Using heart-sense when working with anxiety and panic. I also talk about the James-Lange theory of emotions, pranayama, HRV and more.
Becoming the Heart Whisperer
Anxiety is the most common presentation I see in my psychotherapy practice. Humans are anxious. And those unrelenting pangs of anxiety feel awful.
The good news, however, is that anxiety can be resolved through therapy. I love this work because it is some of the integration of neuroscience and psychotherapy at its best. Neuroscience insight has made a huge difference in how we understand and work with anxiety.
Recently, I began working with Chris, a client experiencing a debilitating, quasi-permanent state of anxiety that occasionally leads to panic attacks.
Anxiety can be sneakily deceptive. Its most obvious manifestation may be in our relentless thoughts and overthinking. And Chris was no exception for that. At first all he could say was: "My thoughts keep racing. I keep overthinking everything".
Yet, in my experience, anxiety really 'hides'* in the body. Trying to ‘attack’ the thoughts alone is like trimming the leaves of Japanese knotweed - it just keeps growing back. To truly do away with this weeds, you have to go for the roots, and only then does it stop growing. Similarly, the key to working with anxiety, at least for me, lies in resolving it within the body. The mind, generally speaking, will follow.
It essentially comes down to the classic conundrum of what would actually happen if one were to see the bear and start running:
Are you running because you are afraid, or you are afraid because you are running.
In other words, what comes first: the body state or the mental state?
The former epitomises the Cannon-Bard theory and the latter the James-Lange theory of emotions.
While I guess the truth lies somewhere in between, I am with James-Lange on this when it comes to finding the best heuristic for working with anxiety in therapy. Generally speaking. The effective use of beta-blockers in the treatment of anxiety supports this heuristic. All beta-blockers ever do is manage heart rhythms by binding to receptors in the brain that regulate the heartbeat.
Calm body, calm thoughts.
As Chris got to know his anxiety better, beyond the racing thoughts, we came to realise that the first telltale sign of his anxiety was his heartbeat. The slight flutter would be early warning sign, as though his anxiety was saying, 'Hello Chris, I’m taking you on this dreadful ride now, and there is nothing you can do about it'. Early mornings, already feeling anxious, with his heart beating with a sense of impending urgency. When a panic attack was looming, his heart would spiral out of control.
So, the heart it was. The heart-sense was the way to go for our work.
And a cool new paper on cardioception came in serendipitously handy...
What is Cardioception
The sense that gives us access to this information consciously is called interoception. It is a sense of our internal states. States like pain, hunger, thirst, heartbeat, tension, calm, general arousal.
And what is cardioception? According to the authors, it is a specialised domain of interoception that focuses on interoceptive signals coming from the heart, who note that the understanding the 'heart-brain interactions have significant implications for understanding autonomic regulation, emotional processing, and behaviour'.
In the view of my work with Chris, I could not agree more. It was bang on what we needed.
The Neuroscience Bit: The Insula, Heartbeat and Anxiety
The areas of the brain considered key for interoceptive processing are the thalamus, which receives signals from the sympathetic and parasympathetic systems, and the insula, which is involved in the cortical integration of interoceptive information.
Interoception in general, and cardioception in particular, are classic examples of bottom-up regulation.
The paper provides further support for the relationship between anxiety and cardioception, drawing on insights from animal studies. One study showed that mice induced into a state of increased heart rate through the experimental design exhibited behavioural correlates of anxiety in mice. The study also demonstrated that inhibiting parts of the insula involved in cardioception stopped these anxious behaviours in the poor little mice.
These, of course, should be taken with a pinch of salt, as the animal models for anxiety does not fully reflect the human mental state and the translation of conclusions between the two can be questioned and questionable. That caution in mind, these results do provide an interesting further indication of the existence of the link between cardioception and anxiety.
At this point, Chris and I didn’t need any more convincing; we needed to start working on leveraging that link.
Just Breathe: Interaction Between Pulmoception and Cardioception
And that’s when pulmoception comes into play. Just as cardioception is the interoception of the heart, pulmoception is the interoception of lung activity, i.e., breathing.
Luckily for us, pulmoception (the awareness of breathing) and cardioception (the heart-sense) overlap in their neural mechanisms and can influence each other.
And here comes the beautiful twist:
We cannot directly influence our heart, but we can, volitionally, influence our breathing. And this gives us the way into the heart. That is the invaluable lever to gain control over our heartbeat and ultimaltely our states of anxiety. That is, in a nutshell, the secret weapon of any pranayama practice.
Take, for instance, the respiratory sinus arrhythmia. It sounds like something that is wrong with us, but in fact it is a normal physiological phenomenon characterised by heart rate increases during inspiration and decreases during expiration. It is mediated through the vagus nerve.
The slowing down during the expiration is mediated by the parasympathetic nervous system while the heart rate increase during the inspiration is mediated by the sympathetic nervous system.
Extending the logic would want it then, that longer the expiration, longer the parasympathetic activation. While I’m not 100% sure that this chain of inference is entirely accurate, I use it as a heuristic to help clients indirectly affect their heart rate by lengthening their outbreath, sometimes to quite extreme(ish) proportions.
The empirical wisdom from breathwork practices and yoga suggests that practicing abdominal breathing slows the breath and promotes a general state of calm (try candle breathing). This aligns with my experience.
Now, being the neurogeek that I am, and using all sorts of gadgets on myself and my clients, I know that abdominal, slow breathing also significantly slows down the heart rate. In fact, just one minute of this intentional breathing can reduce the heart rate by 10 BPM.
I read somewhere that the abdominal breathing is so effective for calming down because it being deeper, activates the lower areas of the lungs supposed to be more innervated by parasympathetic nerves, but I could not really find a solid reference for that claim.
Or could it be the case that abdominal breathing simply slows down the breathing pattern, which then in turn affects the heart rate?
I do not know. If you are reading these lines and know something about this - please let me know, I would really love to know more and understand.
And while I don't understand it (yet), I know it is effective.
So...if you are feeling anxious, if your heart is racing, or it flutters:
listen to your heart...and then breathe. Become your own heart whisperer.
If you are working with the kind of approach I describe above or you are using HRV (heart rate variability, which is related to the respiratory sinus arrhythmia) in your work with clients, I would love to hear your experience - feel free to reach out either via comments below or email.
As always, thank you for reading. For updates you can follow me on BlueSky or Twitter or subscribe to my mailing list.
*I use the word hiding metaphorically. What I mean by it is that the body is in a state of a heightened sympathetic arousal.
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