Original aapb alba presentation 2-97-2003-march [autosaved] (2 - copy

The Psychophysiology
of Posttraumatic Stress Disorder (PTSD)
--or what’s the body’s got to do with it
Terri Zucker, Ph.D.

Presentation Overview
1. PTSD as a Neurophysiological Disorder
 Etiology: Cause
 PTSD onset
 Symptom severity and chronicity
 Underlying biological abnormalities
2. Treatment Implications
 How current treatments address biological abnormalities
3. Psychophysiological Treatment Strategies for
PTSD
 Theoretical
 Experiential

“Medications and psychotherapy effective for acute
PTSD may be less effective or ineffective for chronic
PTSD because of the altered neurobiological state and
the development of secondary symptoms, such as
depression, guilt, and hostility.”
(Charney, Deutch, Krystal, Southwick, & Davis, 1993)
“The current classification of PTSD as a psychiatric
disorder may be limited, and its categorization as well as
treatment as a biological disorder needs further
research.”
(Bonne & Charney, 2004)
What’s the Body Got To Do With It?

PTSD Overview
1. Criteria for Diagnosis
2. Epidemiology
3. Psychiatric Comorbidities
4. Physical Illness
5. PTSD as a Neurophysiological Disorder

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

Criterion E
Symptom Duration
> 1 month
Acute: < 3 months
Chronic: > 3 months
Delayed onset: ≥ 6 months
Criterion F
Distress / Impairment
Clinically significant
Poor functioning
Social
Occupational
PTSD

Unusual
DSM-III, 1980, DSM-III-R,1987
“outside the range of usual human
experience, evokes significant
symptoms of distress in most
people ”
Common
DSM-IV-TR, 2000
“experienced, witnessed” event(s)
involving “death or serious injury, or
threat to physical integrity of self,
others ”
National Comorbidity Survey (Kessler et al.,1995)
8,000 civilian adults, age 15--54
60.7% men; 51.2 % women exposed
Majority exposed to two or more types of trauma
7.8% developed PTSD
Detroit Area Survey (Breslau, 1998)
2,000 adults, age 18--45
Over 90% had trauma exposure
9% developed PTSD
Epidemiology

Comorbidity
Psychiatric Disorders
Comorbidity Rates are 88% for men and 79% for women
More than three diagnoses
59% for men; 44% for women
Alcohol Abuse
Depression
Conduct Disorder
Drug Abuse
Simple phobias
(National Comorbidity Study; 8,000 civilian adults, 18-54; Kessler et al., 1995)

Comorbidity
Substance Abuse
PTSD increases risk of later substance abuse and
dependence
•Self-medication hypothesis for PTSD
(Breslau et al. 1997; Kessler et al. 1995;McFarlane 1998; Mueser et
al.,1998)
PTSD and substance abuse are highly comorbid
(Ouimette, Moos, & Brown, 2002)
Treatment strategies unknown when disorders concurrent
(Oiumette, Moos, & Finney, 2003)

Associated Physical Illness
PTSD associated with higher rates of physical illnesses
Cardiovascular
Neurological
Gastrointestinal
Use medical services more frequently
Demonstrate higher mortality rates
(Beckham, 1999; Schnurr & Jankowski, 1999; Schnurr & Spiro, 1999)
PTSD may not be a separate psychiatric disorder
Part of a biological syndrome
High comorbidities and associated illnesses
(Brady, 1997)

PTSD Criteria and Psychophysiology
1. Cause: Traumatic event? Subjective response?
2. Prominent role of hyperarousal symptoms?
3. How do biological abnormalities mediate
 Chronicity ?
 Psychological symptoms ?
PTSD as a Psychophysiological Disorder

Traumatic Event
Subjective Response
Intense fear, helplessness, horror
Fear invariably activates biological stress response (McEwen, 2002)
Intensity of immediate subjective response increased PTSD onset 6
months later (Brewin, Andrews, & Rose, 2000)
Epidemiological study: intense fear, helplessness response and not
traumatic event increased probability of PTSD onset (Breslau & Kessler,
2001, Bryant, 2005)
Cause: How CRITICAL is
Subjective Response to PTSD Onset?
Criterion A
Cause

Increased heart rate at 1 month predicted PTSD at 3 months
(Elsesser, Sartory, & Tackenberg, 2005)
Meta-analysis of Risk Factors: Peritraumatic dissociation strongest
predictor of PTSD, more than prior experiences
(Ozer, Best, Lipsey, & Weiss, 2003)
Multisite study revealed that elevated HR coupled with increased
respiratory rate predicted onset of chronic PTSD
(Bryant, Creamer, O’Donnell, & McFarlane, 2008)
Subjective Response to PTSD Onset?

Indirect or direct personal experience:
Unexpected or violent death
Serious Harm
Illness
Actual or threatened death
Self
Loved one
Close associate
Violent assault
Sexual assault
Traumatic Exposure
Associated with PTSD
(DSM-IV-TR, 2000)

Traumatic Event Subjective Response
Intense fear, helplessness, horror
Toronto Firefighters: Increased PTSD Onset
 16.5% firefighters vs. 1-3% general population.
 Firefighters averaged 3.91 severe emergencies a year--fires,
medical emergencies, crimes, suicides
(Beaton, Murphy, Johnson, Pike, & Corneil, 1998)
 Rape Victims: Previous rape history > higher incidence of PTSD
Traumatic Event to PTSD Onset?
Criterion A
Cause

Armenian Earthquake, 1988
231 Children Assessed for PTSD, 18 Months Post
Spitak- epicenter- 50%
Gumri- 30 miles- less than 25%
Yerevan- 50 miles- negligible
(Pynoos et al., 1993)

Trauma Exposure Severity
US Active-Duty Soldiers in Iraq
2008 Survey of 1.6 million
 Deployed to Iraq in the last five years
 19% have PTSD symptoms (vs. 8% US general population)
2008 Redeployment Study of 513,000
 Served in Iraq since 2003
197,000 deployed more than once
53,000 deployed three or more times
12 % exhibit PTSD symptoms after one tour
18.5 % exhibit PTSD symptoms after a second deployment
27% exhibit PTSD symptoms on third or fourth tour (Rand, 2008)

Rates of PTSD, Depression, and TBI
2008 Rand Study
•About 300,000 currently suffering from PTSD or major depressive disorder
•About 320,000 report experiencing TBI during deployment

