A pilot study of heart rate variability biofeedback therapy in the treatment of perinatal depression on a specialized perinatal psychiatry inpatient unit

Effect of virtual reality-based biofeedback for depressive and anxiety symptoms: Randomized controlled study

BACKGROUND

The use of virtual reality (VR)-based biofeedback (BF), a relatively new intervention, is a non-pharmacological treatment of depressive and anxiety symptoms. However, studies on VR-based BF are lacking and inconclusive.

METHODS

A total of 131 adults were recruited from the community. Participants who scored ≥10 on the Patient Health Questionnaire-9 (PHQ-9) or ≥9 on the Panic Disorder Severity Scale (PDSS) were included in the group with depressive or anxiety symptoms (DAS group), and others as the healthy control group (HC group). Participants from the DAS group were randomly assigned to VR-based or conventional BF intervention. All individuals visited at three times (weeks 0, 2, and 4), and completed the Montgomery-Asberg Depression Rating Scale (MADRS), the State-Trait Anxiety Inventory (STAI), and a visual analog scale (VAS) before and after the intervention, and PHQ-9 at the beginning and final visit.

RESULTS

The analysis included a total of 118 participants (DAS/VR: 40, DAS/BF: 38, HC/VR: 40). There was no significant difference in demographic variables among the three groups. After the intervention, the DAS/VR group exhibited significant decreases in MADRS (70.0 %), PHQ-9 (64.1 %), STAI (29.5 %), and VAS (61.7 %) scores compared to the baseline (p <0.001). There were no significant differences between the effects of VR-based BF and conventional BF with a therapist. The HC group also showed significant decreases in the measures of depression and anxiety after receiving VR-based BF.

CONCLUSION

VR-based BF was effective in reducing depressive and anxiety symptoms, even for subthreshold depression and anxiety symptoms in the HC group.

Investigating heart rate variability measures during pregnancy as predictors of postpartum depression and anxiety: an exploratory study

Perinatal affective disorders are common, but standard screening measures reliant on subjective self-reports might not be sufficient to identify pregnant women at-risk for developing postpartum depression and anxiety. Lower heart rate variability (HRV) has been shown to be associated with affective disorders. The current exploratory study aimed to evaluate the predictive utility of late pregnancy HRV measurements of postpartum affective symptoms. A subset of participants from the BASIC study (Uppsala, Sweden) took part in a sub-study at pregnancy week 38 where HRV was measured before and after a mild stressor (n = 122). Outcome measures were 6-week postpartum depression and anxiety symptoms as quantified by the Edinburgh Postnatal Depression Scale (EPDS) and the Beck Anxiety Inventory (BAI). In total, 112 women were included in a depression outcome analysis and 106 women were included in an anxiety outcome analysis. Group comparisons indicated that lower pregnancy HRV was associated with depressive or anxious symptomatology at 6 weeks postpartum. Elastic net logistic regression analyses indicated that HRV indices alone were not predictive of postpartum depression or anxiety outcomes, but HRV indices were selected as predictors in a combined model with background and pregnancy variables. ROC curves for the combined models gave an area under the curve (AUC) of 0.93 for the depression outcome and an AUC of 0.83 for the anxiety outcome. HRV indices predictive of postpartum depression generally differed from those predictive of postpartum anxiety. HRV indices did not significantly improve prediction models comprised of psychological measures only in women with pregnancy depression or anxiety.

Pre-partum HRV as a predictor of postpartum depression: The potential use of a smartphone application for physiological recordings

BACKGROUND

This study aimed to investigate the role of a time-domain Heart Rate Variability index (the root mean square of successive difference between NN intervals, rMSSD) as a predictor of the onset of postpartum depression. HRV has been related to an increased risk of depression in the general population. However, its role in pregnant women is not clear, and the potential use of smartphone applications to evaluate HRV in this population has not been investigated.

