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Heart rate variability (HRV) and posttraumatic stress disorder (PTSD): A pilot study

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Abstract

Exposure to combat experiences is associated with increased risk of developing Post Traumatic Stress Disorder. Prolonged exposure therapy and cognitive processing therapy have garnered a significant amount of empirical support for PTSD treatment; however, they are not universally effective with some patients continuing to struggle with residual PTSD symptoms. Heart rate variability (HRV) is a measure of the autonomic nervous system functioning and reflects an individual's ability to adaptively cope with stress. A pilot study was undertaken to determine if veterans with PTSD (as measured by the Clinician-Administered PTSD Scale and the PTSD Checklist) would show significantly different HRV prior to an intervention at baseline compared to controls; specifically, to determine whether the HRV among veterans with PTSD is more depressed than that among veterans without PTSD. The study also aimed at assessing the feasibility, acceptability, and potential efficacy of providing HRV biofeedback as a treatment for PTSD. The findings suggest that implementing an HRV biofeedback as a treatment for PTSD is effective, feasible, and acceptable for veterans. Veterans with combat-related PTSD displayed significantly depressed HRV as compared to subjects without PTSD. When the veterans with PTSD were randomly assigned to receive either HRV biofeedback plus treatment as usual (TAU) or just TAU, the results indicated that HRV biofeedback significantly increased the HRV while reducing symptoms of PTSD. However, the TAU had no significant effect on either HRV or symptom reduction. A larger randomized control trial to validate these findings appears warranted.
Biofeedback ÓAssociation for Applied Psychophysiology & Biofeedback
Volume 41, Issue 3, pp. 131–135 www.aapb.org
DOI: 10.5298/1081-5937-41.3.05
SPECIAL ISSUESPECIAL ISSUE
Heart Rate Variability and Posttraumatic Stress
Disorder
Gabriel Tan, PhD, ABPP,
1
Penelope Wang,
1
and Jay Ginsberg, PhD
2
1
National University of Singapore, Singapore;
2
Dorn VA Medical Center, Columbia, SC
Keywords: posttraumatic stress disorder, combat-related PTSD, civilian PTSD, heart rate variability, biofeedback
The psychophysiology of posttraumatic stress disorder
(PTSD) points towards autonomic dysregulation—specifi-
cally, elevated sympathetic response and attenuated
parasympathetic response. In view of this, heart rate
variability (HRV) biofeedback has been applied and tested
as a treatment for PTSD. Review of existing published
research suggests that HRV biofeedback seems promising
as a treatment for PTSD, both in significantly alleviating
the symptoms and in improving cognition for those
suffering from PTSD. Drop-out rate is low, and inexpensive
and portable HRV biofeedback devices such as the Stress
Eraser make it a viable alternative to traditional treatment
such as prolonged exposure therapy (PET), cognitive
behavior therapy (CBT) and cognitive processing therapy
(CPT). More recent research has also shown that
combining HRV biofeedback with CBT, PET, and Accep-
tance and Commitment Therapy (ACT) improved the
efficacy of these therapies in treating PTSD. More larger-
scale and rigorous controlled trials are needed to confirm
these outcomes.
Posttraumatic stress disorder (PTSD) is an anxiety disorder
characterized by intense fear and helplessness in individuals
following exposure to a traumatic event. There are three
other clusters of symptoms associated with PTSD, including
intrusive recollection of the event, avoidance of stimuli
associated with the trauma or numbing of general
responsiveness, and persistent state of increased arousal
(United States Department of Veteran Affairs, 2013).
PTSD was initially thought to be a rare disorder with a
lifetime prevalence rate of 1%–2% (Kessler, 2000).