Physiological Symptoms
Historical Observations
Traumatic neurosis (Oppenheim,1889; German neurologist):
PTSD caused by molecular changes in the central nervous system that
perpetuates psychiatric neuroses. (challenged Charcot’s hysteria,
“wandering womb” theory)
American Civil War (Da Costa, 1871)
Irritable heart: Da Costa’s syndrome
Heart palpitations
Labored respiration
Physical tremors
World War I (Kardiner, 1941)
Hyperarousal, startle response
Muscle tension
Elevated heart rate
“The nucleus of the neurosis [PTSD] is physioneurosis”(Kardiner)

It is the egg
Severe trauma exposure triggers intense
psychophysiological responses?
--or--
Most significant predictor of PTSD is subjective,
psychophysiological responses, not trauma?
Conclusion: Cause of PTSD has psychophysiological basis

Hyperarousal Increases PTSD Chronicity
Symptoms severity of Hyperarousal Cluster predicts higher symptom
severity of Reexperiencing + Avoidant Clusters
 High hyperarousal symptoms, less overall symptom improvement.
Converse is NOT true (Schell, Grant, Jaycox, 2004)
Intrusive thoughts generate multiple hyperarousal symptoms
 Intrusive thought, victimizes not the traumatic event itself
Chronic hyperarousal leads to ANS imbalance (van der Kolk, 1996)
Criterion B
Symptoms
Reexperiencing
Intrusive thoughts,
Distressing dreams
Cue distress
Criterion C
Symptoms
Avoidant
Avoid trauma-related thoughts,
places, feelings
Criterion D
Symptoms
Hyperarousal
Insomnia
Irritability, anger,
hypervigilance

Biological Abnormalities of PTSD?
Neurological Deficits
Core of chronic PTSD:
Neurological structural and functional abnormalities
(Kolb, 1987; Charney et al., 1993)
Meta-analysis of 30 PTSD neuroimaging studies:
Most replicated were subcortical abnormalities
1.Structural: reduced hippocampal volume
 Impairs integration of new memories with old ones
2.Functional : increased amygdala activation
 Determines emotional valence of information
3.Functional: decreased activation of Broca’s area
 Limits verbal expression of feelings
(Hull, 2002)

Key Neuropsychological Deficits in PTSD
1.Amygdala controls emotional output. “Overactive”, fear-
conditioned amygdala determines and processes emotionally valenced
stimuli.
2.Subcortical “overconsolidation of trauma memories”*.
*During trauma, a surge of catecholamines and neuropeptides,
overstimulate subcortical structures, causing an overconsolidation or
"super conditioning”, The traumatic memory then is indelibly engraved
resulting in over generalized reactions to intrusions and conditioned
emotional and physiological responses.
3. Cortical structures unable to extinguish overconsolidated
fear-conditioned responses. (Sack, Hopper, Lamprecht, 2004)

Why Cortex Unable to Control
Subcortical Responses
“The rational mind, while able to organize feelings and
impulses, does not seem to be particularly well equipped
to abolish emotions, thoughts, and impulses”
(van der Kolk, 2006)
Neuroimaging studies of highly emotional states show intense
emotions of cause increased activation in subcortical brain regions
and significant reductions of blood flow in various areas in the
frontal lobe.(Damasio et al., 2000)
Deactivation in Broca’s area (left anterior prefrontal cortex ) or the
expressive speech center in the brain (Hull, 2002)
Dysfunction of frontal–subcortical circuitry, and in corticothalamic
Integration causes difficulty with focused concentration with being
fully engaged in the present (Vasterling, 1998)

Biological Abnormalities of PTSD
Neuroendocrine System: Paradoxical Low Cortisol
Normal Stress Response:
Stress Response stimulates surge of circulating cortisol:
Catecholamine
Cortisol
Circulating cortisol, like pacmen, eats catecholamines
 Inhibit catecholamines
 Regulate further catecholamine production
 Stabilizes hormonal balance

Neuroendocrine System: Paradoxical Low Cortisol
What happens in PTSD:
• Low cortisol levels in trauma victims
predict PTSD onset. (McFarlane & Yehuda, 1997)
• Trauma survivors with PTSD have low cortisol levels
compared to trauma survivors without PTSD and
persons without trauma exposure (Yehuda et al., 1995)
Psychological Implications?
Inability to control hyperarousal
 Low self esteem
 Learned helplessness
 Depression, substance abuse

Autonomic Nervous System (ANS)
PTSD: Parasympathetic or Sympathetic Dominant?

Autonomic Nervous System (ANS)
Two branches, autonomic reciprocity
Each are equally innervated
Most PTSD research use this model
Sympathetic (active)
Parasympathetic (relaxed) Traditional One-Dimensional
Model of ANS
(Cannon, 1929)
Elevated HR:
Identifies PTSD from other psychiatric disorders (Blanchard et al, 1982)
Identifies PTSD subjects from non-PTSD ones (Keane et al., 1998)
Most salient, consistent response to trauma cues in PTSD, especially
chronic PTSD (Buckley & Kaloupek, 2001)
Predicts PTSD onset (Shalev et al., 1998; Bryant et al. 2000, 2003)
Predicts, with elevated respiration rate, PTSD onset
Autonomic Nervous System

WHY HRV? Differential Physiological Responsivity
1.Heightened physiological responsivity
Most consistent PTSD finding , trauma cue provocation
(Rabois, Batten, & Keane, 2002)
2.Meta-analysis: 2 types of physiological responsivity
Neuroimaging of symptom provocation studies
70% arousal type; 30% dissociative type
(Lanius et al, 2006)
3. Bremner’ s (2003) hypothesis:
 Two subtypes of trauma response, hyperarousal + dissociative
 May represent distinct pathological processes
ANS and Autonomic Space Model

Heart Rate Variability is a more precise biomarker of ANS
•HR rhythms mostly under control of ANS
HRV assesses interaction of both branches
•Parasympathetic branch determines autonomic functioning
•Influences HR more than the sympathetic branch
Sympathovagal balance mediates vulnerability to ANS stress
(Pagini et al., 1991)
•Low HRV is largest predictor of mortality and morbidity;
•High HRV promotes ANS homeostasis; emotional self-regulation
(Lehrer , 2003; Porges, 1994; Task Force, 1986)
Low HRV High HRV

