The Implications of CAPS Biofeedback Research on Treatment
The Implications of CAPS Biofeedback Research on Treatment Strategies: Cutting Edge HRV Training Stress Management and Biofeedback Services Counseling and Psychological Services (CAPS) Brigham Young University Faculty Training Maureen Rice, Barbara Morrell, Yoko Caldwell, Meredith Pescatello, Tristin Roney, Louise Wheeler, Lisa Leavitt, Dianne Nielsen
STUDY #1 – AAPB The Efficacy of Stress Management and Biofeedback Training as an Adjunct to Psychotherapy for University Students Morrell, B. , Nielsen, D. , Rice, M. , Erekson, D. , Marvin, L. , Brown, L. www. themegallery. com
OQ-45 Administered before every counseling session v Items heavily loaded on stress and anxiety § § § § § I tire quickly I feel stressed at work/school. I feel fearful I have difficulty concentrating. My heart pounds too much I feel nervous I have trouble falling asleep or staying asleep I have headaches I have sore muscles
Therapy Outcome for CAPS Clients Receiving No Biofeedback, One session, and Multiple Sessions Significant differences were found between groups on total OQ-45 change from 2008 to 2012 (p =. 018) 12 § 1 or less biofeedback sessions 10 8 averaged 8 points of change e b bi of r m or ss 2 o 1 or le io. . § 2+ biofeedback sessions averaged 11 points of change . . 6 4 2 0
v Additionally, a multilevel analysis of biofeedback and outcome on the OQ-45 from 1996 to 2012 found that the total number of biofeedback sessions in a course of therapy predicted a faster decrease in OQ-45 scores (p =. 005), controlling for initial severity on the OQ
Study #2 – AAPB Impact of Resonant Frequency HRV Training in the Treatment of Depression and Resting-state f. MRI Yoko H. W. Caldwell Brigham Young University Dissertation www. themegallery. com
Depression & Brain Functioning v Structural & Functional dysfunctioning § Volume reduction – hippocampus & amygdala (Drevets, 2001; Mervaala et al. , 2000) § Decreased connectivity • Functional – prefrontal cortex & ACC (Aizenstein et al. , 2009) • Resting-state – ACC, hippocampus, amygdala, orbitofrontal & prefrontal cortex (Anand et al. , 2005; Lui et al. , 2011)
MDD Tx Therapy (Butler, Chapman, Forman, & Beckm, 2006) Meds (Rush et al. , 2006) Adjunct Therapy (Amr, El-Mogy, Shams, Vieira, & Lakhan, 2013; Tonhajzerova et al. , 2009)
Heart-Rate Variability (HRV) v HRV & Health Outcome § Sympathetic Parasympathetic activity (Beevers, Ellis, & Reid, 2011) § Associated with positive health outcome • • Cardiac morbidity (Del Pozo et al. , 2004) Pulmonary function (Lehrer et al. , 2003) Chronic pain (Hallman, Olsson, Scheele, Melin, & Lyskov, 2011) Depressive disorders (Karavidas et al. , 2007)
The Current Study v Purpose § Examine impact of HRV training on depressive symptoms and resting-state connectivity § ROIs: ACC, hippocampus & amygdala
Method v Participants § Exclusion: age <18 or > 25 yrs, Hx of major illness, cardiovascular dx, substance abuse § Females (N = 32) MDD participants: BYU Counseling Center Healthy participants: BYU campus Excluded 2 participants § Final sample size: n = 30 § $20 – each MRI visit; $10 – each HRV visit
v Participants (cont’) w/o MDD Both Tx & HRV Exp (n=10) TAU (n=10) Tx only Ch (n=10) Age M = 20. 09 M = 20. 20 M = 20. 64 SD = 1. 81 SD = 1. 47 SD = 1. 29 Active control
