Content uploaded by Richard Gevirtz
Author content
All content in this area was uploaded by Richard Gevirtz on Jun 22, 2016
Content may be subject to copyright.
Autonomic Nervous System Markers for Psychophysiological, Anxiety, and Physical Disorders
Abstract
This chapter explores the use of autonomic nervous system (ANS) measures as potential biomarkers for medically unexplained disorders. It is proposed that these disorders are better classified and treated as related symptom clusters with logical physiological and psychophysiological involving the sympathetic and parasympathetic branches of the ANS. Heart rate variability is described and several examples are given of how specific autonomic biomarkers are related to mental and physical function. Some examples from the worlds of chronic pain and gastroenterology are presented as exemplars using of a simple marker (HRV) that reflects imbalance between the body's primary excitatory and inhibitory systems, that can readily be linked to gene-brain personalized medicine markers underlying excitation-inhibitory imbalances in brain-based disorders.
... Heart Rate Variability (HRV) is a neurobiological marker of the autonomic nervous system (ANS) with decreased HRV indices being associated with a variety of negative physical and psychological outcomes [1][2][3][4][5]. Heart Rate Variability Biofeedback (HRVB) is 2 of 14 a non-invasive treatment, in which patients are assumed to self-regulate a physiological dysregulated vagal nerve function by restoring the autonomic homeostasis [6][7][8]. This is relevant for stress-related disorders such as sleep disorders, anxiety, asthma, fibromyalgia, recovery of heart failure, and others. ...
... We can describe this as ABC: Action, Balance, or Calm/Sleepy, where A indicates dominance of VLF (Action in the mind or body) B indicates Balance between sympathetic and vagal activity or LF, and C indicates dominance of HF (Calm/sleepy) (see Figure 1). a non-invasive treatment, in which patients are assumed to self-regulate a physiological dysregulated vagal nerve function by restoring the autonomic homeostasis [6][7][8]. This is relevant for stress-related disorders such as sleep disorders, anxiety, asthma, fibromyalgia, recovery of heart failure, and others. ...
Background:
Heart Rate Variability Biofeedback (HRVB) is a treatment in which patients learn self-regulation of a physiological dysregulated vagal nerve function. While the therapeutic approach of HRVB is promising for a variety of disorders, it has not yet been regularly offered in a mental health treatment setting.
Aim:
To provide a systematic review about the efficacy of HRV-Biofeedback in treatment of anxiety, depression, and stress related disorders.
Method:
Systematic review in PubMed and Web of Science in 2020 with terms HRV, biofeedback, Post-Traumatic Stress Disorder (PTSD), depression, panic disorder, and anxiety disorder. Selection, critical appraisal, and description of the Random Controlled Trials (RCT) studies. Combined with recent meta-analyses.
Results:
The search resulted in a total of 881 studies. After critical appraisal, nine RCTs have been selected as well as two other relevant studies. The RCTs with control groups treatment as usual, muscle relaxation training and a "placebo"-biofeedback instrument revealed significant clinical efficacy and better results compared with control conditions, mostly significant. In the depression studies average reduction at the Beck Depression Inventory (BDI) scale was 64% (HRVB plus Treatment as Usual (TAU) versus 25% (control group with TAU) and 30% reduction (HRVB) at the PSQ scale versus 7% (control group with TAU). In the PTSD studies average reduction at the BDI-scale was 53% (HRV plus TAU) versus 24% (control group with TAU) and 22% (HRVB) versus 10% (TAU) with the PTSD Checklist (PCL). In other systematic reviews significant effects have been shown for HRV-Biofeedback in treatment of asthma, coronary artery disease, sleeping disorders, postpartum depression and stress and anxiety.
Conclusion:
This systematic review shows significant improvement of the non-invasive HRVB training in stress related disorders like PTSD, depression, and panic disorder, in particular when combined with cognitive behavioral therapy or different TAU. Effects were visible after four weeks of training, but clinical practice in a longer daily self-treatment of eight weeks is more promising. More research to integrate HRVB in treatment of stress related disorders in psychiatry is warranted, as well as research focused on the neurophysiological mechanisms.