Five assessment cue-provocation studies found
association of PTSD/ HRV:
Low HRV is associated with PTSD diagnosis
Mixed results for baseline
Lower HRV in PTSD compared to panic disorder
Lowest HRV indices associated:
Highest elevated HR
More prolonged HR arousal and recovery
Low HRV indices may mediate PTSD symptom
severity and chronicity
(Cohen et al., 1997, 1998; Hopper, Spinazzola, Simpson, & van der Kolk,
2005; Sack, Hopper, & Lamprecht, 2003; Sahar et al., 2001).
HRV and PTSD

PTSD Neurobiological Pathway:
Sensation to Intense Action Response

PTSD Neurobiological Pathway:
Sensation to Intense Action Response
1. Sensory reminder- e.g. hear trauma cue– (loud noise)
1. Processed in subcortex (thalamus, hippocampus, amygdala)
 Neurological alterations:
 Memory lacks of stimulus discrimination
 “Superconditioned” fear-response increases arousal
2. Prompts ANS arousal (or hypoarousal)
3. Cortical blood flow
 Increases to subcortex; Decreases in frontal lobes .
4. Conditioned, fixed motor responses
 Anger outburst, exaggerated startle responses, immobilization
5. Low cortisol allows more catecholamines: hyperarousal
 Effectiveness of psychotherapy?
Limited effectiveness of cognitive, “insightful” intervention

PTSD Neurobiological Pathway
Sensations run through brain unimpeded by lack of
subcortical stimulus discrimination and overconsolidated
mechanisms and the amygdala smells smoke and screams
WILDFIRE!, which cortical mechanisms are unable to quench,
and body jumps into action...

Treatment Implications
PTSD as a Neurobiological Disorder
Van der Kolk, 2006:
1.Increase awareness of somatic sensations and feelings
2.Regulate arousal and behavior
3.Reprogram automatic physical responses
“In order to come to terms with the past it may be essential to learn to
regulate one’s physiological arousal by mastering one’s physiological
states” (van der Kolk, 2006)

Treatment Implications
PTSD as a Neurobiological Disorder
Active Coping vs. Passive Coping
Active Coping changes how fear-arousing stimuli are processed by the
amygdala and other subcortical structures.
(Amorapanth et al., 2000; Le Doux & Gorman, 2001)

Sensory Awareness Exercise
Waking Up the Central Nervous System
1. Find a partner
2. Ask partner if is ok to gently tap their back– shoulders, sides of
spine, to tailbone, and careful not to tap on spine or kidney area
above hips.
3. Make loose, relaxed fists and gently begin tapping on shoulder
area. Gently.
4. Ask partner: how is this, would you like it harder or softer?
5. Continue tapping for 3-5 minutes on specified areas of back,
continuing to ask, how is this?
6. To finish: stop, focus on being present in the palms of your
hands, especially the center of the palms
7. With this presence, slowly, lightly stroke your partner’s back
from shoulder to above hips. Focus on having your palms sense
your partner’s back. Do this twice.
8. Ask your partner how do they feel.

Part II
Treatment Implications:
Current “Psychological” Treatments and
Biological Abnormalities
Overview
 Two decades of research: no one “gold standard” treatment for
PTSD (Foa, Keane, Friedman, 2000)
 Empirically validated “psychological” treatment approaches
 Innovative treatment approaches
PTSD Treatment Goals
 Stabilize distress and intense arousal (Frewen & Lanius, 2006)
 Affect and physiological dysregulation,
 Teach arousal regulation skills
 After exposure to trauma cues
(Foa, Rothbaum, Riggs, & Murdock, 1992
 Before processing trauma or during, integrated with program
(Ford et al., 2005, Linehan, 1993

Current Treatment Strategies
“Psychological” Treatments Address Biological Core?
Target which psychological and biological abnormalities?
Which symptoms? Psychological? Biological? Both?
How does each target biological abnormalities:
1.Increase awareness of somatic sensations and feelings?
2.Regulate arousal and behavior ?
3.Reprogram automatic physical responses?

Treatment Strategies for PTSD
Empirical Validation + Anecdotal
Psychological
1. Exposure Therapy
2. Anxiety Management Training
3. Combined Treatment Approaches
 Phase-oriented Approaches
 Cognitive Processing Therapy
 EMDR (Eye Movement Desensitization and Reprocessing)
Psychopharmacological
Innovative Approaches
 Acceptance and Commitment Therapy (ACT)
 Dialectical Behavior Therapy
 Physiologically- Oriented
• Somatic Experiencing
• Sensory Motor
 (And finally) Biofeedback

Anxiety Management Training
Method: Skills training to manage symptoms associated with PTSD.
Skill range from relaxation training, breath retaining, to cognitive
restructuring and anger management training.
Effective for symptoms of rape victim
 Not as effective as EX therapy for long-term effects (Foa et al, 1999)
Differential Effects:
 Significant treatment attrition compared to EX ther (Keane et al., 1989)
 Successful treatments focusing on one component
 Biofeedback assisted relaxation (Peniston, 1986)
 AMT focused on anger and rage (Chemtob, 1997)
AMT may have positive impact on physiological arousal.
Discussion
Skill trainings impact different psychophysiological systems?
Biofeedback vs. anger management training?

Muscle Relaxation Techniques
1. Gently, slowly, softly close your RIGHT hand into a
fist.
 Let your right hand tighten even more; hold it tight for 10
seconds
 Allow it to open and relax again.
2. Variation: with LEFT hand.
 Gently, slowly, softly close your LEFT hand into a fist.
 Let your right hand tighten even more; hold it tight for 10
seconds
 This time take 30 seconds to allow it to open and relax
again. Slowly, slowly, feel every little movement, every
little muscle. Are you aware of your breathing too?

Variation of Mind in Body
Stand up, allow arms to hanged relaxed at your sides
Variations:
1. Palms down, raise you arms until your palms are parallel
to the floor, arms outstretched to sides.
 Lower and relax arms to sides.
2. Palms down, allow the air to lift your arms until palms are
parallel to the floor, arms outstretched to sides.
 Allow the air to help lower and relax arms to your sides.
In which was your mind quieter?
What might be occurring neurophysiologically?

Combined Treatment Approaches
Method: Combine components of Exposure Therapy, Cognitive
Restructuring, and AMT. Multiple CBT strategies combined with
empirically supported skills training.
Phase-oriented approach for chronic PTSD
 Six phases: 1. behavioral stabilization; 2. trauma education; 3. anxiety
management skills; 4. trauma focus work; 5. relapse prevention; 6.
aftercare (Keane et al., 1994)
 Multi-component for combat-related: combines EX therapy, AMT, CT
has initial positive treatment effects (Freuh et al. )
 Clinically significant results combined approach for MVA survivors
(Fecteau & Nicki, )
Cognitive Processing Therapy (CPT)
 Combines EX therapy, AMT, and cognitive restructuring.
 Superior to wait-list comparison (Resnick & Schinicke, 1992)
 CPT compared EX Therapy equally effective; both superior to
wait-list.

