Abstract
Recent studies have found a significant association between PTSD and low heart rate variability (HRV), a biomarker of autonomic dysregulation. Research indicates that respiratory sinus arrhythmia (RSA) biofeedback increases HRV while reducing related pathological symptoms. This controlled pilot study compared RSA biofeedback to progressive muscle relaxation (PMR) as adjunctive interventions for 38 persons with PTSD symptoms in a residential treatment facility for a substance use disorder. Both groups were assessed at pre-intervention and 4-week post-intervention. Group × time interactions revealed significantly greater reductions in depressive symptoms and increases in HRV indices for the RSA group. Both groups significantly reduced PTSD and insomnia symptoms and a statistical trend was observed for reduced substance craving for the RSA group. Increases in HRV were significantly associated with PTSD symptom reduction. Overall, these results provide preliminary support for the efficacy of RSA biofeedback in improving physiological and psychological health for individuals with PTSD.
Similar content being viewed by others
References
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders, text revision. Washington, DC: American Psychiatric Association.
Balogh, S., Fitzpatrick, D. F., Hendricks, S. E., & Paige, S. R. (1993). Increases in heart rate variability with successful treatment in patients with major depressive disorder. Psychopharmacology Bulletin, 29(2), 201–206.
Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck depression inventory–II (BDI-II). San Antonio, TX: Psychological Corporation.
Blanchard, E. B. (1990). Elevated basal level of cardiovascular responses in Vietnam veterans with PTSD: A health problem in the making? Journal of Anxiety Disorders, 4(3), 233–237. doi:10.1016/0887-6185(90)90015-2.
Bonnet, M. H., & Arand, D. (1998). Heart rate variability in insomniacs and matched normal sleepers. Psychosomatic Medicine, 60(5), 610–615.
Bremner, J. D. (1999). Acute and chronic responses to psychological trauma: Where do we go from here? The American Journal of Psychiatry, 156(3), 349–351. (editorial).
Breslau, N., & Kessler, R. C. (2001). The stressor criterion in DSM-IV posttraumatic stress disorder: An empirical investigation. Biological Psychiatry, 50(9), 699–704. doi:10.1016/S0006-3223(01)01167-2.
Briere, J. (2001). Detailed assessment of posttraumatic states. Lutz, FL: PAR/Psychological Assessment Resources, Inc.
Bryant, R. A. (2005). Predicting posttraumatic stress disorder from acute reactions. Journal of Trauma & Dissociation, 6(2), 5–15. doi:10.1300/J229v06n02_02.
Bryant, R. A., Creamer, M., O’Donnell, M., Silove, D., & McFarlane, A. C. (2008). A multisite study of initial respiration rate and heart rate as predictors of posttraumatic stress disorder. The Journal of Clinical Psychiatry, 69(11), 1694–1701.
Buckley, T. C., & Kaloupek, D. G. (2001). A meta-analytic examination of basal cardiovascular activity in posttraumatic stress disorder. Psychosomatic Medicine, 63(4), 585–594.
Chambers, A. S., & Allen, J. J. (2002). Vagal tone as an indicator of treatment response in major depression. Psychophysiology, 39(6), 861–864. doi:10.1111/1469-8986.3960861.
Cohen, H., Benjamin, J., Geva, A. B., Matar, M. A., Kaplan, Z., & Kotler, M. (2000a). Autonomic dysregulation in panic disorder and in post-traumatic stress disorder: Application of power spectrum analysis of heart rate variability at rest and in response to recollection of trauma or panic attacks. Psychiatry Research, 96(1), 1–13. doi:10.1016/S0165-1781(00)00195-5.
Cohen, H., Kotler, M., Matar, M. A., & Kaplan, Z. (1997). Power spectral analysis of heart rate variability in posttraumatic stress disorder patients. Biological Psychiatry, 41(5), 627–629. doi:10.1016/S0006-3223(96)00525-2.
Cohen, H., Kotler, M., Matar, M., & Kaplan, Z. (2000b). Normalization of heart rate variability in post-traumatic stress disorder patients following fluoxetine treatment: Preliminary results. The Israel Medical Association Journal, 2(4), 296–301.