METHODS

In study 1, simultaneous electrocardiogram and smartphone photoplethysmography were collected. The rMSSD was determined from each recording to evaluate the accuracy of a smartphone application in the measurement of HRV. In study 2, 135 pregnant women provided rMSSD values measured through a smartphone application in the prepartum (second or third trimester) and filled in the Edinburgh Postnatal Depression Scale in the postpartum (one month after the childbirth).

RESULTS

Study 1 showed the excellent accuracy of the smartphone application in the measurement of rMSSD. Study 2 indicated that lower prepartum rMSSD predicted higher depressive symptoms in the postpartum (β = -0.217, p = 0.010) after controlling for prepartum depressive symptoms and other potential covariates.

LIMITATIONS

Artefacts (e.g., hand movements) might have corrupted the physiological signal registered.

CONCLUSION

This study showed that a reduced vagal tone, indexed by lower rMSSD, during pregnancy was a predictor of depressive symptoms one month after childbirth. The prepartum period may offer an important timeframe to implement preventive intervention on vagal modulation in order to prevent depressive symptoms in the postpartum.

Following the Rhythm of the Heart: HeartMath Institute's Path to HRV Biofeedback

This paper outlines the early history and contributions our laboratory, along with our close advisors and collaborators, has made to the field of heart rate variability and heart rate variability coherence biofeedback. In addition to the many health and wellness benefits of HRV feedback for facilitating skill acquisition of self-regulation techniques for stress reduction and performance enhancement, its applications for increasing social coherence and physiological synchronization among groups is also discussed. Future research directions and applications are also suggested.

Technology-Based Approaches for Supporting Perinatal Mental Health

PURPOSE OF REVIEW

This review explores advances in the utilization of technology to address perinatal mood and anxiety disorders (PMADs). Specifically, we sought to assess the range of technologies available, their application to PMADs, and evidence supporting use.

RECENT FINDINGS

We identified a variety of technologies with promising capacity for direct intervention, prevention, and augmentation of clinical care for PMADs. These included wearable technology, electronic consultation, virtual and augmented reality, internet-based cognitive behavioral therapy, and predictive analytics using machine learning. Available evidence for these technologies in PMADs was almost uniformly positive. However, evidence for use in PMADs was limited compared to that in general mental health populations. Proper attention to PMADs has been severely limited by issues of accessibility, affordability, and patient acceptance. Increased use of technology has the potential to address all three of these barriers by facilitating modes of communication, data collection, and patient experience.

Efficacy of group biofeedback treatment on hyperemesis gravidarum with psychosomatic symptoms diagnosed with the revised version of Diagnostic Criteria for Psychosomatic Research (DCPR-R): study protocol for a randomised controlled trial

INTRODUCTION

Hyperemesis gravidarum (HG) is a condition characterised by dehydration, electrolyte imbalance, lack of nutrition and at least 5% loss in body weight, occurring in the first half of pregnancy. The aim of this trial is to examine the efficacy of group biofeedback treatment on patients with HG with psychosomatic symptoms, which will be evaluated through the revised version of Diagnostic Criteria for Psychosomatic Research (DCPR-R).

METHODS AND ANALYSIS

In this single-blinded randomised controlled clinical trial, 68 patients with HG diagnosed with at least one psychosomatic syndrome according to DCPR-R and aged 18-40 years, will be recruited in a Chinese Maternal and Child Health Hospital. The sample will be randomised (1:1) into two arms: experimental group, which will undergo group biofeedback treatment, psycho-education and treatment as usual (TAU); and control group, which will undergo psycho-education and TAU only. The primary outcomes will be reduction of the frequency of psychosomatic syndromes, severity of nausea/vomiting, quality of life and heart rate variability. The secondary outcomes will include days of hospitalisation, repeated hospitalisation and laboratory investigations.

ETHICS AND DISSEMINATION

This study has received ethical approval from the Nanjing Medical University (No. 2019/491, granted 22 February 2019). All participants will be required to provide written informed consent. Study outcomes will be disseminated through peer-reviewed publications and academic conferences, and used to confirm a tailored biofeedback intervention for patients with HG with psychosomatic symptoms.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR2000028754).

