(The following conference was held at the Royal Society of Medicine (RSM) on 6 October 2008, organised by the hypnosis section of the RSM, attended by 60 people. The chairman was the president of the section, Dr Martin Wall)
Dr David Beales, physician and GP in Bristol, has worked for 33 years in the NHS practising whole person medicine, hypnosis and Mindfulness Based Cognitive Therapy (MBCT). He uses a diagnostic tool called a capnograph and has developed a treatment which he calls ‘breathing awareness’. This teaches patients a self-help way to integrate their emotions into a more balanced life. He gets good results, making his work a pleasure, which he radiated. He spoke on ‘breathing and behavioural change, from CBT to hypnotherapy’.
He said that two out of three (70 per cent of patients presenting to GPs in primary care and 56 per cent of those in secondary care) have symptoms (such as irritable bowel syndrome, fibromyalgia, panic attacks, chronic pain, loss of cognitive ability) which are medically unexplained (non-pathological) because their test results are normal.
He believes that they can be explained by dysfunctional breathing (hyperventilation). These conditions frustrate patients and staff, and cost the NHS around £9 bn per annum, much of which could be saved if the following aetiology was known and acted on in primary care, as he has been doing.
He quoted Carl Jung: ‘each breath has an emotional signature’. He described breathing as the ‘leader of the orchestra’ from which the rest of the organs of the body take their cue. Good breathing creates good body chemistry, and bad breathing creates bad body chemistry and disease. This often becomes a vicious spiral: the worse we breathe, the worse we get, the worse we breathe, and so on.
Good breathing goes deep into the diaphragm, and is regular and appropriate for the body’s demand for oxygen. Hyperventilation is inappropriate. At rest, the breathing rate should be about 6 breaths per minute, but for the average man in the street this is about 14. Breathing is very sensitive to stress, which is the root cause of most dis-eases.
As a survival mechanism, our emotional brain is programmed to react to perceived threats to our security, i.e. stress. The sympathetic nervous system produces the adrenaline reaction of ‘fight or flight’. This causes fast, shallow breathing through the mouth into the upper chest to get ready for action. If it becomes habitual (as it does in many people) it produces chronic hyperventilation.
This in turn produces hypocapnia, which is reduced carbon dioxide levels in the blood. In severe cases this might be around 25 mm of mercury, whereas a normal level is around 40 mm. This leads to hypoxia (lack of oxygen in the cells) as the oxygen in the haemoglobin in the blood cannot be exchanged to the cells (the Bohr effect).
This in turn produces fatigue and alkolosis, which is raised alkalinity to a pH of 7.45 (a normal level is 7.40). This interferes with many bodily functions including calcium deposition, producing osteoporosis in the bones, in an estimated 1:3 elderly women and 1:8 elderly men.
Hyperventilation (HV) can be diagnosed with a questionnaire, such as the Nijmegen HV one, listing 16 symptoms, scoring 1 for rarely, 2 for sometimes, 3 for often and 4 for very often. A score of over 23 is considered to be HV. He quoted a tool for patients to take themselves through a healing cycle, the mnemonic AWARE, as follows:
A Visualise an Activating emotional event.
W Watch yourself monitor your reaction
A Arousal level from 1 to 10.
R Respiration rate – slow your out breath with pursed lips or a throaty (ujjayi)
E Enjoy bringing in a remembered state of pleasure with the in breath.
Dr Beales demonstrated a capnograph machine, which measures carbon dioxide levels. A volunteer was fitted with a nasal device, and her levels appeared on the screen. He showed how she could control her own carbon dioxide levels by controlling her breathing. He teaches patients to do this, usually in 1–3 sessions, with sometimes spectacular results. He quoted a man who was cured in one session, and a woman who had been in and out of mental hospital for 2 years, who was cured in 3 sessions over 6 weeks.
Ranju Roy is a yoga teacher, and the former executive director of the Association for Yoga Studies. He also worked as an art therapist and family therapist in the NHS. During his presentation, entitled ‘Breath, Body and Mind – The Animating Principle of Prana’, he explained how the breath affects us emotionally and physically.
In both the yoga tradition and the ancient Indian medical system (ayurveda), disease is construed as a blockage of the smooth flow of prana (life force, akin to chi in the Chinese tradition). Symptoms are ‘the mind being troubled’ (dis-ease) with emotional tightness, negative thinking, trembling of the body and disturbed breathing.
Prana is the life force (vitality) and is closely related to (but not the same as) the breath, as it is thought to come into the body with it. He quoted ancient texts: ‘a healthy mind has an easy breath’, and ‘when the breath wanders, the mind is unsteady, but when the breath is stilled, the mind is stilled, and the yogi obtains the power of stillness (health)’.
One of the aims of yoga is improvement of health by stilling the mind/body system from the hyper-aroused state. This enables us to see more clearly. The inhale stimulates us and prepares us for action (sympathetic nervous system) and the exhale calms us down (parasympathetic nervous system). He emphasised the importance of long, smooth exhalations ‘as a lamp in a windless place doesn’t flicker’ . . .
