1. This document discusses the potential benefits of adding heart rate variability (HRV) biofeedback training to exposure therapy for post-traumatic stress disorder (PTSD). HRV biofeedback may help manage anxiety during treatment and address underlying physiological abnormalities in PTSD patients. 2. Preliminary evidence suggests HRV biofeedback enhances traditional exposure therapy by reducing trauma symptoms and improving memory recall to a greater extent than treatment as usual. HRV biofeedback may act through vagal nerve stimulation, baroreflex gain, and promoting a mindfulness state to better regulate limbic and autonomic arousal during exposure sessions. 3. An ongoing study is further exploring the addition of HRV biofeedback to prolonged exposure therapy for PTSD, with

1. Emerging Applications of Heart Rate Variability Biofeedback: Trauma Richard Gevirtz, Ph.D., BCIAC CSPP@ AIU, San Diego, CA [email_address]

2. Posttraumatic Stress Disorder Criteria (DSM-IV-TR, 2000) Psychiatric Disorder, Classified as Anxiety Disorder Criterion A Traumatic Event Or, series of events Directly or indirectly experienced Subjective Response Involve: intense fear, helplessness, or horror Criterion B Reexperiencing Symptom Cluster Intrusive thoughts Distressing dreams Trauma cue distress Criterion C Avoidant Symptom Cluster Avoid trauma-related thoughts, places, feelings Criterion D Hyperarousal Symptom Cluster Insomnia Irritability, anger, hypervigilance

4. Criterion A Traumatic Event Subjective Response Fear, helplessness, or horror Magnitude of subjective response Epidemiological study: PTSD onset depended most on it , not traumatic event (Breslau & Kessler, 2001) Peritraumatic hyperarousal Longitudinal: (elevated HR) to imaginal trauma cues at 1 month and at 3 months was most significant predictor of PTSD onset at 3 months (Elsesser, Sartory, & Tackenberg, 2005) Peritraumatic dissociation Meta-analysis of risk factors: most significant predictor of PTSD, and better predictor than prior events (Ozer, Best, Lipsey, Weiss, 2003) Subjective response CRITICAL to PTSD onset?

8. Rostral Anterior Cingulate ↓ ↑ Right Anterior Insula Reexperiencing Dissociation Region implicated in awareness of bodily states ↓ Right Anterior Insula ↑ Medial Prefrontal Cortex Figure 1: Emotion Dysregulation in PTSD Regions implicated in regulation of emotion and arousal ↓ Medial Prefrontal Cortex Amygdala ↑ ↓ Amygdala Regions implicated in regulation of emotion and arousal Rostral Anterior Cingulate ↑ Emotional Undermodulation Emotional Overmodulation

28. HRV Biofeedback

29. 12/20/09 Gevirtz RFT : Notice trend from three waves to a dominant .1 Hz Wave

30. 12/20/09 Gevirtz

33. 12/20/09 Gevirtz

38. Vagal Afferents

39. 12/20/09 Gevirtz

42. VNS=vagal nerve stimulation; NTS=nucleus tractus solitarius; PBN=parabrachial nucleus; MRS=mesolimbic reward system; SMR=sensori-motor rhythm; PRS=post-reinforcement synchronization (Adapted and reproduced with permission from John Wiley & Sons, Ltd.) 19 ( Italics mine) HRV biofeedback?

43. SUDS results from client (Dalenberg) Event SUDS 1 SUD2 SUDS3 SUDS4 1 25 15 5 0 2 35 0 5 0 3 55 35 5 5 4 65 55 15 5 5 75 75 45 5 6 85 85 45 25 7 90 90 40 30

48. Some prliminary data

49. BDI-II Score Pre to Post for the two Groups (Zucker et al., 2008) TM

50. Post Traumatic Stress Disorder Checklist (PCL-C) Score Pre to Post for the two Groups (Zucker et al., 2008) TM

51. Relationship between SDNN increase and trauma symptom decrease, Pre to Post

52. Dalenberg, 2008 Rx N Dropout % nonclin % subjective PE 189 14 81 71 PE+ACT 74 10 83 82 PE+ ACT + HRV 77 4 94 88

53. Treatment success over time

54. The effect of HRV Biofeedback vs TAU on PCL Trauma Scores in PTSD Vets Tan et al. 2008

55. The Effect of HRV Biofeedback vs. TAU on Memory Recall (total list learning) in PTSD Vets Ginsberg, 2009