Mind-Body Techniques in Pregnancy and Postpartum

Maternal stress can perturb physiology and psychiatric health leading to adverse outcomes. This review investigates the effectiveness of several mind-body therapies-namely biofeedback, progressive muscle relaxation, guided imagery, tai chi, and yoga-as interventions in reducing maternal stress and other pregnancy-related conditions. Through randomized trials, these techniques have shown promising benefits for reducing pain, high blood pressure, stress, anxiety, depressive symptoms, labor pain and outcomes, and postpartum mood disturbances. As these interventions are easy to implement, low cost, and safe to perform in pregnancy, they should be considered as alternative, nonpharmaceutical interventions to use during pregnancy and postpartum care.

MAternal Mental Health in the WORKplace (MAMH@WORK): A Protocol for Promoting Perinatal Maternal Mental Health and Wellbeing

Women are exposed to increased burden of mental disorders during the perinatal period: 13–19% experience postpartum depression. Perinatal psychological suffering affects early mother-child relationship, impacting child’s emotional and cognitive development. Return-to-work brings additional vulnerability given the required balance between parenting and job demands. The MAternal Mental Health in the WORKplace (MAMH@WORK) project aims to develop and evaluate the effectiveness of a brief and sustainable intervention, promoting (a) maternal mental health throughout pregnancy and first 12 months after delivery, and (b) quality of mother–child interactions, child emotional self-regulation, and cognitive self-control, while (c) reducing perinatal absenteeism and presenteeism. MAMH@WORK is a three-arm randomized controlled trial. A short-term cognitive-behavioral therapy-based (CBT-based) psychoeducation plus biofeedback intervention will be implemented by psychiatrists and psychologists, following a standardized procedure manual developed after consensus (Delphi method). Participants (n = 225, primiparous, singleton pregnant women at 28–30 weeks gestational age, aged 18–40 years, employed) will be randomly allocated to arms: CBT-based psychoeducation intervention (including mindfulness); psychoeducation plus biofeedback intervention; and control. Assessments will take place before and after delivery. Main outcomes (and main tools): mental health literacy (MHLS), psychological wellbeing (HADS, EPDS, KBS, CD-RISC, BRIEF COPE), quality of mother–child interaction, child–mother attachment, child emotional self-regulation and cognitive self-control (including PBQ, Strange Situation Procedure, QDIBRB, SGS-II, CARE-Index), job engagement (UWES), and presenteeism. Intention-to-treat and per-protocol analyses will be conducted; Cohen’s d coefficient, Cramer’s V and odds ratio will be used to assess the effect size of the intervention. MAMH@WORK is expected to contribute to mental health promotion during the perinatal period and beyond. Its results have the potential to inform health policies regarding work–life balance and maternal mental health and wellbeing promotion in the workplace.

Understanding the experiences of self-injurious behavior in autism spectrum disorder: Implications for monitoring technology design

OBJECTIVE

Monitoring technology may assist in managing self-injurious behavior (SIB), a pervasive concern in autism spectrum disorder (ASD). Affiliated stakeholder perspectives should be considered to design effective and accepted SIB monitoring methods. We examined caregiver experiences to generate design guidance for SIB monitoring technology.

MATERIALS AND METHODS

Twenty-three educators and 16 parents of individuals with ASD and SIB completed interviews or focus groups to discuss needs related to monitoring SIB and associated technology use.

RESULTS

Qualitative content analysis of participant responses revealed 7 main themes associated with SIB and technology: triggers, emotional responses, SIB characteristics, management approaches, caregiver impact, child/student impact, and sensory/technology preferences.

DISCUSSION

The derived themes indicated areas of emphasis for design at the intersection of monitoring and SIB. Systems design at this intersection should consider the range of manifestations of and management approaches for SIB. It should also attend to interactions among children with SIB, their caregivers, and the technology. Design should prioritize the transferability of physical technology and behavioral data as well as the safety, durability, and sensory implications of technology.

