Robby B. Echavez, MAEd, RPm, RPsy, MAGC (cand.)
The many symptoms that have been associated to COVID-19 continue to befuddle. Among the most alarming ones are multisystem inflammatory syndrome in children or MIS-C first brought into wide public view by the Center for Diseases Control (https://www.cdc.gov/mis-c/cases/index.html) in the US and the impact of the virus on the brain and the nervous system. Both rare conditions, they have captured public attention, not to mention, terror, over what it reveals– that we know very little about SARS-Cov-2.
What we do know, beyond a shadow of a doubt is that COVID-19 is principally one that involves severe acute respiratory syndrome, that is at the expense of oversimplification, it affects breathing. We will have to revert to this and remind ourselves of this brazen truth. More than anything, COVID-19 is a respiratory condition.
Why is this an important reminder? Two reasons. First, oxygen and its role in sustaining the body and life itself. Second, breathing as the penultimate regulatory function. Beyond some seconds or minutes of anaerobic respiration that produces lactic acid and results in cramping and fatigue, cellular respiration becomes impossible without oxygen. Prolonged O2 deprivation halts the production of ATP or energy in the body at the cellular level and disallows vital organ functions (think MIS-C). Before long, a human passes out (think brain and nervous system effects) and eventually dies.
Respiration can be labored or pressured and when the breath is unable to catch up with the body’s energy requirements, one can feel lightheaded, exhausted, dizzy, and generally unwell (think COVID-19). Put another way, the healthy way, when one breathes well, one feels well. This is the reason why we need to put in mind that COVID-19 is primarily respiratory in nature. Keeping ourselves aware of this gives us an important advantage in treatment and recovery from the disease.
To apply this orientation to focus on the psychological front, consider the many behavioral implications of COVID-19. A study that appeared very recently in the Brain, Behavior, and Immunity Journal indicates that among COVID-19 survivors 42% qualify for an anxiety diagnosis, 31% for depression, and 28% self-rated as experiencing psychopathological symptoms related to PTSD. When one comes to think about it, these three high-burden, non-communicable diseases involve respiratory markers such as shortness of breath, heaviness on the chest, chest tightening, having a lump in the throat, mouth dryness, and rapid breathing, to mention a few. Testimony from a patient, cited in the same study, goes
“After three weeks of treatments, I was healing from COVID, at home, had no fever, and just a little cough. But sometimes at night, my breath could go away all of a sudden, making me feel as if I was to die. I knew what it was because I had suffered from panic attacks in the past. I stayed there out on the balcony, for hours, trying to put fresh air into my lungs. It was terrible. Panic made me suffer more than COVID.”
This is why we need to remember that COVID-19 is largely a respiratory condition. Our best chance of healing and recovery from the disease lies in the much-explored and already abundantly-studied area of breathing as a therapeutic technique for individuals suffering from depression, anxiety, and PTSD (Creswell, 2017), whether it is part of the disease sequelae of COVID-19, psychiatric outcomes from having survived the disease, or risks that are raised in connection with it and its multifarious and multi-level effects.
Breathing exercises form part of every psychotherapists’ repertoire and could not be more useful and relevant as we respond and recover from the pandemic. While the world scrambles to develop a vaccine and as increasingly complicated pharmacological and non-pharmacological treatments are being devised, breathing it would seem is being set aside, when in fact, as I have stressed many times in this write-up, it stands to have the best efficacy as it fundamentally addresses COVID-19, the scare attached to it, and the stress that derives from it.
Now, more than ever, we should be expanding and deepening breath work as a core of the psychotherapeutic treatments to COVID-19. Below are three clinical vignettes that are followed by suggested breathing techniques.
Matt is 13 years old. Recently he has experienced anxiety attacks that have involved vomitting, abdominal discomfort, and breathing difficulties. The distal cause of his sudden bout with anxiety is him witnessing an uncle stab himself atop a coconut tree at an apparent suicide. Matt has improved significantly after his parents were encouraged to take a walk with him. He also claims to engage in thought replacement. He was taught to do deep breathing following 5 seconds of in-breath, a 5-second hold, and 5 seconds of release. He was asked to do this while tapping his belly and the temples of his head. He has not had an attack in 3 days after these teachniques were implemented.
Mike was a confirmed COVID-19 case in a foreign land. He has been stranded there since the pandemic, killing several compatriots. He was one of the last to recover from his group. He felt guilty over his slow pace of healing, hounded by the thought of infecting others. Although he has tested negative for the virus, he has been suffering from attacks of shakiness, weakness, and breathing difficulty. He has had frequent hunger pangs and for a time reported waking up in a fright, losing his breath. He has been taught the basics of deep breathing, reminded to take calm breaths in and out of his nose, holding to it for at least 3 seconds in between breathing cycles.
Jay had a difficult brush with COVID-19. Since his recovery he has been mostly sleepless and agitated. When he talks there are times he seems to be catching his breath. He has done some some psychotherapeutic work focusing on his life tasks. He has engaged in taking stock of his past and working with losses, regrets, and opportunities. He will be taught the rudiments of deep breathing. This will be coupled with an imagery sequence and a prolonged exhale.
Breathing will likely play a key role in helping people with psychological symptoms and morbidities from COVID-19 and Covid stress. It will require more exploration, how breathing affects the psychoneuroendocrinimmunology (PNEI) systems in relation to the SARS-Cov-2 infection and the stress associated to it. Chances are, as much as breathing has been a regulatory function par excellence in alleviating panic, anxiety, toxic and chronic stress, and depression, through nuanced and complicated PNEI pathways, it will bring a breath of fresh air for those who are now inexplicably suffering from the pandemic.
Creswell, J. D. (2017). Mindfulness interventions. Annual Review of Psychology, 68, 491-516.
Mazza, M. G., De Lorenzo, R., Conte, C., Poletti, S., Vai, B., Bollettini, I., Melloni, E. M. T., Furlan, R., Ciceri, F., Rovere-Querini, P. (2020). Anxiety and depression in COVID-19 survivors: Role of inflammatory and clinical predictors. Brain, Behavior, and Immunity,
Nigam, M., & Gupta, S. (2020, July 31). We’re only just beginning to learn how the coronavirus affects the brain. Retrieved from https://www.msn.com/en-us/health/medical/were-only-just-beginning-to-learn-how-the-coronavirus-affects-the-brain/ar-BB17lnrz