Breathwork refers to a wide range of practices that involve controlling one’s breathing to generate beneficial effects.1 In general terms, breathwork is slow, rhythmic breathing, often performed in conjunction with guided or solo meditation.2 The origins of breathwork are diverse — forms of breathwork have been practiced since ancient times by people of Indigenous cultures, as well as practitioners of Zen Buddhism and yoga.1-3
Although researchers of Western psychology have explored the effects of regulated breathing since the 1940s, breathwork as a practice has gained greater scientific attention in the past 3 decades.1 In that time, breathwork has been found to have powerful effects on mental health, stress, heart rate, respiratory dynamics, and blood pressure.4-6 Considering that breathwork is free to practice and easy to learn, incorporating the practice into care plans represents a potential boon for people living with many health conditions.
Several methods for practicing breathwork focus on the concept of conscious breathing, active awareness, and regulation of breathing patterns.1 Most forms of breathwork rely on diaphragmatic breathing, also known as abdominal breathing. Types of breathwork are defined by the duration of inhalation and exhalation, as well as interbreath rest intervals. Circular breathing involves taking long, slow breaths that completely fill and empty the lungs, with no pauses between breaths.1 In contrast, conscious connected breathing includes a period of rest between long inhalations and exhalations.1 In cyclic sighing, exhalations are sustained longer than inhalations.7
A technique called box breathing is similar to conscious connected breathing, except that each inhalation, rest, and exhalation period are of equal duration. Box breathing — also called “tactical breathing” — is used by US military personnel for stress management. 7 Most forms of breathwork involve slow, rhythmic breathing patterns, but hyperventilation with retention involves longer inhalation periods than exhalation periods. 7 Holotropic breathwork is another practice consisting of prolonged hyperventilation — often paired with a mindfulness activity — that induces an altered state of consciousness.8
What Are the Benefits of Breathwork?
A key feature of slow breathing techniques is that they cause increased activation of the parasympathetic nervous system through modulation of vagal activity.2 The rise in parasympathetic activation induced by slow breathing is associated with states of calmness and reduced stress.9 Numerous studies have demonstrated significant reductions in stress reported by participants engaging in breathing exercises.4
In one study examining the effects of breathwork on stress and mental health, 40 participants were randomly assigned to either a breathing intervention group or a control group.10 Participants in the breathing intervention group experienced a significant decrease in negative affect compared with those in the control group. Participants in the breathing intervention group also experienced lower levels of salivary cortisol compared with participants in the control group, for whom no changes in cortisol level were documented compared with baseline levels. In addition, participants in the breathwork group demonstrated improvements over baseline in sustained attention that were not observed in the control group.
Authors of another study, which was a systematic review, found that breathwork can be beneficial to patients with diagnosed anxiety disorders, although the practice is not recommended as a replacement for standard care; rather, it can be a helpful adjunct therapy.11
While different breathwork techniques have been demonstrated to contribute to stress reduction, the relative benefits between techniques are less clear. For example, investigators recruited participants to a 12-week breath training study in which they were divided into 2 groups, one with a greater inhalation time and one with a longer duration of exhalation.12 Although both groups experienced significant reductions in stress, there were no statistically significant differences between the groups.
Authors of a randomized controlled trial that included 114 participants found that various forms of breathwork, including cyclic sighing, box breathing, and cyclic hyperventilation with retention, all increased positive affect.7 Pooled breathwork groups, especially cyclic sighing, were associated with greater increases in positive affect than mindfulness meditation. Furthermore, participants in the cyclic sighing group experienced greater reductions in respiratory rate than those in the meditation group. Both meditation and breathwork resulted in significant improvements in state anxiety, but no differences were observed between the groups.
