Getting in a Huff about Breathing

Last week during my course on Depression we were discussing strategies to help patients with poor sleep patterns.  We’d spent some time looking at how breathing can promote the relaxation response and a psychologist who was there mentioned that she often recommends the 4-7-8 breathing technique to help patients go off to sleep.  This was “a new one on me”: breathe in for a count of 4, hold for 7, breathe out for 8.  New, but not so new: the technique has obvious similarities to a number of well-known breathing patterns taught widely, including in most IAPT (Improving Access to Psychological Therapies) in the NHS.  It also mimics the 6 breath cycles a minute associated with relaxed states.  My colleague was unsure if there was any evidence for this as a way of promoting prompt sleep, but she reported that many of her clients reported dropping off to sleep very quickly using this exercise.

Time to find out more!

4 7 8 breathing is a pramayana yoga breath pattern popularised by Andrew Weil MD.  As so often I found the usual mixture of enthusiastic endorsement and quack-busting debunkery.  And it was the latter that I found particularly interesting.  The author had some valid points to make about the lack of any specific evidence about this particular breathing technique helping patients get off to sleep within a minute or so – a “fact” widely reported in the British Press.  The lack of evidence was “worrying”: the basis of this particular blog being that treatments should not be recommended until we have cast-iron evidence preferably from a meta-analysis of Double-Blind Randomised Controlled Studies (DBRCTs).  This widely held view is on one level as obvious as "motherhood and apple pie", but can be seen in a wider context.

Having studied the History of Medicine to MD level I have read about one “quackery scare” (in the late 19th century) and am conscious of living through another now (it started in about 2005 in case you are wondering).  Such moments are characterised (from a psychological perspective) by heightened emotion, black and white thinking and entrenched positions.  The basis of the accusation of quackery has changed in important ways over the last 250 years, and now tends to focus about “lack of evidence”.  Yet talk about there being “no evidence for” such and such a treatment tends to distract us from considering the 3 or 4 widely divergent things this statement might mean in practice.  This is important because only one of them is that “we know for sure this treatment doesn’t work”.  So it was no surprise the author overlooked some very obvious points about breathing techniques and sleep.

The first point would surely be that this technique completely aligns with sleep hygiene advice, which usually advises finding boring and/or relaxing activities to do instead of lying there increasingly concerned about not getting off to sleep.  Counting breaths instead of counting sheep.  (Now we’re feeling this paranoid perhaps we should also ask: how many aspects of standard sleep hygiene have been tested in DBRCTs?)

The second is that we know that there is a core set of patterns in breathing which are found in yoga, taiji and meditation that promote the parasympathetic, or ‘vagal’ tone, which is a key part of our relaxation response.  There are 3 main physiological requirements for sleep: these are sufficient adenosine in the brain (its long enough since we last slept and we’ve not “blocked” the adenosine with caffeine), a functioning circadian clock (dark at night and light exposure in the morning) and enough parasympathetic “tone” (we’re not wound up, anxious, or still working way past our bedtime).  The last of these is the only one we can influence close to or during our sleep time: by 1am we can’t now un-drink the coffee, un-have the day indoors, or take a space time worm-hole back to that missing morning dose of sunlight), but we can always turn up the parasympathetic with our breathing.

It is also hard to think of any plausible way in which this advice could harm anyone. And this is crucial to the last point, that suggestion is powerful.  Suggestion can be abused to give the impression that toxic, expensive or otherwise harmful treatments may help.  But the expectation of improvement is part of the mode of action of all treatments – even “scientifically proven evidence based” ones.  We know that the placebo response is in fact a powerful self-regulating resource we can all activate with an expectation of recovery.

So 4-7-8 breathing is congruent with sleep hygiene advice, has a plausible mechanism of action, and the suggestion that this technique will help us drop off in a minute or so, or reporting that many people have found this, will tend to make it so.

So, do we need to get in a huff about it?
Or just breathe in for 4, hold for 7, and breathe out for 8 instead?