Catch Your Breath: Understanding Anxiety and Breathlessness
Presented by Dr Lauren Brown. Written by Yvette and Bernie. AI assistance provided by Claude.
On the Couch is a series that brings expert knowledge into the room, translating the insights of health psychology professionals into accessible, thoughtful reads for anyone curious about the intersection of mind and body.
In this instalment, Dr Lauren Brown, health psychologist with expertise in working with people living with breathlessness, shares her insights on anxiety and breathlessness, drawing from a peer presentation she delivered to a group of health psychology professionals. What follows is an exploration of why breathlessness is so frightening, how anxiety and breathlessness feed each other, and, crucially, what can actually be done about it.
Meet Dr Lauren Brown
Dr Lauren Brown holds a Doctorate in Health Psychology from the University of Newcastle. She currently works in a multidisciplinary community health team, supporting clients living with chronic health conditions. She also works in a multidisciplinary breathlessness clinic dedicated to helping people with severe respiratory conditions manage breathlessness and reclaim their quality of life.
Breathlessness, or shortness of breath, is Lauren's area of deep expertise. As she makes clear from the outset, it's a topic that sits squarely at the intersection of the physical and the psychological, which is exactly where health psychology does its best work.
Why Breathlessness Triggers Anxiety — Every Time
To understand why anxiety and breathlessness are so closely linked, Lauren starts with something fundamental. Breathing is not optional. It is, as she puts it, "part of life", which means that the sensation of not being able to breathe will always, at some level, trigger a fear response.
"Everybody will get to their point of breathlessness — a situation where it will trigger anxiety, it will trigger a fight-or-flight response. Because being able to breathe is part of life."
For people living with respiratory conditions, this fear response is not just occasional. It becomes a constant backdrop. People with respiratory conditions are often hypervigilant to breathlessness, meaning even minor degrees of breathlessness can feel highly threatening. The body is primed to treat any change in breathing as a potential danger signal, which is why avoidance behaviour develops so quickly and so naturally.
But here is the important nuance: the same degree of breathlessness can produce completely different responses depending on the context around it. Lauren's favourite example is the Olympians during COVID, finishing their races with masks on. You could see them breathing hard, really hard, but behind those masks, they were smiling. They were at maximum breathlessness, and they felt no anxiety at all. Why? Because they knew exactly why they were breathless. They had context.
"It's not that you're saying, I just worked really, really hard and my lungs are having trouble keeping up," Lauren explains. "You're having the thought of, I'm going to die, or there's something wrong with me."
That shift in meaning, from effort to threat, is at the heart of what makes breathlessness so distressing for people living with respiratory conditions. The breathlessness itself hasn't changed. The thought attached to it has.
The Model: How Breathlessness, Thinking, Functioning and Breathing Interact
To make sense of how breathlessness becomes such a persistent and consuming experience, Lauren draws on the Cambridge Breathlessness Intervention Service model, a framework that is aligned with the Cognitive Behavioural Therapy (CBT) model. At the centre sits breathlessness itself. Around it, three interconnected circles each drive and are driven by that central experience, and together they create a cycle that can be very difficult to break.
The first circle is breathing. When breathlessness sets in, the body responds by increasing the work of breathing. Breaths become short and shallow, respiratory rate rises, dynamic hyperinflation can occur, and accessory muscles are recruited to help. These physical changes feed directly back into the sensation of breathlessness, making it worse.
The second circle is functioning. As breathlessness increases, physical deconditioning follows, including the chest wall and accessory muscles. People become more reliant on others, withdraw from activities, and decrease their movement overall. This reduction in activity worsens breathlessness over time.
The third circle is thinking. This is where the psychological dimension comes in most clearly. People begin to misattribute what is happening in their bodies, drawing on past experiences and associations. They focus on the physical sensations, have thoughts about illness or dying, and experience distress, anxiety, and fight-or-flight responses that feed straight back into breathlessness at the centre.
