How We Breathe Is the Key to an Effective New Treatment for Anxiety and PTSD

(Courtesy of Freespira)

The Department of Veterans Affairs estimates that up to 20% of those who served in Iraq and Afghanistan suffer from some kind of post-traumatic stress disorder. The same data show 12% of Gulf War veterans and as high as 30% of Vietnam veterans have experienced symptoms in their lifetime.

While treatments for PTSD have improved since the start of the Global War On Terrorism, incidences of PTSD and anxiety disorder have risen dramatically, as high as 327% between 2000 and 2012. Incidences of trauma can lead to major depressive disorders, substance abuse, poor social function and suicide.

Freespira, a new digital treatment, may offer an effective treatment for panic disorder, anxiety disorders and PTSD. Freespira is a 28-day treatment that retrains patients with certain disorders to build a kind of muscle memory that normalizes how they breathe.

The treatment was developed by Freespira's chief clinical officer, Robert Cuyler, along with Michael Telch, professor of psychology and director of the Laboratory for the Study of Anxiety Disorders at the University of Texas at Austin.

"Many individuals with conditions related to panic have what's called dysregulated breathing," Cuyler tells "It's not like a lung disease. They breathe in a dysfunctional way all the time. They can yawn, sigh and breathe as much sitting in a chair as if they were jogging. They hold their breath. This is a factor in the respiratory physiology and the brain network associated with these conditions."

Cuyler cites a Stanford University study that sought to find out what effect fixing dysregulated breathing might have in people who suffer from panic, anxiety and PTSD. What the Stanford research found was that it wasn't just breathing rates; it was also how much carbon dioxide the participants exhaled that mattered.

"There are thousands of breathing apps out there. You've also got yoga and meditative breathing," says Cuyler. "But this group saw a distinct aspect of these conditions, and that is people's carbon dioxide levels are really out of sync with their oxygen levels, and that sets the stage in body physiology for symptom surges."

This led to a laboratory technique to give people breath-by-breath feedback of their respiration rate and their exhaled CO2 level.

"As a treatment, what the client or patient does is pretty simple. They learn how to synchronize their breathing to a rising and falling audio tone, while trying to stabilize their respiratory rate while they see a readout of their exhaled CO2 levels," Cuyler explains. "They adjust their air intake, their breath volume to normalize their CO2."

Using an app to provide that real-time feedback on respiratory rates and carbon dioxide levels, the Freespira treatment monitors a patient's respiration rates, which allows them to adjust how often they breathe and how fast they exhale.


Over the course of about four weeks, the app is designed to manage breathing rates, through two 17-minute sessions per day and a meeting with a certified behavioral health coach once per week. By the end of the course, the system retrains users to breathe at a normal rate. The learning has stayed with users for a full year.

"So we're really doing two things," says Cuyler. "One is, we're retraining the brain to breathe in a normal fashion, but at the same time, we're teaching people a self-management skill that they can use when they feel stressed or triggered."

To measure its efficacy, Freespira compares results using the PCL-5 scale, the VA's self-reporting measurement of PTSD symptoms. A change of 10 points is considered clinically significant in this metric. The average drop on the scale for Freespira users is 19.5 points.

A company-funded study of more than 1,500 patients with PTSD or panic disorder who were treated with Freespira was published in the digital health journal Frontiers on Nov. 17, 2022. It found 75% of users adhered to the treatment, where previous studies have found adherence rates among veterans in medication treatments can be as low as 39.5%.

In the Freespira study, 65% of 1,395 patients with panic disorder showed improvement. The 174 patients with PTSD showed a higher improvement rate of 72%.


"I think there's three reasons why this product works so well," Joe Perekupka, Freespira's CEO, says."The first and most important piece is, we're taking patients from a passive participant in their treatment to being an active one. Then we then bring in a visualization piece so patients can see their measurements, and that creates a higher engagement rate. There's something very powerful when a patient can visualize what's wrong.

"The third piece is, we're pairing each patient with a care coach, who works with them one per week. They guide the patient through the process with weekly touchpoints. Within seven to 10 days, they start seeing improvement."

Perekupka says Freespira uses third-party validated surveys to measure patient progress. Based on this data, greater than 80% of patients have achieved significant reduction or elimination of symptoms. The same surveys find that after 12 months post-treatment, 73% of patients are still free of panic attacks.

Freespira is available only by prescription and it is available through the VA. It is the only FDA-cleared digital therapeutic proven to significantly reduce or eliminate symptoms of panic attacks, panic disorder and PTSD. The FDA does not approve (either positively or negatively) apps like this, however. For more information, visit Freespira online.

Editor’s Note: This story is not intended as an endorsement by of the claims made in the article.

-- Blake Stilwell can be reached at He can also be found on Twitter @blakestilwell or on Facebook.

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