventions will limit improvement in fear of anxiety-related body sensations, attention toward threat, and/or promote misattribution of safety. Conversely, the coping aid hypothesis predicts that adding breathing retraining to other cognitive behavioral interventions will result in reductions in anxiety and increased sense of control, but no interference with improvement in maladaptive cognitive processes.

The purpose of the present study is to conduct an experimental test of the effects of breathing retraining use on coping and cognitive process outcomes. Undergraduate students with high levels of anxiety sensitivity, a risk factor central to the psychopathology of panic attacks and panic disorder (McNally, 2002), were selected to serve as an analog sample. In particular, individuals with fear of respiratory related physical sensations were recruited, as they were theorized to be at elevated risk for using breathing retraining to dampen and avoid respiratory related anxiety sensations. Participants were randomly assigned to either a psychoeducation control condition (EDU) or psychoeducation plus breathing retraining condition (EDU+BR). The safety behavior hypothesis would be supported if participants in the EDU + BR condition evidence worse outcomes on cognitive process measures, regardless of effects on coping measures. The coping aid hypothesis would be supported if participants in the EDU + BR condition evidence significantly greater improvement, as compared to the EDU condition, on anxiety-related distress and perceived control over anxiety (i.e., coping outcomes), with no worse outcome on the cognitive processes examined.

Methods

Participants

Participants were recruited from an undergraduate participant screening pool. Prospective participants (N = 966) completed an online version of the Anxiety Sensitivity Index-Revised Respiratory Subscale (ASI-R Respiratory). Individuals scoring at least one standard deviation above the mean on the ASI-R Respiratory obtained during the first screening time point (M = 11.94; SD = 9.28) were invited to participate. Of the 966 screened individuals, 172 had an ASI-R Respiratory score of 21 or greater and were sent an email invitation to participate. Eligible individuals were instructed by email that they would not be eligible to participate if they had a condition (e.g., asthma, pregnancy, seizure disorders, heart conditions) that would contraindicate participation in a hyperventilation exercise. No participants who attended an initial laboratory visit (N = 63) were excluded due to contraindicated medical conditions and all participants who received informed consent agreed to participate.

The majority of the study sample was female (82.5%), and ages ranged from 18 to 56 years (M = 20.62; SD = 6.76). The racial breakdown of the sample was 87.3% White, 3.2% Asian American, 3.2% Hispanic, and 6.3% described their race as other. The mean ASI-R Respiratory score at the preintervention time point was 27.05 (SD = 8.84), indicating fear of respiratory-related body sensations similar to that of treatment-seeking patients with panic disorder (M = 25.56, SD = 11.53; Deacon & Abramowitz, 2006). The present sample reported similar levels of body vigilance as reported by a panic disorder sample (p > .05; Schmidt, Lerew, & Trakowski, 1997), but less anxiety-related distress than an anxiety disorder sample (p <.05; Beck, Epstein, Brown, & Steer, 1988).

Design

Eligible participants were randomly assigned to one of two intervention conditions: (a) psychoeducation control (EDU; n = 27), or (b) psychoeducation plus breathing retraining (EDU+BR; n = 30). The study occurred across two sessions. Preintervention assessment, group assignment, and initial intervention procedures occurred during session one. Participants recorded their use of the assigned intervention over a homework week, using an online survey. Postintervention assessment and debriefing occurred during session two. Measures were collected at three time points: (a) preintervention, (b) homework week, and (c) postintervention.

Measures

Preliminary Hyperventilation Task (PHT). The PHT was developed for the present study and aided in collection of individualized feared outcomes associated with respiratory symptoms. Participants were asked to hyperventilate for 2 minutes, in unison with prerecorded breathing prompts (45 breaths per min). Following the PHT, each participant identified a feared prediction related to the hyperventilation task (e.g., “I would pass out”). Each participant’s feared prediction formed the basis of the two attributions of safety items (BAT safe and BAT misattribute; see below).

Credibility and Expectancy Questionnaire (CEQ; Devilly & Borkovec, 2000). The CEQ was administered following provision of the intervention rationales. The CEQ consists of six items measuring credibility and outcome expectancies. Credibility and expectancy subscale totals were derived using the scoring procedure established by Noch, Ferriter, and Homberg (2007). Devilly and Borkovec reported that the CEQ has good internal consistency (α’s = .84 to .85) and retest reliability (r’s = .75 to .82) among clinical samples. The CEQ demonstrated good internal consistency in this study (Cronbach’s α = .88).

Manipulation Check. To determine if the intervention resulted in two groups with different levels of controlled breathing over the homework week, participants rated the extent to which they consciously attempted to control their breathing between sessions one and two on a 7-point scale ranging from 0 (never) to 6 (always).

Cognitive Process M easures.

Anxiety Sensitivity Index-Revised Respiratory Concerns Subscale (ASI-R Resp; Taylor & Cox, 1998). The 12-item ASI-R Respiratory subscale measures fear of anxiety-related respiratory symptoms and is a lower-order factor of the complete 36-item ASI-R. The ASI-R respiratory subscale is correlated with other measures of anxiety and successfully discriminates panic disorder patients from other anxiety disorder patients (Taylor & Cox, 1998). Participants completed the ASI-R respiratory subscale at pre and postintervention time-points to assess change in fear of respiratory sensations. The ASI-R respiratory subscale demonstrated good internal consistency in this study (Cronbach’s α = .89).

Body Vigilance Scale (BVS; Schmidt et al., 1997). The BVS is a self-report measure of attention to anxiety-related body sensations. The BVS has acceptable internal consistency (α’s = .74 to .84) and five week test-retest reliability (r’s = .58 to .69) among both clinical and nonclinical samples, respectively (Schmidt et al., 1997). Participants completed the BVS at pre and postintervention time-points to examine changes in self-reported attention to anxiety-related sensations. The BVS demonstrated good internal consistency in this study (Cronbach’s α = .85).

Behavioral Approach Test (BAT). The BAT was developed for the present study and provided an additional index of fear of anxiety-related respiratory symptoms as well as attributions of safety at the postintervention time-point. Participants were instructed to breathe deeply and rapidly, in unison with an audio recording (45 breaths per minute). Though participants were encouraged to continue the exercise as long as they felt able, the exercise was terminated after a maximum of 5 minutes. Immediately following discontinuation of voluntary hyperventilation, participants rated their fear (BAT fear) on a visual analog scale, ranging from 0 (no anxiety) to 100 (extreme anxiety), and the experimenter recorded the length of voluntary hyperventilation in seconds (BAT time). Similar BATs have been utilized in previous research to measure anxiety experienced when exposed to feared stimuli (e.g., Deacon, Sy, Lickel, & Nelson, 2010).