... HRV is a commonly used index in gastroenterology, as it reflects the unbalance between the primary excitatory and inhibitory body systems [104]. ANS is the main communications pathway between brain and intestine, hence it is of particular interest for gastrointestinal disorders, as it is the case of irritable intestine syndrome, which is characterized by a functional abdominal pain [105]. ...
Non-oncologic chronic pain is a common high-morbidity impairment worldwide and acknowledged as a condition with significant incidence on quality of life. Pain intensity is largely perceived as a subjective experience, what makes challenging its objective measurement. However, the physiological traces of pain make possible its correlation with vital signs, such as heart rate variability, skin conductance, electromyogram, etc., or health performance metrics derived from daily activity monitoring or facial expressions, which can be acquired with diverse sensor technologies and multisensory approaches. As the assessment and management of pain are essential issues for a wide range of clinical disorders and treatments, this paper reviews different sensor-based approaches applied to the objective evaluation of non-oncological chronic pain. The space of available technologies and resources aimed at pain assessment represent a diversified set of alternatives that can be exploited to address the multidimensional nature of pain.
... The Polyvagal Theory (Porges 2011) states that measurement of vagal activity provides information on interoception in maintaining homeostasis and the regulation of homeostasis to support environmental challenges. Cardiac vagal tone represents an important underlying mechanism in emotional regulation, self-regulation and behavioral processes (Porges 2011) and can be seen as a stable marker for the ability to sustain attention and regulate emotion (Blase et al. 2016;Gevirtz 2010). ...
Cardiac vagal tone can be seen as a stable marker for the ability to sustain attention and regulate emotion, two factors associated with the quality of meditation. In this study, heart rate variability (HRV) has been monitored in different forms of Shamatha quiescence meditation: three breath meditations, Settling the Mind in its natural state, Awareness of Awareness, Loving-kindness and Tonglen. Establish and test a practical means of monitoring neurobiological effects of meditation. Over 6 weeks, two experimental groups practiced Shamatha meditation on a daily basis (n = 20). HRV patterns and cortisol tests were monitored at three measuring points during these weeks, and an attention focus test was performed at the start and after 6 weeks. Six weeks of regular practice in Shamatha meditation were associated with HRV indices suggesting improvements in the homeostatic regulation of the autonomic nervous system (ANS) in 85% of the HRV recordings (tachogram and frequency specter) of all 20 subjects. Further, a substantial decrease in cortisol levels was also noted. The attention focus test showed a significant increase of 18.7% in sustained attention, moving from medium to high attention focus, with a significant result of t(20) = − 8.764 and p < 0.001. Participants reported positive subjective changes in attention focus, sense of happiness and calmness and increased abilities in emotional regulation and attunement. Six weeks of regular practice in Shamatha meditation contributes to a substantial increase of attention focus and a decrease in stress levels evidenced in changes in diurnal cortisol measures. HRV biofeedback shows that the sympathetic nervous system is counterbalanced by increased vagal tone, and autonomic balance is enhanced by all Shamatha meditations, not only breath meditations, but also mind meditations: Settling the Mind in its natural state, Awareness of Awareness, Loving-kindness and Tonglen. Although these results are promising, further research is recommended with HRV biofeedback instruments to report statistical analysis and to understand unique HRV patterns in Shamatha mind meditation.
... Een belangrijke mijlpaal was in 1996 het moment dat de Taskforce van de European Society of Cardiology (esc) met de North American Society of Pacing and Electrophysiology (naspe) standaarden voor interpretatie van het hrv-signaal en klinisch gebruik heeft geformuleerd (Taskforce 1996; zie FIGUUR 1). Bij stressgerelateerde stoornissen lijken directe biofeedback en 5-minutenmetingen, zoals de taskforce adviseerde, van belang voor het vaststellen van sympathische overactivering en een ontregelde N.-vagusfunctie als maat van de 'cardiale-vagale controle' (Gevirtz 2010;Porges 2011). Ten grondslag aan deze theorie ligt de veronderstelling dat het azs een homeostatische functie heeft, waarbij sympathisch en parasympathisch zenuwstelsel afwisselend worden geactiveerd en gedeactiveerd. ...