Combined Treatment Approaches
EMDR
Method: EMDR: Combines EX therapy + Cognitive Therapy
and Lateral Eye Movements
EMDR : Eight-stage multi-component, treatment
 Eight stages: 1. HX and treatment planning; 2. education on trauma,
PTSD, teach coping skills; 3. identify trauma memory and associated
cognition, affective disturbance and physiologic sensations; 4. EMDR:
holding trauma memory, pt watches lateral finger movement of
therapist; 5. Positive cognitions assessed; 6. Body scan for residual
tension. 7. Closure and 8. Reevaluation.
Dismantling studies: used EMDR protocol with other foci, e.g. fixed
flashing lights or fixed gaze compared to eye movement found equal
improvements, and superior to no-treatment.
Some empirical support (Foa et al., 2000) but more research on
mechanisms, distinguishing from EX therapy and CBT.
(Shapiro, 1995)

Psychopharmacology for PTSD
PTSD is not a unitary psychobiological disorder
Numerous psychobiological systems altered
Diverse symptoms and comorbidiites
Possibly different psychobiological subtypes
Hyperarousal and dissociative
Strong Rationale for Psychopharmacology for PTSD:
1.Emotional and physiological dysregulation
2.Psychiatric comorbidities, e.g., depression, panic attacks
Antidepressants
Anti-anxiety
“Dramatic responses to medication has been exception,
rather than rule.”
(Friedman, Davidson, Mellman, & Southwick, 2000)

Proposed Psychobiological
Abnormality
Possible Clinical Effect
Adrenergic Hyperactivity
Hyperarousal, reexperiencing,
dissociation, rage, panic/anxiety
Hypothalamic-pituitary-adrenocortical
enhanced negative feedback
Stress Intolerance
Opiod dysregulation Numbing
Glutamatergic dysregulation
Dissociation, impaired information
and memory processing
Seratonergic dysregulation
Hyperarousal, reexperiencing,
stress response, associated
psychological symptoms*
Possible Psychobiological Abnormalities
Associated with PTSD
* Associated psychological symptoms: Rage, aggression, impulsivity,
depression, panic/anxiety, obsessional thoughts, substance use disorder
(adapted from Friedman, Davidson, Mellman, & Southwick, 2000)

Present Moment Focus
Acceptance and Commitment Therapy
(ACT)

Acceptance and Commitment Therapy (ACT)
Method: Targets PTSD symptoms of reexperiencing and avoidance.
Hypothesis: experiential avoidance underlies psychopathology,
specifically PTSD. Clients urged to reduce avoidance behavior of
thoughts, emotions, memories, to accept what is. Does not focus on
symptom reduction , i.e., reduction of arousal. Clients are encouraged
not to change self, but to ‘live life” by identifying valued goals and
directions in their lives, while accepting present circumstances.
Six core processes: 1. Acceptance, not experiential avoidance; 2.Cognitive
defusion: change concept of thoughts; 3. Be present with and describe events;
4. Self as experiential reference; 5. Values are chosen, life direction;
6. Committed action toward chosen values.
May lead to increased sensory awareness of internal stimuli. May be
first step in arousal regulation
 Willingness to experience trauma-related affect and cognitions and
associated arousal.

Exposure Therapy
Method: Exposure to trauma cues- imaginal and in vivo; reduced
avoidance and anxiety; promotes habituation –- reduce physiological
arousal. Additional components: relaxation training, arousal regulation,
psychoeducation. (Foa & Rothbaum, 1998)
Highest rated efficacious treatment (Foa et al, 2000)
 Effective with range of traumas – rape to combat veterans
 Exposure Therapy compared to Stress Inoculation Training
 Each more effective at different temporal points (Foa et al., 1999)
Exposure therapy may influence biological correlates of PTSD
 Integration visual + verbal memories (sensory awareness)
 Promotes habituation to trauma cues (affect + physio regulation)
 Extinction of arousal to trauma triggers (physical responses)
More research on pre- and post-intervention biological markers.
(Rabois et al., 2002)

Exposure Therapy
Discussion: symptom improvement is significantly
related to a person’s ability to habituate, or calm down
after exposure to a trauma reminder.

Somatic Exercise
Opening to Pain
Allow yourself to be comfortable and quiet..Focus on a thought or bodily pain or
ache. Chose only one.
Let your attention settle around this thought or sensation. Allow yourself to be with
the discomfort.
Feel the way in which your mind or body tends to push against the unpleasantness,
to close it off. Feel in your mind or body both the pain and the resistance against
the pain: both present yet separate from one another.
Notice your tendency to want to identify with the resistance and to deny or isolate or
push away the pain.
But instead of reactively pushing the thought or painful sensation away stay with it,
gently but firmly.
Now start to loosen the ring of resistance that surrounds the painful thought or
sensation, loosening its hold the same way you might allow a fist to open.
Consider the possibility that the resistance to the pain may be more painful than the
pain itself. Notice how the resistance closes your heart and fills your body with
tension and uneasiness

Somatic Exercise
Opening to Pain (cont.)
Keep relaxing the resistance, the tightness that has accumulated around the pain.
Notice any fear that has developed around this unpleasant thought or sensation.
Allow the fear to melt, to dissolve along with the resistance—softening, opening,
releasing. Let the painful thought or sensation float free, no longer held in the grasp
of resistance.
Keep letting go of any resistance that tries to smother the experience. Allow the
unpleasant thought or sensation to come fully into consciousness. No holding, no
pushing away, just floating free.
Let your grasping go. Just the thought or sensation and the awareness of it,
together, moment to moment.
See that the unpleasant thought is just a thought, the painful sensation is just that
and nothing more.
Softening, opening, releasing, allowing, again and again, until there is just thought,
just sensation.
And it keeps changing from moment to moment. It always keeps changing. Soft,
open, gentle, allowing, floating free. (adapted from Steven Levine, 1986)

