324 TREATMENT OF SPECIFIC ANXIETY DISORDERS
table 8.9. Diaphragmatic breathing retraining protocol for Cognitive therapy of panic
PHASE I. BASELINE PREPARATION
Rationale: Review physical sensations and cognitions of most recent panic attack. Obtain belief
ratings at varying levels of anxiety to show how same sensations can be interpreted differently at
different times.
Instructions: Ask client to describe the physical sensations and the catastrophic misinterpretation
associated with the panic attack; client rates belief in the misinterpretation now and when most
anxious.
PHASE II. HYPERVENTILATION INDUCTION
Rationale: To demonstrate the production of physical sensations similar to a panic attack through
overbreathing.
Instructions: Individuals are asked to overbreathe at rate of 30 breaths per minute for 2 minutes or
until it becomes too difficult to continue. They are instructed in use of paper bag to rebreathe
expired CO 2. They are also instructed to focus on the physical sensations produced by
hyperventilation.
PHASE III. REATTRIBUTION
Rationale: To introduce possibility that physical sensations during panic are wrongly attributed to a
health threat and instead could be due to overbreathing.
Instructions: Clients are asked to review the physical sensations during hyperventilation and
the sensations described during panic. Rate their degree of similarity and discuss how the
overbreathing symptoms might be worse in a naturalistic setting.
PHASE IV. EDUCATION AND TREATMENT RATIONALE
Rationale: Explain the physiology of hyperventilation and how it causes uncomfortable physical
sensations
Instructions: Discuss how hyperventilation can cause an abrupt drop in arterial pCO 2 that causes
uncomfortable physical sensations. When these symptoms are misinterpreted as indicating a
life-threatening danger like a heart attack, going crazy, or suffocation, panic sets in. Learning
to counter overbreathing with a slower, moderate breathing rate will reduce the intensity of the
physical sensations and provide new evidence that the sensations are due to overbreathing and
not the catastrophic health threat.
PHASE V. DIAPHRAGMATIC BREATHING
Rationale: Learn a relaxation coping skill to counter hyperventilation and other breathing
irregularities that cause the production of physical sensations that are misinterpreted in a
threatening manner.
Instructions:
- Place one hand on chest with thumb just below neck and the other hand on stomach with little
finger just above naval. - Have client take short, shallow breaths through nose. Notice how hand on chest slightly rises
but hand on stomach hardly moves. - Now have client take slower, normal breaths through the nose and notice how the abdomen
moves slightly outward with each inhale and then deflates with each exhale. - Practice for 2–3 minutes with the client focusing on the movement of the abdomen with each
inhale and exhale. - Proceed to work on slowing the breathing rate down to 8 or 12 breaths per minute. Introduce a
paced breathing rate in which therapist demonstrates a 4 second inhale–4 second exhale cycle.
This can be done by counting 1–2–3–4 with each inhale, and then 1–2–3–4 with each exhale. A
short pause occurs at the end of each inhale and exhale. As the client exhales the word “relax”
should be repeated. After the therapist and client practice this slow, moderate breathing, the
client should continue with the diaphragmatic breathing with a particular focus on the slow
steady rhythm of breathing and the rise and fall of the stomach with each inhale and exhale. - Homework assignments begin with two to three daily 10-minute diaphragmatic breathing
practice sessions with or without a pacing audiotape. This is followed by daily sessions of 1–2
minutes of hyperventilation followed by slow breathing. - The final phase of homework involves application of diaphragmatic breathing in a variety of
anxious everyday situations.