Erik Peper, Lauren Mason and Cindy Huey
After having constant abdominal pain, severe cramps, and losing 15 pounds from IBS, I found myself in the hospital bed where all the doctors could offer me was morphine to reduce the pain. I searched on my smart phone for other options. I saw that abdominal breathing could help. I put my hands on my stomach and tried to expand it while I inhaled. All that happened was that my chest expanded and my stomach did not move. I practiced and practiced and finally, I could breathe lower. Within a few hours, my pain was reduced. I continued breathing this way many times. Now, two years later, I no longer have IBS and have regained 20 pounds.
– 21-year old woman who previously had severe IBS
Irritable bowel syndrome(IBS) affects between 7% to 21% of the general population and is a chronic condition. The symptoms usually include abdominal cramping, discomfort or pain, bloating, loose or frequent stools and constipation and can significantly reduce the quality of life (Chey et al, 2015). A precursor of IBS in children is called recurrent abdominal pain (RAP) which affects between 0.3 to 19% of school children (Chitkara et al, 2005). Both IBS and RAP appear to be functional illnesses, as no organic causes have been identified to explain the symptoms. In the USA, this results in more than 3.1 physician visits and 5.9 million prescriptions written annually. The total direct and indirect cost of these services exceeds $20 billion (Chey et al, 2015). Multiple factors may contribute to IBS, such as genetics, food allergies, previous treatment with antibiotics, severity of infection, psychological status and stress. More recently, changes in the intestinal and colonic microbiome resulting in small intestine bacterial overgrowth are suggested as another risk factor (Dupont, 2014).
Generally, standard medical treatments (reassurance, dietary manipulation and of pharmacological therapy) are often ineffective in reducing abdominal IBS and other abdominal symptoms (Chey et al, 2015), while complementary and alternative approaches such as relaxation and cognitive therapy are more effective than traditional medical treatment (Vlieger et, 2008). More recently, heart rate variability training to enhance sympathetic/ parasympathetic balance appears to be a successful strategy to treat functional abdominal pain (FAB) in children (Sowder et al, 2010). Sympathetic/parasympathetic balance can be enhanced by increasing heart rate variability (HRV), which occurs when a person breathes at their resonant frequency which is usually between 5-7 breaths per minute. For most people, it means breathing much slower, as slow abdominal breathing appears to be a self-control strategy to reduce symptoms of IBS, RAP and FAP.
This article describes how a young woman healed herself from IBS with slow abdominal breathing without any therapeutic coaching, reviews how slower diaphragmatic breathing (abdominal breathing) may reduce symptoms of IBS, explores the possibility that breathing is more than increasing sympathetic/parasympathetic balance, and suggests some self-care strategies to reduce the symptoms of IBS.
Healing IBS-a case report
After being diagnosed with Irritable Bowel Syndrome her Junior year of high school, doctors told Cindy her condition was incurable and could only be managed at best, although she would have it throughout her entire life. With adverse symptoms including excessive weight loss and depression, Cindy underwent monthly hospital visits and countless tests, all which resulted in doctors informing her that her physical and psychological symptoms were due to her untreatable condition known as IBS, of which no one had ever been cured. When doctors offered her what they believed to be the best option: morphine, something Cindy describes now as a “band-aid,” she was left feeling discouraged. Hopeless and alone in her hospital bed, she decided to take matters into her own hands and began to pursue other options. From her cell phone, Cindy discovered something called “diaphragmatic breathing,” a technique which involved breathing through the stomach. This strategy could help to bring warmth to the abdominal region by increasing blood flow throughout abdomen, thereby relieving discomfort of the bowel. Although suspicious of the scientific support behind this method, previous attempts at traditional western treatment had provided no benefit to recovery; therefore, she found no harm in trying. Lying back flat against the hospital bed, she relaxed her body completely, and began to breathe. Immediately, Cindy became aware that she took her breath in her chest, rather than her stomach. Pushing out all of her air, she tried again, this time gasping with inhalation. Delighted, she watched as air flooded into her stomach, causing it to rise beneath her hands, while her chest remained still. Over time, Cindy began to develop more awareness and control over her newfound strategy. While practicing, she could feel her stomach and abdomen becoming warmer. Cindy shares that for the first time in years, she felt relief from pain, causing her to cry from happiness. Later that day, she was released from the hospital, after denying any more pain medication from doctors.
Cindy continues to practice her diaphragmatic breathing as much as she can, anywhere at all, at the sign of pain or discomfort, as well as preventatively prior to what she anticipates will be a stressful situation. Since beginning her practice, Cindy says that her IBS is pretty much non-existent now. She no longer feels depressed about her situation due to her developed ability to manage her condition. Overall, she is much happier. Moreover, since this time two years ago, Cindy has gained approximately 20 pounds, which she attributes to eating a lot more. In regard to her success, she believes it was her drive, motivation, and willingness to dedicate herself fully to the breathing practice which allowed for her to develop skills and prosper. Although it was not natural for her to breathe in her stomach at first, a trait which she says she often recognizes in others, Cindy explains it was due to necessity which caused her to shift her previously-ingrained way of breathing. Upon publicly sharing her story with others for the first time, Cindy reflects on her past, revealing that she experienced shame for a long time as she felt that she had a weird condition, related to abnormal functions, which no one ever talks about. On the experience of speaking out, she affirms that it was very empowering, and hopes to encourage others coping with a situation similar to hers that there is in fact hope for the future. Cindy continues to feel empowered, confident, and happy after taking control of her own body, and acknowledges that her condition is a part of her, something of which she is proud.
Watch the in-depth interview with Cindy Huey in which she describes her experience of discovering diaphragmatic breathing and how she used this to heal herself of IBS
Video 1. Interview with Cindy Huey describing how she healed herself from IBS.
“Why should the body digest food or repair itself, when it will be someone else’s lunch” (paraphrased from Sapolsky (2004), Why zebras do not get ulcers).
From an evolutionary perspective, we were prey and needed to be on guard (vigilant) to the presence of predators. In the long forgotten past, the predators were tigers, snakes, and the carnivore for whom we were food as well as other people. Today, the same physiological response pathways are still operating, except that the pathways are now more likely to be activated by time urgency, work and family conflict, negative mental rehearsal and self-judgment. This is reflected in the common colloquial phrases: “It makes me sick to my stomach,” “I have no stomach for it,” “He is gutless,” “It makes me queasy,” “Butterflies in my stomach,” “Don’t get your bowels in uproar,” “Gut feelings’, or “Scared shitless.”
Whether conscious or unconscious, when threatened, our body reacts with a fight/flight/freeze response in which the blood flow is diverted from the abdomen to deep muscles used for propulsion. This results in peristalsis being reduced. At the same time the abdomen tends to brace to protect it from injury. In almost all cases, the breathing patterns shift to thoracic breathing with limited abdominal movement. As the breathing pattern is predominantly in the chest, the person increases the risk of hyperventilation because the body is ready to run or fight.
In our clinical observations, people with IBS, small intestine bacterial overgrowth (SIBO), abdominal discomfort, anxiety and panic, and abdominal pain tend to breathe more in their chest, and when asked to take breathe, they tend to inhale in their upper chest with little or no abdominal displacement. Almost anyone who experiences abdominal pain tends to hold the abdomen rigid as if the splinting could reduce the pain. A similar phenomenon is observed with female students experiencing menstrual cramps. They tend to curl up to protect themselves and breathe shallowly in their chest instead of slowly in their abdomen, a body pattern which triggers a defense reaction and inhibits regeneration. If instead they breathe slowly and uncurl they report a significant decrease in discomfort (Gibney & Peper, 2003).
Paradoxically, this protective stance of bracing the abdomen and breathing shallowly in the chest increases breathing rate and reduces heart rate variability. It reduces and inhibits blood and lymph flow through the abdomen as the defensive posture evokes the physiology of fight/flight/freeze. The reduction in venous blood and lymph flow occurs because the ongoing compression and expansion in the abdomen is inhibited by the thoracic breathing and, moreover, the inhibition of diaphragmatic breathing. It also inhibits peristalsis and digestion. No wonder so many of the people with IBS report that they are reactive to some foods. If the GI track has reduced blood flow and reduced peristalsis, it may be less able to digest foods which would affect the bacteria in the small intestine and colon. We wonder if a risk factor that contributes to SIBO is chronic lack of abdominal movement and bracing.
Slow diaphragmatic abdominal breathing to establish health
“Digestion and regeneration occurs when the person feels safe.”
Effortless, slow diaphragmatic breathing occurs when the diaphragm descends and pushes the abdominal content downward during inhalation, which causes the abdomen to become bigger. As the abdomen expands, the pelvic floor relaxes and descends. During exhalation, the pelvic floor muscles tighten slightly, lifting the pelvic floor and the transverse and oblique abdominal muscles contract and push the abdominal content upward against the diaphragm, allowing the diaphragm to relax and go upward, pushing the air out. The following video, 3D view of the diaphragm, from www.3D-Yoga.com by illustrates the movement of the diaphragm.
