Breathwork as Somatic Therapy: From Pranayama to Polyvagal Regulation

Category: Somatic Therapy / Breathwork | Level: Serpent (South) to Eagle (East) — Medicine Wheel

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The Breath as the Bridge

Of all the body’s autonomic functions — heart rate, blood pressure, digestion, immune activity, hormonal secretion — breathing is unique. It is the only autonomic function that is also under voluntary control. You cannot directly command your heart to slow or your adrenals to stop producing cortisol. But you can change your breath. And when you change your breath, you change the autonomic nervous system’s state — which changes heart rate, blood pressure, cortisol output, immune function, and virtually every physiological parameter that the nervous system regulates.

The breath is the bridge between the voluntary and involuntary nervous systems. It is the interface through which conscious intention can directly modulate autonomic function. Every contemplative tradition in human history has recognized this and developed breathwork practices to exploit it: pranayama in yoga, qi cultivation in qigong, hesychastic breathing in Orthodox Christianity, rhythmic chanting in Sufi dhikr, breath-focused meditation in Buddhism.

Modern neuroscience is now explaining what these traditions have practiced for millennia: how specific breathing patterns activate specific neural pathways, producing predictable changes in brain activity, autonomic regulation, emotional state, and even immune function. Breathwork is not merely relaxation. It is a precision tool for autonomic nervous system regulation — and therefore, a somatic therapy with profound implications for trauma resolution, functional medicine, and integrative practice.

The Physiology of Breath and Autonomic Regulation

Respiratory Sinus Arrhythmia

Respiratory Sinus Arrhythmia (RSA) is the natural variation in heart rate that occurs with breathing: heart rate increases slightly during inhalation (sympathetic activation) and decreases during exhalation (parasympathetic activation via the vagus nerve). RSA is the physiological expression of the vagal brake described by Stephen Porges — the myelinated vagus nerve’s tonic influence on heart rate.

RSA is the mechanism through which breathing directly modulates autonomic state. When you inhale, the vagal brake is momentarily released and heart rate increases. When you exhale, the vagal brake re-engages and heart rate decreases. By manipulating the ratio of inhalation to exhalation, you can directly shift the balance between sympathetic and parasympathetic activation:

• Extended exhalation (exhale longer than inhale): Increases vagal tone, promotes parasympathetic dominance, produces calming
• Extended inhalation (inhale longer than exhale): Increases sympathetic activation, promotes alertness and energy
• Equal breathing (inhale and exhale equal length): Balances sympathetic and parasympathetic, promotes homeostasis

The Baroreflex

The baroreflex is a neural feedback loop that modulates blood pressure through heart rate adjustment. Baroreceptors in the carotid arteries and aortic arch detect changes in blood pressure. When blood pressure rises (during inhalation, as increased thoracic pressure reduces venous return), the baroreflex triggers heart rate reduction through vagal activation. When blood pressure falls (during exhalation, as reduced thoracic pressure increases venous return), the baroreflex allows heart rate to increase.

Lehrer and Gevirtz (2014), in their review “Heart rate variability biofeedback: How and why does it work?”, demonstrated that breathing at approximately 6 breaths per minute (0.1 Hz) produces maximum resonance between the respiratory cycle and the baroreflex cycle. At this frequency, the two oscillators synchronize, producing dramatic increases in heart rate variability — the single best biomarker of autonomic flexibility and vagal tone.

This finding provides the physiological basis for “coherent breathing” and explains why breathing at 5-6 breaths per minute is the optimal rate for autonomic regulation.

CO2 Tolerance and the Bohr Effect

Carbon dioxide (CO2) is not merely a metabolic waste product. It is a critical regulator of the body’s acid-base balance, a vasodilator (it relaxes blood vessel walls, improving circulation), and — through the Bohr effect — a modulator of hemoglobin’s oxygen-releasing capacity. The Bohr effect describes how increased CO2 (lower pH) causes hemoglobin to release oxygen more readily to the tissues. Conversely, decreased CO2 (higher pH, as in hyperventilation) causes hemoglobin to hold onto oxygen more tightly — reducing oxygen delivery to the tissues even though blood oxygen saturation may be normal.

