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:
1A Physiological Approach to Stress: Heart Rate Variability (HRV) Biofeedback in a Physical Health SettingLaura OnensAssistant Psychologist for HaematologyPsychological Services for Physical Health
2Contents What do you do in physical health? Psychological distress in Haematology and working away from a predominately medical modelThe introduction of HRV Biofeedback (HeartMath)The results of a pilot evaluationQualitative resultsConclusion and indications for future research
3Health Conditions in Haematology Haematology is the study of blood, the blood- forming organs, and blood diseases.Acute or Chronic CancersE.g. LymphomaLeukaemiaMyelomaOthersThrombotic Disorders e.g. DVTAnaemiaGenetic Related Diseases of the BloodE.g. Sickle CellThalassemiaHaemophilia
4Common Presenting Symptoms of Psychological Distress in Haematology Patients Generalised Anxiety and PanicDepressionHealth AnxietyLoss of controlUncertaintyFear of death & dyingShockNeedle phobiaUnhelpful 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
5Some cope well…some don’t… CommonPredisposing Risk FactorsChildhood 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)Nature of disease e.g. Chronic or palliativeCommonPerpetuating Risk FactorsIntensity of treatment regimeSide effects of treatmentPsychological adjustment to illness can be dependent on several factors:According to attachment theory are we dismissive, avoidant, preoccupied or well equipped to “self sooth”.How do we cope? Do we have healthy coping mechanisms or unhealthy styles. Here I am talking about avoidance or withdrawal, obsessive compulsive behaviour, reduced self awareness.Are we good at dealing with our emotions. How aware are we about how we feel? This can be linked in with attachments and learned behavioursPrevious psychiatric history: Do we already have a predisposition to depression or anxiety?What are our experiences of illness? Have we witnessed friends/relations survive or die of disease. Are there any traumatic or negative life events that have impacted on our self esteem, ability to cope or emotional resilience?Perpetuating : What is the disease? Is it chronic (CLL example). Will it lead to death?How difficult is the treatment, does it require long stays in hospital in isolation away from family, numerous life disrupting trips to the hospital?Does the treatment make you really ill, sick, tired? How does the hair loss, weight loss, loss of sex drive, neuropathy, risk of infertility make you feel?Do you have supportive relationships you can gain strength from and confide in.Did you work to support your family, how much did work mean to you. How supportive are your work colleagues.How uncertain is your prognosis and how well do you cope with uncertainty?Social support networkHome/financial/work circumstancesLevel of uncertaintyHelp seeking
6Physiological effects of psychological distress Diagnosis and treatment is often highly emotive therefore heightened awareness of “fight-or-flight” and physical responseLife consuming - particularly in patients diagnosed with cancer. Therefore stress response often unrelentingHyper vigilant, on guard, expecting threat due to constant activationCortexThalamusAmygdalaBehaviourPhysiologyImmunology(ANS)
7Why do we respond physically? The Autonomic Nervous System (ANS)Negative emotion, stressPositive emotionSympathetic Nervous System (SNS) ActivityCatabolic hormones“Breaking down and releasing enegy”Steroid Hormones e.g. cortisol & adrenaline (HPA axis)Increased glucose release for energyParasympathetic Nervous System (PNS) ActivityAnabolic hormones“Building up andconsuming energy”Steroid hormones e.g. DHEAActivation of sympathetic branch of autonomic nervous system (ANS)“Acceleration” in order to prepare the body for survivalActivation of HPA Axis. Increased levels of glucose, stress related hormones (e.g. cortisol, adrenaline)Other bodily systems regulated by the ANS speed up (respiration and cardiac function)
8Difficulties with the physiological response to threat in this context Fight or Flight is a survival mechanism to help us survive physical threatsNo physical response required for cancer/diseaseA situation which is not easily resolved without further stressPoor physical health limits the opportunity to exercise in order to burn off stress related steroid hormones and excess glucose
9High 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)
10Hypothesis:Can learning to regulate the ANS (physiological regulation) aid emotional regulation when the cause of stress (i.e. cancer) is not easily resolved?
11Performance Behaviour Think Feel Physiology If we are thinking better our memory and coordination is improved - we can perform betterPerformanceBehaviourThinkFeelPhysiologyOur behaviour is more appropriate and controlled if our emotions are regulated and thinking is clearerEmotional 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 feelPhysical symptoms of stress, e.g. racing heart, butterflies, irritable bowel, disrupted sleep may reduce through ANS regulation
12Heart 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 systemThe 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.We now know, based on research done in Canada and the US, that the heart has its own intrinsic nervous system consisting at least 40,000 neurons. This is considered an intelligent system which is constantly sending information to your brain. The neural signals the heart sends to the brain especially affect the brain centers involved in decision-making and emotional experience. Pretty cool stuff, isn’t it? Maybe the old expression “follow your heart” had more truth to it than we knew.The heart has a complex nervous system consisting of many types of neurons. Scientists around the world who study the heart’s nervous system actually call it the “brain in the heart”. There are large nerve pathways connecting the heart and brain. Many of these pathways have connections to the higher perceptual centers in the brain. This means that there is an important on-going neurological conversation taking place between heart and brain. The heart signals especially affect the brain centers involved in decision making, creativity and emotional experience.Heart researchers have learned that the brain sends information to the heart that affects the timing of the heart beat and the heart sends important information back to the brain. When scientists map out this biological conversation they clearly see that the heart is sending a lot more information to the brain than it receives. In fact it’s now well-known that many brain functions are critically dependent on signals coming from the heart.Transition: The heart is the most powerful generator of rhythmic information patterns in the body and helps to synchronize our entire system via information back to the brain.(McCraty et al, 1998; American Journal of Cardiology).
13Clinical AreaAuthorPhysician 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 symptomatologyRozman (1996)Behavioural and cognitive functions in children with ADHDLloyd (2010)Neuropsychology - attention and information processing, recallGinsberg (2008)Blood pressure, cholesterol, glucose and hormone balance in police officersMcCraty (2009)
14Transforming HRV - Directly Impacting Physical and Mental Performance The heart signals especially affect the brain centers involved in strategic thinking, reaction times, and self- regulation.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 FunctionCoherence Facilitates Brain Function
17The 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 patientsEvidence in occupational health of its effectiveness to help staff manage stress levels. Staff have additionally been offered the 6 week course.
18Pre & Post Depression Scores of Haematology Patients Receiving HeartMath N=21 patients with a range of haematological diseases (depression)All but 2 had a reduction in their reported levels of anxiety.6 patients with haemaphilia (genetic blood clotting disorder)15 patients with cancer (lymphoma, myeloma and leukaemia) either before, during or after treatment.
19Pre & Post Anxiety Scores of Haematology Patients Receiving HeartMath 16-21Severe11-15Moderate8-10Mild0-7NormalAnxiety more prevelant than depression. Indicating many being in that “fight or flight” response
20Staff Anxiety & Depression Scores Pre and Post HeartMath 16-21Severe11-15ModerateHospital Anxiety & Depression Scale (HADS) Score8-10Mild0-7NormalN=6 staff members (2 nurses, 1 senior manager, 2 doctors and 1 administrator)Staff Members
21Qualitative information & benefits Increased AWARENESS of emotional regulation and techniques to achieve thisIncreased 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 vitalityImproved 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.
22Qualitative 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”
23Qualitative 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”
24Conducting 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).