CONCLUSIONS

The collected stakeholder perspectives provide preliminary groundwork for an SIB monitoring system responsive to needs as articulated by caregivers. Technology design based on this groundwork should follow an iterative process that meaningfully engages caregivers and individuals with SIB in naturalistic settings.

The Current Evidence Levels for Biofeedback and Neurofeedback Interventions in Treating Depression: A Narrative Review

This article is aimed at showing the current level of evidence for the usage of biofeedback and neurofeedback to treat depression along with a detailed review of the studies in the field and a discussion of rationale for utilizing each protocol. La Vaque et al. criteria endorsed by the Association for Applied Psychophysiology and Biofeedback and International Society for Neuroregulation & Research were accepted as a means of study evaluation. Heart rate variability (HRV) biofeedback was found to be moderately supportable as a treatment of MDD while outcome measure was a subjective questionnaire like Beck Depression Inventory (level 3/5, “probably efficacious”). Electroencephalographic (EEG) neurofeedback protocols, namely, alpha-theta, alpha, and sensorimotor rhythm upregulation, all qualify for level 2/5, “possibly efficacious.” Frontal alpha asymmetry protocol also received limited evidence of effect in depression (level 2/5, “possibly efficacious”). Finally, the two most influential real-time functional magnetic resonance imaging (rt-fMRI) neurofeedback protocols targeting the amygdala and the frontal cortices both demonstrate some effectiveness, though lack replications (level 2/5, “possibly efficacious”). Thus, neurofeedback specifically targeting depression is moderately supported by existing studies (all fit level 2/5, “possibly efficacious”). The greatest complication preventing certain protocols from reaching higher evidence levels is a relatively high number of uncontrolled studies and an absence of accurate replications arising from the heterogeneity in protocol details, course lengths, measures of improvement, control conditions, and sample characteristics.

Daily self-regulation with biofeedback to improve stress and job satisfaction in a primary care clinic

BACKGROUND

Burnout in healthcare professions is higher than other careers. An undesirable work-life balance has resulted in declining job satisfaction among primary care physicians. Biofeedback devices teach self-regulation techniques, which reduce stress and increase resilience.

OBJECTIVES

We assessed whether self-regulation with biofeedback is effective at decreasing stress and improving job satisfaction among primary care clinicians and nurses.

METHODS

Two naturally occurring cohorts of clinicians and nurses were followed over 12 weeks. The treatment group (N = 9) completed 12 weeks of self-regulation with optional clinic-based biofeedback and received peer support for the first half. The control group (N = 9) started a delayed intervention after 6 weeks without peer support. Descriptive and bivariate analyses were conducted.

RESULTS

The treatment group averaged one biofeedback session weekly for 6 min and the control group two sessions for 11 min. Adherence differed by age. Subjects also reported using self-regulation techniques without biofeedback. Perceived stress initially increased in both groups with intervention implementation, more so in the treatment group (P = 0.03) whose stress then decreased but was not significant. Overall and extrinsic job satisfaction similarly increased but were not significance.

CONCLUSION

The initial increase in perceived stress was related to daily biofeedback adherence and clinic responsibilities. Treatment group stress then decreased with self-regulation but was difficult to quantify in a small cohort. Larger studies could increase daily self-regulation adherence by improving biofeedback accessibility for leisurely use. Using self-regulation with biofeedback may be an innovative approach to reduce stress and improve job satisfaction in primary care.

Heartrate variability biofeedback for migraine using a smartphone application and sensor: A randomized controlled trial

INTRODUCTION

Although hand temperature and electromyograph biofeedback have evidence for migraine prevention, to date, no study has evaluated heartrate variability (HRV) biofeedback for migraine.