This expansion and constriction of the abdomen occurs most easily if the person is extended, whether sitting or standing erect or lying down, and the waist is not constricted. If the arches forward in a protected pattern and the spine is flexed in a c shape, it would compress the abdomen; instead, the body is long and the abdomen can move and expand during inhalation as the diaphragm descends (see figure 1). If the person holds their abdomen tight or it is constricted by clothing or a belt, it cannot expand during inhalation. Abdominal breathing occurs more easily when the person feels safe and expanded versus unsafe or fearful and collapsed or constricted.
Figure 1. Erect versus collapsed posture note that there is less space for the abdomen to expand in the protective collapsed position. Reproduced by permission from: Clinical Somatics (http://www.clinicalsomatics.ie/
When a person breathes slower and lower it encourages blood and lymph flow through the abdomen. As the person continues to practice slower, lower breathing, it reduces the arousal and vigilance. This is the opposite state of the flight, fight, freeze response so that blood flow is increased in abdomen, and peristalsis re-occurs. When the person practices slow exhalation and breathing and they slightly tighten the oblique and transverse abdominal muscles as well as the pelvic floor and allow these muscles to relax during inhalation. When they breathe in this pattern effortless they, they often will experience an increase in abdominal warmth and an initiation of abdominal sounds (stomach rumble or borborygmus) which indicates that peristalsis has begun to move food through the intestines (Peper et al., 2016). For a detailed description see https://peperperspective.com/2016/04/26/allow-natural-breathing-with-abdominal-muscle-biofeedback-1-2/
What can you do to reduce IBS
There are many factors that cause and effect IBS, some of which we have control over and some which are our out of our control, such as genetics. The purpose of proposed suggestions is to focus on those things over which you have control and reduce risk factors that negatively affect the gastrointestinal track. Generally, begin by integrating self-healing strategies that promote health which have no negative side effects before agreeing to do more aggressive pharmaceutical or even surgical interventions which could have negative side effects. Along the way, work collaboratively with your health care provider. Experiment with the following:
- Avoid food and drinks that may irritate the gastrointestinal tract. These include coffee, hot spices, dairy products, wheat and many others. If you are not sure whether you are reacting to a food or drink, keep a detailed log of what you eat and drink and how you feel. Do self-experimentation by eating or drinking the specific food by itself as the first food in the morning. Then observe how you feel in the next two hours. If possible, eat only organic foods that have not been contaminated by herbicides and pesticides (see: https://peperperspective.com/2015/01/11/are-herbicides-a-cause-for-allergies-immune-incompetence-and-adhd/).
- Identify and resolve stressors, conflicts and problems that negatively affect you and drain your energy. Keep a log to identify situations that drain or increase your subjective energy. Then do problem solving to reduce those situations that drain your energy and increase those situations that increase your energy. For a detailed description of the practice see https://peperperspective.com/2012/12/09/increase-energy-gains-decrease-energy-drains/
Often the most challenging situations that we cannot stomach are those where we feel defeated, helpless, hopeless and powerless or situations where we feel threatened– we do not feel safe. Reach out to other both friends and social services to explore how these situations can be resolved. In some cases, there is nothing that can be done except to accept what is and go on.
- Feel safe. As long as we feel unsafe, we have to be vigilant and are stressed which affects the GI track. Explore the following:
- What does safety mean for you?
- What causes you to feel unsafe from the past or the present?
- What do you need to feel safe?
- Who can offer support that you feel safe?
Reflect on these questions and then explore and implement ways by which you can create feeling more safe.
- Take breaks to regenerate. During the day, at work and at home, monitor yourself. Are you pushing yourself to complete tasks. In a 24/7 world with many ongoing responsibilities, we are unknowingly vigilant and do not allow ourselves to rest and relax to regenerate. Do not wait till you feel tired or exhausted. Stop earlier and take a short break. The break can be a short walk, a cup of tea or soup, or looking outside at a tree. During this break, think about positive events that have happened or people who love you and for whom you feel love. When you smile and think of someone who loves you, such as a grandparent, you may relax and for that moment as you feel safe which allows regeneration to begin.
- Observe how you inhale. Take a deep breath. If you feel you are moving upward and becoming a little bit taller, your breathing is wrong. Put one hand on your lower abdomen and the other on your chest and take a deep breath. If you observe your chest lifted upward and stomach did not expand, your breathing is wrong. You are not breathing diaphragmatically. Watch the following video, The correct way to breathe in, on how to observe your breathing and how to breathe diaphragmatically.
- Learn diaphragmatic breathing. Take time to practice diaphragmatic breathing. Practice while lying down and sitting or standing. Let the breathing rate slow down to about six breaths per minute. Exhale to the count of four and then let it trail off for two more counts, and inhale to the count of three and let it trail for another count. Practice this sitting and lying down (for more details on breathing see: https://peperperspective.com/2014/09/11/a-breath-of-fresh-air-improve-health-with-breathing/.
- Sitting position. Exhale by feeling your abdomen coming inward slightly for the count of four and trailing off for the count of two, then allow the lower ribs to widen, abdomen expand–the whole a trunk expands–as you inhale while the shoulders stay relaxed for a count of three. Allow it to trail off for one more count before you again begin to exhale. Be gentle, do not rush or force yourself. Practice this slower breathing for five minutes. Focus more on the exhalation and allowing the air to just flow in. Give yourself time during the transition between inhalation and exhalation.
- Lying down position. While lying on your back, place a two to five-pound weight such as a bag of rice on your stomach as shown in Figure 2.
Figure 2. Lying down and practicing breathing with two to five-pound weight on stomach (reproduced by permission from Gorter and Peper, 2011.
As you inhale push the weight upward and also feel your lower ribs widen. Then allow exhalation to occur by the weight pushing the abdominal content down which pushes the diaphragm upward. This causing the breath to flow out. As you exhale, imagine the air flowing out through your legs as if there were straws inside your legs. When your attention wanders, smile and bring it back to imagining the air flowing down your legs during exhalation. Practice this for twenty minutes. Many people report that during the practice the gurgling in their abdomen occurs which is a sign that peristalsis and healing is returning.
- Observe and change your breathing during the day. Observe your breathing pattern during the day. Each time you hold your breath, gasp or breathe in your chest, interrupt the pattern and substitute slow diaphragmatic breathing for the next five breaths. Do this the whole day long. Many people observe that when they think of stressor or are worried, they hold their breath or shallow breathe in the chest. If this occurs, acknowledge the worry and focus on changing your breathing. This does not mean that you dismiss the concern, instead for this moment you focus on breathing and then explore ways to solve the problem.
If you observed that under specific circumstance you held your breath or breathed shallowly in your chest, then whenever you anticipate that the same event will occur again, begin to breathe diaphragmatically. To do this consistently is very challenging and most people report that initially they only seem to breathe incorrectly. It takes practice, practice and practice—mindful practice– to change. Yet those who continue to practice often report a decrease in symptoms and feel more energy and improved quality of life.
Changing habitual health behaviors such as diet and breathing can be remarkably challenging; however, it is possible. Give yourself enough time, and practice it many times until it becomes automatic. It is no different from learning to play a musical instrument or mastering a sport. Initially, it feels impossible, and with lot of practice it becomes more and more automatic. We continue to be impressed that healing is possible. Among our students at San Francisco State University, who practice their self-healing skills for five weeks, approximately 80% report a significant improvement in their health (Peper et al., 2014).
* This blog was adapted and expanded from: Peper, E., Mason, L., & Huey, C. (2017). Healing irritable bowel syndrome with diaphragmatic breathing. Biofeedback. 45(4), 83-87. DOI: 10.5298/1081-5937-45.4.04 https://biofeedbackhealth.files.wordpress.com/2018/02/a-healing-ibs-published.pdf
Chey, W. D., Kurlander, J., & Eswaran, S. (2015). Irritable bowel syndrome: a clinical review. Jama, 313(9), 949-958.
Chitkara, D. K., Rawat, D. J., & Talley, N. J. (2005). The epidemiology of childhood recurrent abdominal pain in Western countries: a systematic review. American journal of Gastroenterology, 100(8), 1868-1875.
Dupont, H. L. (2014). Review article: evidence for the role of gut microbiota in irritable bowel syndrome and its potential influence on therapeutic targets. Alimentary pharmacology & therapeutics, 39(10), 1033-1042.
Gibney, H.K. & Peper, E. (2003). Taking control: Strategies to reduce hot flashes and premenstrual mood swings. Biofeedback, 31(3), 20-24.