Dialectical Behavior Therapy (DBT)Skills Group
Method: Skills Training. Four skills sets taught over period of 6 months
to 2 years. Structured cognitive behavioral program that utilizes sensory
awareness and mindfulness.
Four skill sets.
1. Core mindfulness: Observe, describe. participate
2. Interpersonal Effectives: build positive relationships with others while
retaining self-respect
3. Emotional Regulation. Identifying emotions; moderating emotions
4. Distress Tolerance. If you have a problem, solve it. If you cannot, how
do you tolerate the distress, survive the crises?
Integrated mindfulness: Awareness techniques learned on emotional,
physiological, behavioral, and cognitive levels.
Techniques target:
1. Increased sensory awareness
2. Regulating emotional arousal
(Marsha Linehan,

Physiologically-Oriented
Method: Treatment cornerstone is sensory awareness:
Separate, or uncouple, sensations , which reduces:
Conditioned fear response
Automatic action patterns
Processing of trauma experience, with psycho-education,
Restructure cognitions
Theory
Integration of sensations-- cognitions-- emotions
Leads psychological insight, physiological self-control
Physiologically-oriented Modalities
Somatic Experiencing (Peter Levine, PhD)
http://en.wikipedia.org/wiki/Somatic_Experiencing
Sensorimotor Psychotherapy (Pat Ogden, PhD)
http://www.trauma-pages.com/articles.php#Ogden

1. Active components similar
 Focus on integrating emotions, cognitions, and regulating arousal
 Somatic/ physiological treatment is employed
 Primary component
 Adjunctive skills training component
2. Difference?
Emphasis: Starting point
CognitionsPhysiology
Behavior
Emotions
Discussion
Exposure therapy vs. Somatic Experiencing

Hypnosis
Method: “Procedure during which professional suggest that subject
experiences change in sensation, perceptions, thought or behavior.
Brings aroused focus, deceased peripheral awareness, increased
suggestibility to suggestion.” Div 30, APA
Hypnosis historically used with trauma- combat and sexual abuse
Targets dissociation, i.e., hypoarousal and hyperarousal
Enhances effectiveness of psychodynamic and CBT interventions
(Kirsch, 1996)
Case studies: effect with PTSD symptoms of pain, anxiety and
nightmares
Controlled study: hypnosis useful for intrusion symptoms (Brom et
al., 1989)

Progressive Muscle Relaxation (PMR)
Method: Progressively reduce muscle tension by alternately tense /relax groups
of muscles. Affects symptoms associated with PTSD, including anxiety, high blood
pressure stomach pain, insomnia. (Jacobsen, 1929)
PMR as Control Group?
Cognitive restructuring with coping skills vs.
MR
-20 female rape victims. Five one-hour sessions,
-Both improved all measures post, 1, 3, 5 months
-At 12-month follow-up, cognitive group superior in
TSD symptoms, but not other measures.
(Echeburua, de Corral, Sarasua, & Zubizarreta,1996)
Exposure with cognitive restructuring vs. PMR
-20 female rape victims, Five one-hour sessions
-Both groups improved in all measures at all periods
-Exposure group. Possible significant improvements
all periods
(Echeburua, de Corral, Zubizarreta, & Sarasua,1997)

Progressive Muscle Relaxation
Method: To Tense or Not to Tense? ( Lehrer, 2003)
Tensing then releasing muscle is a didactic tool
Tensing does not increase subsequent relaxation
Tensing increases sensory awareness and control of muscles
(Jacobsen ,1939)
Surface EMG study on Facial Area
Repeated tense-release cycles did not increase self-reported
relaxation
Evidence that muscle tension persists after several seconds of
tension
Followed by immediate deep relaxation
High level of muscle tension does not, by itself, improve
sensory awareness of tension.
Conclusion:”only very low levels of induced muscle tension
may be necessary”.
(Lehrer, Batey, Woolfolk, Remde, & Garlick, 1988).

Biofeedback + HRV Biofeedback
Method: ANS functioning measured in real time
Increases cognitive and sensory awareness of physiological
functioning.
Increase awareness, leads to control automatic physiological
processes. Improves health; increases self-efficacy.
Biofeedback Modalities
EMG: Muscle tension
Thermal : Temperature
Galvanic Skin Response/ Skin
Resistance
Heart Rate Variability Biofeedback:
Paced breathing; 6 breaths per
minute

Biofeedback Research
RCT: Comparison of EMG, Relaxation, Training, and
EMDR as Adjunctive Treatment in Inpatient program
Inpatient treatment program added, compared EMG biofeedback,
relaxation training, and EMDR in 100 Vietnam vets. EMDR was found to
be most effective with Relaxation training somewhat and EMG no
statistical significance. However, article gave no description or number of
Relax and EMG treatment. (Silver, Brooks, & Obenchain, 1995)
Quasi: Six patients with PTSD received between 8 and
14 sessions of biofeedback and relaxation training in
addition to individual and group therapy.
Pts. had slight to marked improvements on biofeedback measures.
Confounds: low power; treatment sessions were not standardized nor were
pts. matched ; no control group.; all pts. were involved in individual and
group therapy for PTSD. Possibility biofeedback might be an effective
adjunctive treatment. (Hickling, Sison, & Vanderpoeg, 1986)

Quasi: Muscle Relaxation, thermal feedback, and deep
breathing compared in 90 veterans with PTSD.
Ten 30-minute session. . Improvement sonly 4 of the 21 PTSD and
physiological dependent variables studied; .all 21 Treatment X Time
interactions were non-significant. Indicates treatment “mildly therapeutic”
but no different than quiet sitting in a comfortable chair.”
(Watson, Tuorila, Vickers, Gearhart, & Mendez, 1997)
Preliminary: Diaphragmatic breathing techniques and
mental imagery skills training to reduce hyperarousal in
traumatized children (13- 17) using thermal biofeedback
as biomarker and intervention.
Thermal biofeedback is practiced twice daily. Twenty-two participant pre-
and post-intervention measures suggest reduction in anxiety and PTSD
reaction. Stage two: investigate efficacy of thermal biofeedback assisted
exposure therapy.
(Scherzer, Aurora Mental Health Center, www.NCTSNet.org)

Wounded Warriors Program
Wild Divine’s Healing Rhythm Biofeedback
Preliminary study:
 Target PTSD symptoms, hyperarousal symptoms: outbursts of anger,
and anxiety, brain injury
“sensors measure stress (GSR), body temperature, and heart and brain
rhythms”
taught methods of controlling anxiety, such as breathing techniques or
thinking of pleasant topics.
Biofeedback is only one modality
relaxation, recreation and social interaction. East Carolina University’s
psychophysiology and biofeedback lab