METHODS

2-arm randomized trial comparing an 8-week app-based HRV biofeedback (HeartMath) to waitlist control. Feasibility/acceptability outcomes included number and duration of sessions, satisfaction, barriers and adverse events. Primary clinical outcome was Migraine-Specific Quality of Life Questionnaire (MSQv2).

RESULTS

There were 52 participants (26/arm). On average, participants randomized to the Hearthmath group completed 29 sessions (SD = 29, range: 2-86) with an average length of 6:43 min over 36 days (SD = 27, range: 0, 88) before discontinuing. 9/29 reported technology barriers. 43% said that they were likely to recommend Heartmath to others. Average MSQv2 decreases were not significant between the Heartmath and waitlist control (estimate = 0.3, 95% CI = -3.1 - 3.6). High users of Heartmath reported a reduction in MSQv2 at day 30 (-12.3 points, p = 0.010) while low users did not (p = 0.765).

DISCUSSION

App-based HRV biofeedback was feasible and acceptable on a time-limited basis for people with migraine. Changes in the primary clinical outcome did not differ between biofeedback and control; however, high users of the app reported more benefit than low users.

Systematic Review of Biofeedback Interventions for Addressing Anxiety and Depression in Children and Adolescents with Long-Term Physical Conditions

Children and adolescents with long-term physical conditions are at increased risk of psychological problems, particularly anxiety and depression, and they have limited access to evidence-based treatment for these issues. Biofeedback interventions may be useful for treating symptoms of both psychological and physical conditions. A systematic review of studies of biofeedback interventions that addressed anxiety or depression in this population was undertaken via MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Central Register of Controlled Trials databases. Primary outcomes included changes in anxiety and depression symptoms and 'caseness'. Secondary outcomes included changes in symptoms of the associated physical condition and acceptability of the biofeedback intervention. Of 1876 identified citations, 9 studies (4 RCTs, 5 non-RCTs; of which all measured changes in anxiety and 3 of which measured changes in depression) were included in the final analysis and involved participants aged 8-25 years with a range of long-term physical conditions. Due to the heterogeneity of study design and reporting, risk of bias was judged as unclear for all studies and meta-analysis of findings was not undertaken. Within the identified sample, multiple modalities of biofeedback including heart rate variability (HRV), biofeedback assisted relaxation therapy and electroencephalography were found to be effective in reducing symptoms of anxiety. HRV was also found to be effective in reducing symptoms of depression in two studies. A range of modalities was effective in improving symptoms of long-term physical conditions. Two studies that assessed acceptability provided generally positive feedback. There is currently limited evidence to support the use of biofeedback interventions for addressing anxiety and depression in children and adolescents with long-term physical conditions. Although promising, further research using more stringent methodology and reporting is required before biofeedback interventions can be recommended for clinical use instead or in addition to existing evidence-based modalities of treatment.

Autonomic Dysfunction in Preeclampsia: A Systematic Review

Background: Preeclampsia (PE) is a major obstetric complication that leads to severe maternal and fetal morbidity. Early detection of preeclampsia can reduce the severity of complications and improve clinical outcomes. It is believed that the autonomic nervous system (ANS) is involved in the pathogenesis of PE. We aimed to review the current literature on the prevalence and nature of ANS dysfunction in women with PE and the possible prognostic value of ANS testing in the early detection of PE.

Methods: Literature search was performed using Medline (1966–2018), EMBase (1947–2018), Google Scholar (1970–2018), BIOSIS (1926–2018), Web of science (1900–2018); CINAHL (1937–2018); Cochrane Library, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Methodology Register (1999–2018). Additionally, the reference lists of articles included were screened.