Gorter, R. & Peper, E. (2011). Fighting Cancer-A NonToxic Approach to Treatment. Berkeley: North Atlantic.
Peper, E., Booiman, A., Lin, I-M, Harvey, R., & Mitose, J. (2016). Abdominal SEMG Feedback for Diaphragmatic Breathing: A Methodological Note. Biofeedback. 44(1), 42-49.
Peper, E., Lin, I-M, Harvey, R., Gilbert, M., Gubbala, P., Ratkovich, A., & Fletcher, F. (2014). Transforming chained behaviors: Case studies of overcoming smoking, eczema and hair pulling (trichotillomania). Biofeedback, 42(4), 154-160.
Sapolsky, R. (2004). Why Zebras Don’t Get Ulcers. New York: Owl Books
Sowder, E., Gevirtz, R., Shapiro, W., & Ebert, C. (2010). Restoration of vagal tone: a possible mechanism for functional abdominal pain. Applied psychophysiology and biofeedback, 35(3), 199-206.
Vlieger, A. M., Blink, M., Tromp, E., & Benninga, M. A. (2008). Use of complementary and alternative medicine by pediatric patients with functional and organic gastrointestinal diseases: results from a multicenter survey. Pediatrics, 122(2), e446-e451.
“After two and a half years of trying, ups and downs, and a long period of thinking it will never happen, it did happen. I followed your advice by only applying pressure with the cones while inhaling and at the same time relaxing the pelvic floor. We succeeded! we had “real” sex in the first time.”
Millions of women experience involuntary contraction of the musculature of the outer third of the vagina (vaginismus) interfering with intercourse, causing distress and interpersonal difficulty (ter Kuile et, 2010) or pain during intercourse (dyspareunia). It is estimated that 1 to 6% of women have vaginismus (Lewis et al, 2004) and 6.5% to 45.0% in older women and from 14% to 34% in younger women experience dyspareunia (Van Lankveld et al, 2010). The most common treatment for vaginismus is sequential dilation of the vaginal opening with progressively larger cones, psychotherapy and medications to reduce the pain and anxiety. At times clients and health care professionals may be unaware of the biological processes that influence the muscle contraction and relaxation of the pelvic floor. Success is more likely if the client works in harmony with the biological processes while practicing self-healing and treatment protocols. These biological processes, described at the end of the blog significantly affects the opening of vestibule and vagina are: 1) feeling safe, 2) inhale during insertion to relax the pelvic floor, 3) stretch very, very slowly to avoid triggering the stretch reflex, and 4) being sexual aroused.
Successful case report: There is hope to resolve pain and vaginismus
Yesterday my husband and I had sex in the first time, after two and a half years of “trying”. Why did it take so long? Well, the doctor said “vaginismus”, the psychologist said “fear”, the physiotherapist said “constricted muscles”, and friends said “just relax, drink some wine and it will happen”.
Sex was always a weird, scary, complicated – and above all, painful – world to me. It may have started in high school: like many other teens, I thought a lot about sex and masturbated almost every night. Masturbation was a good feeling followed by tons of bad feelings – guilt, shame, and feeling disgusting. One of the ideas I had to accept, later in my progress, is that ‘feeling good is a good thing’. It is normal, permitted and even important and healthy.
My first experience, at age 20, was short, very painful, and without any love or even affection. He was…. well, not for me. And I was…. well, naive and with very little knowledge about my body. The experiences that came after that, with other guys, were frustrating. Neither of them knew how to handle the pain that sex caused me, and I didn’t know what to do.
The first gynecologist said that everything is fine and I just need to relax. No need to say I left her clinic very angry and in pain. The second gynecologist was the first one to give it a name: “vaginismus”. He said that there are some solutions to the problem: anesthetic ointment, physiotherapy (“which is rarely helps”, according to his optimistic view..), and if these won’t work “we will start thinking of surgery, which is very painful and you don’t want to go there”. Oh, I certainly didn’t want to go there.
After talking to a friend whose sister had the same problem, I started seeing a great physiotherapist who was an expert in these problems. She used a vaginal biofeedback sensor, that measured muscles’ tonus inside the vagina. My homework were 30 constrictions every day, plus working with “dilators” – plastic cones comes in 6 sizes, starting from a size of a small finger, to a size of a penis.
At this point I was already in a relationship with my husband, who was understanding, calm and most important – very patient. To be honest, we both never thought it would take so long. Practicing was annoying and painful, and I found myself thinking a lot “is it worth it?”. After a while, I felt that the physical practice is not enough, and I need a “psychological breakthrough”. So I stopped practicing and started seeing a psychologist, for about a half a year. We processed my past experiences, examined the thoughts and beliefs I had about sex, and that way we released some of the tension that was shrinking my body.
The next step was to continue practicing with the dilators, but honestly – I had no motivation. My husband and I had great sex without the actual penetration, and I didn’t want the painful practice again. Fortunately, I participated in a short course given by Professor Erik Peper, about biofeedback therapy. In his lecture he described a young woman, who suffered from vulvodynia, a problem that is a bit similar to vaginismus (Peper et al, 2015; See: https://peperperspective.com/2015/09/25/resolving-pelvic-floor-pain-a-case-report/). She learned how to relax her body and deal with the pain, and finally she had sex – and even enjoyed it! I was inspired.
Erik Peper gave me a very important advice: breathing in. Apparently, we can relax the muscles and open the vagina better while inhaling, instead of exhaling – as I tried before. During exhalation the pelvic floor tightens and goes upward while during inhalation the pelvic floor descends and relaxes especially when sitting up (Peper et al, 2016). He advised me to give myself a few minutes with the dilator, and in every inhale – imagine the area opening and insert the dilator a few millimeters. I started practicing again, but in a sitting position, which I found more comfortable and less painful. I advanced to the biggest dilator within a few weeks, and had a just little pain – sometimes without any pain at all. The most important thing I understood was not to be afraid of the pain. The fear is what made me even more tensed, and tension brings pain. Then, my husband and I started practicing with “the real thing”, very slowly and gently, trying to find the best position and angle for us. Finally, we did it. And it was a great feeling.
The biological factors that affect the relaxation/contraction of the pelvic floor and vaginal opening are:
Feeling safe and hopeful. When threatened, scared, anticipate pain, and worry, our body triggers a defense reaction. In this flexor response, labeled by Thomas Hanna as the Red Light Reflex, the body curls up in defense to protect itself which includes the shoulders to round, the chest to be depressed, the legs pressing together, the pelvic floor to tighten and the head to jut forward (Hanna, 2004). This is the natural response of fear, anxiety, prolonged stress or negative depressive thinking.
Before beginning to work on vaginismus, feel safe. This means accepting what is, accepting that it is not your fault, and that there are no demands for performance. It also means not anticipating that it will be again painful because with each anticipation the pelvic floor tends to tightens. Read the chapter on vaginismus in Dr. Lonnie Barbach’s book, For each other: Sharing sexual intimacy (Barbach, 1983).
Inhale during insertion to relax the pelvic floor and vaginal opening. This instruction is seldom taught because in most instances, we have been taught to exhale while relaxing. Exhaling while relaxing is true for most muscles; however, it is different for the pelvic floor. When inhalation occurs, the pelvic floor descends and relaxes. During exhalation the pelvic floor tightens and ascends to support breathing and push the diaphragm upward to exhale the air. Be sure to allow the abdomen to expand during inhalation without lifting the chest and allow the abdomen to constrict during exhalation as if inhalation fills the balloon in the abdomen and exhalation deflates the balloon (for detailed instructions see Peper et al, 2016). Do not inhale by lifting and expanding your chest which often occurs during gasping and and fear. It tends to tighten and lift the pelvic floor.
Experience the connection between diaphragmatic breathing and pelvic floor movement in the following practice.
While sitting upright make a hissing noise as the air escapes with pressure between your lips. As you are exhaling feel, your abdomen and your anus tightening. During the inhalation let your abdomen expand and feel how your anus descends and pelvic floor relaxes. With practice this will become easier.
Stretch very, very slowly to avoid triggering the stretch reflex. When a muscle is rapidly stretched, it triggers an automatic stretch reflex which causes the muscle to contract. This innate response occurs to avoid damaging the muscle by over stretching. The stretch reflex is also triggered by pain and puts a brake on the stretching. Always use a lubricant when practicing by yourself or with a partner. Practice inserting larger and larger diameter dilaters into the vagina. Start with a very small diameter and progress to a larger diameter. These can be different diameter cones, your finger, or other objects. Remember to inhale and feel the pelvic floor descending as you insert the probe or finger. If you feel discomfort/pain, stop pushing, keep breathing, relax your shoulders, relax your hips, legs, and toes and do not push inward and upward again until the discomfort has faded out.