Background:
Heartrate variability biofeedback (HRVB) is a non-invasive treatment in which patients are assumed to self-regulate a physiological dysregulated vagal nerve. Although the therapeutic approach of HRVB is promising in various stress-related disorders, it has only been offered on a regular basis in a few mental health treatment settings.
Aim:
To analyse the efficacy of HRV biofeedback as an additional psychophysiological treatment for depression and PTSD.
Method:
Systematic review with search terms HRV, biofeedback, PTSD, depression, panic disorder and anxiety disorder.
Results:
Our search of the literature yielded 789 studies. After critical appraisal using the GRADE method, we selected 6 randomised controlled trials (RCTs) and 4 relevant studies. The RCTs with control groups 'treatment as usual' and muscle relaxation training revealed significant clinical efficacy and better results than control conditions after 4 to 8 weeks training.
Conclusion:
Although this systematic review shows the popularity of HRV in literature, it does not indicate that HRVB really has been reviewed systematically. Significant outcomes of this limited number of randomised studies indicate there may be a clinical improvement when HRVB training is integrated into treatment of PTSD and depression, particularly when this integration procedure is combined with psychotherapy. More research needs to be done with larger groups and further efforts are needed to integrate HRVB into treatment of stress-related disorders in psychiatry. Future research also needs to focus on the psychophysiological mechanisms involved.
... The experimental procedure consisted of participants sitting in front of a computer screen looking at a visual moving object, and monitoring their physiology data as they performed focused breathing. [19,20,21,22]. MoodWings is a truthful visual biofeedback system in the form of a flapping butterfly that reacts to a users stress levels [34]. ...
Emotion regulation is crucial for healthy adaptation [47, 24],while emotion dysregulation can lead to the development of mental health disorders such as anxiety or depression [7]. Everyone, one way or another, sometimes fails to effectively regulate their emotions, making this a challenging problem with broad potential impact. In our research, we are exploring three ways in which haptics-enabled wearables can facilitate effective emotion regulation, formulated based onGross’s model of emotion regulation [23]. We hypothesize that an individual-level biofeedback haptic could foster healthier and more effective patterns of emotion regulation.We have designed and implemented HapLand, a scalable, robust biofeedback haptic system testbed to facilitate research-based haptics-enabled wearables design for the purpose of emotion regulation. In this paper, we give an overview of HapLand and our plans for using HapLand for future re-search.
... Een belangrijke mijlpaal was in 1996 het moment dat de Taskforce van de European Society of Cardiology (esc) met de North American Society of Pacing and Electrophysiology (naspe) standaarden voor interpretatie van het hrv-signaal en klinisch gebruik heeft geformuleerd (Taskforce 1996; zie FIGUUR 1). Bij stressgerelateerde stoornissen lijken directe biofeedback en 5-minutenmetingen, zoals de taskforce adviseerde, van belang voor het vaststellen van sympathische overactivering en een ontregelde N.-vagusfunctie als maat van de 'cardiale-vagale controle' (Gevirtz 2010;Porges 2011). Ten grondslag aan deze theorie ligt de veronderstelling dat het azs een homeostatische functie heeft, waarbij sympathisch en parasympathisch zenuwstelsel afwisselend worden geactiveerd en gedeactiveerd. ...
Efficacy of HRV-biofeedback as additional treatment of depression and PTSD
HeartRate Variability biofeedback (HRVB) is a non-invasive treatment in which patients are assumed to self regulate a physiological dysregulated vagal nerve. Although the therapeutic approach of HRVB is promising in various stress-related disorders it has only been offered on a regular basis in a few mental health treatment settings
Aim:to analyse the efficacy of HRV biofeedback as an additional psychophysiological treatment for depression and PTSD
Method: systematic review with search terms: HRV, biofeedback, PTSD, depression, panic disorder, and anxiety disorder.