Results: A total of 26 studies were included in the present review presenting data of 1,854 pregnant women. Among these women, 453 were diagnosed with PE, 93.6% (424/453) of which displayed autonomic dysfunction. ANS function was assessed by cardiovascular reflex tests (n = 9), heart rate variability (n = 11), cardiac baroreflex gain (n = 5), muscle sympathetic nerve activity (MSNA) (n = 3), and biomarkers of sympathetic activity (n = 4). Overall, 21 studies (80.8%) reported at least one of the following abnormalities in ANS function in women diagnosed with PE compared to healthy pregnant control women: reduced parasympathetic activity (n = 16/21, 76%), increased sympathetic activity (n = 12/20, 60%), or reduced baroreflex gain (n = 4/5, 80%). Some of these studies indicated that pressor and orthostatic stress test may be useful in early pregnancy to help estimate the risk of developing PE. However, autonomic function tests seem not to be able to differentiate between mild and severe PE.

Conclusions: Current evidence suggests that autonomic dysfunction is highly prevalent in pre-eclamptic women. Among autonomic functions, cardiovascular reflexes appear to be predominantly affected, seen as reduced cardiac parasympathetic activity and elevated cardiac sympathetic activity. The diagnostic value of autonomic testing in the prediction and monitoring of autonomic failure in pre-eclamptic women remains to be determined.

The Relationship Between Perinatal Mental Health and Stress: a Review of the Microbiome

PURPOSE OF REVIEW

Our current understanding of the underlying mechanisms and etiologies of perinatal mood and anxiety disorders (PMADs) is not clearly identified. The relationship of stress-induced adaptations (i.e., the hypothalamic-pituitary-adrenal (HPA) axis, the autonomic nervous system (ANS), the immune system) and the microbiota are potential contributors to psychopathology exhibited in women during pregnancy and postpartum and should be investigated.

RECENT FINDINGS

The stress response activates the HPA axis and dysregulates the ANS, leading to the inhibition of the parasympathetic system. Sustained high levels of cortisol, reduced heart variability, and modulated immune responses increase the vulnerability to PMAD. Bidirectional communication between the nervous system and the microbiota is an important factor to alter host homeostasis and development of PMAD. Future research in the relationship between the psychoneuroimmune system, the gut microbiota, and PMAD has the potential to be integrated in clinical practice to improve screening, diagnosis, and treatment.

Biofeedback to treat anxiety in young people at clinical high risk for developing psychosis

AIM

Anxiety is a common presenting concern for individuals at clinical high risk (CHR) for psychosis. Treatment for CHR is still in the early stages and has focused on transition to psychosis and positive symptom reduction, but little is known about what may be effective in reducing anxiety for these young people. One treatment that may be effective for anxiety is heart rate variability (HRV) biofeedback. The aim of this study was to test the efficacy and feasibility of using HRV biofeedback to reduce anxiety and distress in those at CHR.

METHODS

Twenty participants who met minimum scores for anxiety and distress completed 4 weeks of an HRV biofeedback intervention and received pre- and post-intervention assessments. Repeated measures were used to examine changes in scores over time.

RESULTS

There was a significant decrease in impaired ability to tolerate normal stressors (P ≤ 0.001) and dysphoric mood (P ≤ 0.001) over time. There was no change on self-reported measures of anxiety and distress. However, when two outliers were removed there was a trend towards improvement in self-reported anxiety (P = 0.07). These results were not impacted by including usage time as a covariate. Feedback and adherence were significant.

CONCLUSIONS

HRV biofeedback may be a feasible treatment option for individuals at CHR who have concerns with impaired stress tolerance and dysphoric mood. Future studies with a randomized controlled trial design will be necessary to further determine efficacy.