However, recent studies in the United States (e.g., Kessler
et al., 2005) have indicated a higher lifetime prevalence of
6.8%. Apart from being a highly distressing disorder for
the individual, PTSD can also prove to be damaging for
society, as work impairment resulting from PTSD could
translate to an annual loss of $3 billion or more in the
United States (Kessler, 2000). Rates among veterans are
significantly higher, ranging from 30% for the Vietnam
War (Kang, Natelson, Mahan, Lee, & Murphy, 2003) to
more recent estimates for the Iraqi and Afghanistan wars of
16.7% for active troops and 24.5% for reservists (Millikan,
Auchterlonie, & Hoge, 2007). In addition to the untold
sufferings for those diagnosed with PTSD and their
families, the economic burden to society is very significant.
The RAND Corporation estimated the economic costs of
PTSD to be between $4 billion and $6.2 billion over two
years, with an average cost per case ranging from $5,904 to
$10,298 (Tanielian, 2009).
Given this state of affairs, it is important that effective
treatments are made available to those suffering from PTSD
in order for them to cope with the disorder and improve
their life functioning. While reports have been published on
psychological interventions (including prolonged-exposure
therapy (PET) and cognitive-processing therapy (CPT;
DeAngelis, 2008), little attention has been accorded to
interventions from a psychophysiological perspective.
Psychophysiology of PTSD and Heart Rate
Variability
The persistent state of hyperarousal that characterizes
PTSD suggests autonomic dysregulation—in particular, a
weakened parasympathetic nervous system (PNS) and an
elevated sympathetic nervous system (SNS; Blechert,
Michael, Grossman, Lajtman, & Wilhelm, 2007). The
elevated heart rate found in individuals suffering from
PTSD also supports this idea. Because heart rate is regulated
by both PNS and SNS, such heart rate increases could be
due to increased sympathetic activity, attenuated parasym-
pathetic activity, or both (Pole, 2007). As heart rate
variability (HRV) can be used as a simple, noninvasive
indicator of the autonomic nervous system (Sztajzel, 2004),
there is the potential for individuals suffering from PTSD to
benefit from HRV interventions, such as HRV biofeedback.
The article by Lehrer in this special issue has eloquently
described the principle behind HRV biofeedback, which
131
Biofeedback |Fall 2013
trains individuals to control their breathing such that they
will become accustomed to breathing at resonant frequency.
By doing this, individuals can produce large increases in
both HRV and baroreflex gain and patient PTSD symptoms
can be alleviated as a result. Van der Kolk, a leading
authority on trauma, has argued that interoceptive body-
oriented therapies can directly confront the core clinical
issue in PTSD and that traumatized individuals are prone to
experience the present with physical sensations and
emotions associated with the past. In order for therapy to
be successful, these individuals need to focus on physical
self-experience and increase self-awareness rather than
focusing on the meaning and narrative of the past (van der
Kolk, 2006). HRV biofeedback would appear to fit the bill.
Evidence for the Efficacy of HRV
Biofeedback with PTSD
Tan, Dao, Farmer, Sutherland, and Gevirtz (2011) conduct-
ed a pilot study at the Houston VA Medical Center in order
to assess current HRV among veterans, as well to determine
the efficacy of HRV biofeedback as a treatment of veterans
suffering from combat-related PTSD. By comparing 20
veterans diagnosed with PTSD with 10 healthy control
participants, they found that the veterans with PTSD
displayed lower HRV than individuals without PTSD
(mean standard deviation of the normal-to-normal heart-
beat interval [SDNN] for PTSD group ¼48.10 versus mean
SDNN for control group ¼138.70, p,.001; d¼1.89). In
addition to supporting Sztajzel’s (2004) argument that HRV
can be used as an indicator for autonomic nervous system
dysfunction, Tan et al.’s (2011) finding also highlights how
HRV can be used to distinguish individuals with PTSD and
those without.