Measures v Psychological § M. I. N. I International Neuropsychiatric Interview (Sheehan et al. , 1998) § Beck Depression Inventory-II (BDI-II) (Beck, Steer, & Brown, 1996) § Outcome Questionnaire-45 (OQ 45) (Lambert, 1994) v Physiological for HRV § Biofeedback system (J&J) • Standard deviation of normal-to-normal intervals (SDNN) • High frequency (HF) • Low frequency (LF) • LF/HF ratio
v Physiological variables § SDNN • Amount of variability in heartbeat interval across time § HF and LF 0. 05 § LF/HF ratio 0. 15 0. 4
MRI Scanner v BYU MRI RF v Siemens 3 T Tim Trio MR scanner § Functional images § Structural images
Procedure v Recruitment phase § M. I. N. I v Experimental phase Wk 1 (Exp, TAU, Ch) Baseline HRV & f. MRI (Exp) Abdominal breathing Wk 2 • (Exp) Resonant Frequency 6. 5 to 4. 5 breathe/min Wk 4 • (Exp) breathe w. pacer 1 st, then in phase w. heart rate Wk 3 • (Exp) with pacer Wk 5 • (Exp) breathe w. pacer 1 st, then in phase w. heart rate Wk 6 • (Exp, TAU, Ch) Follow-up HRV & f. MRI
Capture the Moments
Analytic Strategy v Repeated measure ANOVA § § 3 (Exp, TAU, Ch) x 2 (Baseline, follow-up) BDI-II OQ-45 All HRV variables (SDNN, LF, HF, LF/HF) • LF, HF, LF/HF Log 10 transformation § Resting-state connectivity between each ROIs
Results- Baseline BDI-II Comparison 30 Mild -Moderate Total BDI-II Scores 25 20 Ch 15 Exp TAU 10 5 Minimal 0 Baseline Group difference F(2, 27) = 14. 65; p =. 000 Follow-up BDI Cutoffs 0 -13 Minimal 14 -19 Mild 20 -28 Moderate 29 -63 Severe
Results OQ 45 Comparison 90 Above clinical cut-off Total OQ 45 Scores 80 Below clinical cut-off 70 60 Ch Exp 50 TAU 40 30 <63 >64 20 >14 pts change Baseline Group difference F(2, 27) = 11. 26; p =. 000 Follow-up OQ 45 Cutoffs NOT clinical distress Clinical distress Reliable change
Results v Imaging data – no significant differences across each ROIs (ACC, Hipp. , Amyg. ) at baseline Exp (M, SD) TAU (M, SD) Ch (M, SD) p-value L ACC – L Hipp 0. 19 (0. 19) 0. 75 (1. 53) 0. 12 (0. 15) 0. 185 L ACC – L Amyg 0. 16 (0. 22) 0. 66 (1. 42) 0. 07 (0. 13) 0. 227 L Hipp – L Amyg R ACC – R Hipp 0. 31 (0. 12) 0. 82 (1. 44) 0. 35 (0. 19) 0. 306 0. 20 (0. 16) 0. 73 (1. 57) 0. 15 (0. 12) 0. 216 R ACC – R Amyg 0. 10 (0. 16) 0. 68 (1. 44) 0. 09 (0. 09) 0. 174 R Hipp – R Amyg L ACC – R ACC 0. 31 (0. 07) 0. 83 (1. 38) 0. 43 (0. 16) 0. 222 0. 65 (0. 15) 1. 11 (1. 55) 0. 47 (0. 15) 0. 312 L Amyg – R Amyg 0. 30 (0. 13) 0. 79 (1. 41) 0. 35 (0. 12) 0. 311 L Hipp – R Hipp 0. 56 (0. 13) 0. 95 (1. 62) 0. 56 (0. 13) 0. 332 L ACC – R Hipp 0. 15 (0. 18) 0. 69 (1. 56) 0. 13 (0. 13) 0. 225 L ACC – R Amyg 0. 06 (0. 14) 0. 58 (1. 47) 0. 09 (0. 11) 0. 284 L Hipp – R ACC 0. 20 (0. 21) 0. 77 (1. 56) 0. 16 (0. 12) 0. 190 L Hipp – R Amyg 0. 25 (0. 14) 0. 76 (1. 44) 0. 29 (0. 15) 0. 244 L Amyg – R ACC 0. 17 (0. 19) 0. 72 (1. 42) 0. 11 (0. 08) 0. 181 L Amyg – R Hipp 0. 37 (0. 10) 0. 77 (1. 43) 0. 32 (0. 13) 0. 327
Results - Follow-up Exp: A significant decrease from moderate to minimal level TAU: A shift from mild to minimal level Post-hoc Tukey: M baseline = 17. 7; M follow-up = 12. 10; p-value =. 23 Ch: Stayed at the minimal level Post-hoc Tukey: M baseline = 3. 70; M follow-up = 2. 50; p-value =. 99 30 25 Total BDI-II Scores Post-hoc Tukey: M baseline = 24. 9; M follow-up = 12. 00; p-value =. 0003 BDI-II Comparison 20 Ch 15 Exp TAU 10 5 0 Baseline Follow-up BDI Cutoffs 0 -13 Minimal 14 -19 Mild 20 -28 Moderate 29 -63 Severe
