322 TREATMENT OF SPECIFIC ANXIETY DISORDERS
be less likely in individuals who can engage in exaggerated physiological activation when
experiencing high levels of anxiety.Breathing Retraining (Optional)
Breathing retraining is a relaxation strategy that was incorporated into early versions of
cognitive therapy for panic disorder (e.g., Beck, 1988; Beck & Greenberg, 1988; D. M.
Clark, 1986a). Based on the notion that hyperventilation, which involves deep and rapid
breathing, is an important factor in the production of panic attacks, it was proposed
that training in slow, shallow breathing should counter panic symptoms (D. M. Clark,
Salkovskis, & Chalkley, 1985; Salkovskis, Jones, & Clark, 1986). Key elements of D. M.
Clark and Salkovskis’s (1986) early cognitive treatment protocol for panic included:
- A 2-minute voluntary hyperventilation exercise of breathing at a rate of 30
breaths per minute. - Observation of the physical sensations caused by hyperventilation and their sim-
ilarity to panic symptoms. - Education on the physiology of hyperventilation and how it can produce the
physical sensations of a panic attack. - Reattribution of the physical symptoms of panic to stress- induced hyperventila-
tion (or overbreathing) rather than to a misperceived catastrophic health threat
(e.g., “I am having a heart attack”). - Training in slow breathing in order to provide a coping response that is incom-
patible with hyperventilation. Controlled breathing also becomes a behavioral
experiment by demonstrating that physical symptoms must be due to overbreath-
ing rather than the catastrophic threat because the symptoms are so quickly
reduced when slow, shallow breathing is established.
The hyperventilation exercise and breathing retraining became key elements of the
cognitive therapy treatment protocol for panic offered at the Center for Cognitive Ther-
apy in Philadelphia from the mid-1980s to the late 1990s (Beck & Greenberg, 1988).
Together they provided a critical empirical hypothesis- testing experiment indicating
that the catastrophic misinterpretation of symptoms was incorrect, and that the physical
symptoms were actually a harmless consequence of overbreathing or even hyperventila-
tion (Beck & Greenberg, 1987).
Breathing Retraining Exercise
Abdominal or diaphragmatic breathing has been the most common form of breathing
retraining used in the treatment of anxiety disorders. It assumes a key role for hyper-
ventilation in the etiology of panic by causing an acute decrease in arterial partial
pressure carbon dioxide (pCO 2 ), called hypocapnia, that in turn results in a wide range
of unpleasant bodily sensations (e.g., dizziness, heart palpitations, tingling in extremi-
ties, breathlessness), which the individual misinterprets as representing a serious medi-
cal threat (Meuret, Ritz, Wilhelm, & Roth, 2005; D. M. Clark et al., 1985). Various
studies have found other breathing abnormalities in anxiety disorders such as shallow