Wild Divine
“McClain said he was skeptical when he started the
program in March but is now a believer, because it has
helped him control his hair-trigger temper, a typical PTSD
symptom. "I still express my emotions, but I don't act
wild," he said. "It's helping a lot, and I mean a whole lot."
http://www.wilddivineproducts.com/ptsd-biofeedback.htm

HRV Biofeedback Rationale
Low HRV associated with PTSD
Five assessment cue-provocation studies
Low HRV is associated with PTSD diagnosis
Lowest HRV indices associated:
Highest elevated HR
More prolonged HR arousal and recovery
(Cohen et al., 1997, 1998; Hopper, Spinazzola, Simpson, &
van der Kolk, 2005; Sack, Hopper, & Lamprecht, 2003; Sahar
et al., 2001).
Low HRV associated with PTSD comorbidities
Depression (Stein et al., 2000)
Insomnia (Bonnet & Arand, 1998)
Substance Use Disorder (Ingjaldsson, Thayer, Laberg, 2003)
 Inhibits Allostasis Regulation
Three systems: glucose regulation, HPA functioning; inflammation
Linked to neuronal structures, amygdala, prefrontal cortex
(Thayer, & Sternberg, 2006)

HRV Biofeedback Intervention
Pre- Post-Assessment
Can HRV biofeedback increase HRV (SDNN) in PTSD?
Baseline
HRV Biofeedback Recovery
5-min 10-min 5-min
RSA = Respiratory Arrhythmia Biofeedback
20-Minute Assessment Period

HRV Biofeedback
20- minute Assessment
≥ .050 msec SDNN is normal for healthy adults

HRV Biofeedback
RSA Biofeedback vs. PMR for PTSD symptoms
RCT: N= 38; 19 persons each group
 4-week intervention: adjunctive treatment; daily 20-minute RSA*
biofeedback practice
The StressEraser
RSA* Biofeedback
Respiratory Sinus Arrhythmia =
HRV with no

Results
Depressive symptoms decreased for HRV (RSA) group
Significant interaction effect for group x time on the BDI-II, p < .01
Significant within-group analysis: RSA reduced depressive symptoms,
p = .038 compared to PMR, p =.973
Minimal = 0-13; Mild = 14-19; Moderate= 20-28; Severe = 29-63

Results
HRV amplitude increased for HRV (RSA) Group only.
SDNN ≥ 50 msec is normal for healthy adults

Results
Increased in HRV amplitude for HRV (RSA) Group only
Significant interaction effect for group x time on SDNN at BASE, p < .02
Significant within-group analysis: RSA increased SDNN, p = .03 compared to
PMR, p = .57

Results (cont.)
Increase in HRV amplitude is associated with
psychiatric symptom improvement
Autonomic homeostasis (HRV)
PTSD symptoms
and
EOT SDNN uniquely accounted for 17% of the variance in EOT PCL-C scores, p. = .016
EOT SDNN uniquely accounted for 6.2% of the variance in EOT BDI-II scores, p = .09 (trend level)
Depressive symptoms
(trend level)

Results
PTSD Symptoms Decreased for Both Groups
 T scores range from 36- 100
Mild = 60 – 65; Moderate = 65 – 74;
Severe = 75 -100
Within-group p’ s < .01
Scores range from 17-85
PTSD Dx Cut-Off = 44
Within-group p’ s <. 01

Heart Rate Variability and PTSD:
A pilot research
(Tan et al., 2008)
Method:
Twenty participants (veterans)
Two groups
Experimental: TAU* + 7 one-half hour HRV biofeedback
Control: TAU*
*TAU= Treatment as Usual: self-selected modalities from a
VA trauma treatment program. Including, but not limited to
group or individual therapy, medication,.
Pre- Post-Assements:
CAPS
PCL-S
HRV (SDNN)

Results
HRV significantly increased the SDNN
Comparison of SDNN before and after
treatm ent (D iff e r e nc e s b e t w e e n t he tw o g ro up s w e re
s ig . a t t he .0 0 9 le v e l)
20
40
60
80
1 2
Time
SDNN
EXP
CON
SDNN of 50 is normal for healthy adults

Results
HRV biofeedback significantly reduced symptoms of
PTSD compared to TAU
Between Group Comparison for PTSD Measures
EXP Group Control
Group t-statistics p-value Cohen's d
Mean SD Mean SD
CAPS 15.2 7.1 8.3 17.3 1.17 .266 .52
PCLS 10.4 13.3 1.0 13.5 1.57 .135 .70

Results
Post-hoc Qualitative Analysis: Follow up phone interviews
Nine patients in the experimental group reported:
Continued practice of HRV breathing
HRV breathing training helped manage
•Anxiety
•Anger
•PTSD symptoms

Integrated Treatment of Trauma Symptoms
HRV Biofeedback as Adjunct
Four components:
•Psychoeducation
•CBT
•Acceptance and Commitment Therapy
•HRV Biofeedback
On going trial at Trauma Research Institute, San Diego
•88% (24 of 27) had clinically significant improvements
•22 met clinical goals within 3 months
•2 met goal in 6 months
•3 did not drop below clinically significant cutoffs
(Gevirtz & Dalenberg, 2008)

Active vs. Passive Coping
Increases in Vagal tone– HRV– associated with active
coping
•Two groups of women watched distressing film
•Experimental group instructed to cognitively suppress or
reappraise the film
Revealed larger increases in HRV than controls

“Given that understanding and insight are the main
staples of both cognitive behavioral therapy and
psychodynamic psychotherapy, the discoveries of
neuroscience has been difficult to integrate into
therapeutic practice.
Neither CBT protocols nor psychodynamic therapeutic
techniques pay sufficient attention to the experience and
interpretation of disturbed physical sensations and
preprogrammed physical action patterns.”
What’s the Body Got To Do With It?

Physiological Intervention Conundrums
When are Physiological Interventions Best Utilised?
Beginning, to stabilize?
After exposure to trauma?
Adjunct skill?
Primary approach?
Can We Identify More Effective Physiological Modalities?
Decreases hyperarousal? Hypoarousal?
Addresses comorbidities: depression, substance abuse,
 Promotes self-regulation, self-efficacy, physical health?

Part III
Psychophysiological Treatment Strategies
for PTSD
“Despite a plethora of studies and writings on the
neurobiology and psychobiology of stress, trauma, and
PTSD, the psychotherapist has had few tools to for
healing the traumatized body as well as the traumatized
mind.”

