The effects of breathing retraining on the phenomenology of panic:

BREATHING RETRAINING 1

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: james.lickel@va.gov

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 2

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

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 4 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 posttreatment, 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

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 5 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

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 7 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

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 9 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 Measures.

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).

Following completion of the fear rating, participants in the EDU+BR condition utilized diaphragmatic breathing for 90 seconds, while participants in the EDU condition were asked to sit quietly for a 90 second resting period. Following the resting period, participants completed two items to assess attributions for the failed occurrence of their individualized feared outcomes identified during the PHQ (e.g., “I will pass out”). Specifically, participants rated the extent to which they attributed the failed occurrence of their feared outcome to the use of preventative

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 11 actions (BAT misattribute) and/or to the benign nature of the task (BAT safe). Attribution of safety ratings were made on visual analog scales ranging from 0 ( totally disagree ) to 100 ( totally agree ).

Coping Measures.

Beck Anxiety Inventory (BAI; Beck, et al., 1988). The BAI is a widely used self-report measure that assesses distress related to 21 symptoms of anxiety (e.g., heart pounding or racing, sweating). Although not developed as a measure of coping, the BAI was utilized in the present study to examine the safety behavior and coping aid hypotheses, as reductions in anxiety-related distress were posited to be an important coping outcome. Respondents rated the extent to which they were bothered by each symptom over the past week. Items are scored on a 4-point scale ranging from 0 (not at all) to 3 (severely, I could barely stand it). Participants completed the BAI at pre and postintervention time-points to measure change in distress related to anxious arousal.

Beck et al. reported that the BAI has high internal consistency (α = .92) and one-week retest reliability ( r = .75). The BAI demonstrated good internal consistency in this study (Cronbach’s α

= .86).

Revised Anxiety Control Questionnaire (R-ACQ; Brown, White, Forsyth, & Barlow,

2004). The R-ACQ is a 15-item self-report measure assessing perceived control over anxiety and anxiety provoking stimuli. The full scale R-ACQ has been shown to have favorable internal reliability (ρ = .85; Brown et al., 2004) among a nonclinical sample. Respondents rate the extent to which they agree with each item on a 6-point scale ranging from 0 ( strongly disagree ) to 5

( strongly agree ). Participants completed the R-ACQ at pre and postintervention time-points to assess change in perceived control over anxiety. The R-ACQ demonstrated good internal consistency in this study (Cronbach’s α = .90).


Homework Week Measures.

Participants were asked to complete a daily online homework measure that assessed the frequency, style, and function of use of diaphragmatic breathing (“Diaphragmatic Breathing Use

Questionnaire”) and psychoeducation materials (“Psychoeducation Review Questionnaire”), among participants in the EDU + BR and EDU conditions respectively. The homework week measures were developed for the present study and adapted from Stewart and Westra’s (1996)

Medication Use Questionnaire. Frequency was measured by the number of times the intervention was used each day. Two items were included to assess the style of diaphragmatic breathing/education review (i.e., “used diaphragmatic breathing/education review only when I started to feel anxious” [anxiety], and “used diaphragmatic breathing/education review at prescheduled times, such as when I woke up or before I went to bed” [prescheduled]. Three items assessed the reported function of diaphragmatic breathing/education review use (i.e., “used diaphragmatic breathing/education review to avoid feared consequences of body sensations”

[catastrophe], “used diaphragmatic breathing/education review to avoid having a panic attack”

[panic], and “used diaphragmatic breathing/education review to cope with the general symptoms of anxiety” [cope]). Participants rated their agreement with the two style and three function items on 7-point scales (1 = never; 7 = always). Daily responses were averaged to form composite scores of frequency, style, and function of homework intervention use.

Procedures

Participants were administered all study procedures during individual sessions with a trained experimenter. At the beginning of session one, eligible participants completed the informed consent procedures and consenting participants were screened for contraindicated

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 13 medical conditions. Participants were then administered the PHT and all preintervention measures.