Feel sexually aroused by allowing enough foreplay. When sexually aroused the tissue is more lubricated and may stretch easier. Continue to use a good lubricant.
Putting it all together.
When you feel safe, practice slow diaphragmatic breathing and be aware of the pelvic floor relaxing and descending during inhalation and contracting and going up during exhalation. When practicing stretching the opening with cones or your finger, go very, very slow. Only apply pressure of insertion during the mid-phase of inhalation, then wait during exhalation and then again insert slight more during the next inhalation. When you experience pain, relax your shoulders, keep breathing for four or five breaths till the pain subsides, then push very little during the next inhalation. Go much slower and with more tenderness.
Be patient. Explain to your partner that your body and mind need time to adjust to new feelings. However, don’t stop having sex – you can have great sex without penetration. Practice both alone and with your partner; together find the best angle and rate. Use different lubricants to check out what is best for you. Any little progress is getting you closer to having an enjoyable sex. I recommend watching this TED video of Emily Nagoski explaining the “dual control model” and practicing as she suggests: https://www.youtube.com/watch?v=HILY0wWBlBM
Finally, practice the exercises developed by Dr. Lonnie Barbach, who as one of the first co-directors of clinical training at the University of California San Francisco, Human Sexuality Program, created the women’s pre-orgasmic group treatment program. They are superbly described in her two books, For each other: Sharing sexual intimacy, and For yourself: The fulfillment of female sexuality, and are a must read for anyone desiring to increase sexual fulfillment and joy (Barbach, 2000; 1983).
Barbach, L. (1983). For each other: Sharing sexual intimacy. New York: Anchor
Barbach, L. (2000). For yourself: The fulfillment of female sexuality. New York: Berkley.
BarLewis, R. W., Fugl‐Meyer, K. S., Bosch, R., Fugl‐Meyer, A. R., Laumann, E. O., Lizza, E., & Martin‐Morales, A. (2004). Epidemiology/risk factors of sexual dysfunction. The journal of sexual medicine, 1(1), 35-39. http://www.jsm.jsexmed.org/article/S1743-6095(15)30062-X/fulltext
Hanna, T. (2004). Somatics: Reawakening the mind’s control of movement, flexibility, and health. Boston: Da Capo Press.
Martinez Aranda, P. & Peper, E. (2015). The healing of vulvodynia from a client’s perspective. https://biofeedbackhealth.files.wordpress.com/2011/01/a-healing-of-vulvodynia-from-the-client-perspective-2015-06-15.pdf
Peper, E., Booiman, A., Lin, I-M, Harvey, R., & Mitose, J. (2016). Abdominal SEMG Feedback for Diaphragmatic Breathing: A Methodological Note. Biofeedback. 44(1), 42-49. https://biofeedbackhealth.files.wordpress.com/2011/01/1-abdominal-semg-feedback-published.pdf
Peper, E., Martinez Aranda, P., & Moss, E. (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback. 43(2), 103-109. https://biofeedbackhealth.files.wordpress.com/2011/01/a-vulvodynia-treated-with-biofeedback-published.pdf
Ter Kuile, M. M., Both, S., & van Lankveld, J. J. (2010). Cognitive behavioral therapy for sexual dysfunctions in women. Psychiatric Clinics of North America, 33(3), 595-610. https://www.researchgate.net/publication/45090259_Cognitive_Behavioral_Therapy_for_Sexual_Dysfunctions_in_Women
Van Lankveld, J. J., Granot, M., Weijmar Schultz, W., Binik, Y. M., Wesselmann, U., Pukall, C. F., . Achtrari, C. (2010). Women’s sexual pain disorders. The Journal of Sexual Medicine, 7(1pt2), 615-631. http://www.jsm.jsexmed.org/article/S1743-6095(15)32867-8/fulltext
*We thank Dr. Lonnie Barbach for her helpful feedback and support. Written collaboratively with Tal Cohen, biofeedback therapist (Israel) and Erik Peper.
It was late in the afternoon and I was tired. A knock on my office door. One of my students came in and started to read to me from a card. “I want to thank you for all your help in my self-healing project…I didn’t know the improvements were possible for me in a span of 5 weeks…. I thank you so much for encouraging and supporting me…. I have taken back control of myself and continue to make new discoveries about my identity and find my own happiness and fulfillment… Thank you so much.”
I was deeply touched and my eyes started to fill with tears. At that moment, I felt so appreciated. We hugged. My tiredness disappeared and I felt at peace.
In a world where we are constantly bombarded by negative, fearful stories and images, we forget that our response to these stories impacts our health. When people watch fear eliciting videos, their heart rate increases and their whole body responds with a defense reaction as if they are personally being threatened (Kreibig, Wilhelm, Roth, & Gross, 2007). Afterwards, we may continue to interpret and react to new stimuli as if they are the same as what happened in the video. For example, while watching a horror movie, we may hold our breath, perspire and feel our heart racing; however, when we leave the theatre and walk down the street by ourselves, we continue to be afraid and react to stimuli as if what happened in video will now happen to us.
When we feel threatened, our body responds to defend itself. It reduces the blood flow to the gastrointestinal tract where digestion is taking place and sends it to large muscles so that we can run and fight. When threatened, most of our resources shifted to the processes that promote survival while withdrawing it from processes that do not lead to immediate survival such as digestion or regeneration (Sapolsky, 2004). From an evolutionary perspective, why spent resources to heal yourself, enhance your immune system or digest your food when you will become someone else’s lunch!
The more we feel threatened, the more we will interpret the events around us negatively. We become more stressed, defensive, and pessimistic. If this response occurs frequently, it contributes to increased morbidity and mortality. We may not be in control of external or personal event; however, we may be able to learn how to change our reactions to these events. It is our reactions and interpretations of the event that contributes to our ongoing stress responses. The stressor can be labeled as crisis or opportunity.
Mobilize your own healing when you take charge. When 92 students as part of a class at San Francisco State University practiced self-healing skill, most reported significant improvements in their health as shown in Figure 1.
Figure 1. Average self-reported improvement after practicing self-healing skills for at least four weeks. (Reproduced with permission from Tseng, Abili, Peper, & Harvey, 2016).
A strategy that many students used was to interrupt their cascading automatic negative reactions. The moment they became aware of their negative thought and body slumping, they interrupted the process and practiced a very short relaxation or meditation technique.
Implement what the students have done by taking charge of your stress responses and depressive thoughts by 1) beginning the day with a relaxation technique, Relax Body-Mind, 2) interrupting the automatic response to stressors with a rapid stress reduction technique, Breathe and be a Tree, and 3) increasing vitality by the practice, Share Gratitude (Gorter & Peper, 2011).
Relax Body-Mind to start the day*
- Lie down or sit and close your eyes. During the practice if your attention wanders, just bring it back to that part of the body you are asked to tighten or let go.
- Wrinkle your face for ten seconds while continuing to breathe. Let go and relax for ten seconds.
- Bring your hands to your face with the fingers touching the forehead while continuing to breathe. While exhaling, pull your fingers down your face so that you feel your jaw being pulled down and relaxing. Drop your hands to your lap. Feel the sensations in your face and your fingers for ten seconds.
- Make a fist with your hands and lift them slightly up from your lap while continuing to breathe. Feel the sensations of tension in your hands, arms and shoulders for ten seconds. Let go and relax by allowing the arms to drop to your lap and relax. Feel the sensations change in your hands, arms and shoulders for ten seconds.
- Tighten your buttocks and flex your ankles so that the toes are reaching upwards to your knees. Hold for ten seconds while continuing to breathe. Let go and relax for ten seconds.
- Take a big breath while slightly arching your back away from the bed ore chair and expand your stomach while keeping your arms, neck, buttocks and legs relaxed. Hold the breath for twenty seconds. Exhale and let your back relax while allowing the breathing to continue evenly while sensing your body’s contact with the bed or chair for twenty seconds. Repeat three times.
- Gently shake your arms and legs for ten seconds while continuing to breathe. Let go and relax. Feel the tingling sensations in your arms and legs for 20 seconds.
- Evoke a past positive memory where you felt at peace and nurtured.
- Stretch and get up. Know you have done the first self-healing step of the day.
*Be gentle to yourself and stop the tightening or breath holding if it feels uncomfortable.
Breathe and be a Tree to dissipate stress and focus on growth
- Look at a tall tree and realize that you are like a tree that is rooted in the ground and reaching upward to the light. It continues to grow even though it has been buffeted by storms.
- When you become aware of being stressed, exhale slowly and inhale so that your stomach expands, the while slowly exhaling, look upward to the top of a real or imagined tree, admire the upper branches and leaves that are reaching towards the light and smile.
- Remember that even though you started to respond to a stressor, the stressor will pass just like storms battering the tree. By breathing and looking upward, accept what happened and know you are growing just like the tree.