Results- Follow-up Exp: From above to below clinical cut-off (25 pts ) OQ 45 Comparison 90 Post-hoc Tukey: M baseline = 84. 20; M follow-up = 59. 00 p-value =. 0002 Post-hoc Tukey: M baseline = 71. 10; M follow-up = 63. 20 p-value =. 61 Ch: Stayed below the clinical cut-off Post-hoc Tukey: M baseline = 32. 50; M follow-up = 33. 60 p-value =. 99 Total OQ 45 Scores TAU: Stayed above the clinical cut-off 80 70 60 Ch Exp 50 TAU 40 30 <63 >64 20 >14 pts change Baseline Follow-up OQ 45 Cutoffs NOT clinical distress Clinical distress Reliable change
Results- Follow-up Exp: A significant increase (17. 39 pts) SDNN Comparison Post-hoc Tukey: M baseline = 42. 93; M follow-up = 60. 33; p-value =. 002 65 Ch: No significant change Post-hoc Tukey: M baseline = 56. 74; M follow-up = 56. 32; p-value =. 99 TAU: No significant change Post-hoc Tukey: M baseline = 50. 01; M follow-up = 48. 51; p-value =. 99 SDNN (ms) 60 55 Ch Exp TAU 50 45 40 Baseline Follow-up
Results- Follow-up Exp: A significant increase Log 10 LF Values Comparison Post-hoc Tukey: M baseline = 2. 74; M follow-up = 3. 22; p-value =. 009 3. 3 TAU: No significant change Post-hoc Tukey: M baseline = 2. 97; M follow-up = 2. 92; p-value =. 99 Ch: No significant change Post-hoc Tukey: M baseline = 3. 15; M follow-up = 3. 21; p-value =. 99 Log 10 LF (ms²) 3. 2 3. 1 3 Ch Exp 2. 9 TAU 2. 8 2. 7 2. 6 Baseline Follow-up
Results- Follow-up Exp: A significant increase Log 10 LF/HF Ratio Comparison Post-hoc Tukey: M baseline = 1. 08; M follow-up = 1. 29; p-value =. 01 1. 35 TAU: No significant change Post-hoc Tukey: M baseline = 1. 00; M follow-up = 1. 03; p-value =. 99 Ch: No significant change Post-hoc Tukey: M baseline = 1. 07; M follow-up = 1. 15; p-value =. 70 Log 10 LF/HF 1. 25 Ch 1. 15 Exp TAU 1. 05 0. 95 Baseline Follow-up
Results- Follow-up v Imaging data - no significant differences across each ROIs (ACC, Hipp. , Amyg. ) between the two time points Variables L ACC – L Hipp L ACC – L Amyg L Hipp – L Amyg R ACC – R Hipp R ACC – R Amyg R Hipp – R Amyg L ACC – R ACC L Hipp – R Hipp L Amyg – R Amyg L ACC – R Hipp L ACC – R Amyg L Hipp – R ACC L Hipp – R Amyg L Amyg – R ACC L Amyg – R Hipp df MS F p partial η 2 Time*Groups 2 0. 03 0. 973 0. 00 Time*Groups 2 0. 02 0. 980 0. 00 Time*Groups 2 0. 01 0. 990 0. 00 Time*Groups 2 0. 02 0. 984 0. 00 Time*Groups 2 0. 01 0. 987 0. 00 Time*Groups 2 0. 08 0. 07 0. 933 0. 00 Time*Groups 2 0. 17 0. 15 0. 864 0. 01 Time*Groups 2 0. 11 0. 08 0. 921 0. 00 Time*Groups 2 0. 01 0. 993 0. 00 Time*Groups 2 0. 01 0. 990 0. 00 Time*Groups 2 0. 00 1. 000 0. 00 Time*Groups 2 0. 04 0. 03 0. 967 0. 00 Time*Groups 2 0. 03 0. 974 0. 00 Time*Groups 2 0. 02 1. 000 0. 00 Time*Groups 2 0. 03 1. 000 0. 00
Discussion v Main findings § Exp: significant decreases in total OQ 45 score (25 pts) and total BDI-II score (moderate to minimal level) between the two time points § Exp: significant increases in SDNN (17. 39 pts), LF, LF/HF between the two points § Imaging data – no significant difference between groups across the two time points – Gender – Age – # of depression episodes/depression duration
Limitations and Future Directions v A very selected population § Longitudinal study § Male v No active experimental condition in the control group v Comparing different psychotherapy approaches § Long-term effect
Conclusion v Pilot study v 3 comparison groups v Results only partially followed predictions v The need for additional studies on HRV biofeedback training at different stages of depression and how it might affect participants’ neurologically.