Eligible participants were assigned to the EDU or EDU+BR condition in an alternating sequence. After completion of the preintervention measures, each participant received psychoeducation detailing anxiety reactions and anxiety-related body sensations. Consistent with current cognitive behavioral models of panic attacks (e.g., Clark, 1986), the experimenter explained that the experience of anxiety-related body sensations may be intensified by fear of such sensations. All participants were informed of the detrimental effects of avoiding feared body sensations and anxiety provoking situations. Following provision of psychoeducation,

EDU participants scheduled a postintervention session (session two), which occurred approximately one week following session one. EDU participants were instructed to review a psychoeducational pamphlet when anxious arousal occurred or when they confronted anxiety provoking situations. EDU participants were asked to review the psychoeducation material a minimum of two times each day and were instructed to complete the online ERQ daily.

With the exception of reviewing psychoeducation materials over the homework week,

EDU+BR participants completed all of the procedures described above and were additionally trained in breathing retraining per the instructions provided in the Mastery of Anxiety and Panic-

4 th

Edition (MAP-IV; Barlow & Craske, 2007). Participants were instructed: “apply breathing skills as a technique for helping you to face anxiety and situations that bother you. In other words, as you feel anxious symptoms building, begin to concentrate on slow diaphragmatic breathing” (p. 93; Barlow & Craske, 2007). EDU+BR participants were instructed to utilize diaphragmatic breathing at least twice daily and complete the online homework measure each day over the homework week. During the second session, all participants completed the

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 14 manipulation check and each of the postintervention measures. Following collection of all postintervention measures, participants were debriefed about the study details and reimbursed

$10 for their time.

Analytic Plan

Data were first analyzed to examine the success of the manipulation and description of the style, frequency, and function of use of the respective interventions over the homework week. Outcome variables were then analyzed to examine the safety behavior and coping aid hypotheses. Although it was hypothesized that participants in both conditions would evidence significant pre to post improvement on both measures of coping (i.e., BAI and R-ACQ) and cognitive processes (i.e., ASI-R resp, BVS), the safety behavior hypothesis would be supported if the addition of EDU + BR condition evidenced significantly worse outcome on the cognitive process measures as compared to the EDU condition. The coping aid hypotheses would be supported if the EDU + BR condition evidenced greater improvement on measures of coping as compared to the EDU condition. To test the above hypotheses, a series of 2 (EDU vs EDU+BR, between groups) x 2 (pre to post, within groups) mixed analyses of variance (ANOVA) were employed. For each analysis, the presence of a significant time x condition interaction would indicate differential magnitude of change from pre to postintervention between the two conditions. Participants completed BAT measures (i.e., BAT-time, BAT-fear, BATmisattribute, and BAT-safe) at postintervention only. Thus, between-group differences on the

BAT measures were analyzed using a series of independent samples t -tests. Lastly, the relationship between preintervention variables and frequency, function, and style of breathing retraining use was examined.


Type I error is inflated in this study owing to the large number of outcomes examined.

As recommended by Perneger (1998), results are reported without Bonferroni correction to avoid inflation of Type II error given the preliminary nature of the research and relatively small sample size to detect differences among two active interventions. The reader is encouraged to interpret the findings with this caveat in mind and pay special attention to the effect sizes, which are reported throughout. Following the recommendations of Morris and DeShon (2002) for pretestposttest designs, between-groups effect sizes were calculated using the following formula:

[( M post, EDU

- M

pre, EDU

) / SD

pre, EDU

] - [( M

Post, EDU+BR

- M

Pre, EDU+BR

) / SD

pre, EDU+BR

].

Uncontrolled within-condition effect sizes were also calculated for each variable as the difference between pre and postintervention means divided by the preintervention standard deviation. To characterize the magnitude of change on the BAT measures, Cohen’s d betweengroup effect sizes were calculated as the mean difference between conditions divided by the pooled standard deviation.

Results

Attrition

Based on an a priori decision, participants were removed from outcome analyses if they failed to utilize their assigned intervention (i.e., breathing retraining or education review) on a majority (i.e., at least four separate days) of days over the homework week. Six particpants

(9.52%) failed to complete the minimum required number of homework tasks. The relationship between condition and failure to complete postintervention assessment was not significant.

Baseline Equivalence and Manipulation Check

Outcome measures were examined for violations of assumptions of normality. Visual and statistical evaluations were satisfactory. As determined by one-sample K-S tests, dependent

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 16 measures did not differ significantly from standardized normal distributions at pre or postintervention time-points ( p’s > .05).

The two conditions did not differ significantly on demographic (see Table 1) or preintervention variables (see Table 2), suggesting that randomization was successful.

