Donna Schuman, PhD, LCSW (TX), BCB, BCN University of Kentucky College of Social Work

August 17, 2017

Heart Rate Variability (HRV) Biofeedback in the treatment of Combat-Related Posttraumatic

Stress Symptoms

My Background Credentials • Licensed Clinical Social Worker (TX) • Licensed Professional Counselor

(TX) • BCIA Certified in Biofeedback and

Neurofeedback • HRV specialty certificate

Education BA, Psychology University of Maryland University College M.Ed., Counseling & Personnel Services University of Maryland at College Park MSSW, Social Work University of Texas at Austin PhD Social Work University of Texas at Arlington

BCIA.org AAPB.org ISNR.org

PTSD Posttraumatic Stress Disorder (PTSD) is a chronic, disabling stress disorder, that results from direct or indirect exposure to actual or threatened death, serious injury, or sexual violence (American Psychiatric Association, 2013) Prevalence:

15% Iraq/Afghanistan Veterans (Yarvis, 2011). ~30% Vietnam Veterans (Kulka et al., 1990). Many more experience partial or subsyndromal PTSD (Maguen et al, 2013; Pietrzak et al., 2009; Pietrzak et al., 2011).

Mindfulness Meditation

Behavioral Activation

Yoga

Non-Trauma-Focused

Interventions for PTSD

Prolonged exposure (PE)

Cognitive processing therapy (CPT)

Eye movement desensitization and reprocessing (EMDR)

Evidence-Based (VA/DoD)

Stress inoculation training (SIT)

Heart Rate Variability (HRV) biofeedback

Acceptance & Commitment Therapy

PTSD: Making Treatment Effective

Hyperarousal Insomnia/sleep disturbance

Intrusive thoughts Avoidance Flashbacks/nightmares Memory Loss Concentration problems

Shame/Guilt Existential numbing Despair

Anger Sadness/depression

Mind

Emotions

Body

Spirit

Polyvagal Theory: Role of the Vagus

Vagus 10th Cranial nerve Latin for “wanderer”

Vagal Tone: measure of functional state of PNS Vagal Brake: myelinated vagus can override SNS

Vagal Functions

ANS balance Breathing, HR, BP Lowers inflammation Mood Fear management Learning/rewiring Social Behavior (facial expression, prosody, eye gaze, facial expression)

Polyvagal Theory: Hierarchical response to challenge in PTSD

1.

2.

3.

SNS HPA

PNS/SNS HPA

PNS Neural changes

Immobilization

(Freeze)

Social Engagement

System

Mobilization

(Fight or Flight)

Polyvagal Theory: Threat Response

PTSD: HRV and Emotions

• People with flat affect, and blank expression, monotone voice, noise sensitivity are also experiencing low HRV

Where does the heart fit in?

Contains roughly 40,000 neurons Most powerful bioelectrical generator in human body – 50 times more power than brain Rhythm of the heart sets the beat for the entire biological system

The Heart Is Not a Metronome

Heart Rate vs HRV: What’s the Difference?

Heart rate variability (HRV) is a measure of the beat-to-beat fluctuations in the rhythm of the heart.

Heart rate is the speed of the heartbeat measured by the number of contractions of the heart per minute (bpm).

Variation = Good HRV!

What is HRV?

Good HRV is when the intervals between heartbeats vary Poor HRV is when the intervals between heartbeats are the same

What is HRV?

HRV: What generates it?

Ways to Measure HRV Electrocardiogram (ECG)

Photoplethysmograph

Blood volume pulse oximeter

Pre-gelled electrodes for ECG Chest placement

Wrist placement

HRV: Why Is It So Bad If It’s Low?

Psychological: • Social avoidance, • Poor self-regulation • Reductions in

psychological flexibility in the face of stressors

• Psychiatric multi-morbidities

(Kemp & Quintana, 2013).

Physical: • Immune system dysfunction

and inflammation • Diabetes • CVD, • Premature aging, • Morbidity and premature death

HRV: What Lowers It?

HRV: Why Is It Good If It’s High? Better physical and psychological health!

Predictor of recovery after myocardial infarct (Carney et al., 2001); increased emotion recognition (Quintana et al., 2012); better performance on executive functioning tasks (Hansen et al., 2003); positive psychological well-being (Boehm and Kubzansky, 2012)

HRV: What Raises It?

Praxagoras First to write

about pulse in ancient

literature

Herophilus First to

measure pulse

Galen First to use pulse to as a

diagnostic and prognostic indicator

Carl Ludwig

Invented Kymograph to measure both heart rate

and respiration--RSA

William Enthoven

Produced the first electrocardiogram

HRV Timeline

Joseph Fourier

Work contributed to Fast Fourier transform—mathematical technique to separate waves into component parts

Holter Ambulatory ECG

Vashillo Lehrer & Gevirtz

Hon & Lee First clinical use of

HRV; fetal distress—changes

in beat-to-beat variation

McCraty (HeartMath)

emotions induce a change in the

sine wave pattern of the heart without any change in

breathing

Research on HRV biofeedback

Tan et al.