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STUDY #3 Heart Rate Variability: Biofeedback's Effect on Symptoms of Clients with Generalized Anxiety Disorder Tristin Roney, Meredith Pescatello Brigham Young University Dissertation www. themegallery. com
The Study v Purpose: To determine if Heart Rate Variability (HRVB) is an effective treatment for GAD v 60 participants with a diagnosis of GAD § Prevalence of GAD in the US ~ 2 -5% § CAPS clients identifying anxiety as their top concern ~20% (Winter 2016) v Heart Rate Variability: the physiological phenomenon of variation in the time interval between heartbeats. It is measured by the variation in the beat-to-beat interval. § Measure of adaptability to stress § Linked to several measures of health
The Process 6 week protocol § Maximize Heart Rate Variability • Diaphragmatic Breathing • Resonance Frequency Breathing Rate • Synchronization of breathing and heart rate
How It Works
Preliminary Results v First OQ § TAU: 87. 08 § HRVB: 81. 90 v Last OQ § TAU: 73. 39 § HRVB: 56. 55 v Mean Change § TAU: -13. 69 (SD=13. 29) § HRVB: -24. 35 (SD=18. 73) § Total: -20. 76 (SD=17. 55) • HRVB—treatment group • TAU—treatment as usual OQ SCORE Change for HRVB 12 120 100 80 60 40 20 0 0 2 4 6 8
Moving Forward… v Protocol consistency v Lots of positive feedback from participants v Most of our participants are female v Still need 10 -20 more participants (especially TAU) v The importance of homework! § Rationale § Practice makes perfect v Lasting effects?
STUDY #4 AAPB Stress Physiology and Psychotherapy: Implementation of an HRV Biofeedback Intervention to Improve Outcome in Psychotherapy Andrea De Barros, Tara Austin, Louise Wheeler Doctoral Students www. themegallery. com
Previous Study Results ◦ Participants reporting higher levels of distress (OQ > 62) had a more elevated physiological stress response and a longer physiological recovery after exposure to a stressor. ◦ Stress reduction strategies may be a useful adjunct for those in psychotherapy ○ Particularly important for high distress groups
GOAL & HYPOTHESES • GOAL: Assess if a HRV biofeedback intervention can help improve the psychotherapy outcome of patients with increased stress reactivity • HYPOTHESES: » 1. Biofeedback participants will show a significant drop in OQ scores over time » 2. Biofeedback participants will show a significantly more elevated stress physiology at baseline » 3. Biofeedback participants will show less stress physiology at 6 -week follow-up
PARTICIPANTS College students attending psychotherapy at university counseling center ○ Early treatment (first or second session) ○ Agreed on being contacted about research ○ Ages 18 to 30 ◦ Randomly assigned to groups •
MAIN MEASURES ◦ Trier Social Stress Test (TSST) ○ Two stress inducing tasks ○ Gold standard ◦ OQ-45 •
BIOFEEDBACK INTERVENTION ◦ Session 1: Pre-measure of stress physiology and introduction of HRV training ○ TSST ○ Introduction of diaphragmatic breathing o Session 2: Introduction of optimal rate of breathing o Session 3 -5: Practice of breathing at optimal rate o Session 6: post-measure of stress physiology ○ TSST o Based on evidence-based protocol (Lehrer, 2007) o Homework assignment and adherence
CONTROL CONDITION Session 1: Pre-measure of stress physiology ○ TSST Session 2 -5: passive relaxation o Session 6: post-measure of stress physiology ○ TSST
PRELIMINARY RESULTS Hypothesis 1: Biofeedback participants will show a significant drop in OQ scores over time
RESULTS Hypothesis 2: Biofeedback participants will show a significantly more elevated stress physiology at baseline ○ Treatment group has lower SDNN, RMSSD, and HF ◦ Hypothesis 3: Biofeedback participants will show less stress physiology at 6 -week follow-up ○ Unclear because of low N but appears promising
STUDY #5 A Study to Determine the Efficacy of Integrating Heart Rate Variability Feedback with Psychotherapy TAU Leavitt, L. , Rice, M. , Morrell, B. www. themegallery. com
Qualitative study looking at the impact of HRV used in session with clients It is a simple process: v Become trained on the use of em. Wave and have it installed on your computer - takes about 20 minutes. v It starts in one of two ways § The client approaches you and asks about it (fliers and posters at the front desk) § If you believe it would help the client you can suggest it to them as their therapist www. themegallery. com