In this pilot study, the veterans diagnosed with PTSD
(experimental group) were also administered the Lehrer’s
treatment protocol (Lehrer, Vaschillo, & Vaschillo, 2000) in
addition to treatment as usual. The treatment was provided
in eight sessions. Results indicated that the HRV biofeed-
back was efficacious for reducing PTSD symptoms as
assessed by the Clinician-Administered PTSD Scale (CAPS)
and the PTSD Checklist-Specific (PCL-S). Both instruments
indicated significantly reduced scores from baseline to the
posttreatment follow-up for those who received the HRV
biofeedback treatment (p,.001 for CAPS, d¼0.80; p,
.035 for PLC-S, d¼1.08). The control group (who received
treatment as usual only) showed no statistical differences in
pre- to posttreatment scores for both CAPS and PCL-S. The
findings indicated that HRV biofeedback significantly
reduced symptoms of PTSD and provided benefits in
treating PTSD beyond those of treatment as usual.
The results in Tan et al. (2011) are not only statistically
significant, but are also clinically significant and important.
In a meta-analysis by Hoffman and Smits (2008), the
average Hedges g (comparable to the dscores in this study)
was 0.64 for six well-controlled trials; the values of 0.80 for
the CAPS and 1.08 for the PCL in this study would
compare favorably. Freed et al. (2009) used a Preference-
Weighted Health Status (PWHS) measure to assign clinical
meaning to PCL scores and reported that a change of 0.041
units would be considered clinically important. Based on the
PCL improvement in this study, the differential PWHS was
0.06, a large improvement in overall health status.
In addition to efficacy, the Tan et al. (2011) study also
showed a very high adherence rate for the HRV
biofeedback protocol of 95%. This was most likely due to
the high satisfaction and acceptability patients felt towards
the treatment. A post follow-up phone interview of
participants confirmed this suspicion, and all participants
reported looking forward to the treatment sessions, which is
in contrast to other veterans at the same facility who had
participated in the more traditional PET and CPT treat-
ments where adherence has often been a problem for many
therapists. The high adherence rate indicated that HRV
biofeedback would be well-received by clients as an
alternative treatment to the more commonly used PET
and CPT interventions.
More recently Ginsberg and colleagues presented
preliminary findings from an ongoing research project
entitled ‘‘Heart Rate Variability Biofeedback for OIF-OEF
Combat Veterans with PTSD,’’ during the AAPB Annual
Meeting in Portland, OR (Ginsberg et al., 2013). This is a
pre-post, single-blind, sham-controlled study of the effects
of HRV biofeedback on PTSD symptoms and cognition in
Operation Iraqi Freedom–Operation Enduring Freedom
combat Veterans, funded by the Deployment-Related
Medical Research Program (DRMRP). Combat veterans
with PTSD who agreed to participate were randomly
assigned to one of two groups: (1) active HRV biofeedback
training, or (2) sham HRV biofeedback training (see the
Table).
After signing the consent form, participants underwent
15 minutes of passive HRV monitoring (without visual
feedback) followed by psychological assessment. The HRV
monitoring and psychological assessment was administered
at three time points: pretraining, posttraining, and eight
weeks follow-up (i.e. 16 weeks from pretraining). During
the 15-minute passive HRV recording period, subjects
viewed a static relaxing nature picture on the computer
screen (e.g., mountains, sky, and clouds) while HRV was
recorded with a fingertip plethysmograph. Visual HRV
HRV and PTSD
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Fall 2013 |Biofeedback
feedback was not provided during passive HRV recording.
The psychological assessment consisted of the Posttrau-
matic Stress Disorder Checklist-Military Version (PCLM;
Orsillo, 2001; Weathers, Litz, Herman, Huska, & Keane,
1993) and the CAPS (Blake et al., 1995; Orsillo, 2001;
Weathers, Keane, & Davidson, 2001).
Treatment of the PTSD groups consisted of a six-week
training protocol with active and sham HRV biofeedback.
The active HRV biofeedback training consisted of a 25-
minute biofeedback training and coaching period (with
visual HRV feedback), followed by a 15-minute passive
HRV recording period. During the 15-minute passive HRV
recording period, subjects were instructed to put into
practice the technique they had just been coached on. Sham
training participants viewed a static relaxing picture for 25
minutes (without visual HRV feedback) and were told to
relax by the biofeedback coach. They then had a 15-minute
passive HRV recording period. Active HRV biofeedback
subjects were issued an EmWavetPersonal Stress Reliever
(a handheld biofeedback training device, which assists
individuals to increase heart rate variability) and encour-
aged to practice at home while sham training subjects were
issued a ‘‘squeeze stress reliever’’ (in the shape of a brain)
and encouraged to practice at home.