Chronic stress and anxiety typically produce habitual hyperventilation — rapid, shallow, chest-dominant breathing that blows off excessive CO2, producing respiratory alkalosis. This reduces oxygen delivery to the tissues (Bohr effect), constricts cerebral blood vessels (CO2 is a cerebral vasodilator; its depletion produces vasoconstriction), and maintains sympathetic activation (the brain interprets the resulting tissue hypoxia as threatening).

Breathwork practices that slow the breathing rate and reduce minute ventilation allow CO2 levels to normalize. This restores the Bohr effect (improving tissue oxygenation), dilates cerebral blood vessels (improving brain oxygenation), and supports parasympathetic activation (the brain no longer detects a hypoxic threat).

Coherent Breathing (Stephen Elliott)

Stephen Elliott, a researcher and breathwork developer, introduced “Coherent Breathing” — a practice of breathing at a rate of approximately 5 breaths per minute (6-second inhale, 6-second exhale) that produces optimal heart rate variability and autonomic balance.

The Practice

1. Posture: Seated upright, spine elongated, shoulders relaxed
2. Breathing: Through the nose (nasal breathing activates the parasympathetic nervous system through stimulation of the nasal mucosa and production of nitric oxide)
3. Rate: Inhale for approximately 6 seconds. Exhale for approximately 6 seconds. (Some individuals may find 5 or 5.5 seconds more comfortable; the optimal rate varies slightly by individual.)
4. Depth: Gentle, comfortable — not deep forced breathing. The diaphragm moves naturally. The belly expands on inhalation and contracts on exhalation.
5. Duration: Begin with 5 minutes. Build to 20 minutes.
6. Consistency: Daily practice. The autonomic benefits accumulate with consistent practice.

Physiological Effects

Elliott’s research and the subsequent work of Lehrer, Gevirtz, and others demonstrate that coherent breathing at ~5 breaths per minute produces:

• Maximum heart rate variability (the respiratory cycle synchronizes with the baroreflex at 0.1 Hz)
• Increased vagal tone (extended, rhythmic exhalation repeatedly engages the vagal brake)
• Decreased sympathetic activation (reduced cortisol, reduced muscle tension, reduced sweat gland activity)
• Improved gas exchange (optimal CO2 levels, improved Bohr effect, improved tissue oxygenation)
• Emotional regulation (the neurological calm produced by high vagal tone supports prefrontal cortex function, reducing amygdala reactivity)

Clinical Applications

Coherent breathing is the most accessible breathwork technique for trauma populations because it does not require intense or altered breathing patterns. It is gentle, predictable, and rhythmic — qualities that activate the ventral vagal system without triggering sympathetic defense.

For clients who cannot tolerate even gentle breathing practice (because attention to the breath triggers panic or dissociative responses — common in complex trauma), the practice can be introduced through auditory pacing (following a tone or metronome) rather than body-focused instruction, or through movement-based breathing (synchronizing breath with slow walking or gentle rocking).

Box Breathing (Tactical Breathing)

Box breathing — also called “square breathing” or “tactical breathing” — is a four-phase breathing technique used by military special operations, emergency medicine, law enforcement, and high-performance athletics:

1. Inhale for 4 counts
2. Hold (lungs full) for 4 counts
3. Exhale for 4 counts
4. Hold (lungs empty) for 4 counts
5. Repeat

Physiological Mechanism

Box breathing differs from coherent breathing in its inclusion of breath holds. The holds produce several effects:

Full-lung hold: Increases thoracic pressure, stimulating baroreceptors and triggering the baroreflex. The subsequent release of pressure on the exhale produces a pronounced parasympathetic shift. The hold also allows CO2 to accumulate slightly, increasing CO2 tolerance and triggering the Bohr effect.

Empty-lung hold: Creates a brief, controlled stress — the body registers the cessation of air supply and the beginning of CO2 accumulation. This activates a mild sympathetic response, which is then resolved by the subsequent inhale. The cycle of controlled stress and resolution builds autonomic resilience — the nervous system practices moving between activation and settling.

Clinical Applications

Box breathing is particularly useful for acute stress management — moments of panic, anger, or overwhelm when immediate autonomic regulation is needed. Its structured, counting-based format provides cognitive engagement that competes for working memory resources (similar to EMDR’s dual-attention mechanism), reducing the vividness and emotionality of distressing experiences.