Furthermore, conditions did not differ significantly on perceived intervention credibility or expectancy ( ps .

66 and .64, respectively). The manipulation check revealed that conditions differed significantly in use of controlled breathing when anxious, t (55) = 2.19, p = .03; Cohen’s d = .59. As expected, EDU+BR participants characterized their use of controlled breathing as more frequent than participants in the EDU condition (EDU+BR, M = 4.00, SD = 1.31; EDU, M

= 3.22, SD = 1.37).

Description of Intervention Use

There was no difference between conditions in the number of days that online homework questionnaires were completed, t (1, 55) = 0.62, p = 0.54 (EDU, M = 5.43, SD =1.20; EDU +

BR, M = 5.63, SD = 1.26). Average daily use of breathing retraining was higher among EDU +

BR participants ( M = 3.28, SD = 0.84) than was average daily review of the psychoeducation handout by EDU participants ( M = 2.49, SD = 0.56), t (1, 55) = 4.13, p < .001. As compared to

EDU participants, EDU + BR participants reported using their intervention procedure (i.e., diaphragmatic breathing) more often when feeling anxious, t (1, 55) = 2.00, p =.05, and EDU participants more often reported using their intervention procedure at prescheduled times, t (1,

55) = 3.25, p = .002. There were no significant differences between groups on the reported function of intervention procedure use. Specifically, EDU and EDU + BR participants evidenced no significant difference in their use of respective intervention procedures as a way to cope ( p = .89), avoid catastrophe ( p = .94), or avoid panic ( p = .98).


Intervention Outcomes

Cognitive process outcomes. As hypothesized, there was a significant effect of time on the cognitive process measures collected at both pre and postintervention time points: ASI-R respiratory, F (1, 55) = 71.82, p < 0.001; BVS, F (1, 55) = 20.29, p < 0.001. The magnitudes of within-group pre to postintervention improvement were in the medium to large range ( see Table

3 ). Contrary to the safety behavior hypothesis, there were no significant condition x time interactions on the cognitive process measures: ASI-R respiratory, F (1, 55) = 0.06, p = 0.81

(Between-group d = .13); BVS, F (1, 55) = 0.02, p = 0.89 (Between-group d = .05).

Contrary to the safety behavior hypothesis, conditions did not differ at the postintervention time-point in peak fear reported following voluntary hyperventilation (BAT fear); t (1, 54) = 0.32, p = 0.75, d = .09. Similarly, there was no between-group difference in postintervention length of voluntary hyperventilation (BAT time), t (1, 50) = 0.40, p = 0.69, d =

.11. The difference between conditions was not significant for misattribution of safety to intentional efforts to avoid threat (BAT misattribute), t (1, 54) = 0.57, p = 0.57, d = .15, or attributing safety to the benign nature of the voluntary hyperventilation task (BAT safe), t (1, 54)

= 1.27, p = 0.21, d = .33.

Coping outcomes. As hypothesized there was a significant effect of time on the BAI, F

(1,55) = 36.07, p < 0.001, and R-ACQ, F (1,55) = 43.00, p < 0.001, which suggests pre to postintervention improvements across conditions. The magnitudes of within-group pre to post improvements among both conditions were in the medium range (see Table 3). Contrary to the coping aid hypothesis, condition x time interactions were nonsignificant on the BAI, F (1,55) =

0.05, p = 0.82 (Between-group d =.02), and R-ACQ, F (1,55) = 1.07, p = 0.31 (Between-group d

= .25).


Predictors of Breathing Retraining Use and Outcome

Among individuals assigned to the EDU + BR condition, preintervention variables were predictive of subsequent frequency, style, and function of diaphragmatic breathing use (see Table

4). General distress related to anxiety at preintervention, as measured by the BAI, was positively correlated with use of diaphragmatic breathing in response to anxiety, use of diaphragmatic breathing to avoid panic, and use of diaphragmatic breathing as a way to cope. Perceived control over anxiety at preintervention, as measured by the R-ACQ, was negatively correlated with frequency of diaphragmatic breathing use, use of diaphragmatic breathing to avoid panic, and use of diaphragmatic breathing as a way to cope. Fear of anxiety-related respiratory sensations, as measured by the ASI-R respiratory, was positively correlated with frequency of diaphragmatic breathing use and use of diaphragmatic breathing to avoid catastrophe and panic. Attention toward body sensations at preintervention, as measured by the BVS, was positively correlated with frequency of diaphragmatic breathing use, use of diaphragmatic breathing when anxious, use of diaphragmatic breathing to avoid panic, and use of diaphragmatic breathing to cope.