Results: Our search of the literature yielded 789 studies. After critical appraisal using the GRADE method we selected 6 randomized controlled trials (RCTs) and 4 relevant studies. The RCTs with control groups "treatment as usual" and muscle relaxation training revealed significant clinical efficacy and better results than control conditions after 4 to 8 weeks training. PTSD studies showed an average reduction of 53% on the Beck Depression Index for HRVB versus average 24% with the control groups. HRVB treatment with depression showed an average reduction of 76% on BDIscale versus 36% with control groups.
Conclusion: Significant outcomes of this limited number of randomized studies indicate there may be a clinical improvement when HRVB training is integrated into treatment of PTSD and depression, particularly when this integration procedure is combined with psychotherapy. More research needs to be done with larger groups and further efforts are needed to integrate HRVB into treatment of stress-related disorders in psychiatry. Future research also needs to focus on the psychophysiological mechanisms involved.
... Moreover, recent publications argue that heart rate and its variability play an important role in emotion recognition (Quintana et al., 2012) as well as for BCI control (Kaufmann et al., 2012;Pfurtscheller et al., 2013). This suggests that training children on the spectrum to increase their vagal tone via biofeedback (Lehrer, 2007;Gevirtz, 2010Gevirtz, , 2007 should lead to additional improvements in the social engagement system, including emotional responsiveness. ...
Individuals with autism spectrum disorder (ASD) show deficits in social and communicative skills, including imitation, empathy, and shared attention, as well as restricted interests and repetitive patterns of behaviors. Evidence for and against the idea that dysfunctions in the mirror neuron system are involved in imitation and could be one underlying cause for ASD is discussed in this review. Neurofeedback interventions have reduced symptoms in children with ASD by self-regulation of brain rhythms. However, cortical deficiencies are not the only cause of these symptoms. Peripheral physiological activity, such as the heart rate and its variability, is closely linked to neurophysiological signals and associated with social engagement. Therefore, a combined approach targeting the interplay between brain, body, and behavior could be more effective. Brain-computer interface applications for combined neurofeedback and biofeedback treatment for children with ASD are currently nonexistent. To facilitate their use, we have designed an innovative game that includes social interactions and provides neural- and body-based feedback that corresponds directly to the underlying significance of the trained signals as well as to the behavior that is reinforced.
This conceptual chapter presents a multidimensional model of person-centered psychospiritual maturation. It describes five dimensions of self that can be dysregulated by humanity’s chain of pain: bio-behavioral, cognitive-sociocultural, social-emotional, existential-spiritual, and integrative worldview formation. It further presents and discusses person-centered psychospiritual maturation as an antidote to these dysregulating effects. In addition, the chapter examines the human capacity for person-centered psychospiritual maturation as an emergent phenomenon of bio-cultural evolution.
Background:
With a life time prevalence estimated at 16%, major depression (MD) is a major public health issue. Previous studies have shown that depression has been associated with a variety of cognitive impairments. In addition to cognitive impairments, major depression is usually accompanied by alterations of cortical activity, especially in prefrontal areas. Recent studies have highlighted the importance of noninvasive brain stimulation as a means of modulating cortical excitability. Recent studies on major depression (MD) have revealed that transcranial direct current stimulation induces cortical excitability which facilitates memory and especially working memory. On the other hand visual aspects of memory in MD have not been yet investigated.
Objective:
This study aimed to investigate whether anodal and cathodal tDCS applied over dorsolateral prefrontal cortex (DLPFC), would significantly improve visual memory in patients with major depression.
Methods:
Thirty (N=30) patients with major depression were randomly assigned to receive either experimental(active) or control (sham) tDCS. The participants underwent a series of visual memory tasks before and after 10 sessions of tDCS. The parameters of active tDCS included 2 mA for 20 minutes per day for 10 consecutive days, anode over the left DLPFC (F3), cathode over the right DLPFC (F4) region.