For trauma clients, box breathing can serve as a Phase 2 stabilization resource in EMDR, a grounding technique in SE, or a self-regulation tool that parts can use in IFS when Firefighter activation threatens to overwhelm the system.

Sudarshan Kriya Yoga (SKY)

Sudarshan Kriya Yoga, developed by Sri Sri Ravi Shankar, is a cyclical breathing technique that involves sequential breathing patterns of varying rates: slow breathing (ujjayi pranayama at 2-4 breaths per minute), medium breathing (bhastrika-like bursts), and fast cyclical breathing (Sudarshan Kriya proper at varying rates of 20-30 breaths per minute).

Brown and Gerbarg’s Research

Richard Brown and Patricia Gerbarg, psychiatrists at Columbia University, conducted extensive research on SKY and related breathing techniques, publishing their findings in multiple peer-reviewed papers and their 2012 book The Healing Power of the Breath.

Brown and Gerbarg (2005) published a comprehensive review of the neurophysiology of yogic breathing practices, proposing that controlled breathing techniques modulate autonomic function through multiple pathways:

1. Vagal afferent stimulation: Slow, deep breathing stimulates pulmonary stretch receptors that send vagal afferent signals to the brainstem, activating the parasympathetic nervous system
2. Baroreceptor stimulation: Changes in thoracic pressure during breathing stimulate arterial baroreceptors, modulating heart rate through the baroreflex
3. Central nervous system effects: Breathing patterns directly influence the locus coeruleus (the brain’s primary norepinephrine center), which modulates arousal, attention, and stress response
4. GABAergic effects: Yogic breathing increases GABA (gamma-aminobutyric acid) activity in the brain (Streeter et al., 2012), producing anxiolytic effects without medication

Brown and Gerbarg’s clinical research demonstrated that SKY produced significant improvements in PTSD symptoms, depression, anxiety, and insomnia in populations including tsunami survivors (Descilo et al., 2010), veterans (Seppälä et al., 2014), and individuals with treatment-resistant depression.

Seppälä and colleagues (2014) conducted a randomized controlled trial of SKY in veterans with PTSD and found clinically significant reductions in PTSD symptoms, anxiety, and startle response. Critically, the veterans also showed normalized cortisol patterns — the HPA axis dysfunction associated with PTSD improved through breathwork alone.

Holotropic Breathwork (Stanislav Grof)

Holotropic Breathwork, developed by psychiatrist Stanislav Grof and his wife Christina Grof in the 1970s, uses prolonged hyperventilation (accelerated breathing at 2-3 times the normal rate) combined with evocative music and focused bodywork to induce non-ordinary states of consciousness.

The Non-Ordinary State

Grof developed Holotropic Breathwork as a legal alternative to LSD-assisted psychotherapy after psychedelic research was prohibited. He observed that prolonged hyperventilation produced altered states of consciousness remarkably similar to those produced by psychedelics: vivid imagery, emotional catharsis, access to early and perinatal memories, transpersonal experiences, and spontaneous resolution of psychological and somatic symptoms.

Physiological Mechanism

The altered state produced by Holotropic Breathwork is primarily mediated by respiratory alkalosis — the increase in blood pH produced by hyperventilation-driven CO2 depletion. Respiratory alkalosis produces:

• Cerebral vasoconstriction: Reduced blood flow to the cortex, particularly the prefrontal cortex. This reduces the activity of the brain’s executive and censoring functions, allowing unconscious material to surface.
• Increased neural excitability: Alkalosis reduces the firing threshold of neurons, increasing the brain’s overall excitability and producing the heightened sensory, emotional, and imaginal activity characteristic of the holotropic state.
• Tetany and spasmophilia: The alkalosis-induced shift in ionized calcium can produce tingling, muscle spasms, and carpopedal spasm (involuntary contraction of the hands and feet). In Grof’s framework, these are viewed as somatic manifestations of held tension being released.
• Endogenous neurochemical changes: Prolonged hyperventilation may trigger the release of endogenous dimethyltryptamine (DMT) and other psychoactive compounds, though this hypothesis remains speculative.