Method
• Sensory awareness of (bodily) somatic sensations and
emotions (feelings)
Goal
•Increase awareness of sensations and feelings
•Regulate arousal and behavior
Core Principle:
•Meditation principle
Mindfulness/ Meditation as Core Principle
Focus --- Presence ---- Awareness
Focus
Awareness Presence
(adapted from Middendorf, 1990)

1. Breath Awareness Meditations
•Breath Awareness
•Diaphragmatic/ paced breathing
•HRV Biofeedback
2. Present Moment Mediations
•DBT Core Mindfulness
•Focusing
3. Physical Movement Mediations
•Play Meditations: Group Juggling
•Progressive Muscle Relaxation– “to tense or not to tense”
•Yoga
4. Biofeedback
•EMG, GSR, Temperature
•Hypnosis
Physiologically-oriented Exercises

Be Aware
The Tyranny of Meditation/ Mindfulness
•If I am ecstatically aware of my belly button and a tiger
comes and eats me, who is mindful now?
•Ongoing question: what does one be mindful of?
•Toes, nose, breath, not-noticing-thoughts
•Mindfulness can bring calmness but does not equal it.
Calmness can be repression, or not being present.
•Mindfulness can bring action, hopefully right action.

Be Aware
What is Meditation/ Mindfulness?
Being and Mindfulness by Judith Warner
“The other night at a dinner party, a friend described how she tried to
practice mindfulness meditation to keep herself from losing it during an
utterly wretched seven-hour layover in an airport while she was exhausted,
ill and desperate to get home to her children. “I kept trying to be all ‘Be
Here Now,’” she said, “but I just wanted to be anywhere but here.”
http://warner.blogs.nytimes.com/2009/03/05/the-worst-buddhist-in-
the-world/?scp=1&sq=judith%20warner%20meditation&st=cse
Anxiety, Fear
__________________________________________
FLOW
__________________________________________
Boredom
Csikszentmihalyi , 2002

Breath Awareness Meditations
The Experience of the Breath
Sensory awareness of Breath coming and going on it’s own
Non-judgementally. Just be with it.
Where is it in your body? Where does it move your body wall?
What is your breath telling you about what your are feeling?
Aches? Pains? Emotions?
Research; Peritrauma increased respiration rate predicts PTSD onset (Bryant)
Anecdotally: Decreases arousal symptoms, improves sleep
Techniques: Chi gong, Middendorf Breath work, various yogas
Breath Exercise:
Rest hands on stomach; sense your breathing
Sense the rhythm just as it is.
Is it fast, slow. Where do you feel it? Chest? Shoulders? Belly? Legs?
True letting go: Can you allow the breath to breathe you?

Breath Awareness Meditation
Diaphragmatic Breathing
Exercise:
Slowly, inhale to stomach,
relax diaphragm,
shoulder muscles
Slowly, exhale from
stomach, diaphragm,
relaxed, shoulder muscles
relaxed
During inhalation ,the diaphragm descends
and air fills the lungs. During exhalation
the diaphragm rises and the lungs expel air.

Diaphragmatic Breathing/
Paradoxical Breathing
On inhale:
shoulders go up
+ belly tense
On exhale:
shoulders stay
up or go down,
+ belly stays
tense Shoulder, neck pain
from paradoxical breathing

Paradoxical Breathing
Anxiety Symptoms
07/21/16 94Gevirtz
This is your brain
on normal breathing
This is your brain
on hyperventilation
Low blood flow High blood flow

HRV Biofeedback-- Paced Breathing
Slow breathing, 6 BPM, using visual feedback
Promotes autonomic homeostasis, balance
Affects symptoms of both hyperarousal and hypoarousal
Mediates appropriate emotional and behavioral
responsivity
Non-invasive, effective within minutes
Improves symptoms over 4-weeks of training

Inhale heart rate >> increases sympathetic branch arousal
Exhale heart rate >> increases parasympathetic arousal
What does HRV Biofeedback do:
 6 BPM: Balances ANS
 Reduces symptoms of both psychological and physical illnesses
 By consciously breathing at 6 BPM, one can improve health
 Breath pacer (free): www.BFE.org; Download EZ-Air
Exercise
Imagine being startled. How do you breathe?
Imagine relaxing. How do you breathe?
How Does HRV (Breathing) Biofeedback
Affect the ANS ?

HRV Biofeedback
Biomarker for PTSD Treatment Effectiveness
Intervention Studies with PTSD and HRV
Increased HRV associated with decreased PTSD symptoms
Hatha yoga (van der Kolk, 2006)
Fluoxetine treatment (Cohen, Kotler, Matar, & Kaplan, 2000)
EMDR (Sack, Nickel, Lempa, and Lamprecht, 2003)
Cognitive Behavioral Therapy (Nishith et al., 2003)
HRV indices depict different ANS states
Stages of Somatic Experiencing
(Whitehouse & Heller, 2008)

Yogic Breathing
Sudarshun Kriya Yoga (SKY)
(Gerbarg & Brown, 2005)
22- hour program for trauma
Combines hatha yoga, yogic breathing, guided mediations, group process,
psycho education.
Breath-Water-Sound (BWS)
8-hour course adapted for immediate disasters
Primary uses three types yogic breathing
Pilot studies:
Decrease depressive. PTSD, anxiety, and anger symptoms
Proposed mechanisms
Voluntary control of breath patterns affects ANS
Stimulates vagal afferents, hypothalamic structures (attention and memory),
limbic system (forebrain reward systems)
Prolactin and oxytocin may be stimulated by limbic system
www.artofliving.org

Present Moment Awareness
Dialectical Behavior Therapy (DBT)

Developed for traumatized, borderline, population
(Linehan)
PTSD and Borderline similar biological abnormalities
(“Traumatic Antecedents of Borderline Personality Disorder”, Herman &
van der Kolk, 1987)
Study: Decrease HRV for BPD watching films
( Austin,
, Riniolo,
& Porges, 2007)
Currently: positive results with trauma populations
Primary treatment
Integrated with other treatments
DBT and Trauma

DBT
Three States of Mind
Wise Mind

DBT
Core Mindfulness Meditation-- What Skills
Four DBT Skills Group Modules:
•Core Mindfulness
•Distress Tolerance
•Interpersonal Effectiveness
•Emotion Regulation
Core Mindfulness
Derived Christian contemplative prayer and Zen meditation
•Observe: Notice your experience, focus attention
•Describe: Put words on experience
•Participate: Enter into experience; be in the moment
***Awareness brings change, control