- Think of someone who did something for you that impacted your life in a positive direction and whom you never properly thanked. This could be a neighbor, teacher, friend, parent, or other family members.
- Write a 300-word testimonial describing specifically what the person did and how it positively impacted you and changed the course of your life.
- Arrange an actual face-to-face meeting with the person. Tell them you would like to see him/her. If they are far away, arrange a Skype call where you can actually see and hear him/her. Do not do it by email or texting.
- Meet with the person and read the testimonial to her/him.
- It may seem awkward to read the testimonial, after you have done it, you will feel closer and more deeply connected to the person. Moreover, the person to whom you read the testimonial, will usually feel deeply touched. Both your hearts will open.
Gorter, R. & Peper, E. (2011). Fighting cancer: A nontoxic approach to treatment. Berkeley, CA: North Atlantic Books, 205-207.
Kreibig, S. D., Wilhelm, F. H., Roth, W. T., & Gross, J. J. (2007). Cardiovascular, electrodermal, and respiratory response patterns to fear‐and sadness‐inducing films. Psychophysiology, 44(5), 787-806.Kreibig, Sylvia D., Frank H. Wilhelm, Walton T. Roth, and James J. Gross. “Cardiovascular, electrodermal, and respiratory response patterns to fear‐and sadness‐inducing films.” Psychophysiology 44, no. 5 (2007): 787-806.
Sapolsky, R. (2004). Why Zebras Don’t Get Ulcers. New York: Owl Books
Seligman, M. (2014). The new era of positive psychology. Ted Talk. Retrieved, December 10, 2016. https://www.ted.com/talks/martin_seligman_on_the_state_of_psychology
Tseng, C., Abili, R., Peper, E., & Harvey, R. (2016). Reducing Acne-Stress and an integrated self-healing approach. Appl Psychophysiol Biofeedback, 4(4), 445.)
“I opened the exam booklet and I went blank.”
“When I got anxious, I took a slow breath, reminded myself that I would remember the material. I successfully passed the exam.”
“I was shocked, when I gasped, I could not remember my girlfriend’s name and then I could not remember my mother’s name. When breathed slowly, I had no problem and easily remembered both”
Blanking out the memorized information that you have studied on an exam is a common experiences of students even if they worked hard (Arnsten, Mazure, & Sinha, 2012). Fear and poor study habits often contribute to forgetting the material (Fitkov-Norris, & Yeghiazarian, 2013). Most students study while listening to music, responding to text message, or monitoring social network sites such as, Facebook, twitter, Instagram, or Pinterest (David et al., 2015).. Other students study the material for one class then immediately shift and study material from another class. While at home they study while sitting or lying on their bed. Numerous students have internalized the cultural or familial beliefs that math is difficult and you do not have the aptitude for the material—your mother and father were also poor in math (Cherif, Movahedzadeh, Adams, & Dunning, 2013). These beliefs and dysfunctional study habits limit learning (Neal, Wood, & Drolet, 2013).
Blanking out on an exam or class presentation is usually caused by fear or performance anxiety which triggers a stress response (Hodges, 2015; Spielberger, Anton, & Bedell, 2015). At that moment, the brain is flooded with thoughts such as, I can’t do it,” “I will fail,” “I used to know this, but…”, or “What will people think?” The body responds with a defense reaction as if you are being threatened and your survival is at stake. The emotional reactivity and anxiety overwhelms cognition, resulting in an automatic ‘freeze’ response of breath holding or very shallow breathing. At that moment, you blank out (Hagenaars, Oitzl, & Roelofs, 2014; Sink et al., 2013; Von Der Embse, Barterian, & Segool, 2013).
Experience how your thinking is affected by your breathing pattern. Do the following practice with another person.
Have the person ask you a question and the moment you hear the beginning of the question, gasp as if you are shocked or surprised. React just as quickly and automatically as you would if you see a car speeding towards you. At that moment of shock or surprise, you do not think, you don’t spend time identifying the car or look at who is driving. You reflexively and automatically jump out of the way. Similarly in this exercise, when you are asked to answer a question, act as if you are as shocked or surprised to see a car racing towards you.
Practice gasping at the onset of hearing the beginning of a question such as, “What day was it yesterday?” At the onset of the sound, gasp as if startled or afraid. During the first few practices, many people wait until they have heard the whole phrase before gasping. This would be similar to seeing a car racing towards you and first thinking about the car, at that point you would be hit. Repeat this a few times till it is automatic.
Now change the breathing pattern from gasping to slow breathing and practice this for a few times.
When you hear the beginning of the question breathe slowly and then exhale.” Inhale slowly for about 4 seconds while allowing your abdomen to expand and then exhale softly for about 5 or six seconds. Repeat practicing slow breathing in response to hearing the onset of the question until it is automatic.
Now repeat the two breathing patterns (gasping and slow breathing) while the person asks you a subtraction or math questions such as, “Subtract 7 from 93.”
In research with more than 100 college students, we found that students had significantly more self-reported anxiety and difficulty in solving math problems when gasping as compared to slow breathing as shown Figure 1 (Lee et al, 2016; Peper, Lee, Harvey & Lin, 2016).
Fig 1. The effect of breathing style on math performance. Diaphragmatic breathing significantly increased math performance and decreased anxiety (from: Peper, Lee, Harvey & Lin, 2016).
As one 20 year old college student said, “When I gasped, my mind went blank and I could not do the subtraction. When I breathed slowly, I had no problem doing the subtractions. I never realized that breathing had such a big effect upon my performance.”
When you are stressed and blank out, take a slow diaphragmatic breath to improve performance; however, it is only effective if you have previously studied the materials effectively. To improve effective learning incorporate the following concepts when studying.
- Approached learning with a question. When you begin to study the material or attend a class, ask yourself a question that you would like to be answered. When you have a purpose, it is easier to stay emotionally present and remember the material (Osman, & Hannafin, 1994).
- Process what you are learning with as many sensory cues as possible. Take hand written notes when reading the text or listening to your teacher. Afterwards meet with your friends in person, on Skype and again discuss and review the materials. As you discuss the materials, add comments to your notes. Do not take notes on your computer because people can often type almost as quickly as someone speaks. The computer notes are much less processed and are similar to the experience of a court or medical transcriptionist where the information flows from the ears to the fingers without staying in between. College students who take notes in class on a computer or tablets perform worse on exams than students who write notes. When you write your notes you have to process the material and extract and synthesis relevant concepts.
- Review the notes and material before going to sleep. Research has demonstrated that whatever material is in temporary memory before going to sleep will be more likely be stored in long term memory (Gais et al., 2006; Diekelmann et al., 2009). When you study material is stored in temporary memory, and then when you study something else, the first material tends to displaced by the more recent material. The last studied material is more likely stored in long term memory. When you watch a movie after studying, the movie content is preferentially stored in permanent memory during sleep. In addition, what is emotionally most important to you is usually stored first. Thus, instead of watching movies and chatting on social media, discuss and review the materials just before you go to sleep.
- Learning is state dependent. Study and review the materials under similar conditions as you will be tested. Without awareness the learned content is covertly associated with environmental, emotional, social and kinesthetic cues. Thus when you study in bed, the material is most easily accessed while lying down. When you study with music, the music become retrieval trigger. Without awareness the materials are encoded with the cues of lying down or the music played in the background. When you come to the exam room, none of those cues are there, thus it is more difficult to recall the material (Eich, 2014).
- Avoid interruptions. When studying each time you become distracted by answering a text message or responding to social media, your concentration is disrupted (Swingle, 2016). Imagine that learning is like scuba diving and the learning occurs mainly at the bottom. Each interruption forces you to go to the surface and it takes time to dive down again. Thus you learn much less than if you stayed at the bottom for the whole time period.
- Develop study rituals. Incorporate a ritual before beginning studying and repeat it during studying such as three slow breaths. The ritual can become the structure cue associated with the learned material. When you come to exam and you do not remember or are anxious, perform the same ritual which will allow easier access to the memory.
- Change your internal language. What we overtly or covertly say and believe is what we become. When you say, “I am stupid”, “I can’t do math,” or “It is too difficult to learn,” you become powerless which increases your stress and inhibits cognitive function. Instead, change your internal language so that it implies that you can master the materials such as, “I need more time to study and to practice the material,” “Learning just takes time and at this moment it may take a bit longer than for someone else,” or “I need a better tutor,”
When you take charge of your study habits and practice slower breathing during studying and test taking, you may experience a significant improvement in learning, remembering, accessing, and processing information.
Arnsten, A., Mazure, C. M., & Sinha, R. (2012). This is your brain in meltdown. Scientific American, 306(4), 48-53.
Cherif, A. H., Movahedzadeh, F., Adams, G. E., & Dunning, J. (2013). Why Do Students Fail?. Higher Learning, 227, 228.