Clinical Considerations

Holotropic Breathwork is not a gentle practice. It is a powerful, potentially destabilizing intervention that should only be conducted in a structured setting with trained facilitators. Contraindications include:

• Cardiovascular disease (the respiratory alkalosis and sympathetic activation can stress the cardiovascular system)
• Epilepsy (the increased neural excitability can lower the seizure threshold)
• Pregnancy
• Active psychosis (the non-ordinary state can exacerbate psychotic symptoms)
• Severe dissociative disorders (the altered state can trigger uncontrolled dissociation)

For trauma populations, Holotropic Breathwork presents a paradox: it can produce profound processing and resolution of traumatic material, but the intensity of the experience — the loss of ordinary consciousness, the emergence of powerful emotions and body sensations — can also overwhelm a fragile system. SE’s principle of titration suggests that approaches like Holotropic Breathwork should be reserved for individuals with sufficient Self-energy (IFS), sufficient ventral vagal capacity (polyvagal), and sufficient window of tolerance (SE) to contain the experience.

The Wim Hof Method

Wim Hof, a Dutch athlete known for his extraordinary cold tolerance, developed a method combining cyclic hyperventilation, breath retention, and cold exposure.

The Breathing Protocol

1. 30-40 deep breaths: Rapid, deep inhalations followed by passive exhalations. Approximately 30-40 cycles.
2. Breath retention (lungs empty): After the last exhalation, hold the breath for as long as comfortably possible (typically 1-3 minutes). The prior hyperventilation has reduced CO2, delaying the urge to breathe.
3. Recovery breath: Inhale deeply, hold for 15-20 seconds, then exhale.
4. Repeat: 3-4 rounds.

Physiological Effects

Kox and colleagues (2014), in a landmark study published in the Proceedings of the National Academy of Sciences, demonstrated that the Wim Hof Method produced measurable effects on the immune system. Participants trained in the method showed:

• Increased epinephrine (adrenaline) levels during the breathing practice — a controlled sympathetic activation
• Increased production of anti-inflammatory cytokine IL-10
• Decreased production of pro-inflammatory cytokines TNF-alpha, IL-6, and IL-8
• Reduced symptoms when experimentally exposed to bacterial endotoxin (a model of systemic inflammation)

This was the first controlled demonstration that a voluntary breathing practice could modulate the innate immune response — a finding that was previously considered impossible. The mechanism appears to involve the controlled sympathetic activation produced by the hyperventilation phase, which triggers the release of anti-inflammatory mediators.

Implications for Functional Medicine

The Wim Hof Method’s demonstrated capacity to modulate inflammation has direct implications for the stress-disease cascade described in the functional medicine bridge article. Chronic inflammation — driven by autonomic dysregulation, gut permeability, and HPA axis dysfunction — is the common pathway to chronic disease. A breathing practice that can directly reduce pro-inflammatory cytokines while increasing anti-inflammatory mediators represents a non-pharmacological intervention for the inflammatory component of the cascade.

However, the practice’s intensity (hyperventilation plus cold exposure) places it at the activating end of the breathwork spectrum. For trauma populations with sympathetic hyperactivation, the controlled sympathetic stimulus may be re-triggering rather than therapeutic. Clinical judgment is required: the Wim Hof Method may be appropriate for individuals with sufficient autonomic flexibility (adequate ventral vagal capacity) who need to develop CO2 tolerance and immune regulation. It is not appropriate for individuals in dorsal vagal collapse or sympathetic hyperactivation without adequate stabilization.

Zaccaro’s Systematic Review

Andrea Zaccaro and colleagues (2018) published a systematic review of the effects of slow breathing on autonomic and central nervous system activity. Reviewing 15 studies, they found that slow breathing (typically at rates below 10 breaths per minute, with optimal effects at 5-6 breaths per minute) consistently produced:

• Increased heart rate variability: The primary marker of vagal tone and autonomic flexibility
• Increased alpha brain wave activity: Associated with calm alertness and the relaxation response
• Decreased cortisol levels: The primary stress hormone
• Increased theta brain wave activity: Associated with meditative states, memory consolidation, and emotional processing
• Increased comfort and relaxation ratings: Subjective wellbeing improved alongside physiological changes

Zaccaro’s review concluded that slow breathing techniques produce their effects through the “bottom-up” pathway: the breathing pattern directly modulates brainstem nuclei (particularly the pre-Bötzinger complex and the locus coeruleus), which then modulate cortical activity and emotional state. This is a somatic intervention — it works from body to brain, not from mind to body.