DBT
Core Mindfulness Meditation- How Skills
Core Mindfulness
•Non-Judgementally: Don’t evaluate; unglue your opinions;
focus on “what”, not “good” , ‘bad”, terrible
•One-Mindfully : Do one thing at a time. When your are
eating, eat. When your are walking, walk.
Let go of distractions, and go back to what you are
doing, again, and again, and again.
Effectively: Focus on what works. Act as skilfully as you can
Keep your eye on your objectives.
Let go of vengeance, useful anger, righteousness that hurt
you and does not work
(Skills Training Manual for Treating Borderline Personality
Disorder, Marsha Linehan, PhD)

Focusing
Eugene Gendlin, PhD
1. Clearing a space
Allow yourself to be silent. Take a moment just to relax. Pay attention inwardly, in
your body. Ask yourself "How is my life going? What is the main thing for me right
now?" Sense within your body. Let the answers come slowly from this sensing.
When some concern comes, DO NOT GO INSIDE IT. Stand back, say "Yes, that’s
there. I can feel that, there." Let there be a little space between you and that. Then
ask what else you feel. Wait again, and sense. Usually there are several things.
2. Felt Sense
From among what came, select one. There are many parts to that one thing. Feel
all of these things together. Where you usually feel things, get a sense of what all
of the problem feels like. Let yourself feel the unclear sense of all of that.
3. Handle
What is the quality of this unclear felt sense? Let a word, a phrase, or an image
come up from the felt sense itself. It might be a quality-word, like tight, sticky,
scary, stuck, heavy, jumpy or a phrase, or an image. Stay with the quality of the
felt sense till something fits it just right.

Focusing (2)
6. Receiving. Receive whatever comes with a shift in a friendly way. Stay with it a
while, even if it is only a slight release. Whatever comes, this is only one shift;
there will be others. You will probably continue after a little while, but stay here for
a few moments.
If during these instructions somewhere you have spent a little while sensing and
touching an unclear holistic body sense of this problem, then you have focused. It
doesn't matter whether the body-shift came or not. It comes on its own. We don't
control that.
4. Asking. Now ask: what is it, about this whole problem, that makes this quality
(which you have just named or pictured)? Make sure the quality is sensed again,
freshly, vividly (not just remembered from before). When it is here again, tap it,
touch it, be with it, asking, "What makes the whole problem so ______?" Or you
ask, "What is in this sense?
"If you get a quick answer without a shift in the felt sense, just let that kind of
answer go by. Return your attention to your body and freshly find the felt sense
again. Then ask it again. Be with the felt sense till something comes along with a
shift, a slight "give" or release.

Focusing (3)
Somatic Experiencing™ and Focusing
Somatic Experiencing is a form of therapy that targets PTSD
symptoms of PTSD by focusing on the client’s perceived body
sensations (or somatic experience).
The procedure involves a client tracking his or her own felt-
sense experience similar to done Eugene Gendlin's “Focusing”
technique.
Somatic Experiencing attempts to promote awareness and
release of physical tension that proponents believe remains in the
body in the aftermath of trauma.
Somatic Experiencing uses procedural elements that have been
said to work anecdotally, but have yet to be subjected to a double-
blind study.
(developed by Peter Levine, PhD)

Physical Movement Meditations
Play Meditation– Focus, Awareness, Presence
Group Juggling
Anecdotal: Article: “How Exercise Helps Symptoms Of PTSD”
http://www.giftfromwithin.org/html/exercise.html
Research: Arnson et al, 2007; mostly anecdotal, e.g., Wild Divine PTSD project

PMR
Systematic muscle tension reduction balances ANS
Affects various symptoms associated with PTSD: anxiety, high blood pressure,
stomach pain, insomnia (Jacobsen, 1928)
PMR Exercise
Exercise 1: Tensing: Sit or lie, comfortable as possible
•Alternately tense /relax groups of muscles
• Sense how much more relaxed the muscles are
Hands, Arms, Shoulders, Face, and, so on
for about 20 minutes until you have scanned whole body.
Exercise 2: Not- Tensing: Sit or lie, comfortable as
possible
•Put your sensory awareness into groups of muscles and relax each group
Separately before moving to next.
Hands, Arms, Shoulders, Face, and, so on
Which relaxes the muscles more? What is the difference?

Hatha (Physical) Yoga
Restorative Yoga

Active Yoga

Hatha Yoga for PTSD
Research
Study 1- Hatha Yoga Only
11 participants with PTSD symptoms
8 sessions Hatha yoga
Results: Decrease reexperiencing and avoidance
Increase in HRV
Study 2- Hatha Yoga vs. DBT
8 female PTSD participants, 25-55,
Random assignment
8 sessions: 1. Group therapy based on DBT
2. 75 minutes hatha yoga
Results:
Yoga group only had PTSD symptoms decrease:
Frequency of intrusive thoughts
Hyperarousal symptoms
“I learned to be able to focus and sense where my body was”
“ I was able to go shopping and know what I needed”

Discussion
Hatha Yoga Superior to DBT for PTSD?
Pilot studies; small sample size
Unclear Interventions:
Which hatha yoga?
• Which poses or asanas? 66 basic ones, up to 908 variations.
•Bikrim? Iyengar? Ashtanga (aerobics), Restorative?
•Different speeds, focus of awareness
What was the “group therapy based on DBT”?
8 sessions of Core Mindfulness vs. 8 sessions Distress Tolerance
Skills?
Physiology, sensory awareness addressed?
More research needed.

Biofeedback and Hypnosis
Hypnosis and Biofeedback Exercise
 Muscle tension
Thermal – temperature– biofeedback
Skin Conductance- lie detector test
HRV biofeedback

Future Research
Rabois, Batten, & Keane, 2002:
“In addition, for future advances in the psychological treatment
of PTSD, psychological researchers would benefit from a
more complete understanding of the biological correlates of
the disorder. Similarly, those interested in the biology of PTSD
would enhance the field by attending to the measurement and
analysis of the relevant psychological variables.
Finally, as a field, we would benefit from increased
collaboration among those committed to a scientific, multi-
level analysis of PTSD and the goal of developing empirically
supported, comprehensive treatments for PTSD.”

Future Research
Discussion
More biofeedback studies? Randomized controlled.
Which physiologic interventions are effective? Why?
Alone? Adjuncts?
Which effective assessing other treatment efficacy?
Problems with convergent validity between psychological
and physiological PTSD measures?

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