What makes the model particularly striking is the direction of the arrows. The three outer circles move clockwise, each one feeding into the next, and all of them feeding back into breathlessness at the centre. The breathlessness circle itself moves anticlockwise, pushing back against the other three, sustaining the cycle and making it harder and harder to step out of.
It is, in other words, a self-reinforcing loop. And understanding that loop is the first step to interrupting it.
The Avoidance Trap
One of the most significant and most understandable responses to breathlessness is avoidance. If something makes you feel like you can't breathe, the natural instinct is to stop doing it. But avoidance, Lauren explains, is one of the most powerful drivers of the breathlessness cycle.
"Avoidance is really, really common. And unfortunately, avoidance leads to deconditioning, which exacerbates that breathlessness cycle."
What makes avoidance particularly tricky is that it can be subtle and it can look like something else entirely. Someone might appear to be pacing themselves sensibly, or practising energy conservation, when what they are actually doing is avoiding breathlessness altogether. Lauren describes this as "masked avoidance", and she notes that the more you start looking for it, the more you find it.
One of the red flags she looks for is whether someone will only exercise in certain settings. A person who is willing to get breathless in a supervised pulmonary rehabilitation group but is completely sedentary at home may be using the safety of that environment as a crutch, avoiding any breathlessness that doesn't come with that safety net. Another indicator is someone who is consistently unwilling to work above a level 1 or 2 on the Borg scale, even when they are capable of more.
"It can be quite tricky, because pacing can sound like they're doing some energy conservation strategies — but really, looking into it, is it just masked avoidance?"
The Borg Scale: Finding the Green Zone
To help clients understand and monitor their own breathlessness, Lauren uses the Modified Borg Scale, a straightforward tool that measures breathlessness across ten levels, colour-coded into three zones.
The blue zone covers levels 0 to 1: nothing at all, very very slight, or very slight breathlessness. This is where most people sit when they are resting or sitting still. It is comfortable and familiar, but as Lauren puts it, for the purposes of addressing avoidance and building fitness, the blue zone is ineffective. Staying there feels safe, but it doesn't move anything forward.
The green zone covers levels 2 to 4: slight, moderate, and somewhat severe breathlessness. This is the equivalent of moderate intensity exercise, the zone where you can walk and talk but feel noticeably out of breath. It is also, crucially, the sweet spot. This is where exercise benefits are gained, where avoidance begins to be interrupted, and where confidence starts to build. The goal, simply put, is to get people working and staying in the green.
The red zone covers levels 5 to 10: severe through to maximal breathlessness. This is the zone likely to trigger panic and avoidance. Once someone is working at this level, the anxiety response kicks in, thoughts of dying or something being seriously wrong tend to emerge, and the cycle of fear and avoidance is most likely to be reinforced rather than broken.
One important caveat Lauren raises is around how people use the scale. Clients sometimes report being in the blue zone when their body language tells a different story: accessory muscles visible, unable to speak in full sentences. Part of the work is educating people on what each zone actually feels like and making sure they are anchoring the scale correctly.
"The subjective experience of breathlessness is very subjective — but when we're using a scale, we're still trying to anchor where they're using it correctly. Sometimes people think they're working in the green, but they're actually working much higher than that — and that's why every time they move, they trigger the anxiety response."
Getting Moving Again: Walking as Exposure Therapy
If avoidance is the problem, movement is the solution, but getting there requires a careful, confidence-building approach. This is where pacing comes in.
Lauren is direct about one thing: talking alone is not enough. Non-psychologists are often surprised to see her walking clients rather than sitting with them, expecting the work to happen in the cognitive space alone. But as Lauren is clear: anxiety will not reduce without the behavioural component. "Any breathlessness, it really isn't effective to just talk about it," she says. Walking, in this context, is exposure therapy to breathlessness. To address avoidance, you have to actually experience breathlessness in a safe, controlled, and carefully graduated way.
A physio Lauren worked with had a favourite saying that she has adopted as her own: less talking, more walking.
