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).