Results:
After 10 sessions of anodal and cathodal tDCS, patients showed significantly improved performance in visual and spatial aspects of memory tasks. Specifically, anodal stimulation improved visual memory perfo
rmance for the experimental group relative to baseline, whereas sham stimulation did not differentiate performance from baseline in the control group.
Conclusion:
This study showed that anodal tDCS over DLPFC concurrently with cathodal tDCS over right DLPFC improved visual and spatial aspects of memory in patients with MD. This finding is in generally consistent with previous findings about effectiveness of tDCS on cognition in major depression, while additionally provides support for effectiveness of tDCS on visual memory in MD.
Keywords: Major depression, memory, tDCS, visual memory
This work has proposed a methodology based on the concept of entropy rates to study the complexity of the short-term heart-rate variability (HRV) for improving risk stratification to predict sudden cardiac death (SCD) of patients with established ischemic-dilated cardiomyopathy (IDC). The short-term HRV was analyzed during daytime and nighttime by means of RR series. An entropy rate was calculated on the RR series, previously transformed to symbol sequences by means of an alphabet. A statistical analysis permitted to stratify high- and low-risk patients of suffering SCD, with a specificity (SP) of 95% and sensitivity (SE) of 83.3%.
This multiple case study describes pulmonary function changes in 20 asthmatic children from 30 consecutive cases undergoing biofeedback training for increasing the amplitude of respiratory sinus arrhythmia (RSA). The Smetankin protocol was used, which, in addition to RSA biofeedback, includes instructions in relaxed abdominal pursed-lips breathing. Ten individuals were excluded, including 6 who had been taking asthma medication, 2 who developed viral infections during the treatment period, and 2 who dropped out prior to completing treatment. Patients each received 13 to 15 sessions of training. Asthma tended to be mild, with mean spirometric values close to normal levels. Nevertheless, significant improvements were noted in 2 spirometry measures taken during forced expiratory maneuvers from maximum vital capacity: FEV1 and FEF50. These preliminary uncontrolled data suggest that the Smetankin protocol warrants further evaluation as a nonpharmacological psychophysiological treatment for this condition, although these data could not definitively prove that the method is effective.
Studies show that the proportion of elderly will reach 30% of the total population by 2050 in developed countries, such as France. The elderly live generally alone, thus many health problems related to age are under reported. Falling is one of these problems and several devices have been developed recently, based on accelerometers, in order to detect it and alert carers. In order to improve the detection success of these devices, we propose quantifying autonomic nervous system activity (ANS) using a wearable ambulatory device developed for this purpose. We studied the A.N.S's response on 7 adult subjects during simulated falls and standing-lying transitions. We implemented a classification method using the Support Vector Machine in order to classify these two situations using measured heart rate variability and electrodermal response. Good results (sensibility = 70.37%, specificity = 80%, positive predictor = 73.8%) were obtained using a Polynomial kernel (p = 5) for the support vector machine implementation.
The early prediction of pregnancy-induced hypertension (PIH), a common morbid disorder of pregnancy is unsatisfactory. Therefore, in the present study we have investigated the role of spectral analysis of heart rate variability (HRV) in the early prediction of PIH. Spectral analysis of HRV was performed in three groups of subjects (Group I: normal pregnant women; Group II: pregnant women with risk factors, but did not develop PIH; Group III: pregnant women with risk factors and developed PIH). It was observed that the LF-HF ratio, the most sensitive indicator of sympathovagal balance, was significantly high (p < 0.01) since early pregnancy in group III compared to other groups, which was significantly correlated with heart rate and blood pressure. It was suggested that the predictive knowledge of sympathovagal imbalance should be utilized in designing the prevention and management of PIH.
Irritable bowel syndrome (IBS) as a functional disorder of the gastrointestinal tract has been related to psychological factors. Aim of this study is to study the differences of personality factors between IBS patients compared to our general population.
This study was performed in clinics of Tabriz Medical University during 2006-2007. IBS was diagnosed using the Rome II diagnostic criteria after exclusion of organic bowel pathology. The entry of each patient was confirmed following a psychiatric interview and after any comorbid psychiatry disorder was ruled out. Personality traits and score of each factor was evaluated using NEO five factor personality inventory compared to results of a previous study on general population of Iran.