Preliminary findings indicated that among the 42
veterans enrolled, 31 were assigned to a group (13 HRV
treatments, 14 sham, 4 controls). Controls were only
assessed at baseline (pretraining) and did not receive active
or sham biofeedback. Eighteen combat veterans with PTSD
have completed through follow-up (7 HRV, 11 sham).
Among completers, active HRV biofeedback reduced the
severity of PTSD on both measures at posttraining and at
follow-up, while only negligible differences were noted for
the sham HRV biofeedback group from pretraining levels.
Repeated measures analysis (three time periods 3two
groups) showed similar results for both PCLM and CAPS,
with significant effects for PTSD (both ps,.004) and
PTSD 3Group (both ps,.02), and main effect of Group
(both ps,.05). Simple paired ttests of preTraining versus
follow-up PTSD among active HRV biofeedback (HRVB)
completers were both significant (55.6 versus 48.9 on
PCLM, 77.0 versus 57.4 on CAPS, both ps(1t),.02). The
authors provided the following tentative conclusion:
Combat veterans with PTSD appeared to experience
improvement in their PTSD symptoms immediately
following six weeks of HRV biofeedback, and although
the effect decreased at follow-up, the benefit from
pretraining through follow-up was nonetheless significant.
Using the Stress Erasert(SE; a portable electronic device
displaying heart rate oscillations, and enabling self-guided
HRV biofeedback training), Zucker, Samuelson, Muench,
Greenberg, and Gevirtz (2009) conducted a study to
examine the effect of respiratory sinus arrhythmia (RSA)
on PTSD. Zucker et al. (2009) defined their intervention as
RSA biofeedback. They did not assess resonance frequency
or train resonance frequency breathing; rather they
instructed the participants to use the Stress Erasertdevice
to create optimal heart rate oscillations. The participants
who received the RSA intervention significantly reduced
their PTSD symptomatology, as measured by the Post-
Table. Ginsberg et al. Training Protocol for combat Veterans with PTSD
Active Training Group Sham Training Group
Pretraining passive HRV recording þ
psychological assessment
yes yes
Six weekly lab sessions 25-minute HRVB training followed by
15-minute passive HRV recording
25-minute passive computer screen
viewing followed by 15-minute
passive HRV recording
Home practice EmWave Personal Stress Reliever ‘‘Squeeze stress reliever’’
Posttraining passive HRV recording þ
psychological assessment
yes yes
Follow-up passive HRV recording þ
psychological assessment
yes yes
Note. PTSD ¼posttraumatic stress disorder, HRV ¼heart rate variability, HRVB ¼HRV biofeedback.
Tan et al.
133
Biofeedback |Fall 2013
traumatic Stress-Total scale of the Detailed Assessment of
Posttraumatic States and the PTSD Checklist-Civilian
Version (PCL-C) (all ps,.01). Such decrease was due to
an increase in HRV in these participants as standard
deviation of the normal-to-normal beats (SDNN) noted
increases in HRV postintervention.
The significance of Zucker’s et al. (2009) study is that a
community sample is used. This is crucial because the
samples used in the earlier studies discussed were made up
of veterans, which leaves one to question if the findings can
be generalized to civilian populations. The fact that Zucker
et al. (2009) found the alleviation of PTSD symptoms by
increasing HRV in their participants is a strong indication
that such results can be generalized to community
populations. Specifically, individuals who suffer from PTSD
can reduce their symptoms by increasing their HRV,
regardless whether the origin of their PTSD stems from
combat experience or otherwise.
