A Physiological Approach to Stress: Heart Rate
Variability (HRV) Biofeedback in a Physical Health
Setting
Laura Onens
Assistant Psychologist for Haematology
Psychological Services for Physical Health
Laura.Onens@uhcw.nhs.uk
Contents
What do you do in physical health?
• Psychological distress in Haematology and working
away from a predominately medical model
• The introduction of HRV Biofeedback (HeartMath)
• The results of a pilot evaluation
• Qualitative results
• Conclusion and indications for future research
Health Conditions in Haematology
• Haematology is the study of blood, the blood-forming organs, and blood diseases.
Genetic Related Diseases
of the Blood
E.g. Sickle Cell
Thalassemia
Haemophilia
Acute or Chronic Cancers
E.g. Lymphoma
Leukaemia
Myeloma
Others
Thrombotic
Disorders e.g. DVT
Anaemia
Common Presenting Symptoms of Psychological
Distress in Haematology Patients
•
•
•
•
•
•
•
•
•
Generalised Anxiety and Panic
Depression
Health Anxiety
Loss of control
Uncertainty
Fear of death & dying
Shock
Needle phobia
Unhelpful coping styles e.g. Avoidance, obsessive
compulsive behaviours etc.
• Unhelpful thinking styles e.g. Catastrophising, black & white
thinking patterns etc.
• Emotional maturity to manage a life-long condition particularly
at the child-to-adult transition stage
Some cope well…some don’t…
Common
Predisposing Risk
Factors
Childhood attachment (Hamama-Raz &
Solomon)
Coping styles (Coifman, 2007)
Emotional resilience/maturity
(Tugade et al, 2005)
Previous psychiatric history
(Grasso et al, 2007)
Trauma History (Green et al, 2000)
Common
Perpetuating Risk
Factors
Nature of disease e.g. Chronic or
palliative
Intensity of treatment regime
Side effects of treatment
Social support network
Home/financial/work circumstances
Level of uncertainty
Help seeking
Physiological effects of psychological
distress
• Diagnosis and treatment is
often highly emotive
therefore heightened
awareness of “fight-or-flight”
and physical response
• Life consuming - particularly
in patients diagnosed with
cancer. Therefore stress
response often unrelenting
• Hyper vigilant, on guard,
expecting threat due to
constant activation
Cortex
Thalamus
Amygdala
Behaviour
Physiology
Immunology
(ANS)
Why do we respond physically?
The Autonomic Nervous System (ANS)
Negative emotion, stress
Sympathetic Nervous
System (SNS) Activity
Positive emotion
Parasympathetic Nervous
System (PNS) Activity
Catabolic hormones
Anabolic hormones
“Breaking down and
releasing enegy”
“Building up and
Steroid Hormones e.g.
cortisol & adrenaline (HPA
axis)
Increased glucose release
for energy
consuming energy”
Steroid hormones e.g.
DHEA
Difficulties with the physiological response to
threat in this context
• Fight or Flight is a survival mechanism to help us survive physical
threats
• No physical response required for cancer/disease
• A situation which is not easily resolved without further stress
• Poor physical health limits the opportunity to exercise in order to
burn off stress related steroid hormones and excess glucose
High cortisol : Low DHEA (Dehydroepiandrosterone)
•Accelerated aging (Kerr et al., 1991; Namiki, 1994)
•Brain cell death (Kerr et al., 1991; Sapolsky, 1992)
•Impaired memory and learning (Kerr et al., 1991; Sapolsky, 1992)
•Decreased bone density; increased osteoporosis (Manolagas, 1979)
•Reduced muscle mass (Beme, 1993)
•Reduced skin growth and regeneration (Beme, 1993)
•Impaired immune function (Hiemke, 1994)
• Increased blood sugar (DeFeo, 1989)
• Increased fat accumulation around waist and hips
(Marin, 1992)
Hypothesis:
• Can learning to regulate the ANS
(physiological regulation) aid emotional
regulation when the cause of stress (i.e.
cancer) is not easily resolved?
Performance
Behaviour
Think
Feel
Physiology
If we are thinking better our memory
and coordination is improved - we can
perform better
Our behaviour is more appropriate
and controlled if our emotions are
regulated and thinking is clearer
Emotional regulation facilitates higher
levels of brain functions that may have
switched off from “fight or flight”
Reduction of physical symptoms may
help how we would physically feel
Physical symptoms of stress, e.g.
racing heart, butterflies, irritable
bowel, disrupted sleep may reduce
through ANS regulation
Heart Rate Variability (HRV) Biofeedback A Physiological Approach to Stress
•Re-emergence of interest into biofeedback due
to mind-body connection research (Pert, 1998).
Facilitates a connection to our internal state –
How well is the mind aware of the body?
•Cardiologists now know that the heart has its
own complex intrinsic nervous system
•The heart sends far more information to the
brain than the brain sends to the heart.
•HRV “a window to our autonomic nervous
system”. Simpler to use than EEG feedback
techniques.
•Focusing on the role of the heart during fight
or flight and its role in emotion.
•The heart signals especially affect the brain
centers involved in decision- making, creativity
and emotional experience.
(McCraty et al, 1998; American Journal of Cardiology).