Gerritsen and Band: Contemplative Breathing Across Traditions

Roderik Gerritsen and Guido Band (2018), in their comprehensive review “Breath of Life: The Respiratory Vagal Stimulation Model of Contemplative Activity,” proposed a unifying model for how breathing-based contemplative practices across traditions produce their physiological and psychological effects.

Their “Respiratory Vagal Stimulation” (RVS) model proposes that all effective contemplative breathing practices — pranayama, qigong breathing, Zen breathing, Christian contemplative breathing, Sufi breathing — share a common mechanism: vagal afferent stimulation through controlled breathing, producing:

1. Activation of the ventral vagal complex
2. Modulation of the locus coeruleus-norepinephrine system
3. Increased GABA activity
4. Decreased amygdala reactivity
5. Enhanced prefrontal cortex-amygdala connectivity

This model unifies the physiological understanding of breathing practices across cultures and traditions, supporting the hypothesis that different cultures discovered the same neurobiological pathway through independent exploration.

Pranayama Connection

The yoga library in this collection covers pranayama in detail. Here, we note the key connections between pranayama and the somatic therapy framework:

Nadi Shodhana (Alternate Nostril Breathing): This practice — inhaling through one nostril while closing the other, then switching — has been shown to balance autonomic function, increasing heart rate variability and producing equal activation of left and right hemispheres (Telles et al., 1994). The bilateral nasal stimulation may activate the same bilateral processing mechanisms that EMDR employs, though through a different sensory channel.

Kapalabhati (Skull-Shining Breath): Rapid, forceful exhalations with passive inhalations. This practice is sympathetically activating (similar to the Wim Hof hyperventilation phase) and may serve to mobilize frozen sympathetic energy (similar to SE’s facilitation of sympathetic discharge). In TCM terms, Kapalabhati moves stagnant qi in the Lung and Liver meridians.

Bhramari (Humming Bee Breath): Exhalation with a humming sound. The vibration stimulates the vagus nerve directly (the vagus innervates the larynx) and produces nitric oxide in the nasal sinuses (Weitzberg & Lundberg, 2002), a vasodilator and neurotransmitter modulator. Bhramari is one of the most directly vagal-stimulating practices available.

The Four Directions in Breathwork

Serpent (South): The breath is the body’s most fundamental rhythm. The Serpent’s medicine is the recognition that the body’s intelligence — expressed through breath — is the primary instrument of healing. Every breathwork practice begins and ends with the body.

Jaguar (West): Breathwork can surface powerful emotions — grief, rage, terror — as the autonomic nervous system shifts state. Holotropic breathwork explicitly facilitates this emotional surfacing. Even gentle coherent breathing can bring tears as the nervous system releases its chronic holding. The Jaguar’s courage is required to breathe through the emotions that emerge.

Hummingbird (North): The altered states produced by intensive breathwork — holotropic, Wim Hof, deep pranayama — access transpersonal dimensions of experience. Grof’s participants reported experiences of birth, death, past lives, archetypal encounters, and cosmic unity. The Hummingbird’s soul journey is facilitated by the breath’s capacity to open doors of perception.

Eagle (East): The witness. The person who can observe their own breath without controlling it — who can watch the breath breathe itself — has achieved the Eagle’s perspective. This witnessing awareness is the foundation of mindfulness meditation and the ultimate integration of breathwork as somatic therapy: not doing the breathing, but being breathed.

Clinical Protocol: Breathwork for Trauma Populations

Assessment

Before introducing breathwork, assess:

1. Relationship to breath: Can the client tolerate attention to their breathing? For some trauma survivors, the breath is a trigger — attention to breathing produces panic or dissociation. These clients need gradual, titrated introduction to breath awareness.

2. Autonomic baseline: Is the client in chronic sympathetic hyperactivation (rapid, shallow breathing, elevated heart rate) or dorsal vagal hypoactivation (barely perceptible breathing, low heart rate, dissociation)? The breathwork approach must match the client’s autonomic state.

3. Window of tolerance: How much activation can the client tolerate before becoming overwhelmed? Intensive breathwork (holotropic, Wim Hof) is only appropriate for clients with sufficient window of tolerance.