David, P., Kim, J. H., Brickman, J. S., Ran, W., & Curtis, C. M. (2015). Mobile phone distraction while studying. new media & society, 17(10), 1661-1679.
Diekelmann, S., Wilhelm, I., & Born, J. (2009). The whats and whens of sleep-dependent memory consolidation. Sleep medicine reviews, 13(5), 309-321.
Eich, J. E. (2014). State-dependent retrieval of information in human episodic memory. Alcohol and Human Memory (PLE: Memory), 2, 141.
Fitkov-Norris, E. D., & Yeghiazarian, A. (2013). Measuring study habits in higher education: the way forward?. In Journal of Physics: Conference Series (Vol. 459, No. 1, p. 012022). IOP Publishing.
Gais, S., Lucas, B., & Born, J. (2006). Sleep after learning aids memory recall. Learning & Memory, 13(3), 259-262.
Hagenaars, M. A., Oitzl, M., & Roelofs, K. (2014). Updating freeze: aligning animal and human research. Neuroscience & Biobehavioral Reviews, 47, 165-176.
Hodges, W. F. (2015). The psychophysiology of anxiety. Emotions and Anxiety (PLE: Emotion): New Concepts, Methods, and Applications, 12, 175.
Lee, S., Sanchez, J., Peper, E., & Harvey, R. (2016). Effect of Breathing Style on Math Problem Solving. Presented at the 47th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Seattle WA, March 9-12, 2016
Neal, D. T., Wood, W., & Drolet, A. (2013). How do people adhere to goals when willpower is low? The profits (and pitfalls) of strong habits. Journal of Personality and Social Psychology, 104(6), 959.
Osman, M. E., & Hannafin, M. J. (1994). Effects of advance questioning and prior knowledge on science learning. The Journal of Educational Research,88(1), 5-13.
Peper, E., Lee, S., Harvey, R., & Lin, I-M. (2016). Breathing and math performance: Implication for performance and neurotherapy. NeuroRegulation, 3(4),142–149.
Spielberger, C. D., Anton, W. D., & Bedell, J. (2015). The nature and treatment of test anxiety. Emotions and anxiety: New concepts, methods, and applications, 317-344.
Sink, K. S., Walker, D. L., Freeman, S. M., Flandreau, E. I., Ressler, K. J., & Davis, M. (2013). Effects of continuously enhanced corticotropin releasing factor expression within the bed nucleus of the stria terminalis on conditioned and unconditioned anxiety. Molecular psychiatry, 18(3), 308-319.
Swingle, M. (2016). i-Minds: How cell phones, computers, gaming and social media are changing our brains, our behavior, and the evolution of our species. Gabriola Island, BC, Canada: New Society Publishers.
Von Der Embse, N., Barterian, J., & Segool, N. (2013). Test anxiety interventions for children and adolescents: A systematic review of treatment studies from 2000–2010. Psychology in the Schools, 50(1), 57-71.
*I thank Richard Harvey, PhD. for his constructive feedback and comments and Shannon Lee for her superb research.
** This blog was adapted from: Lee, S., Sanchez, J., Peper, E., & Harvey, R. (2016). Effect of Breathing Style on Math Problem Solving. Presented at the 47th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Seattle WA, March 9-12, 2016
When I allowed my lower abdomen to expand during inhalation without any striving and slightly constrict during exhalation, breathing was effortless. At the end of exhalation, I just paused and then the air flowed in without any effort. I felt profoundly relaxed and safe. With each effortless breath my hurry-up sickness dissipated.
Effortless breathing from a developmental perspective is a whole body process previously described by the works of Elsa Gindler, Charlotte Selver and Bess M. Mensendieck (Brooks, 1986; Bucholtz, 1994; Gilbert 2016, Mensendieck, 1954). These concepts underlie the the research and therapeutic approach of Jan van Dixhoorn (2008, 2014) and is also part of the treatment processes of Mensendieck/Cesar therapists (Profile Mensendeick) . During inhalation the body expands and during exhalation the body contracts. While sitting or standing, during exhalation the abdominal wall contracts and during inhalation the abdominal wall relaxes. This whole body breathing pattern is often absent in clients who tend to lift their chest and do not expand or sometimes even constrict their abdomen when they inhale . Even if their breathing includes some abdominal movement, often only the upper abdomen above the belly button moves while the lower abdomen shows limited or no movement. This may be associated with physical and emotional discomfort such as breathing difficulty, digestive problems, abdominal and pelvic floor pains, back pain, hyper vigilance, and anxiety. (The background, methodology to monitor and train with muscle biofeedback, and pragmatic exercises are described in detail in our recent published article, Peper, E., Booiman, A.C, Lin, I-M, Harvey, R., & Mitose, J. (2016). Abdominal SEMG Feedback for Diaphragmatic Breathing: A Methodological Note. Biofeedback. 44(1), 42-49.)
Some of the major factors that contribute to the absence of abdominal movement during breathing are (Peper et, 2015):
- ‘Designer jean syndrome’ (the modern girdle): The abdomen is constricted by a waist belt, tight pants or slimming underwear such as Spanx and in former days by the corset as shown in Figure 1 (MacHose & Peper, 1991; Peper & Tibbitts, 1994).
- Self-image: The person tends to pull his or her abdomen inward in an attempt to look slim and attractive.
- Defense reaction: The person unknowingly tenses the abdominal wall –a flexor response-in response to perceived threats (e.g., worry, external threat, loud noises, feeling unsafe). Defense reactions are commonly seen in clients with anxiety, panic or phobias.
- Learned disuse: The person covertly learned to inhibit any movement in the abdominal wall to protect themselves from experiencing pain because of prior abdominal injury or surgery (e.g., hernia or cesarean), abdominal pain (e.g., irritable bowel syndrome, dysmenorrhea, vulvodynia, pelvic floor pain, low back pain).
- Inability to engage abdominal muscles because of the lack of muscle tone.
Figure 1. How clothing constricts abdominal movement. Previously it was a corset as shown on the left and now it is Spanx or very tight clothing which restricts the waist.
Whether the lower abdominal muscles are engaged or not (either by chronic tightening or lack of muscle activation), the resultant breathing pattern tends to be more thoracic, shallow, rapid, irregular and punctuated with sighst. Over time participants may not able to activate or relax the lower abdominal muscles during the respiratory cycle. Thus it is no longer involved in whole body movement which can usually be observed in infants and young children.
In our published paper by Peper, E., Booiman, A.C, Lin, I-M, Harvey, R., & Mitose, J. (2016), we describe a methodology to re-establish effortless whole body breathing with the use of surface electromyography (SEMG) recorded from the lower abdominal muscles (external/ internal abdominal oblique and transverse abdominis) and strategies to teach engagement of these lower abdominal muscles. Using this methodology, the participants can once again learn how to activate the lower abdominal muscles to flatten the abdominal wall thereby pushing the diaphragm upward during exhalation. Then, during inhalation they can relax the muscles of the abdominal wall to expand the abdomen and allow the diaphragm to descend as shown in Figure 2.
Figure 2. Correspondence between respiratory strain gauge changes and SEMG activity during breathing. When the person exhales, the lower abdominal SEMG activity increases and when the person inhales the SEMG decreases.
The published article discusses the factors that contribute to the breathing dysregulation and includes guidelines for using SEMG abdominal recording. It describes in detail–with illustrations–numerous practices such as tactile awareness of the lower abdomen, active movements such as pelvic rocking and cats and dogs exercises that people can practice to facilitate lower abdominal breathing. One of these practices, Sensing the lower abdomen during breathing, is developed and described by Annette Booiman, Mensendieck therapist
Sensing the lower abdomen during breathing
The person place their hands below their belly button with the outer edge of hands resting on the groin. During inhalation, they practice bringing their lower abdomen/belly into their hands so that the person can feel the lower abdomen expanding. During exhalation, they pull their lower abdomen inward and away from their palms as shown in Figure 3.
Figure 3. Hands placed below the belly button to sense the movement of the lower abdomen.
Lower abdominal SEMG feedback is useful in retraining breathing for people with depression, rehabilitation after pregnancy, abdomen or chest surgery (e.g., Cesarean surgery, hernia, or appendectomy operations), anxiety, hyperventilation, stress-related disorders, difficulty to become pregnant or maintain pregnancy, pelvic floor problems, headache, low back pain, and lung diseases. As one participant reported:
“Biofeedback might be the single thing that helped me the most. When I began to focus on breathing, I realized that it was almost impossible for me since my body was so tightened. However, I am getting much better at breathing diaphragmatically because I practice every day. This has helped my body and it relaxes my muscles, which in turn help reduce the vulvar pain.”