Altered autonomic reactivity in Korean military soldiers with adjustment disorder

Only few studies addressing the biological background of adjustment disorder (AD) exist. We examined the psychophysiological correlates indicative of autonomic regulation in AD. Heart rate variability (HRV), skin conductance, skin temperature, electromyography, and respiration were measured during serial stress tasks in 33 soldiers with AD and 60 healthy controls (HC). Patients with AD displayed lower relative power of high frequency (rHF) HRV and higher relative power of very low frequency (rVLF) HRV compared with HC at baseline. Inversely, the rHF of patients with AD remained higher and their rVLF remained lower compared with HC parameters after the single stress task, which suggests a reversed sympathovagal balance in AD. Mean heart rate and skin conductance increased during stress tasks in patients, although to a lesser extent than in HC. Skin temperature remained unchanged in all tasks in patients with AD. The tension of the frontalis muscle was higher in patients compared with HC from the second stress task onward. Thoracic breathing was more prevalent in patients with AD. Our study suggests altered autonomic reactivity in AD, which leads to a lack of sympathetic response to stress. We conclude that the distinctive biological mechanisms underlying AD are different from normal stress reactions.

The effect of heart rate variability biofeedback training on stress and anxiety: a meta-analysis

BACKGROUND

Some evidence suggests that heart rate variability (HRV) biofeedback might be an effective way to treat anxiety and stress symptoms. To examine the effect of HRV biofeedback on symptoms of anxiety and stress, we conducted a meta-analysis of studies extracted from PubMed, PsycINFO and the Cochrane Library.

METHODS

The search identified 24 studies totaling 484 participants who received HRV biofeedback training for stress and anxiety. We conducted a random-effects meta-analysis.

RESULTS

The pre-post within-group effect size (Hedges' g) was 0.81. The between-groups analysis comparing biofeedback to a control condition yielded Hedges' g = 0.83. Moderator analyses revealed that treatment efficacy was not moderated by study year, risk of study bias, percentage of females, number of sessions, or presence of an anxiety disorder.

CONCLUSIONS

HRV biofeedback training is associated with a large reduction in self-reported stress and anxiety. Although more well-controlled studies are needed, this intervention offers a promising approach for treating stress and anxiety with wearable devices.

New Frontiers in Heart Rate Variability and Social Coherence Research: Techniques, Technologies, and Implications for Improving Group Dynamics and Outcomes

Concepts embraced by the term coherence have been identified as central to fields such as quantum physics, physiology, and social science. There are different types of coherence, although the term always implies a harmonious relationship, correlations and connections between the various parts of a system. A specific measure derived from heart rate variability (HRV) provides a measure of physiological coherence. Another type of coherence, social coherence, relates to the harmonious alignment between couples or pairs, family units, small groups, or larger organizations in which a network of relationships exists among individuals who share common interests and objectives. A high degree of social coherence is reflected by stable and harmonious relationships, which allows for the efficient flow and utilization of energy and communication required for optimal collective cohesion and action. Social coherence requires that group members are attuned and are emotionally connected with each other, and that the group’s emotional energy is organized and regulated by the group as a whole. A number of studies are reviewed which have explored various types of synchronization in infants, pairs and groups, indicating that feelings of cooperation, trust, compassion and increased prosocial behaviors depends largely on the establishment of a spontaneous synchronization of various physiological rhythms between individuals. This article discusses a new application using HRV monitoring in social coherence research and the importance of physiological synchronization in group developmental processes and dynamics. Building on the extensive body of research showing that providing feedback of HRV coherence level at the individual level can improve self-regulation, we suggest the following hypotheses: (1) providing feedback of individual and collective HRV coherence and the degree of heart rhythm synchronization will increase group coherence, and heart rhythm synchronization among group members. (2) Training in techniques to increase group coherence and heart rhythm synchronization will correlate with increased prosocial behaviors, such as kindness and cooperation among individuals, improved communication, and decreases in social discord and adversarial interactions. (3) Biomagnetic fields produced by the heart may be a primary mechanism in mediating HRV synchronization among group members. Data supporting each of the hypothesis is discussed.

A Literature Review of Alternative Therapies for Postpartum Depression

Postpartum depression is a debilitating disorder that requires greater awareness and treatment. Depending on severity of symptoms, standard treatment calls for individual psychotherapy and medication. Although postpartum depression can lead to negative health outcomes for women and their offspring, numerous barriers prevent women from receiving appropriate care. A review of the literature shows that nontraditional modes of psychotherapy dominate recent studies, whereas data for other complementary options are severely lacking. Further research is needed to help identify cost-effective alternative therapies for treating postpartum depression. Combined with prevention and screening, treatment options that suit women's varied situations and preferences must be explored to increase reception and adherence to treatment and, ultimately, to improve outcomes.