HRVB significantly

reduced PTSD symptoms in

veterans

Research on Russian

Cosmonauts—Resonance Frequency

breathing enabled control of heart rate patterns

HRV Timeline

Herzman Photoplethysmograph

What is HRV Biofeedback (HRVB)?

• Biofeedback is a process that enables an individual to learn how to change physiological activity for the purposes of improving health and performance

• HRVB refers to a technique for using slow diaphragmatic breathing to increase time and frequency domain parameters in HRV.

HRV: How Does Breathing At Different Rates Affect the Heart?

(Brown and Gerbarg, 2012)

HRV: Respiratory Sinus Arrhythmia

HRV-BF Targets Baroreflex System

• Heart rate variability biofeedback (HRV-BF) targets the baroreflex system

• HRV BF leads to improved Baroreflex sensitivity

HRVB: Phase Angle

In Phase Out of Phase

HRVB: Resonance Frequency Assessment

• Each person has a specific breath rate, or “resonant frequency,” at which heart rate variability is the greatest (Lehrer, 2000)

HRVB: Resonance Frequency Assessment

ECG vs PPG

ECG: measures biopotential generated by electrical activity of the heart, using multiple electrodes. PPG: optical measure using light-based technology to sense the rate of blood flow (arterial volume) using a single photodiode.

Interpretation: HRV Statistics

Time Domain: SDNN, RMSSD, NN50, PNN50 Frequency Domain: VLF, LF, HF, LF/HF ratio Geometric Measures: HRV Triangular Index, TINN, Differential Index, Logarithmic index

HRV: SDNN PTSD vs “Normal”

Tan, G., Dao, T. K., Farmer, L., Sutherland, R. J., & Gevirtz, R. (2011). Heart rate variability (HRV) and posttraumatic stress disorder (PTSD): a pilot study. Applied psychophysiology and biofeedback, 36(1), 27-35.

Data Analsis: HRV

SDNN

3200

HRV: Time Domain & Spectral Measures

IBI SAMPLES

All Stats refer to IBI

HRV: Power Spectral Analysis

Fast Fourier Transform (FFT)

FFT converts time domain to frequency domain to analyze a waveform and break it into its component parts.

Autonomic Balance – LF/HF Ratio

Low Frequency (LF): Both Sympathetic and Parasympathetic High Frequency (HF): Parasympathetic LF/HF ratio: Higher ratio=sympathetic dominance; smaller values=parasympathetic dominance

HRVB: PTSD

How does HRVB work to counteract symptoms of PTSD? Stimulating the vagus through HRVB could activate GABA inhibitory processes to regions of the amygdala, thereby reducing over-activation in regions of brain affected by PTSD (Streeter, Gerbarg, Sape, Ciraulo, & Brown, 2012).

• Combat veterans with PTSD show reduced HRV (Chang et al., 2013; Ginsberg et al., 2010; Tan et al., 2011).

• HRVB is effective in treating ANS dysregulation in combat veterans with PTSD (Tan et al. 2011; Tan et al., 2013; Ginsberg et al, 2010; Zucker et al., 2009).

• Compared to other therapies, HRVB shows a robust change in HRV (Wahbeh et al., 2016).

HRV & PTSD

Research on HRVB and PTSD

Background: Veterans with traumatic stress symptoms exhibit reduced heart rate variability characteristic of autonomic nervous system dysregulation. Studies show heart rate variability biofeedback is effective in reducing combat-related posttraumatic stress symptoms by improving autonomic functioning.

Method: In this quasi-experimental pilot study that featured a switching replication design, a comparison group was used to determine if participation in a single-session heart rate variability biofeedback intervention, reinforced by twice daily practice for four weeks, could: (a) reduce posttraumatic stress symptoms in combat veterans (N=12), and (b) yield an intervention that the veterans would find acceptable. Veterans ranged in age from 26 to 50 (M = 36.16, SD = 10.45), with 33% non-White, and 25% women.

Results: Heart rate variability biofeedback significantly reduced global posttraumatic stress symptoms, whereas diaphragmatic breathing did not. Further, veterans found the approach acceptable, as demonstrated by a high degree of compliance with prescribed practice, low study attrition, and continued use over time.

Conclusion: Results contributed cautious evidence that a single-session heart rate variability biofeedback intervention, followed by brief twice-daily mobile app-enabled practice sessions over a four-week period could reduce posttraumatic stress symptoms.