Cohen, H., Kotler, M., Matar, M. A., Kaplan, Z., Loewenthal, U., Miodownik, H., et al. (1998). Analysis of heart rate variability in posttraumatic stress disorder patients in response to a trauma-related reminder. Biological Psychiatry, 44(10), 1054–1059. doi:10.1016/S0006-3223(97)00475-7.
Elsesser, K., Sartory, G., & Tackenberg, A. (2005). Initial symptoms and reactions to trauma-related stimuli and the development of posttraumatic stress disorder. Depression and Anxiety, 21(2), 61–70. doi:10.1002/da.20047.
Foa, E. B., Keane, T. M., & Friedman, M. J. (2000a). Effective treatments for PTSD. New York: Guilford Press.
Foa, E. B., Keane, T. M., & Friedman, M. J. (2000b). Guidelines for treatment of PTSD. Journal of Traumatic Stress, 13(4), 539–588. doi:10.1023/A:1007802031411.
Foa, E. B., Riggs, D. S., & Gershuny, B. S. (1995). Arousal, numbing, and intrusion: Symptom structure of PTSD following assault. The American Journal of Psychiatry, 152, 116–122.
Frewen, P. A., & Lanius, R. A. (2006). Toward a psychobiology of posttraumatic self-dysregulation: Reexperiencing, hyperarousal, dissociation, and emotional numbing. In Yehuda (Ed.), Psychobiology of posttraumatic stress disorders: A decade of progress (Vol. 1071, pp. 110–124). Oxford: Blackwell Publishing.
Hopper, J. W., Spinazzola, J., Simpson, W. B., & van der Kolk, B. A. (2006). Preliminary evidence of parasympathetic influence on basal heart rate in posttraumatic stress disorder. Journal of Psychosomatic Research, 60(1), 83–90. doi:10.1016/j.jpsychores.2005.06.002.
Karavidas, M., Lehrer, P., Vaschillo, E., Vaschillo, B., Marin, H., Buyske, S., et al. (2007). Preliminary results of an open label study of heart rate variability biofeedback for the treatment of major depression. Applied Psychophysiology and Biofeedback, 32(1), 19–30. doi:10.1007/s10484-006-9029-z.
Keane, T. M., Kolb, L. C., Kaloupek, D. G., Orr, S. P., Blanchard, E. B., Thomas, R. G., et al. (1998). Utility of psychophysiology measurement in the diagnosis of posttraumatic stress disorder: Results from a department of Veterans affairs cooperative study. Journal of Consulting and Clinical Psychology, 66(6), 914–923. doi:10.1037/0022-006X.66.6.914.
Lanius, R. A., Bluhm, R., Lanius, U., & Pain, C. (2006). A review of neuroimaging studies in PTSD: Heterogeneity of response to symptom provocation. Journal of Psychiatric Research, 40(8), 709–729. doi:10.1016/j.jpsychires.2005.07.007.
Lehrer, P. (2003). Applied psychophysiology: Beyond the boundaries of biofeedback (mending a wall, a brief history of our field, and applications to control of the muscles and cardiorespiratory systems). Applied Psychophysiology and Biofeedback, 28(4), 291–304. doi:10.1023/A:1027330909265.
Lehrer, P. M., Vaschillo, E., & Vaschillo, B. (2000). Resonant frequency biofeedback training to increase cardiac variability: Rationale and manual for training. Applied Psychophysiology and Biofeedback, 25(3), 177–191. doi:10.1023/A:1009554825745.
Linehan, M. M. (2005). Track 7: Long progressive muscle relaxation. Putting your worries on a shelf (compact disc recording). Seattle: Behavioral Tech, LLC.
Morin, C. M. (1993). Insomnia: Psychological assessment and management. Treatment manual for practitioners. New York: Guilford Press.
Morin, C. M., Hauri, P. J., Espie, C. A., Spielman, A. J., Buysse, D. J., & Bootzin, R. R. (1999). Nonpharmacologic treatment of chronic insomnia. Sleep, 22(8), 1134–1156.
Nishith, P., Duntley, S. P., Domitrovich, P. P., Uhles, M. L., Cook, B. J., & Stein, P. K. (2003). Effect of cognitive behavioral therapy on heart rate variability during REM sleep in female rape victims with PTSD. Journal of Traumatic Stress, 16(3), 247–250. doi:10.1023/A:1023791906879.