The starting point for pacing is always where the person already is. If someone is walking to the bathroom and back during the day, that is the baseline and that is where you start. Lauren describes the process of slowing people right down, often far more than they expect, and using positioning and equipment to support them.
"One really good tip for getting people to move when they're very breathless is each big movement. If I stand up, I've used the stored oxygen, and my lungs need to catch up. So a pacing technique might be — stand up, wait, and then walk."
From there, pausing at furniture along the way, using a four-wheeled walker, picking a distance they can manage and lapping it, always monitoring breathlessness and keeping to the green zone. If pacing breaks are needed, they count as part of the exercise time, not time out of it. "Those pacing breaks count in that 20 minutes," Lauren explains, "because you're still keeping at that moderate intensity."
The payoff, when it comes, tends to surprise people. "Often people are quite impressed by how not breathless they are when we do get them pacing," Lauren says. They are slower than they would like, and Lauren doesn't shy away from acknowledging that. But slower is exactly what is needed. Confidence builds first, and fitness follows.
A participant in the session raised an important question about the overlap between breathlessness and panic, noting that for people with respiratory conditions, panic is often triggered physiologically rather than cognitively. It's not a runaway thought that sets it off; it's a degree of breathlessness so severe that the thought "I'm going to die" follows almost automatically. Lauren's response was clear: "If we just get them not to get that breathless, if we just get them working in the green zone, then the triggers are not there."
Breathing Strategies: Focus on the Breath Out
Alongside pacing, Lauren introduces a range of breathing strategies, but with an important caveat for people with severe respiratory conditions. Many standard breathing techniques simply don't work for this group because their lungs cannot keep up. Breath holding and counting techniques may become distressing or impossible as a progressive condition worsens. Lauren's preference is always to set people up with strategies that can travel with them across the whole course of their illness, techniques they can use reliably whether they are relatively stable or significantly unwell.
The common thread running through all of her preferred techniques is a focus on the breath out, which is counterintuitive but makes physiological sense. Many people with conditions like COPD feel as though they cannot get air in. The reason, Lauren explains, is that their lungs are already full and hyperinflated. The solution is not to try harder to breathe in, but to focus on breathing out, creating a little more space for the breath in to follow.
"I don't time the breath or really force that breath out," she says. "All I do is ask people to focus and think about their breath out, and that in itself triggers something. You can see their shoulders start to relax, and they look different, and then they're like, oh yeah, the breath in is much better."
The first technique is relaxed breathing, simply dropping the shoulders, which tend to creep up as accessory muscles work harder throughout the day, and allowing each breath out to be a tiny bit longer than the breath in. It sounds almost too simple, but Lauren reports that clients consistently find it one of the most helpful strategies she offers. Carers can learn it quickly too, making it a practical tool for the whole support network.
The second is pursed lip breathing, sometimes called "smell the rose, cool the soup", where the lips are pursed on the breath out as though blowing through a whistle. For people with COPD specifically, there is a physiological mechanism behind this: the pressure created by pursing the lips helps to splint open the small airways, which become floppy and inelastic with the condition. For people with other respiratory conditions, the benefit is more cognitive. The act of focusing on the technique provides distraction and helps slow the breath naturally. It is, as Lauren describes it, a cognitive distraction as much as a breathing one.
The third is rectangle breathing, a simple visual technique where the person traces the edges of a rectangle with their eyes: breathe in on the short edge, breathe out on the long edge. A phone screen, a picture frame, a window; rectangles are everywhere. This is particularly useful for clients who have some degree of hypoxia or mild cognitive impairment, as it provides a simple, concrete cue that carers can also use in moments of distress. "Let's just trace the phone together" can make all the difference when panic is setting in.
One mistake Lauren flags is trying to move someone from a very fast respiratory rate to a very slow one too quickly. The brain, not getting enough oxygen, will simply ramp the breathing straight back up. The key is not to force the pace of slowing down. Just get them to switch their focus to the breath out, and let the calming happen gradually.