Van Dixhoorn, J. (2014). Indirect approaches to breathing dysregulation. In: Chaitow, L., Gilbert, C., & Morrison, D. (2014). Recognizing and treating breathing disorders pp. 155-161). Elsevier Health Sciences.
Gilbert, C. (2016). Working with breathing , some early influences. Paper presented at the 47th Annual Meeting of the Association for Applied Psychophysiology and Biofeedback, Seattle WA, March 9-12, 2016.
2. .I thank Annette Booiman for her constructive feedback in writing this blog.
Can abdominal surgery cause epilepsy, panic and anxiety and be reversed with breathing biofeedback?*Posted: March 5, 2016
“I had colon surgery six months ago. Although I made no connection to my anxiety, it just started to increase and I became fearful and I could not breathe. The asthma medication did not help. Learning effortless diaphragmatic breathing and learning to expand my abdomen during inhalation allowed me to breathe comfortably without panic and anxiety—I could breathe again.” (72 year old woman)
“One year after my appendectomy, I started to have twelve seizures a day. After practicing effortless diaphragmatic breathing and changing my lifestyle, I am now seizure-free.” (24 year old male college student)
One of the hidden long term costs of surgery and injury is covert learned disuse. Learned disuse occurs when a person inhibits using a part of their body to avoid pain and compensates by using other muscle patterns to perform the movements (Taub et al, 2006). This compensation to avoid discomfort creates a new habit pattern. However, the new habit pattern often induces functional impairment and creates the stage for future problems.
Many people have experienced changing their gait while walking after severely twisting their ankle or breaking their leg. While walking, the person will automatically compensate and avoid putting weight on the foot of the injured leg or ankle. These compensations may even leads to shoulder stiffness and pain in the opposite shoulder from the injured leg. Even after the injury has healed, the person may continue to move in the newly learned compensated gait pattern. In most cases, the person is totally unaware that his/her gait has changed. These new patterns may place extra strain on the hip and back and could become a hidden factor in developing hip pain and other chronic symptoms.
Similarly, some women who have given birth develop urinary stress incontinence when older. This occurred because they unknowingly avoided tightening their pelvic floor muscles after delivery because it hurt to tighten the stretched or torn tissue. Even after the tissue was healed, the women may no longer use their pelvic floor muscles appropriately. With the use of pelvic floor muscle biofeedback, many women with stress incontinence can rapidly learn to become aware of the inhibited/forgotten muscle patterns (learned disuse) and regain functional control in nine sessions of training (Burgio et al., 1998; Dannecker et al., 2005). The process of learned disuse is the result of single trial learning to avoid pain. Many of us as children have experienced this process when we touched a hot stove—afterwards we tended to avoid touching the stove even when it was cold.
Often injury will resolve/cure the specific problem. It may not undo the covert newly learned dysfunctional patterns which could contribute to future iatrogenic problems or illnesses (treatment induced illness). These iatrogenic illnesses are treated as a new illness without recognizing that they were the result of functional adaptations to avoid pain and discomfort in the recovery phase of the initial illness.
Surgery creates instability at the incision site and neighboring areas, so our bodies look for the path of least resistance and the best place to stabilize to avoid pain. (Adapted from Evan Osar, DC).
After successful surgical recovery do not assume you are healed!
Yes, you may be cured of the specific illness or injury; however, the seeds for future illness may be sown. Be sure that after injury or surgery, especially if it includes pain, you learn to inhibit the dysfunctional patterns and re-establish the functional patterns once you have recovered from the acute illness. This process is described in the two cases studies in which abdominal surgeries appeared to contribute to the development of anxiety and uncontrolled epilepsy.
How abdominal surgery can have serious, long-term effect on changing breathing patterns and contributing to the development of chronic illness.
When recovering from surgery or injury to the abdomen, it is instinctual for people to protect themselves and reduce pain by reducing the movement around the incision. They tend to breathe more shallowly as not to create discomfort or disrupt the healing process (e.g., open a stitch or staple. Prolonged shallow breathing over the long term may result in people experiencing hyperventilation induced panic symptoms or worse. This process is described in detail in our recent article, Did You Ask about Abdominal Surgery or Injury? A Learned Disuse Risk Factor for Breathing Dysfunction (Peper et al., 2015). The article describes two cases studies in which abdominal surgeries led to breathing dysfunction and ultimately chronic, serious illnesses.
Reducing epileptic seizures from 12 per week to 0 and reducing panic and anxiety
A routine appendectomy caused a 24-year-old male to develop rapid, shallow breathing that initiated a series of up to 12 seizures per week beginning a year after surgery. After four sessions of breathing retraining and incorporating lifestyle changes over a period of three months his uncontrolled seizures decreased to zero and is now seizure free. In the second example, a 39-year-old woman developed anxiety, insomnia, and panic attacks after her second kidney transplant probably due to shallow rapid breathing only in her chest. With biofeedback, she learned to change her breathing patterns from 25 breaths per minute without any abdominal movement to 8 breathes a minute with significant abdominal movement. Through generalization of the learned breathing skills, she was able to achieve control in situations where she normally felt out of control. As she practiced this skill her symptoms were significantly reduced and stated:
“What makes biofeedback so terrific in day-to-day situations is that I can do it at any time as long as I can concentrate. When I feel I can’t concentrate, I focus on counting and working with my diaphragm muscles; then my concentration returns. Because of the repetitive nature of biofeedback, my diaphragm muscles swing into action as soon as I started counting. When I first started, I had to focus on those muscles to get them to react. Getting in the car, I find myself starting these techniques almost immediately. Biofeedback training is wonderful because you learn techniques that can make challenging situations more manageable. For me, the best approach to any situation is to be calm and have peace of mind. I now have one more way to help me achieve this.” (From: Peper et al, 2001).
The commonality between these two participants was that neither realized that they were bracing the abdomen and were breathing rapidly and shallowly in the chest. I highly recommend that anyone who has experienced abdominal insults or surgery observe their breathing patterns and relearn effortless breathing/diaphragmatically breathing instead of shallow, rapid chest breathing often punctuated with breath holding and sighs.
It is important that medical practitioners and post-operative surgery patients recognize the common covert learned disuse patters such as shifting to shallow breathing to avoid pain. The sooner these patterns are identified and unlearned, the less likely will the person develop future iatrogenic illnesses. Biofeedback is an excellent tool to help identify and retrain these patterns and teach patients how to reestablish healthy/natural body patterns.
The full text of the article see: “Did You Ask About Abdominal Surgery or Injury? A Learned Disuse Risk Factor for Breathing Dysfunction,”
Burgio, K. L., Locher, J. L., Goode, P. S., Hardin, J. M., McDowell, B. J., Dombrowski, M., & Candib, D. (1998). Behavioral vs drug treatment for urge urinary incontinence in older women: a randomized controlled trial. Jama, 280(23), 1995-2000.
Dannecker, C., Wolf, V., Raab, R., Hepp, H., & Anthuber, C. (2005). EMG-biofeedback assisted pelvic floor muscle training is an effective therapy of stress urinary or mixed incontinence: a 7-year experience with 390 patients. Archives of Gynecology and Obstetrics, 273(2), 93-97.
Osar, E. (2016). http://www.fitnesseducationseminars.com/
Peper, E., Castillo, J., & Gibney, K. H. (2001, September). Breathing biofeedback to reduce side effects after a kidney transplant. In Applied Psychophysiology and Biofeedback (Vol. 26, No. 3, pp. 241-241). 233 Spring St., New York, NY 10013 USA: Kluwer Academic/Plenum Publ.
Peper, E., Gilbert, C.D., Harvey, R. & Lin, I-M. (2015). Did you ask about abdominal surgery or injury? A learned disuse risk factor for breathing dysfunction. Biofeedback. 34(4), 173-179. DOI: 10.5298/1081-5937-43.4.06
Taub, E., Uswatte, G., Mark, V. W., Morris, D. M. (2006). The learned nonuse phenomenon: Implications for rehabilitation. Europa Medicophysica, 42(3), 241-256.
It’s been a little over a year since I began practicing biofeedback and visualization strategies to overcome vulvodynia. Today, I feel whole, healed, and hopeful. I learned that through controlled and conscious breathing, I could unleash the potential to heal myself from chronic pain. Overcoming pain did not happen overnight; but rather, it was a process where I had to create and maintain healthy lifestyle habits and meditation. Not only am I thankful for having learned strategies to overcome chronic pain, but for acquiring skills that will improve my health for the rest of my life. –-24 year old woman who successfully resolved vulvodynia
Pelvic floor pain can be debilitating, and it is surprisingly common, affecting 10 to 25% of American women. Pelvic floor pain has numerous causes and names. It can be labeled as vulvar vestibulitis, an inflammation of vulvar tissue, interstitial cystitis (chronic pain or tenderness in the bladder), or even lingering or episodic hip, back, or abdominal pain. Chronic pain concentrated at the entrance to the vagina (vulva), is known as vulvodynia. It is commonly under-diagnosed, often inadequately treated, and can go on for months and years (Reed et al., 2007; Mayo Clinic, 2014). The discomfort can be so severe that sitting is uncomfortable and intercourse is impossible because of the extreme pain. The pain can be overwhelming and destructive of the patient’s life. As the participant reported,
I visited a vulvar specialist and he gave me drugs, which did not ease the discomfort. He mentioned surgical removal of the affected tissue as the most effective cure (vestibulectomy). I cried immediately upon leaving the physician’s office. Even though he is an expert on the subject, I felt like I had no psychological support. I was on Gabapentin to reduce pain, and it made me very depressed. I thought to myself: Is my life, as I know it, over?