v You administer the emwave HRV in session with the client, at least once. v It typically takes up about 10 -15 minutes of the session time, less once you have done it a few times. v Once you have done session you put the consent form in Lisa’s box with the client contact information on it. v The client has a short interview about their experience and gets $15. 00 v You have a short interview about your experience – unfortunately no $15. 00 for us, we just get the satisfaction of knowing we helped out our client and a colleague!. v Voila!! You are done! www. themegallery. com
Biofeedback • Integral Part of the CAPS for 40 Years – Adjunct to therapy – – – General stress management Referrals from physicians Class Assignments • Increasing Demand for Services – Our Role – Most students come to 1 -2 biofeedback sessions – Many psychotherapy clients tend to come for multiple sessions – individual or open hours – Provide training so students learn skills they can practice at home – breathing strategies – cutting edge treatment
HRV – Heart Rate Variability Breathing § Decrease depression (Karavidas, et al, 2007) § Decrease stress (Palomba, et al, 2011) § Improve cardiovascular functioning (Del Pozo, Gevirtz, Scher, & Guarneri, 2004) § H/O on Breathing and Apps, Stress Cards § Stress the value of Breathing and the positive effects of HRV Breathing Training
Paced Breathing Resources v v Stress Cards Breathing H/O EZ-Air Pacer Smart Phone Apps § My Calm Beat § Breathe 2 Relax § Azumio Stress Doctor § Inner Balance § Sleep Time § Sleepytime § Sleepcycles v Websites § calm. com § asoftmurmur. com § Stopbreathethink. org
What is and Why Teach and Train HRV Breathing For Autonomic Balance? Breathing is the fastest and most effective way to calm down, reduce anxiety, attain peak performance § Em. Wave measures Heart Rate and Heart Rhythms § Trains Autonomic Balance - balance between stress (sympathetic NS) and feeling calm (parasympathetic NS) § With slow diaphragmatic breathing HRV increases as the heart rate speeds up with inhalation and slows down with exhalation
Biofeedback HRV Training Results § Develops Sensory Awareness of tension/anxiety vs. relaxation/calmness § Aids in the Learning Process of releasing tension and stress § Conditions the Relaxation Response to be easy and more automatic • This results in § Greater instant calmness and mental clarity § Positive mental and emotional focus § Improved heart health over time § Peak Performance in: • Academics • Music • Sports • Social Interactions
Biofeedback for All Clinicians Customized em. Wave license through the Heart Math Educational Division: § Software loaded on all computers of counselors § Use limited to number of sensors Advantages § Integrate biofeedback with therapy § Biofeedback is more effective way to teach diaphragmatic breathing § Helpful with students in crisis: Immediate skills for calming § University students enjoy biofeedback Also in Career and Academic Success Center for student use
em. Wave Main Screen Saved Session Data Games and Activities Breath Pacer Heart Rate Variability Wave Heart Rate Scale Various Displays Average Heart Rate Gray Arrow Changes Display Coherence Ratio Sound on/off Start & Stop buttons
Summary of Counseling and Psychological Services Biofeedback: Faculty and Student Dissertation Research 1. The Efficacy of Stress Management and Biofeedback Training as an Adjunct to Psychotherapy for University Students (Morrell, B. , Nielsen, D. , Rice, M. , Erekson, D. , Marvin, L. , Brown, L. ) 2. The Impact of Resonant Frequency HRV Training in the Treatment of Depression and Resting State f. MRI (Caldwell, Y. , Dissertation) 3. HRV Biofeedback’s Effect on Symptoms of Clients with Generalized Anxiety Disorder (Roney, T. , Pescatello, M. , Dissertation) 4. Stress Physiology and Psychotherapy: Implementation of an HRV Biofeedback intervention to improve outcome in psychotherapy (Barros, A. , Austin, T. , Wheeler, L. – AAPB) 5. The Efficacy of Integrating Heart Rate Variability Feedback with Psychotherapy (Leavitt, L. , Rice, M. , Morrell, B. ) www. themegallery. com
Kelly Mc. Gonigal, Ph. D. Make Stress Your Friend TED TALK THANK YOU. . .
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