Practical Strategies: From the Shower to the Shops
Beyond pacing and breathing techniques, Lauren brings a refreshingly practical eye to the everyday challenges of living with breathlessness. One of the most common and most revealing is the shower.
The shower, it turns out, is a perfect storm of breathlessness triggers. Undressing takes effort. The humidity is challenging. The enclosed space, the sensation of water on the face, the movement of arms; all of it taxes the respiratory muscles simultaneously. Then there is getting dressed again on the other side.
The solution Lauren recommends most often is a shower chair, and she acknowledges the resistance it tends to meet. "The amount of discussions I've had with the shower chair," she says with a laugh. But her go-to response is simply to tell people that other clients keep telling her how helpful it is. She doesn't have to sell it. The evidence, she has found, sells itself.
A lightweight terry towelling robe is another simple but effective tip. It does most of the drying for you, reducing the effort of getting dressed post-shower. Choosing the best time of day for high-effort activities is another consideration. The broader principle, as Lauren frames it, is about energy conservation: being intentional about where you spend your limited capacity, and making sure it goes towards the things that matter most.
"I just want people to be able to do what they want to do for as long as possible. If that is mow the lawn, or hang the washing on the line — that's what the goal will be."
Treatable Traits: The Bigger Picture
Underlying all of these approaches is a concept Lauren returns to throughout her work: treatable traits. The idea, well established in respiratory medicine and increasingly influential across health more broadly, is that within any chronic condition there are aspects that cannot be changed and aspects that can. Identifying and targeting those treatable traits is where meaningful and lasting progress becomes possible.
Alongside fitness, anxiety, energy conservation and pacing, Lauren also highlights nutrition and medication as key treatable traits, both of which can have a direct and significant impact on breathlessness.
Nutrition is particularly relevant because people with respiratory conditions often lose weight rapidly, as the muscles involved in breathing are working so hard. Supporting good nutrition, or connecting clients with a dietitian, is a direct way of supporting breathlessness management.
Medication is the other area worth close attention, with a particular focus on salbutamol, commonly known as Ventolin. Salbutamol is frequently overused, and when used too often, it can actually increase heart rate and trigger breathlessness. Someone going through two inhalers a week, Lauren notes, needs a respiratory review.
Together, these six traits offer a way of looking at the whole person, not just their lungs, and asking: where can we actually make a difference here?
The Role of Carers
For people with severe or progressive breathlessness, carers play a crucial role, and Lauren is clear that involving them in the intervention can make a significant difference to outcomes.
Some of the best results Lauren has seen have been when carers come along to the sessions as well. Carers receive the same information about the condition, about pacing, about breathing strategies. They become the person who can cue a calming response when panic sets in, because once someone is panicking, they cannot think straight.
Simple things make a big difference. A Borg scale attached to a four-wheeled walker, right there in view. A planned route through the shops, with specific chairs identified as rest stops. A carer who knows to say "let's just trace the phone together" when breathing becomes frightening.
"It's such a temptation to rush. Having someone to remind them — to kind of cue it — is where carers can be really helpful."
When It All Comes Together
At the end of the session, one of the attending professionals shared a case that brought everything Lauren had presented to life. A client with severe COPD had come to them terrified, afraid to move, reluctant to go out, her world shrinking around her breathlessness.
Using the Borg scale as a starting point, the psychologist worked through each zone with her, not in the abstract, but in relation to her own life. What did the blue zone feel like for her? What did the green zone look like in her day? How did each level of breathlessness map onto her activities at home? She was able to describe it all. And with that understanding, she had a tool she could use herself.
The change that followed was significant. She began moving. She started going out. She visited her family. She cooked for them.
Lauren's response said it all: "It's such a buzz when they start to do what they want to do."
That, in a sentence, is what the work is for. Not eliminating breathlessness, because for many people that is not possible. But interrupting the cycle of fear and avoidance that turns breathlessness into a prison. Slowing down enough to find the green zone. Building confidence, one careful step at a time.
As Lauren puts it: "It's just getting them over that first bit, which sounds like an easy thing. But it's not an easy thing."