Pilot Study: Effects of a Single Session Heart Rate Variability Biofeedback Intervention on Military Posttraumatic Stress Symptoms

Belly breathing education

1

Procedure Relaxation Breathing & HRVB Training/Assessment

Protocol

Respiratory Sinus Arrhythmia training

4 HRVB practice 5 MyCalmBeat App

6

Baseline measures

2 Resonance Frequency

Assessment 3

Results Global PCL-5: HRVB vs. Relaxation Breathing at 4 weeks

Group A showed a significant reduction in the PCL-5 Global scores from baseline (Mdn = 41.0) to four weeks post-intervention (Mdn = 24.0), z = -2.2, p = .02, r = - .64); Group B did not show a significant reduction from baseline (Mdn = 38.5) to four weeks (Mdn = 28.0), z = .41, p=.41, r =.24)

0

5

10

15

20

25

30

35

40

45

50

BASELINE POST

Group A (n=6) Group B (n=5)

Changes in the primary measures for combined groups from T1/1.5 to T3

40

50

60

70

TIME 1 TIME 2 TIME 3

SDNN SDANN

20

30

40

50

TIME 1 TIME 2 TIME 3

RMSSD RMSSD

T1 to T2 : No significant differences T2 to T3 : No significant differences T1 to T3 : Significant improvement in RMSSD

Results

Results: • Initial Assessment: 8 of 12

(66.66%) met dx criteria for PTSD and all had some sxs (min. score >/=15 on PCL-5)

• Only 30% met criteria at the end

of the study

• All 10 who completed the study saw significantly improved global scores by T3

Group T1 (Mean, SD)

T3 (Mean, SD)

Group A 45.50, 13.30

30.50, 13.39

Group B 42.50, 21.28

18.50, 14.88

Combined 44.0, 16.99

25.70, 14.56

PCL-5 Scores

HRV: Psychophysiological Research & Clinical Applications

Alive Clinical and Alive Pioneer http://www.somaticvision.com/AlivePioneerIOM

HeartMath https://www.heartmath.org/#

Biocomm Heart Rhythm Scanner https://www.biof.com/heartscanner.asp https://www.mybrainsolutions.com/mycalmbeat

Unyte http://unyte.com/ (formerly Wild Divine)

MindMedia NeXus 4, 10, 32 https://stens-biofeedback.com/

HRV: APPS

https://www.heartmath.org/#

http://t2health.dcoe.mil/apps/breathe2relax

https://www.mybrainsolutions.com/mycalmbeat

Simple Takeaway: You do not need to be a biofeedback clinician! Teaching diaphragmatic breathing and having your clients use a pacing app set to 6 breaths per minute, with twice daily practice for 5-10 minutes will improve their HRV.

HRV: Wearables

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed., DSM-5®). Washington, D.C.: Author. Boehm, J. K., & Kubzansky, L. D. (2012). The heart's content: the association between positive psychological well-being and cardiovascular health. Psychological bulletin, 138(4), 655. Brown, R., & Gerbarg, P. (2012). The Healing Power of the Breath: Simple Techniques to Reduce Stress and Anxiety, Enhance Concentration, and Balan ce Your Emotions. Shambhala Publications. Carney, R. M., Blumenthal, J. A., Stein, P. K., Watkins, L., Catellier, D., Berkman, L. F., ... & Freedland, K. E. (2001). Depression, heart rate variability, and acute myocardial infarction. Circulation, 104(17), 2024-2028. Ginsberg, J. P., Berry, M. E., & Powell, D. A. (2010). Cardiac coherence and posttraumatic stress disorder in combat veterans. Alternative Therapies in Health and Medicine, 16(4), 52-60. Retrieved from http://www.heartmathbenelux.com/doc/cardiac-coherence-and-ptsd-in-combat-veterans.pdf Hansen, A. L., Johnsen, B. H., & Thayer, J. F. (2003). Vagal influence on working memory and attention. International Journal of Psychophysiology, 48(3), 263-274. Kemp, A. H., & Quintana, D. S. (2013). The relationship between mental and physical health: insights from the study of heart rate variability. International Journal of Psychophysiology, 89(3), 288-296. Kulka, R. A., Schlenger, W. E., Fairbank, J. A., Hough, R. L., Jordan, B. K., Marmar, C. R., & Weiss, D. S. (1990). Trauma and the Vietnam war generation: Report of findings from the National Vietnam Veterans Readjustment Study. Brunner/Mazel. Lehrer, P. M., Vaschillo, E., & Vaschillo, B. (2000). Resonant frequency biofeedback training to increase cardiac variability: Rationale and manual for training. Applied Psychophysiology and Biofeedback, 25(3), 177–191. doi:10.1023/A:1009554825745