Limited evidence suggests that slow breathing can increase heart rate variability (HRV) and induce a higher low frequency/high frequency ratio.2 Interestingly, these effects seem to be dependent on the breathing rate. Slow breathing at a rate of 9 to 10 breaths per minute triggers increases in high frequency power, while slower rates of approximately 6 breaths per minute tend to increase low frequency power.13,14 However, the investigators caution that this evidence is not conclusive and findings of the study could be limited by false-positive results.2
Other research has found that breathwork, alongside HRV biofeedback, can synergistically augment HRV and low frequency power.15 In addition, no changes in resting heart rate or HRV were observed either using any breathwork method or practicing mindfulness meditation. Another study found that heart rate, blood pressure, and body mass, as well as perceived stress, were reduced after 12 weeks of slow breathing training.5 Pranayama yoga has also been demonstrated to reduce resting heart rate after only 1 week of breathing training.16
Numerous trials have documented breathwork to have improved symptoms of depression among participants with major depressive disorder. Authors of a study examining the effects of 8 weeks of Sudarshan Kriya yoga on patients with antidepressant-resistant major depressive disorder found that breathing-based meditation in conjunction with stable antidepressant use significantly improved depressive symptoms on the 17-Item Hamilton Depression Rating Scale and the Beck Depression Inventory compared with control.17 In addition, participants in the yoga group had greater improvements in Beck Anxiety Inventory total scores than participants in the control group.
The antidepressant mechanisms of breathing exercises are unclear, but preliminary evidence suggests that changes in gamma-aminobutyric acid (GABA) signaling may play a role.18 Authors of a study examining the effects of a 12-week Iyengar yoga and breathwork intervention reported significant reductions in GABA levels and improvement in scores on the Beck Depression Inventory II. However, these increases were not sustained beyond 1 week after the breathwork and yoga session, suggesting that the intervention must be practiced regularly to maintain beneficial effects.
A small pilot study with 20 participants examined the effects of holotropic breathwork on self-awareness, as measured by the Temperament and Character Inventory Revised (TCI-R) instrument.8 Average temperament scores on the TCI-R are associated with well-regulated automatic emotional responses to stimuli, while high character scores are representative of high self-awareness. The investigators reported that temperament scores decreased toward beneficial levels after participants engaged in 4 holotropic breathing sessions over a 12-week period. Furthermore, scores on the Symptom Checklist (SCL-90-R), which measures a range of different mental health symptoms, showed a decrease from baseline in symptoms of hostility. This finding is critical, as hostility and anger are associated with an increased risk for cardiovascular events.19 However, the SCL-90-R results also demonstrated an increase in symptoms of paranoid ideation.8
Another psychosocial measure found that holotropic breathing reduced self-reported interpersonal problems. It should be noted that these results are preliminary and based, in part, on internally validated scales.
Breathwork also appears to have beneficial effects on glycemic control in people living with type 2 diabetes. Authors of a study that recruited 123 participants with type 2 diabetes found that 3 months of diaphragmatic breathing combined with standard treatment reduced oxidative stress, resting and postprandial blood glucose levels, glycated hemoglobin (HbA1c), and body mass index compared with standard treatment alone.20 However, no effects were observed on blood pressure or waist circumference. Authors of a similar trial investigating the effects of 6 months of diaphragmatic breathing reported that resting, postprandial, and random blood glucose levels and HbA1c were lower at follow-up evaluation compared with standard treatment.21 In addition, participants in the breathwork group reported lower levels of anxiety and depression compared with participants in the control group.
In addition, research has demonstrated beneficial effects of breathwork on gastroesophageal reflux disease (GERD). Authors of a study that recruited 33 participants found that diaphragmatic breathing reduced the number of postprandial reflux events and esophageal acid exposure in both participants with GERD and subjects without GERD.22 Similarly, diaphragmatic breathing training improved quality-of-life scores and reduced the use of proton pump inhibitors (PPIs) in participants with nonerosive GERD or healed esophagitis.23 This breathing technique also reduced belching and other symptoms in patients with GERD refractory to PPI therapy.24
A key benefit of breathwork is that it is free. Most patients learn the techniques quickly and easily, and can practice them on their own time outside the clinic with minimal instruction.25 Moreover, the time needed to perform most breathwork methods is short, requiring only minutes to complete. Sessions lasting as few as 5 minutes have shown demonstrable improvements in mood and stress.7 In addition, breathwork methods can be added to most other therapeutic regimens as an adjunctive therapy with little risk of adverse effects. Patients — even those with busy schedules — can be encouraged to incorporate breathwork into their daily routines.26 In doing so, patients can take an active role in their own well-being with little difficulty and no expense, while achieving numerous benefits to their mental and physical health.