Clinical Area
Author
Physician Stress
Lemaire et al (2011)
PTSD
Ginsberg et al (2010)
Health Care Costs (GP
visits/prescriptions etc)
Bedell et al (2010)
Breast cancer (pilot study)
Groff et al (2010)
Older adults with heart failure
Luskin et al (2002)
QoL in patients with diabetes
McCraty (2000)
HIV psycho and physiological
symptomatology
Rozman (1996)
Behavioural and cognitive functions in Lloyd (2010)
children with ADHD
Neuropsychology - attention and
information processing, recall
Ginsberg (2008)
Blood pressure, cholesterol, glucose
McCraty (2009)
and hormone balance in police officers
Transforming HRV - Directly Impacting Physical and Mental
Performance
The heart signals especially affect the
brain centers involved in strategic
thinking, reaction times, and selfregulation.
Resonant Frequency Breathing
transforms HRV to 0.1Hz (sine
wave). Synchronised activity of
SNS and PNS.
The heart sends far more
information to the brain
than the brain sends to the
heart.
Incoherence
Inhibits Brain
Function
Coherence
Facilitates Brain
Function
Cortex: Thinking Brain
Amygdala:
Emotional Memory
Thalamus:
synchronizes
cortical activity
Medulla:
Blood pressure
and ANS
regulation
Inhibits cortical function
Atrial Peptide
Oxytocin
Dopaminie
Norepinephrine
Epinephrine
Cortex: Thinking Brain
Amygdala:
Emotional Memory
Thalamus:
synchronizes
cortical activity
Medulla:
Blood pressure
and ANS
regulation
Facilitates cortical function
The pilot evaluation of HRV Biofeedback Therapy in
Haematology
• Patients offered 6 week HRV biofeedback course
“HeartMath”
• Good clinical evidence of HeartMath’s effectiveness at
reducing stress, anxiety and depression but not
robustly tested with haematology/cancer patients
• Evidence in occupational health of its effectiveness to
help staff manage stress levels. Staff have additionally
been offered the 6 week course.
16-21
Severe
11-15
Moderate
8-10
Mild
0-7
Normal
Hospital Anxiety and Depression Scale (HADS) Score
Pre & Post Depression Scores of Haematology Patients Receiving
HeartMath
Pre Depression
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Post Depression
Patients
16-21
Severe
11-15
Moderate
8-10
Mild
0-7
Normal
Hospital Anxiety & Depression Scale (HADS) Score
Pre & Post Anxiety Scores of Haematology Patients Receiving
HeartMath
Pre Anxiety
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Post Anxiety
Patients
16-21
Severe
11-15
Moderate
8-10
Mild
0-7
Normal
Hospital Anxiety & Depression Scale (HADS) Score
Staff Anxiety & Depression Scores Pre and Post
HeartMath
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Pre Anxiety
Post Anxiety
Pre Depression
Post Depression
Staff 1
Staff 2
Staff 3
Staff Members
Staff 4
Staff 5
Staff 6
Qualitative information & benefits
• Increased AWARENESS of emotional regulation and techniques to achieve this
• Increased ability to learn to control and regulate emotional responses and identify
triggers. Increases SELF AWARENESS and therefore SELF MANAGEMENT.
• Objective feedback MOTIVATES and doing relaxing techniques is therefore more
attractive.
• Promotes biochemical change and therefore improved physical vitality
• Improved mental function i.e. thinking clearer, handling situations better,
increased control, resilience and coping.
• In a better, calmer position to engage in further therapy if required i.e. a beneficial
precursor to CBT with patients who find it difficult to engage due to distress.
• Playful and pleasant context to sessions due to Biofeedback imagery and games.
Qualitative feedback from Patients
• “I didn’t realise my body could be affected by stress in this way. Now I know how to calm
myself down symptoms I was relating to the cancer have suddenly gone.”
• “The objective feedback gave me the motivation to practice the techniques.”
• “I found the techniques made me feel calm.”
• “HeartMath seems to help me to control my anger…my family say I am less irritable since I
have been remembering to use the techniques when I feel stressed.”
• “The doctor has asked me what I have been doing to lower my blood pressure!”
• “I am sleeping for at least 7 hours a night. Before HeartMath I was lucky to get 4 or 5 and it
was always disrupted sleep.”
• “Cancer and the stress I felt was making me feel like I was losing control. Even when I went
into remission I could not shake the feelings. Everything had been taken away. HeartMath
helped me to feel in control of myself again and step by step I finally feel like I am getting back
on track. I have gone back to university!”
• “I laughed at the doctor when she said she thought I should be referred to a psychologist. I’m
not going mad I have cancer! To see my reaction to cancer on screen is unreal. I wish I had
been more open minded in the past. I understand now how I have been feeling”
Qualitative feedback from Staff
• “The course helped me to see that the way I feel on the inside can
affect my perceptions…By practicing HeartMath work pressures
didn’t seem quite so bad anymore.”
• “It is a useful thing to know to share with distressed patients on the
ward to help them during difficult times”
• “My dexterity has improved in surgery and I find I am more tolerant
of less competent staff and the errors others make”
• “It has not only helped at work but with family life too”
• “I have been less sick this year, my manager has commented on my
improved attendance at work”
Conducting a Controlled Study for a Formal
Evaluation
• The Department of Health recognise that survivors of cancer
often have unmet psychological needs due to reduced contact
with the hospital.
• Aim – evaluate the effectiveness of a 6 week HeartMath
course at reducing anxiety, depression and improving quality
of life of survivors. This will be in comparison to a group that
receive CBT and a control group (treatment as normal).