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A Physiological Approach to Stress: Heart Rate Variability (HRV) Biofeedback in a Physical Health Setting Laura Onens Assistant Psychologist for Haematology.

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Presentation on theme: "A Physiological Approach to Stress: Heart Rate Variability (HRV) Biofeedback in a Physical Health Setting Laura Onens Assistant Psychologist for Haematology."— Presentation transcript:

1 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

2 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

3 Health Conditions in Haematology Haematology is the study of blood, the blood- forming organs, and blood diseases. Acute or Chronic Cancers E.g. Lymphoma Leukaemia Myeloma Others Thrombotic Disorders e.g. DVT Anaemia Genetic Related Diseases of the Blood E.g. Sickle Cell Thalassemia Haemophilia

4 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

5 Some cope well…some don’t… Common Predisposing Risk Factors Childhood attachment ( Hamama-Raz & Solomon) Coping styles (Coifman, 2007) Emotional resilience/maturity Previous psychiatric history Trauma History ( Green et al, 2000 ) Common Perpetuating Risk Factors Nature of disease e.g. Chronic or palliative Intensity of treatment regime Social support network Home/financial/work circumstances Side effects of treatment Level of uncertainty Help seeking (Tugade et al, 2005) ( Grasso et al, 2007 )

6 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 Behaviour Physiology Immunology (ANS) Cortex Thalamus Amygdala

7 Why do we respond physically? Negative emotion, stress Positive emotion The Autonomic Nervous System (ANS) Sympathetic Nervous System (SNS) Activity Catabolic hormones “Breaking down and releasing enegy” Steroid Hormones e.g. cortisol & adrenaline (HPA axis) Increased glucose release for energy Parasympathetic Nervous System (PNS) Activity Anabolic hormones “Building up and consuming energy” Steroid hormones e.g. DHEA

8 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

9 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) High cortisol : Low DHEA (Dehydroepiandrosterone)

10 Hypothesis: Can learning to regulate the ANS (physiological regulation) aid emotional regulation when the cause of stress (i.e. cancer) is not easily resolved?

11 Performance Behaviour Think Feel Physiology Physical symptoms of stress, e.g. racing heart, butterflies, irritable bowel, disrupted sleep may reduce through ANS regulation Reduction of physical symptoms may help how we would physically feel Emotional regulation facilitates higher levels of brain functions that may have switched off from “fight or flight” Our behaviour is more appropriate and controlled if our emotions are regulated and thinking is clearer If we are thinking better our memory and coordination is improved - we can perform better

12 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).

13 Clinical AreaAuthor Physician StressLemaire et al (2011) PTSDGinsberg 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 failureLuskin et al (2002) QoL in patients with diabetesMcCraty (2000) HIV psycho and physiological symptomatology Rozman (1996) Behavioural and cognitive functions in children with ADHD Lloyd (2010) Neuropsychology - attention and information processing, recall Ginsberg (2008) Blood pressure, cholesterol, glucose and hormone balance in police officers McCraty (2009)

14 The heart sends far more information to the brain than the brain sends to the heart. Resonant Frequency Breathing transforms HRV to 0.1Hz (sine wave). Synchronised activity of SNS and PNS. The heart signals especially affect the brain centers involved in strategic thinking, reaction times, and self- regulation. Incoherence Inhibits Brain Function Coherence Facilitates Brain Function Transforming HRV - Directly Impacting Physical and Mental Performance

15 Amygdala: Emotional Memory Thalamus: synchronizes cortical activity Medulla: Blood pressure and ANS regulation Cortex: Thinking Brain Inhibits cortical function Atrial Peptide Oxytocin Dopaminie Norepinephrine Epinephrine

16 Amygdala: Emotional Memory Thalamus: synchronizes cortical activity Medulla: Blood pressure and ANS regulation Cortex: Thinking Brain Facilitates cortical function

17 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.

18 Pre & Post Depression Scores of Haematology Patients Receiving HeartMath

19 Pre & Post Anxiety Scores of Haematology Patients Receiving HeartMath Severe Moderate 8-10 Mild 0-7 Normal

20 Staff Anxiety & Depression Scores Pre and Post HeartMath Hospital Anxiety & Depression Scale (HADS) Score Staff Members Severe Moderate 8-10 Mild 0-7 Normal

21 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.

22 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”

23 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”

24 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).


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