Breathing to improve well-being

Breathing affects all aspects of your life. This invited keynote, Breathing and posture: Mind-body interventions to improve health, reduce pain and discomfort, was presented at the Caribbean Active Aging Congress, October 14, Oranjestad, Aruba.

The presentation includes numerous practices that can be rapidly adapted into daily life to improve health and well-being.

Do you blank out on exams? Improve school performance with breathing* **

lec03a-breathing-part-1-intro“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.

  1. 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).
  2. 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.
  3. 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.
  4. 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).
  5. 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.
  6. 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.
  7. 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 consolidationSleep medicine reviews13(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 & Memory13(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

Can abdominal surgery cause epilepsy, panic and anxiety and be reversed with breathing biofeedback?*

“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,”

*Adapted from: Biofeedback Helps to Control 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).

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.


The surprising and powerful links between posture and mood

Enjoy Vivian Giang’s superb blog, The surprising and powerful links between posture and mood,  published by Fast Company and reprinted with permission.   It summarizes in a very readable way how posture affects health and well being.

The Surprising and Powerful Links between Posture and Mood

Why feeling taller tricks your brain into making you feel more confident and why your smartphone addiction might be making you depressed.

The next time you’re feeling sad and depressed, pay close attention to your posture. According to cognitive scientists, you’ll likely be slumped over with your neck and shoulders curved forward and head looking down.

While it’s true that you’re sitting this way because you’re sad, it’s also true that you’re sad because you’re sitting this way. This philosophy, known as embodied cognition, is the idea that the relationship between our mind and body runs both ways, meaning our mind influences the way our body reacts, but the form of our body also triggers our mind.

In large part due to Amy Cuddy’s widly popular 2012 TED talk, most of us know that two minutes of “power poses” a day can change how we feel about ourselves. This isn’t just about displaying confidence to others around; this is about actually changing your hormones—increased levels of testosterone and decreased levels of cortisol, or the stress hormone, in the brain.

“The brain has an area that reflects confidence, but once that area is triggered it doesn’t matter exactly how it’s triggered,” says Richard Petty, professor of psychology at Ohio State University. “It can be difficult to distinguish real confidence from confidence that comes from just standing up straight … these things go both ways just like happiness leads to smiling, but also smiling leads to happiness.”

When it comes to posture, Petty explains that the way we ultimately feel has a lot to do with the associations we have with being taller. For example, if you take two people and you put one on a chair that’s above the other person, the one that’s looking down will feel more powerful because “we have all these associations” with height and power that “gets triggered automatically when certain movements are made,” he says. The function of your body posture tells your brain that you’re powerful, which, in turn, affects your attitude.

In a 2009 study published in the European Journal of Social Psychology, Petty along with other researchers instructed 71 college students to either “sit up straight” and “push out [their] chest” or “sit slouched forward” with their “face looking at [their] knees.” While holding their assigned posture, the students were asked to list either three positive or negative personal traits they thought would contribute to their future job satisfaction and professional performance. Afterward, the students were asked to take a survey where they rated themselves on how well they thought they would perform as a future professional.

The researchers found that how the students rated themselves depended on the posture they kept when they wrote the positive or negative traits. Those who were in the upright position believed in the positive and negative traits they wrote down while those in the slouched over position weren’t convinced of their positive or negative traits. In other words, when the students were in the upright, confident position, they trusted their own thoughts whether those thoughts were positive or negative. On the other hand, when the students sat in a powerless position, they didn’t trust anything they wrote down whether it was positive or negative.

However, those in the upright position likely had an easier time thinking of “empowering, positive” traits about themselves to write down while those in the slouched over position probably had an easier time recalling “hopeless, helpless, powerless, and negative” feelings, according to Erik Peper, professor of Holistic Health at San Francisco State University.

In a series of experiments, Peper found that sitting in a collapsed, helpless position makes it easier for negative thoughts and memories to appear while sitting in an upright, powerful position makes it easier to have empowering thoughts and memories.

“Emotions and thoughts affect our posture and energy levels; conversely, posture and energy affect our emotions and thoughts,” says one of Peper’s studies from 2012, and two minutes of skipping versus walking in a slouched position can make a significant difference on our energy levels. Like Cuddy, Peper’s research finds that it only takes two minutes to change your hormones, meaning you can basically change the chemistry in your brain while waiting for your food to heat up in the microwave.

Since posture affects our mood and thoughts so much, the increase of collapsed sitting and walking—from sitting in front of our computer to looking down at our smartphones—may very much have an effect on the rise of depression in recent years. Peper and his team of researchers suggest that posture is a significant contributor to decreased energy levels and depression. Slouching is also known to result in frequent headaches and neck and shoulder pains.

With so much research proving the influence posture has on our mind, Peper suggests hanging photos of people you love slightly higher on the wall or above your desk so that you have to look up. Also, adjust your rear view mirror slightly higher so that you have to sit up taller while driving. If you need reminders, Petty advises setting reminders on your phone, computer, or even a Post-It note. When you do have negative thoughts, instead of validating them by slumping over or bending your head, Petty says that you should write them down on a piece of paper, then throw that piece of paper away in the trash.

“People who throw those negative thoughts into the trash can are less affected by them then people who had the same thoughts but symbolically put them in their pocket,” he says. “It’s this idea that it’s not what we think that’s important; it’s how much we trust what we think.”

Reprinted by permission from Vivian Giang

Look up! Be aware and be open new possibilities

How is it possible that one is lonely while being connected to hundreds of Facebook friends, networked with even more LinkiedIn  colleagues,  and continuously sending and receiving Tweets and texts?  Are we so captured by the digital devices that we do not notice the actual reality around us? Watch Gary Turk’s remarkable video and then remember to look up and connect with others.

Great resource: Dr. Mike Evans-The Single Most Important Thing You Can Do for Your Stress

A major factor that contributes to illness and health is how we cope with stress.  Learning stress management techniques and integrating them into our daily life can significantly reduce illness and discomfort. Patients report significant improvement in numerous disorders such as hypertension, headaches, cancer, pain, or arthritis.

A great health resource are the short YouTube videos by Dr. Mike Evans who is founder of the Health Design Lab at the Li Ka Shing Knowledge Institute, an Associate Professor of Family Medicine and Public Health at the University of Toronto, and a staff physician at St. Michael’s Hospital. His informative short video clips cover a range of medical conditions from concussions to stopping smoking (see his website:

Watch the following video presentation on The Single Most Important Thing You Can Do for Your Stress.



Simple Ways to Manage Stress- An experiential lecture for people impacted by the March 11, 2011 Great East Japan Earthquake

Stress can be reduced by simple pragmatic exercises. This 99 minute participatory lecture was presented in Sendei, Japan, on July 20, 2013 to people who were impacted by the 2011 Tohoku earthquake and tsunami disaster.* The lecture includes practices that demonstrate 1) how thoughts, emotions and images affect the body, 2) how simple movements can reduce muscle tension, 3) how breathing can be used to reduce stress, 4) how changing posture can change access to positive or negative memories, 5) how acceptance is the beginning step for healing. This approach based upon a holistic evolutionary perspective of stress and health can be used to reduce symptoms caused or increased by stress such as neck, shoulder and back tension, digestive problems, worrying and insomnia. The video lecture is sequentially translated from English to Japanese.  Click on the link to watch the video lecture.


*The program was organized by Toshihiko Sato, Ph.D., Dept. Health and Social Services, Faculty of Medical Sciences and Welfare Tohoku Bunka Gakuen University, Sendai.