Sequencing

Phase 1 — Breath awareness only (no intervention): “Just notice your breath. Don’t try to change it. Where do you feel it? What is its natural rhythm?”

Phase 2 — Gentle coherent breathing: 5-6 breaths per minute, equal inhale and exhale. 5-10 minutes daily. Build tolerance gradually.

Phase 3 — Extended exhalation: Inhale for 4 counts, exhale for 6-8 counts. This increases vagal tone and produces calming for sympathetically activated clients.

Phase 4 — Box breathing: When the client can tolerate breath holds. 4-4-4-4 progressing to 5-5-5-5 or 6-6-6-6.

Phase 5 — Integrated breathwork: Pranayama techniques, rhythmic breathing with movement, breathwork combined with bilateral stimulation, breathwork combined with body awareness (SE tracking).

Phase 6 — Intensive breathwork (if appropriate): Holotropic breathwork, extended Wim Hof protocol, deep pranayama sequences. Only for clients with demonstrated autonomic flexibility, adequate Self-energy, and therapeutic support.

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References

Brown, R. P., & Gerbarg, P. L. (2005). Sudarshan Kriya yogic breathing in the treatment of stress, anxiety, and depression: Part I — neurophysiologic model. Journal of Alternative and Complementary Medicine, 11(1), 189-201.

Brown, R. P., & Gerbarg, P. L. (2012). The Healing Power of the Breath: Simple Techniques to Reduce Stress and Anxiety, Enhance Concentration, and Balance Your Emotions. Shambhala.

Descilo, T., Vedamurtachar, A., Gerbarg, P. L., Nagaraja, D., Gangadhar, B. N., Damodaran, B., … & Brown, R. P. (2010). Effects of a yoga breath intervention alone and in combination with an exposure therapy for PTSD and depression in survivors of the 2004 South-East Asia tsunami. Acta Psychiatrica Scandinavica, 121(4), 289-300.

Gerritsen, R. J. S., & Band, G. P. H. (2018). Breath of Life: The Respiratory Vagal Stimulation Model of Contemplative Activity. Frontiers in Human Neuroscience, 12, 397.

Grof, S. (1988). The Adventure of Self-Discovery: Dimensions of Consciousness and New Perspectives in Psychotherapy and Inner Exploration. SUNY Press.

Kox, M., van Eijk, L. T., Zwaag, J., van den Wildenberg, J., Sweep, F. C., van der Hoeven, J. G., & Pickkers, P. (2014). Voluntary activation of the sympathetic nervous system and attenuation of the innate immune response in humans. Proceedings of the National Academy of Sciences, 111(20), 7379-7384.

Lehrer, P. M., & Gevirtz, R. (2014). Heart rate variability biofeedback: How and why does it work? Frontiers in Psychology, 5, 756.

Seppälä, E. M., Nitschke, J. B., Tudorascu, D. L., Hayes, A., Goldstein, M. R., Nguyen, D. T., … & Davidson, R. J. (2014). Breathing-based meditation decreases posttraumatic stress disorder symptoms in U.S. military veterans: A randomized controlled longitudinal study. Journal of Traumatic Stress, 27(4), 397-405.

Streeter, C. C., Whitfield, T. H., Owen, L., Rein, T., Karri, S. K., Yakhkind, A., … & Jensen, J. E. (2012). Effects of yoga versus walking on mood, anxiety, and brain GABA levels: A randomized controlled MRS study. Journal of Alternative and Complementary Medicine, 16(11), 1145-1152.

Telles, S., Nagarathna, R., & Nagendra, H. R. (1994). Breathing through a particular nostril can alter metabolism and autonomic activities. Indian Journal of Physiology and Pharmacology, 38(2), 133-137.

Weitzberg, E., & Lundberg, J. O. (2002). Humming greatly increases nasal nitric oxide. American Journal of Respiratory and Critical Care Medicine, 166(2), 144-145.

Zaccaro, A., Piarulli, A., Laurino, M., Garbella, E., Menicucci, D., Neri, B., & Gemignani, A. (2018). How breath-control can change your life: A systematic review on psycho-physiological correlates of slow breathing. Frontiers in Human Neuroscience, 12, 353.