Physically, I was in pain every single day. Sometimes it was a raging burning sensation, while other times it was more of an uncomfortable sensation. I could not wear my skinny jeans anymore or ride a bike. I became very depressed. I cried most days because I felt old and hopeless instead of feeling like a vibrant 23-year-old woman. The physical pain, combined with my negative feelings, affected my relationship with my boyfriend. We were unable to have sex at all, and because of my depressed status, we could not engage in any kind of fun. (For more details, read the published case report,Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report).
The four-session holistic biofeedback interventions to successfully resolved vulvodynia included teaching diaphragmatic breathing to transform shallow thoracic breathing into slower diaphragmatic breathing, transforming feelings of powerlessness and hopelessness to empowerment and transforming her beliefs that she could reduce her symptoms and optimize her health. The interventions also incorporated self-healing imagery and posture-changing exercises. The posture changes consisted of developing awareness of the onset of moving into a collapsed posture and use this awareness to shift to an erect/empowered postures (Carney, Cuddy, & Yap, 2010; Peper, 2014; Peper, Booiman, Lin, & Harvey, in press). Finally, this case report build upon the seminal of electromyographic feedback protocol developed by Dr. Howard Glazer (Glazer & Hacad, 2015) and the integrated relaxation protocol developed Dr. David Wise (Wise & Anderson, 2007).
Through initial biofeedback monitoring of the lower abdominal muscle activity, chest, and abdomen breathing patterns, the participant observed that when she felt discomfort or was fearful, her lower abdomen muscles tended to tighten. After learning how to sense this tightness, she was able to remind herself to breathe lower and slower, relax the abdominal wall during inhalation and sit or stand in an erect power posture.
The self-mastery approach for healing is based upon a functional as compared to a structural perspective. The structural perspective implies that the problem can only be fixed by changing the physical structure such as with surgery or medications. The functional perspective assumes that if you can learn to change your dysfunctional psychophysiological patterns the disorder may disappear.
The functional approach assumed that an irritation of the vestibular area might have caused the participant to tighten her lower abdomen and pelvic floor muscles reflexively in a covert defense reaction. In addition, ongoing worry and catastrophic thinking (“I must have surgery, it will never go away, I can never have sex again, my boyfriend will leave me”) also triggered the defense reaction—further tightening of her lower abdomen and pelvic area, shallow breathing, and concurrent increases in sympathetic nervous activation—which together activated the trigger points that lead to increased chronic pain (Banks et al, 1998).
When the participant experienced a sensation or thought/worried about the pain, her body responded in a defense reaction by breathing in her chest and tightening the lower abdominal area as monitored with biofeedback. Anticipation of being monitored increased her shoulder tension, recalling the stressful memory increased lower abdominal muscle tension (pulling in the abdomen for protection), and the breathing became shallow and rapid as shown in Figure 1.
Figure 1. Physiological recording of pre-stressor relaxation, the recall of a fearful driving experience, and a post-stressor relaxation. The scalene to trapezius SEMG increased in anticipation while she recalled the experience, and then initially did not relax (from Peper, Martinez Aranda, & Moss, 2015).
This defense pattern became a conditioned response—initiating intercourse or being touched in the affected area caused the participant to tense and freeze up. She was unaware of these automatic protective patterns, which only worsened her chronic pain.
During the four sessions of training, the participant learned to reverse and interrupt the habitual defense reaction. For example, as she became aware of her breathing patterns she reported,
It was amazing to see on the computer screen the difference between my regular breathing pattern and my diaphragmatic breathing pattern. I could not believe I had been breathing that horribly my whole life, or at least, for who knows how long. My first instinct was to feel sorry for myself. Then, rather than practicing negative patterns and thoughts, I felt happy because I was learning how to breathe properly. My pain decreased from an 8 to alternating between a 0 and 3.
The mastery of slower and lower abdominal breathing within a holistic perspective resulted in the successful resolution of her vulvodynia. An essential component of the training included allowing the participant to feel safe, and creating hope by enabling her to experience a decrease in discomfort while doing a specific practice, and assisting her to master skills to promote self-healing. Instead of feeling powerless and believing that the only resolution was the removal of the affected area (vestibulectomy). The integrated biofeedback protocol offered skill mastery training, to promote self-healing through diaphragmatic breathing, somatic postural changes, reframing internal language, and healing imagery as part of a common sense holistic health approach.
For more details about the case report, download the published study, Peper, E., Martinez Aranda, P., & Moss, E. (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback. 43(2), 103-109.
The participant also wrote up her subjective experience of the integrated biofeedback process in the paper, Martinez Aranda & Peper (2015). Healing of vulvodynia from the client perspective. In this paper she articulated her understanding and experiences in resolving vulvodynia which sheds light on the internal processes that are so often skipped over in published reports.
At the five year follow-up on May 29, 2019, she wrote:
“I am doing very well, and I am very healthy. The vulvodynia symptoms have never come back. It migrated to my stomach a couple of years after, and I still have a sensitive stomach. My stomach has gotten much, much better, though. I don’t really have random pain anymore, now I just have to be watchful and careful of my diet and my exercise, which are all great things!”
Banks, S. L., Jacobs, D. W., Gevirtz, R., & Hubbard, D. R. (1998). Effects of autogenic relaxation training on electromyographic activity in active myofascial trigger points. Journal of Musculoskeletal Pain, 6(4), 23-32. https://www.researchgate.net/profile/David_Hubbard/publication/232035243_Effects_of_Autogenic_Relaxation_Training_on_Electromyographic_Activity_in_Active_Myofascial_Trigger_Points/links/5434864a0cf2dc341daf4377.pdf
Carney, D. R., Cuddy, A. J., & Yap, A. J. (2010). Power posing brief nonverbal displays affect neuroendocrine levels and risk tolerance. Psychological Science, 21(10), 1363-1368. Available from: https://www0.gsb.columbia.edu/mygsb/faculty/research/pubfiles/4679/power.poses_.PS_.2010.pdf
Glazer, H. & Hacad, C.R. (2015). The Glazer Protocol: Evidence-Based Medicine Pelvic Floor Muscle (PFM) Surface Electromyography (SEMG). Biofeedback, 40(2), 75-79. http://www.aapb-biofeedback.com/doi/abs/10.5298/1081-5937-40.2.4
Martinez Aranda, P. & Peper, E. (2015). Healing of vulvodynia from the client perspective. Available from: https://biofeedbackhealth.files.wordpress.com/2011/01/a-healing-of-vulvodynia-from-the-client-perspective-2015-06-15.pdf
Mayo Clinic (2014). Diseases and conditions: Vulvodynia. Available at http://www.mayoclinic.org/diseases-conditions/vulvodynia/basics/definition/con-20020326
Peper, E. (2014). Increasing strength and mood by changing posture and sitting habits. Western Edition, pp.10, 12. Available from: http://thewesternedition.com/admin/files/magazines/WE-July-2014.pdf
Peper, E., Booiman, A., Lin, I, M.,& Harvey, R. (in press). Increase strength and mood with posture. Biofeedback.
Peper, E., Martinez Aranda, P., & Moss, E. (2015). Vulvodynia treated successfully with breathing biofeedback and integrated stress reduction: A case report. Biofeedback. 43(2), 103-109. Available from: https://biofeedbackhealth.files.wordpress.com/2011/01/a-vulvodynia-treated-with-biofeedback-published.pdf
Reed, B. D., Haefner, H. K., Sen, A., & Gorenflo, D. W. (2008). Vulvodynia incidence and remission rates among adult women: a 2-year follow-up study. Obstetrics & Gynecology, 112(2, Part 1), 231-237. http://journals.lww.com/greenjournal/Abstract/2008/08000/Vulvodynia_Incidence_and_Remission_Rates_Among.6.aspx
Wise, D., & Anderson, R. U. (2006). A headache in the pelvis: A new understanding and treatment for prostatitis and chronic pelvic pain syndromes. Occidental, CA: National Center for Pelvic Pain Research.http://www.pelvicpainhelp.com/books/