Breathing Exercises for Panic Attacks: A 4-6 Breathing Guide

What the NHS and Cleveland Clinic say about breathing

When a panic attack starts, the NHS advice is to stay where you are, if possible, and to breathe slowly and deeply. It also suggests reminding yourself that the attack will pass, and remembering that it is not life threatening. For the longer term, it lists learning breathing exercises for stress among the things that may help ease symptoms.

Cleveland Clinic lists difficulty breathing, such as hyperventilation, among the symptoms of a panic attack, and says that hyperventilating can increase fear. It says deep breathing can reduce symptoms of panic during an attack, and describes it this way: breathe in as slowly, deeply and gently as you can through your nose, breathe out slowly through your mouth, close your eyes and focus on your breathing.

The NHS breathing exercise, step by step

The NHS describes a calming breathing technique for stress, anxiety and panic that takes just a few minutes and can be done anywhere. It says you will get the most benefit if you do it regularly, as part of your daily routine.

• You can stand, sit in a chair that supports your back, or lie on a bed or yoga mat. Make yourself as comfortable as possible and, if you can, loosen any clothes that restrict your breathing.
• If you are sitting or standing, place both feet flat on the ground, roughly hip-width apart. If you are lying down, rest your arms a little away from your sides with the palms up.
• Let your breath flow as deep down into your belly as is comfortable, without forcing it.
• Try breathing in through your nose and out through your mouth.
• Breathe in gently and regularly. Some people find it helpful to count steadily from 1 to 5. You may not be able to reach 5 at first.
• Then let the breath flow out gently, counting from 1 to 5 again if that helps.
• Repeat for at least 5 minutes.

A 4-in, 6-out version

The guided breathing circle on this site uses a 4-second breath in through the nose and a 6-second breath out through the mouth. This is our own choice of pace for the pacer. None of the sources on this page tested a 4-6 pattern on people having panic attacks, and the NHS counts from 1 to 5 in each direction instead, so treat 4-6 as one way to slow down rather than the only way.

One reason for choosing it is simple arithmetic: a 4-second inhale plus a 6-second exhale is a 10-second breath, which is six breaths per minute. In a review of heart rate variability biofeedback, Lehrer and Gevirtz note that higher heart rate variability is reached with slower breathing, and that most studies find the maximum effects at about six breaths per minute. They also note that longer exhalations and slower breathing may increase respiratory sinus arrhythmia, the rise and fall of heart rate with breathing. That review is about heart rate variability training, not about panic attacks, so it does not show that 4-6 breathing stops a panic attack.

What one study of breathing practices found

Balban and colleagues ran a randomized, controlled study in which people did one of three different daily 5-minute breathing exercises, or 5 minutes of mindfulness meditation, for a month. The breathing exercises were cyclic sighing, which emphasizes prolonged exhalations, box breathing, and cyclic hyperventilation with retention.

The authors report that breathwork, especially the exhale-focused cyclic sighing, produced greater improvement in mood and a greater reduction in respiratory rate than mindfulness meditation. They describe daily 5-minute cyclic sighing as having promise as a stress management exercise.

Keep the limits in mind. The study measured mood, anxiety and physical arousal, not panic attacks. Most of the participants were recruited from an undergraduate psychology class at Stanford University. It did not test a 4-6 pattern either. It is evidence that short daily breathing practice can be worth trying, not proof that a particular method works best in a panic attack.

Practise when you are calm

The NHS says you get the most benefit from its breathing exercise when you do it regularly, as part of your daily routine. That suggests trying it on an ordinary day rather than waiting for the next attack, so the steps feel familiar.

If you have a panic attack, the guided reset on this site shows a circle that grows as you breathe in and shrinks as you breathe out, so you can follow the rhythm instead of counting in your head. You do not need the pacer. The NHS version, counting from 1 to 5 in each direction, is a simple alternative.

• Pick a regular moment, such as after waking or before bed, and do the NHS exercise for at least 5 minutes.
• If you cannot reach the full count at first, that is fine. The NHS says you may not be able to reach 5 at first.
• Keep your breathing gentle. The NHS says to let your breath flow without forcing it.
• During an attack, remind yourself that it will pass. Cleveland Clinic says knowing you are having a panic attack, and not a dangerous health episode, can help manage the fear.

When breathlessness may not be a panic attack

Shortness of breath and chest pain are on the NHS list of panic attack symptoms, but the NHS also says that most of these symptoms can be symptoms of other conditions or problems, so you may not always be experiencing a panic attack.

Cleveland Clinic says that if you have chest pain, trouble breathing or lose consciousness, you should seek emergency medical care. Do not rely on a breathing exercise in that situation. It also says to call a healthcare provider if panic attack symptoms last longer than 15 minutes.

Getting help for panic

Breathing exercises are self-help. They are not a treatment and they cannot tell you whether you have a condition. The NHS says to see a GP if you have been experiencing symptoms of panic disorder, and that panic disorder is treatable, so it is best to get medical help as soon as you can. A GP or pharmacist can explain the options that exist.