Oiumette, P. C., Moos, R. H., & Finney, J. W. (2003). PTSD treatment and 5-year remission among patients with substance use and posttraumatic stress disorder. Journal of Clinical and Consulting Psychology, 71(2), 410–414. doi:10.1037/0022-006X.71.2.410.
Ouimette, P. C., Moos, R. H., & Brown, P. J. (2002). Posttraumatic stress disorder–substance use disorder comorbidity: A survey of treatments and proposed practice guidelines. In P. C. Ouimette & P. J. Brown (Eds.), Trauma and substance abuse: Causes, consequences, and treatment of comorbid disorders (pp. 91–110). Washington, DC: American Psychological Association.
Porges, S. W., Doussard-Roosevelt, J. A., & Maiti, A. K. (1994). Vagal tone and the physiological regulation of emotion. Monographs of the Society for Research in Child Development, 59(2/3), 167–186. (the development of emotion regulation: biological and behavioral considerations).
Rabois, D., Batten, S. V., & Keane, T. M. (2002). Implications of biological findings for psychological treatments of post-traumatic stress disorder. The Psychiatric Clinics of North America, 25(2), 443–462. doi:10.1016/S0193-953X(01)00002-8. (viii).
Sack, M., Hopper, J. W., & Lamprecht, F. (2004). Low respiratory sinus arrhythmia and prolonged psychophysiological arousal in posttraumatic stress disorder: Heart rate dynamics and individual differences in arousal regulation. Biological Psychiatry, 55(3), 284–290. doi:10.1016/S0006-3223(03)00677-2.
Sack, M., Nickel, L., Lempa, W., & Lamprecht, F. (2003). Psychophysiologische regulation bei patienten mit PTSD: Veränderungen nach EMDR-behandlung = psychophysiological regulation in patients with PTSD: Improvement after EMDR-treatment. Zeitschrift für Psychotraumatologie und Psychologische Medizin, 1(3), 47–57.
Sahar, T., Shalev, A. Y., & Porges, S. W. (2001). Vagal modulation of responses to mental challenge in posttraumatic stress disorder. Biological Psychiatry, 49(7), 637–643.
Schell, T. L. M., Grant, N., & Jaycox, L. H. (2004). All symptoms are not created equal: The prominent role of hyperarousal in the natural course of posttraumatic psychological distress. Journal of Abnormal Psychology, 113(2), 189–197. doi:10.1037/0021-843X.113.2.189.
Stein, P. K., Carney, R. M., Freedland, K. E., Skala, J. A., Jaffe, A. S., Kleiger, R. E., et al. (2000). Severe depression is associated with markedly reduced heart rate variability in patients with stable coronary heart disease. Journal of Psychosomatic Research, 48, 493–500. doi:10.1016/S0022-3999(99)00085-9.
Task Force of the European Society of Cardiology, the North American Society of Pacing, Electrophysiology. (1996). Heart rate variability: Standards of measurement, physiological interpretation and clinical use. Circulation, 93(5), 1043–1065.
van der Kolk, B. A. (2006). Clinical implications of neuroscience research in PTSD. In Yehuda (Ed.), Psychobiology of posttraumatic stress disorders: A decade of progress (Vol. 1071, pp. 277–293). Oxford: Blackwell Publishing.
Weathers, F. W., Litz, B. T., Huska, J. A., & Keane, T. M. (1994). PTSD checklist—civilian version. Boston: National Center for PTSD, Behavioral Science Division.
Acknowledgments
This study was partially supported by a dissertation stipend from Helicor, Inc., the makers of the StressEraser portable biofeedback device used in the current study. Frederick Muench is the former Director of Clinical Research at Helicor. Richard Gevirtz is on the Scientific Advisory Board of Helicor. Investigators have no other financial conflicts of interest with the Sponsor.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Zucker, T.L., Samuelson, K.W., Muench, F. et al. The Effects of Respiratory Sinus Arrhythmia Biofeedback on Heart Rate Variability and Posttraumatic Stress Disorder Symptoms: A Pilot Study. Appl Psychophysiol Biofeedback 34, 135–143 (2009). https://doi.org/10.1007/s10484-009-9085-2
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10484-009-9085-2