One hundred and sixty six patients were studied. The mean age (+/-SD) of them was 33.6(+/-11.4) years (60.8% female). Our study population had their symptoms for a mean interval of 47.3 month. The bowel problems were provoked by distress in more than 80% of patients. Pain in female patients was reported to be more frequent but both gender described the association between stressors and their symptoms. NEO Five-Factor Inventory showed a significantly higher level of neuroticism and conscientiousness and lower level of openness and agreeableness in theses nonpsychiatric IBS patients. Women with IBS had significantly higher levels of openness, conscientiousness, and extraversion compared to men.
Differences were observed between IBS patients and general population. Patients with IBS may benefit from psychological interventions.
Somatization disorder is a condition characterized by multiple unexplained complaints. This study was done to determine the prevalence of somatization disorder in a family practice office setting, to characterize the patients so affected, and to assess their impact on the practice. A sample of ill patients was interviewed, of whom 6 (5 percent) had definite somatization disorder and another 4 (4 percent) had borderline somatization disorder (ten or more symptoms). All were women, and they were more likely than controls to live in households with children but no spouse (P less than .01). They were also more likely than their unaffected counterparts to be from the lowest two social classes (P less than .01). Compared with matched controls, their rate of office visits and charges incurred was about 50 percent greater (.58 visits per month vs .41 visits per month; $23.28 per month vs $14.44 per month). Their charts were thicker (7 cm vs 3.6 cm) and heavier (3076 g vs 1843 g) and had more diagnoses (85 vs 51) than controls. The physicians of the somatizers were significantly less satisfied with the care rendered to them than to the controls (P less than .01). This study demonstrates that somatization disorder is a prevalent, expensive, and difficult problem for family physicians.
Somatization disorder is a condition characterized by multiple unexplained complaints. To characterize this disorder as it occurs in a university hospital, a sample of 213 patients admitted to adult medical and surgical services was studied. Nineteen of these patients (9 percent) met the Diagnostic and Statistical Manual of Mental Disorders, ed 3, criteria for somatization disorder. A significantly higher proportion of the women compared with the men interviewed had the disorder (14 percent vs 3 percent, P less than .01). Fourteen percent of the divorced, separated, or widowed subjects qualified for the diagnosis, compared with 7 percent of the married subjects and 5 percent of the never-married subjects (P less than .05). Likewise, 32 percent of single patients with children at home had somatization disorder, compared with 4 percent of subjects in all other household configurations (P less than .001). When compared with matched controls, patients with somatization disorder had hospitalizations of roughly equal duration and expense, but had a much higher proportion of negative findings on workup for their presenting complaints (74 percent vs 21 percent, P less than .01). Nevertheless, these patients perceived their health as significantly worse than those without the disorder (P less than .001). None of the patients enrolled in this study had the diagnosis of somatization disorder at admission or discharge. This study documents that patients with somatization disorder are common, are unrecognized, and are admitted to the hospital for nonproductive workups.
We studied the influence of respiratory and cardiac phase on responses of the cardiac pacemaker to brief (0.35-s) increases of carotid baroreceptor afferent traffic provoked by neck suction in seven healthy young adult subjects. Cardiac responses to neck suction were measured indirectly from electrocardiographic changes of heart period. Our results show that it is possible to separate the influences of respiratory and cardiac phases at the onset of a neck suction impulse by a product of two factors: one depending only on the respiratory phase and one depending only on the cardiac phase. This result is consistent with the hypothesis that efferent vagal activity is a function of afferent baroreceptor activity, whereas respiratory neurons modulate that medullary throughput independent of the cardiac phase. Furthermore, we have shown that stimulus broadening and stimulus cropping influence the outcome of neck suction experiments in a way that makes it virtually impossible to obtain information on the phase dependency of the cardiac pacemaker's sensitivity to vagal stimulation without accurate knowledge of the functional shape of stimulus broadening.