Other Benefits of HRV Treatment for PTSD
Research by other investigators suggests that in addition to
the alleviation of PTSD symptoms following HRV biofeed-
back, veterans with PTSD who underwent the HRV
biofeedback treatment also exhibited improvements in
attention and immediate memory performance when
compared to their counterparts who did not have a PTSD
diagnosis (Ginsberg, Berry, & Powell, 2010). A follow-up
grant is currently investigating the cognitive effect of HRV
biofeedback training on veterans suffering from PTSD
(Ginsberg et al., 2013). Preliminary data analysis suggests
that the PTSD biofeedback group showed more improve-
ment in cognitive performance tasks posttreatment as
compared to those receiving sham treatment. These
findings, though preliminary, suggest that HRV biofeed-
back may also improve cognitive performance in addition to
relieving symptoms of PTSD among veterans.
A series of research is being conducted at the Trauma
Research Institute (Gevirtz & Dalenberg, 2008) to investi-
gate the efficacy of integrating HRV biofeedback with more
traditional psychological therapies including PET, CBT, and
ACT. Their protocol for treatment of PTSD has four
components: psycho-education, CBT, ACT, and HRV
biofeedback. Preliminary findings are encouraging, show-
ing significant improvement in PTSD symptoms achieved
by 24 of 27 (88%) consecutive patients.
Finally, a number of ongoing research investigations are
showing promise to further delineate the effect of HRV
biofeedback for PTSD among veterans. First, a meta-analysis
has recently been completed showing the effect sizes of
various HRV parameters for samples of veterans of PTSD as
compared to control (Nagpal, Gleichauf, & Ginsberg,
unpublished). Second, an animal model is being tested to
identify individual differences in PTSD-like phenotypes that
are resistant to extinction of conditioned cardiovascular
responses, including reduced HRV to repeated trauma
exposure in a VA Merit Review funded grant project,
(Marlene Wilson, PhD, Principal Investigator).
Conclusion
In a nutshell, PTSD affects many individuals, and although
there are several psychosocial treatment approaches that
have been well researched, the same cannot be said for
psychophysiological treatment approaches to PTSD. A
promising form of psychophysiological intervention in-
volves increasing HRV in order to alleviate PTSD
symptoms and improve information processing in PTSD
patients. However, research is still lacking in this area and
only pilot studies have been published, and larger scales
controlled research is still lacking. However, we have
identified at least one larger scale controlled study that is
still pending completion.
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... This would allow the authors to draw a comparison between acute and recovery phases. Finally, as a stressful situation sets off a chain of physical reactions, such as a temporary acceleration of breathing and heart rate (Muraoka et al., 1998;Tan et al., 2011;Kim et al., 2018;Bustamante-Sánchez et al., 2020), we also aimed to assess if the two aforementioned parameters might provide additional and useful information. ...
... The number of heartbeats was obtained through the implementation of the Pan-Tompkins algorithm, a method that detects the QRS complexes in an EKG signal (Pan and Tompkins, 1985). Then, the standard deviation of R-R intervals (SDRR) was derived as a time-domain measurement of heart rate variability (HRV) (Tan et al., 2011;Järvelin-Pasanen et al., 2018;Kim et al., 2018). Finally, because the respiratory signals can be indirectly derived by the EKG signal, the respiratory sinus arrhythmia (RSA) method was implemented to calculate the breathing rate (Cysarz et al., 2008). ...
... Finally, the heart rate was slightly higher in the first session of the FLCO group, although still within physiological values. As we know, a stressful situation sets off a chain of events: the body releases adrenaline, a hormone causing a momentaneous acceleration of breathing and heart rate (Muraoka et al., 1998;Tan et al., 2011;Kim et al., 2018;Bustamante-Sánchez et al., 2020). However, heart rate variability analysis did not show any difference between the two groups but only within the two sessions in both groups. ...
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... However, they did not report physiological data while the patients practiced RSA or PMR (Zucker et al., 2009). Another pilot study found preliminary evidence for an adjunctive therapy-enhancing effect of RSA biofeedback compared to TAU (Tan, Dao, Farmer, Sutherland, & Gevirtz, 2011). The results of both pilot studies must be interpreted cautiously due to their small sample sizes. ...