Although several preintervention variables were related to participants’ subsequent use of diaphragmatic breathing, the frequency, style, or function of self-reported diaphragmatic breathing were not related to pre to postintervention changes on any of the coping or cognitive process measures (all p's >.05).

Discussion

Contrary to both the safety behavior and coping hypotheses, there were no significant between-group differences in pre to postintervention improvement on cognitive process or coping outcomes. If breathing retraining was an effective coping aid, its addition to psychoeducation would have resulted in additional improvement in anxiety-related distress

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 19 and/or perceived control by postintervention. Although uncontrolled examinations of breathing retraining suggest that breathing retraining results in reliable pre to post-treatment improvement

(e.g. Clark et al., 1985; Rapee, 1985; Salkovskis et al., 1986), the extent to which such improvements are specific to breathing retraining and exceed expectations alone remains in question.

Schmidt and colleagues (2000) previously reported that breathing retraining adds no benefit to a cognitive behavioral treatment for panic disorder, which included both cognitive and exposure interventions. It remained possible that the potentially deleterious effects of breathing retraining were overshadowed by the large magnitude of change produced by cognitive and exposure interventions. To provide a more sensitive test, cognitive and exposure interventions were excluded from this examination of the coping aid and safety behavior hypotheses. The results of this study are similar to those reported by Hibbert and Chan (1989), who found that breathing retraining failed to produce significantly greater improvements than a control intervention that included psychoeducation and promoted equivalent expectancies for improvement.

Cognitive behavioral theorists have cautioned that when used as an avoidance strategy, breathing retraining may function as a safety behavior and thereby interfere with correction of maladaptive cognitive processes (e.g., Taylor, 2001). In particular, purposeful avoidance of feared catastrophes (e.g., passing out) has been cited as a likely route to maintenance of maladaptive cognitive processes (Salkovskis, 1999; Thwaites & Freeston, 2005). This sample of individuals with elevated fears of respiratory symptoms were no more likely to utilize breathing retraining as an avoidance strategy (i.e. to avoid "catastrophe" or "panic") than they were to utilize review of psychoeducation materials as an avoidance strategy. Thus, it is not surprising

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 20 that use of breathing retraining did not impair improvement on cognitive processes believed to contribute to the maintenance of panic. Individuals in the EDU+BR and EDU conditions evidenced similar improvements on measures of fear of anxiety-related body sensations, attention toward threat, and attributions of safety.

The results of the present study are consistent with Hazlett-Stevens and Craske’s (2009) assertion that individuals with the strongest belief in the dangerousness of anxiety-related body sensations may be the most likely to use breathing retraining as a way to avoid body sensations and perceived catastrophe. Preintervention severity of anxiety sensitivity, as well as other indicators of anxiety severity, was positively correlated with subsequent frequency, style, and function of breathing retraining use. Participants with the greatest fear of anxiety-related body sensations reported using breathing retraining more frequently over the homework week and more strongly characterized their use as a way to avoid perceived catastrophe and panic. The aforementioned findings add to past research that documents a relationship between focus of feared prediction and selected avoidance behavior (Davey, Burgess, & Rashes, 1995; Salkovskis,

1996; Kamphuis & Telch, 1998). In clinical practice it is common for therapists to warn clients not to use relaxation techniques as an avoidance strategy. Results of the present study indicate that such instructions are more likely to be ignored by individuals who most strongly fear anxiety-related body sensations, but use of breathing retraining as an avoidance tool may not ultimately prove detrimental. Data from the present study suggest that use of diaphragmatic breathing to purposefully avoid catastrophe and panic was not associated with impaired improvement on coping or cognitive process measures.

Failure to establish a relationship between reported function of diaphragmatic breathing use and pre to postintervention change may be due to a floor effect in reported function of

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 21 diaphragmatic breathing use. Indeed, EDU+BR participants rarely described their use of diaphragmatic breathing as a way to avoid catastrophe or panic. In fact, there was no betweengroup difference in use of their respective intervention procedures (i.e., psychoeducation review or diaphragmatic breathing) as a way to avoid catastrophe or panic. Subsequent research might benefit from experimentally manipulating the function of diaphragmatic breathing use, which would provide a more powerful analysis of the effects of using diaphragmatic breathing as a way to avoid perceived catastrophe or panic.