He taught ujjayi breathing in which the glottis is partially closed (‘caressing’ the throat) so that a slight hiss can be heard. This enables us to listen to the breath, like the mindfulness practice of watching the breath, and its practice is vital for good health.
He quoted Eckhart Tolle who says: ‘Being aware of the breath forces you into the present moment – the key to all inner transformation. Whenever you are conscious of your breath you are absolutely present. You may also notice that you cannot think and be aware of your breathing. Conscious breathing stops your mind. And if you look more closely you will find that those two things – coming fully into the present and ceasing thinking – are actually one and the same thing – the arising of space consciousness’ (A New Earth, p. 246).
Ranju then led various yoga practices and visualisations to help us become aware of hunched shoulders and how to relax them, to open our constricted chest and also have a feeling of opening the central axis of our spine to allow prana to flow. This process was assisted by slow (almost tai chi like) movements of our arms and trunk.
These made me feel more spacious inside. He quoted a Zen saying: ‘If you have an angry cow, put it in a big field.’ Breathing can be the vehicle for spaciousness, to give ourselves and our emotions space. He agreed with a questioner that ‘Inspiration is like taking in spirit’, and that ‘it’s as if we’re being breathed’.
Elizabeth Holloway is a research physiotherapist and Ph.D. student at University College London. She has specialised in treating hyperventilation and asthma for over 30 years in the NHS and private practice. She spoke on ‘Breathing and relaxation, integrated training (the Papworth method); effective and practical treatment for a wide spectrum of stress-related disorders.’
The importance of good breathing has become neglected in modern conventional healthcare, but this was not so 40 years ago. She defined normal breathing as ‘appropriate to current metabolic needs’. Abnormal breathing may be obvious (acute hyperventilation) but it may also be subtle, nevertheless causing the chronic ill health described above by Dr Beales.
The symptoms of overbreathing are suffered by many people. For example, asthma is diagnosed in over 5 million people in the UK (8 per cent or 1 in 12 of the population, and over 300 million people worldwide). She believes that relevant factors in asthma and many other diseases are inappropriate breathing habits.
To correct these, the Papworth method was developed in the 1960s in the Department of Respiratory Medicine, Papworth Hospital, Cambridge. Severely affected patients were admitted for 3 weeks to remove them from the stress of their normal life. They received two 20-minute treatments per weekday, totalling 30 in all. Trigger factors were identified, such as tight jeans or corsets, and habitual stress.
Together with relaxation, breathing from the diaphragm was taught progressively –first, resting (at a rate of 6 breaths a minute), progressing to standing and speaking, and incorporating visualisation of a pleasant scene. The patients were encouraged to spend their spare time practising these techniques to prepare them for return to everyday life and stressful situations.
We were invited to try the breathhold measurement of how many seconds we could hold our breath after the exhale while resting. (I did 17 seconds.) Less than 20 is considered overbreathing, but some were less than 10.
Elizabeth then demonstrated the Papworth treatment on a volunteer lying on a couch with a pillow under her knees to relax her diaphragm. She used her hands to encourage a reduction in the patient’s upper chest movement and to enable gentle diaphragmatic/abdominal breathing.
She created an atmosphere of calm and tranquillity, and took the patient’s awareness systematically through her body, tensing and relaxing the muscles in turn, twice suddenly and the third time slowly. She led her through a guided visualisation, talking to her body, and telling it to let go of tensions, and reminding her to breathe gently into her abdomen.
My impressions were as follows. The patient went into an altered state of consciousness in which her breathing became normal of its own accord. The Papworth method’s repeated teaching of this for 30 sessions over 3 weeks, together with ample spare time between them for patients to practise on their own and with fellow patients could break the habit of hyperventilation, thereby effecting a cure. Many complementary and alternative treatments now use similar relaxation and visualisation techniques to equally good effect but are not yet integrated into the NHS.
Conclusion: self-help breathing treatments should be commissioned in the NHS.
Most healthcare staff have been taught to believe that breathing is unimportant, and so neglect it in both their patients and themselves. On the contrary, breathing is actually the most important thing in life, as we breathe in both oxygen and vitality, and die without them. Two out of three patients breathe dysfunctionally, blocking their vitality and contributing to (if not causing) their disease.
Breathing is like the conductor of our orchestra (our physiology via our nervous systems), which in turn depends on our emotions. When we are stressed (as most of us frequently are) our breathing rate is fast and chaotic. The messages sent from our thoracic muscles to our brain cause the adrenaline reaction of fight or flight. If this becomes habitual, it may set up a vicious spiral of hyperventilation, which can become chronic ill health, with or without abnormal test results (pathology).
Post Darzi, the NHS has the objective of improving health, as well as alleviating sickness. To do so, it should recognise the facts about breathing described in this conference and commission treatments that teach patients to control their emotions with self-help breathing techniques such as MBCT, yoga and relaxation, which have an evidence base stronger than drugs.