How to do box breathing step by step during a panic attack

Short answer: Breathe in for 4, hold for 4, breathe out for 4, hold for 4, and repeat for a few minutes. In a recent trial it kept heart rate and anxiety from climbing before a stressful task, and if the holds feel too much mid-panic, a shorter count or a longer out-breath works too.

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The count gives your attention a job, not just your lungsWhat the evidence shows, and what it doesn'tWhen the holds feel wrong mid-panicTry this today

Box breathing is four equal steps: breathe in through your nose for a count of 4, hold for 4, breathe out slowly for 4, hold with your lungs empty for 4. Then go round again, for a few minutes, until your body starts to follow the count.

That is the whole technique. The useful part is knowing what to expect, and what to change when it does not feel right in the middle of a spike.

The count gives your attention a job, not just your lungs

The NHS advice for a panic attack is to stay where you are if you can and breathe slowly and deeply, and to remind yourself that it will pass and is not dangerous. Most panic attacks, the NHS says, last between 5 and 20 minutes.

The trouble is that "breathe slowly" is hard to follow when your heart is racing. Counting fixes that. Four equal sides give your mind something exact to track, so the breath has a rhythm to lock onto instead of following the panic.

The holds also slow the whole cycle down. One round of 4-4-4-4 takes 16 seconds, which works out to under four breaths a minute, far slower than the quick, shallow breathing panic tends to bring.

Counting on your fingers helps if numbers slip away. Press thumb to one fingertip for each step, moving round the hand. On the MRT or in a meeting, nobody can tell you are doing anything, and your eyes can stay open.

Start at the first sign rather than at the peak. The earlier the rhythm takes hold, the less ground your body has to come back from.

What the evidence shows, and what it doesn't

A recent trial split 66 healthy adults into three groups before a stressful online presentation: normal breathing, box breathing at 4-4-4-4, or slow breaths with a long out-breath. Each group practised for five minutes beforehand.

The normal breathers' heart rate went up and their anxiety rose. In both breathing groups, heart rate went down instead, and a saliva marker of the body's fight-or-flight response stayed level. Cortisol and focus did not differ between groups.

Two honest limits. The people in that trial had no anxiety diagnosis, and they breathed before the stress, not during a panic attack. It did not test box breathing during real panic. What the trial does show is that a few minutes of the pattern can keep your body from climbing as high, which is why practising it on calm days matters.

When the holds feel wrong mid-panic

For some people, holding the breath while already breathless feels like the walls closing in. If that happens:

• Shorten the count to 3 or even 2. An even rhythm you can keep beats a long one you abandon.
• Drop the holds and just make the out-breath longer than the in-breath, like in for 3 and out for 6. In the trial, this pattern also kept the stress response from rising.
• Sit down if you feel lightheaded. A review of breathing techniques notes some people feel dizzy at first when they slow down this much.

Expect the first minute to feel like nothing is happening. The change tends to show up as the pace sticks, not on the first breath.

Panic symptoms overlap with other conditions. Get urgent help if you have chest pain, breathlessness that is new or does not settle, or symptoms unlike your usual attacks. See a GP if panic attacks keep coming back or you are living in fear of the next one.

Try this today

When you are calm, do three minutes of box breathing at 4-4-4-4, sitting down, at a time you will remember tomorrow, like after brushing your teeth. A pattern you have rehearsed is far easier to reach for when your heart is pounding than one you are reading about for the first time.

Sojiwa has a free "Box Breathing 4-4-4-4" exercise with a circle animation and a seconds countdown for each phase, so you can follow the shape instead of counting in your head.