Several limitations of this study exist and deserve careful consideration. The extent to which the findings of the present study generalize to a treatment-seeking sample is unclear.

Participants were recruited based on their fear of respiratory symptoms, which resulted in a homogeneous sample of individuals who, based on previous research (e.g., Davey et al., 1995;

Salkovskis, 1996), were most likely to utilize breathing retraining as an avoidance strategy.

Although the present sample reported similar fear of respiratory symptoms and body vigilance as panic disorder samples, the relatively low response rate of eligible participants (37%) suggests that the target population may not have been adequately sampled.

This study examined the effects of a brief breathing retraining intervention; however, the extent to which the findings generalize to a more prolonged trial of breathing retraining has yet to be established. Further, controlled breathing interventions vary greatly in application. Meuret and colleagues (Meuret et al., 2008; Meuret, Rosenfield, Hofmann, Roth, & Suvak, 2009;

Meuret, Rosenfield, Seidel, Bhaskara, & Hofmann, 2010) have developed a controlled breathing intervention that is characterized by measured modulation of pCO

2 levels via capnometry assistance. The results of this line of research suggest that capnometry-assisted breathing training results in significantly greater pre to post-treatment improvement in anxiety sensitivity

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 22 than wait-list control and comparable pre to posttreatment improvement as compared to a brief cognitive-based intervention. Improvement observed among individuals with panic disorder utilizing capnometry-assisted respiration training was shown to be mediated by changes in pCO

2 levels. The present study did not measure pCO

2

; thus, it is possible that breathing retraining did not result in additional benefit over psychoeducation alone because EDU+BR participants were unsuccessful in normalizing pCO

2 levels. However, at this time, the use of capnometry-feedback in clinical practice is rare and it is likely that the delivery of breathing retraining in the present study is more representative of clinical practice than the treatment described by Meuret and colleagues.

A strength of the present study was the inclusion of measures of both cognitive process and coping measures. However, the validity and reliability of the misattribution of safety measures employed has not yet been established. Despite the hypothesized importance of misattribution of safety, there is not currently an established tool for measuring this construct.

Development of a comprehensive tool for measuring attributions of safety is critical to further our understanding of the role of safety attributions in the maintenance of pathological anxiety.

This study attempted to measure misattribution of safety by asking participants to rate why their individualized feared outcome did not occur during a BAT. Given the demands of the BAT in this study, EDU+BR participants were unable to use controlled breathing during the BAT, rather they were encouraged to utilize diaphragmatic breathing following completion of the BAT. The design of the BAT may have obstructed participants from misattributing the failed occurrence of their feared outcome. Future research examining the misattribution of safety hypothesis may benefit from examining attributions of safety in the context of a behavioral experiment in which

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY 23 participants are able to utilize the suspected avoidance behavior while simultaneously confronting their feared stimuli.

Researchers have begun to question the assumption that all forms of avoidance must be eliminated for treatment to be successful (Parish, Radomsy, & Dugas, 2008; Rachman,

Radomsy, & Shafran, 2008). In fact, Rachman et al. suggested that judicious use of safety behaviors within the context of exposure therapy might improve treatment effectiveness by reducing drop-out and increasing approach behavior. Preliminary evidence indicates that some safety behaviors have the potential to increase approach behavior during exposure therapy, while not interfering with threat disconfirmation (Milsovec & Radomsy, 2008). Unfortunately, we do not yet know why some behaviors appear to interfere with resolution of maladaptive anxiety and others do not (Rachman et al., 2008).

In summary, the findings of this study suggest that among the present sample: (a) breathing retraining did not impair improvements on pathologic cognitive processes, (b) breathing retraining did not add to the efficacy of psychoeducation on measures of distress or perceived control, (c) the frequency, style, and purported function of breathing retraining use is not related to the magnitude of improvement on measures of coping or cognitive processes, and

(d) indicators of preintervention severity were correlated with subsequent frequency, style and reported function of diaphragmatic breathing. The present study did not find support for either the safety behavior or coping aid hypothesis.