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... Heart rate variability (HRV), a measure of the autonomic nervous system's functioning, reflects an individual's ability to adaptively cope with stress. Veterans with combat-related PTSD have shown significantly depressed HRV compared to those without PTSD (Tan et al. 2010). ...
Technical Report
The US Army Combat Capabilities Development Command (DEVCOM) Army Research Laboratory has a long-term effort toward enhancing our understanding of the physiological and behavioral components of Warfighter-relevant tasks, such as situational awareness (SA) acquisition and maintenance. A critical component of this effort is to understand the effects of stress on Warfighter state to predict and enhance performance during operational missions, especially in high-stress environments, and how individual differences (resiliency, mental health, etc.) impact performance. While we can often induce only a limited amount of stress in traditional laboratory settings, we can induce elevated stress responses by utilizing immersive environments (e.g., virtual environments or virtual reality) and by leveraging certain military personnel and veteran populations to better understand performance effects. In particular, those with posttraumatic stress disorder (PTSD) demonstrate altered physiological and behavioral processes that support SA. This report provides a basic overview of PTSD, its prevalence in the military, and how it is related to individual differences, behavior, and physiology. We hope that this review will provide an insightful and ethical lens to other DEVCOM Army Research Laboratory researchers considering leveraging this population for research.
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Chapter
Paramilitary and military tactical personnel perform various activities utilizing a range of specialized skills. The activities they are required to perform, the load carriage of their ballistic personnel protective equipment and other operation equipment together with the stressors within the operations and the potential for injury death can cause in the moment as well as long-term implications for paramilitary and military tactical personnel. There is great potential to use engineering, computing and information technology to enable individualized and population-based assessment and development of health, wellness, resilience and adaption of paramilitary and military tactical personnel. In this chapter, we present opportunities and challenges for engineering, computing and information technology solutions for use with paramilitary and military tactical personnel.
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The use of structured interviews that yield continuous measures of symptom severity has become increasingly widespread in the assessment of posttraumatic stress disorder (PTSD). To date, however, few scoring rules have been developed for converting continuous severity scores into dichotomous PTSD diagnoses. In this article, we describe and evaluate 9 such rules for the Clinician-Administered PTSD Scale (CAPS). Overall, these rules demonstrated good to excellent reliability and good correspondence with a PTSD diagnosis based on the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev.; DSM-III—R ; American Psychiatric Association, 1987). However, the rules yielded widely varying prevalence estimates in 2 samples of male Vietnam veterans. Also, the use of DSM-III—R versus DSM-IV criteria had negligible impact on PTSD diagnostic status. The selection of CAPS scoring rules for different assessment tasks is discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Book
This therapist guide of prolonged exposure (PE) treatment is accompanied by the patient workbook, Reclaiming Your Life from a Traumatic Experience. The treatment and manuals are designed for use by a therapist who is familiar with cognitive behavioral therapy (CBT) and who has undergone an intensive training workshop for prolonged exposure by experts in this therapy. The therapist guide instructs therapists to implement this brief CBT program that targets individuals who are diagnosed with posttraumatic stress disorder (PTSD) or who manifest PTSD symptoms that cause distress and/or dysfunction following various types of trauma. The overall aim of the treatment is to help trauma survivors emotionally process their traumatic experiences to diminish or eliminate PTSD and other trauma-related symptoms. The term prolonged exposure (PE) reflects the fact that the treatment program emerged from the long tradition of exposure therapy for anxiety disorders in which patients are helped to confront safe but anxiety-evoking situations to overcome their unrealistic, excessive fear and anxiety. At the same time, PE has emerged from the adaption and extension of Emotional Processing Theory (EPT) to PTSD, which emphasizes the central role of successfully processing the traumatic memory in the amelioration of PTSD symptoms. Throughout this guide, the authors highlight that emotional processing is the mechanism underlying successful reduction of PTSD symptoms.