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. 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

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) Nature of disease e.g. Chronic or palliative Common Perpetuating Risk Factors Intensity of treatment regime Side effects of treatment Psychological 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 behaviours Previous 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 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 Positive emotion 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 Activation of sympathetic branch of autonomic nervous system (ANS) “Acceleration” in order to prepare the body for survival Activation 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)

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 Performance Behaviour Think Feel Physiology 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. 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).

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 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)

Transforming 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 Function Coherence Facilitates Brain Function

Transforming Stress into Resilience Workshop Trainer’s Notes Cortex: Thinking Brain Amygdala: Emotional Memory Thalamus: synchronizes cortical activity dd Medulla: Blood pressure and ANS regulation Animated Slide All brain centers can be affected by these HRV signals. One of these is the thalamus, which is responsible for several key functions that support the higher thinking centers of the brain. The signals from the heart and body also go to the amygdala. This is how the brain knows what the body is feeling. When the heart’s signals to the thalamus are incoherent, they interfere with the ability of the thalamus to perform these functions. The emotional centers interpret the message as a stressful feeling—anxiety, frustration, and so on. This results in what is called cortical inhibition. In this state the brain is not working as well as it could—your reactions are slowed and you cannot think as clearly. This is why when you get angry or upset, you can say or do something that you wouldn’t normally say or do--something you may later regret. This mechanism did have survival implications. Incoherent signals told the brain to prepare the body to run or fight. Fred had to react quickly and get out of there FAST. If he took time to think about the situation, he could be dinner. Today, our saber tooth tigers show up wearing different clothes: they’re angry co workers, corporate policies and procedures, the guy on the freeway. Regardless, when we feel stress, our bodies react the old fashioned way and consequently the HRV signal is incoherent, compromising all brain centers. It’s biological! And it’s why smart people can say and do stupid things under stress. Or spill the coffee on the computer! Transition: On the other hand… Inhibits cortical function Atrial Peptide Oxytocin Dopaminie Norepinephrine Epinephrine ©2009 HeartMath

Transforming Stress into Resilience Workshop Trainer’s Notes Cortex: Thinking Brain Amygdala: Emotional Memory Thalamus: synchronizes cortical activity dd Medulla: Blood pressure and ANS regulation … once we learn how to shift the heart rhythms to a coherent pattern, this signals the brain that everything is OK and working in harmony. Coherent heart signals result in what’s called cortical facilitation. In this state, your brain is working at its best. You can think more clearly and see more options and solutions to problems than you could before. You might be interested to know how stress becomes a pattern. The repeated emotions and heart rhythms that we experience a lot of the time become the familiar pattern. We associate what is familiar with what is comfortable, even if it is anxiety, anger, or depression. It becomes what is called a “maladapted pattern.” The brain then does everything it can to maintain that feeling. Transition: To summarize, Facilitates cortical function ©2009 HeartMath

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.

Pre & 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.

Pre & Post Anxiety Scores of Haematology Patients Receiving HeartMath 16-21 Severe 11-15 Moderate 8-10 Mild 0-7 Normal Anxiety more prevelant than depression. Indicating many being in that “fight or flight” response

Staff Anxiety & Depression Scores Pre and Post HeartMath 16-21 Severe 11-15 Moderate Hospital Anxiety & Depression Scale (HADS) Score 8-10 Mild 0-7 Normal N=6 staff members (2 nurses, 1 senior manager, 2 doctors and 1 administrator) Staff Members

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).