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Table 1.

Demographic Characteristics and Between-Group Baseline Comparisons

EDU (n = 27 ) EDU + BR (n = 30) Effect of Condition

Variable

Age

M

19.81

SD

3.39

M

21.70

SD

9.20 t = 1.01 p = .32

Gender

Male

Female

Ethnicity

African-American

Asian

7

20

0

2 n %

25.93

74.07

0.00

7.41

4

26

0

0 n %

13.33

86.67

0.00

0.00

X

2

= 1.45 p = .23

X 2 = 5.37 p = .15

Caucasian

Hispanic

Other

22

2

1

81.48

7.41

3.70

27

0

3

90.00

0.00

10.00

Note . EDU = psychoeducation control condition; EDU + BR = psychoeducation plus breathing retraining condition.


Table 2.

Descriptive Statistics and Between-Group Comparisons on Outcome Measures at Preintervention

EDU EDU+BR

Baseline

Comparison

Measure n M SD n M SD t p

Cognitive Process

ASI-R respiratory

Preintervention 27 27.48

Postintervention 27 18.26

8.36 30 26.20 10.03

7.12 30 16.43 8.46

0.52 .61

BVS



BAT time

7.26 30 21.88

6.38 30 18.18

7.57

7.10

Postintervention 22 110.59 76.90 30 103.03 58.81

BAT fear


BAT misattribute


BAT safe


Coping

BAI



R-ACQ

9.82

6.94

30

30

18.97

12.20

9.33

6.77

Preintervention 27 35.74 11.46 30 40.57 12.19


Note.

ASI-R respiratory = Anxiety Sensitivity Index-Revised respiratory subscale; BVS = Body

0.33

1.54

0.36

.74

.13

.72

Vigilance Scale; BAT time = length of Behavioral Approach Task; BAT fear = peak fear during

Behavioral Approach Task; BAT misattribute = attribution of safety to avoidance during

BREATHING RETRAINING FOR HIGH ANXIETY SENSITIVITY

Behavioral Approach Task; BAT safe = attribution of safety to benign nature of Behavioral

Approach Task; BAI = Beck Anxiety Inventory; R-ACQ = Revised-Anxiety Control

Questionnaire.

33


Table 3.

Within-Group Effect Size Estimates (d)

Measures

Coping

Pre-Post Test

EDU a

Within-Group d

EDU+BR a

BAI

R-ACQ

Cognitive Process

.74

.79

.72

.54

ASI-R respiratory

BVS

1.10

.54

.97

.49

Note. BAI = Beck Anxiety Inventory; R-ACQ = revised-Anxiety Control Questionnaire; ASI-R respiratory = Anxiety Sensitivity Index-Revised respiratory subscale; BVS = Body Vigilance

Scale. a Positive effect size estimates indicate pre to postintervention improvement. b Positive values indicate greater improvement among EDU participants.


Table 4.

Correlations (r) Between Preintervention Means and Frequency, Style, and Function of

Diaphragmatic Breathing Use.

Diaphragmatic Breathing Use Questionnaire ( n = 30)

Measure Frequency Anxiety Prescheduled Catastrophe a

Panic a

Cope a

ASI-R

BVS -

.36*

.50** ---

.31

.50**

.03

-.04

^

-.43*

.36

---

---

.55**

.46** ---

.28

.61**

BAI

R-ACQ

.27

6

-.48**

--.55**

-.32

-.15

^

.06

.35

-.33

.37*

-.45*

.48*

-.44*

Note.

ASI-R = Anxiety Sensitivity Index-Revised respiratory subscale; BVS = Body Vigilance

Scale; BAI = Beck Anxiety Inventory; R-ACQ = revised-Anxiety Control Questionnaire;

Frequency = frequency of daily use of diaphragmatic breathing; Anxiety = use of diaphragmatic breathing when anxious; Prescheduled = use of diaphragmatic breathing at prescheduled times;

Catastrophe = use of diaphragmatic breathing to avoid catastrophe; Panic = use of diaphragmatic breathing to avoid panic; Cope = use of diaphragmatic breathing to cope with anxiety. a

Due to skewed distributions on the function items of the DBQ, nonparametric correlations

(Spearman’s r ) were employed to examine the relationship between the catastrophe, panic, and cope items and preintervention measures.

* < .05, ** < .01.

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