Lehrer, P., Vaschillo, B., Zucker, T., Graves, J., Katsamanis, M., Aviles, M., & Wamboldt, F. (2013). Protocol for heart rate variability biofeedback training. Biofeedback, 41(3), 98–109. doi:10.5298/1081-5937-41.3.08 Maguen, S., Madden, E., Bosch, J., Galatzer-Levy, I., Knight, S. J., Litz, B. T., . . . McCaslin, S. E. (2013). Killing and latent classes of PTSD symptoms in Iraq and Afghanistan veterans. Journal of Affective Disorders, 145(3), 344–348. doi: 10.1016/j.jad.2012.08.021 Pietrzak, R. H., Russo, A. R., Ling, Q., & Southwick, S. M. (2011). Suicidal ideation in treatment-seeking veterans of Operations Enduring Freedom and Iraqi Freedom: The role of coping strategies, resilience, and social support. Journal of Psychiatric Research, 45(6), 720–726. doi:10.1016/j.jpsychires.2010.11.015 Pietrzak, R. H., & Southwick, S. M. (2009). The importance of four-factor emotional numbing and dysphoria models in PTSD. The American Journal of Psychiatry, 166(6), 726. doi:10.1176/appi.ajp.2009.09010032 Porges, S. W. (1997). Emotion: An evolutionary by-product of the neural regulation of the autonomic nervous system. Annals of the New York Academy of Sciences, 807, 62–77. doi:10.1111/j.1749-6632.1997.tb51913.x Porges, S. W. (2007). The polyvagal perspective. Biological Psychology, 74(2), 116-143. Retrieved from http://dx.doi.org/10.1016/j.biopsycho.2006.06.009 Porges, S. W. (2011). The polyvagal theory: Neurophysiological foundations of emotions, attachment, communication, and self-regulation (Norton Series on Interpersonal Neurobiology). New York, NY: W. W. Norton & Company. Quintana, D. S., Guastella, A. J., Outhred, T., Hickie, I. B., & Kemp, A. H. (2012). Heart rate variability is associated with emotion recognition: direct evidence for a relationship between the autonomic nervous system and social cognition. International Journal of Psychophysiology, 86(2), 168-172. Schiller, D., Levy, I., Niv, Y., LeDoux, J. E., & Phelps, E. A. (2008). From fear to safety and back: reversal of fear in the human brain. The Journal of Neuroscience, 28(45), 11517-11525. Retrieved from http://dx.doi.org/10.1523%2FJNEUROSCI.2265-08.2008

Streeter, C. C., Gerbarg, P. L., Saper, R. B., Ciraulo, D. A., & Brown, R. P. (2012). Effects of yoga on the autonomic nervous system, gamma-aminobutyric-acid, and allostasis in epilepsy, depression, and post-traumatic stress disorder. Medical hypotheses, 78(5), 571-579. Tan, G., Dao, T., Farmer, L., Sutherland, R., & Gevirtz, R. (2011). Heart rate variability (HRV) and posttraumatic stress disorder (PTSD): A pilot study. Applied Psychophysiology and Biofeedback, 36(1), 27-35. doi:10.1007/s10484-010-9141-y Tan, G., Wang, P. & Ginsberg, J. (2013). Heart rate variability and posttraumatic stress disorder. Biofeedback, 41 (3), 131-135. Retrieved from http://dx.doi.org/10.5298/1081-5937-41.3.05 Thayer, J. F., Åhs, F., Fredrikson, M., Sollers III, J. J., & Wager, T. D. (2012). A meta-analysis of heart rate variability and neuroimaging studies: Implications for heart rate variability as a marker of stress and health. Neuroscience & Biobehavioral Reviews, 36(2), 747-756. Retrieved from http://dx.doi.org/10.1016/j.neubiorev.2011.11.009 van der Kolk, B. A., Boyd, H., Krystal, J., & Greenberg, M. (1984). Post-traumatic stress disorder as a biologically based disorder: Implications of the animal model of inescapable shock. In B. A. van der Kolk (Ed.), Post-traumatic Stress Disorder: Psychological and Biological Sequelae (pp. 124-134). Washington, DC: American Psychiatric Press. Voss A, Schroeder R, Heitmann A, Peters A, Perz S. Short-Term Heart Rate Variability—Influence of Gender and Age in Healthy Subjects. PLoS ONE. 2015; 10(3): e0118308. Wahbeh, H., & Oken, B. S. (2013). Peak high-frequency HRV and peak alpha frequency higher in PTSD. Applied psychophysiology and biofeedback, 38(1), 57-69. doi:10.1007/s10484-012-9208-z Yarvis, J. S. (2011). A civilian social worker's guide to the treatment of war-induced PTSD. Social work in Health Care, 50(1), 51-72. Zucker, T., Samuelson, K., Muench, F., Greenberg, M., & Gevirtz, R. (2009). The effects of respiratory sinus arrhythmia biofeedback on heart rate variability and posttraumatic stress disorder symptoms: A pilot study. Applied Psychophysiology and Biofeedback, 34(2), 135-143. doi:10.1007/s10484-009-9085-2