Building resilience with the Stress Resilience Training System: Design validation and applications

BACKGROUND

Resilience to stress is critical in today's military service. Past work has shown that experts handle stress in more productive ways compared to novices. Training that specifically addresses stress regulation, such as the Graduated Stress Exposure paradigm, can build individual and unit resilience as well as adaptability so that stressors trigger effective stress coping skills rather than stress injury.

OBJECTIVE

We developed the Stress Resilience Training System (SRTS), a product of Perceptronics Solutions Inc., to demonstrate that a software training app can provide an effective individualized method for mitigating the negative effects of situational and mission-related stress, at the same time eliciting potentially positive effects on performance.

METHODS

Seven separate evaluations including a usability study, controlled experiments, and field evaluations have been conducted to date.

RESULTS

These studies have shown that the SRTS program effectively engages users to manage their stress, effectively reduces stress symptoms, and improves job performance.

CONCLUSIONS

The SRTS system is a highly effective method for individualized training to inoculate professionals against the negative consequences of stress, while teaching them to harness its positive effects. SRTS is a technology that can be widely applied to many professions that are concerned with well-being. We discuss applications to law enforcement, athletics, personal fitness and healthcare in the Appendix.

Biofeedback

Although evidence supports the efficacy of biofeedback for treating a number of disorders and for enhancing performance, significant barriers block both needed research and payer support for this method. Biofeedback has demonstrated effects in changing psychophysiological substrates of various emotional, physical, and psychosomatic problems, but payers are reluctant to reimburse for biofeedback services. A considerable amount of biofeedback research is in the form of relatively small well-controlled trials (Phase II trials). This article argues for greater payer support and research support for larger trials in the “real life” clinical environment (Phase III trials) and meta-analytic reviews.

Guidelines for Reporting Articles on Psychiatry and Heart rate variability (GRAPH): recommendations to advance research communication

The number of publications investigating heart rate variability (HRV) in psychiatry and the behavioral sciences has increased markedly in the last decade. In addition to the significant debates surrounding ideal methods to collect and interpret measures of HRV, standardized reporting of methodology in this field is lacking. Commonly cited recommendations were designed well before recent calls to improve research communication and reproducibility across disciplines. In an effort to standardize reporting, we propose the Guidelines for Reporting Articles on Psychiatry and Heart rate variability (GRAPH), a checklist with four domains: participant selection, interbeat interval collection, data preparation and HRV calculation. This paper provides an overview of these four domains and why their standardized reporting is necessary to suitably evaluate HRV research in psychiatry and related disciplines. Adherence to these communication guidelines will help expedite the translation of HRV research into a potential psychiatric biomarker by improving interpretation, reproducibility and future meta-analyses.

Heart rate variability biofeedback intervention for reduction of psychological stress during the early postpartum period

This study examined the effectiveness of heart rate variability (HRV) biofeedback intervention for reduction of psychological stress in women in the early postpartum period. On postpartum day 4, 55 healthy subjects received a brief explanation about HRV biofeedback using a portable device. Among them, 25 mothers who agreed to implement HRV biofeedback at home were grouped as the biofeedback group, and other 30 mothers were grouped as the control group. At 1 month postpartum, there was a significant decrease in total Edinburgh Postnatal Depression Scale score (P < 0.001) in the biofeedback group; this change was brought about mainly by decreases in items related to anxiety or difficulty sleeping. There was also a significant increase in standard deviation of the normal heartbeat interval (P < 0.01) of the resting HRV measures in the biofeedback group after adjusting for potential covariates. In conclusion, postpartum women who implemented HRV biofeedback after delivery were relatively free from anxiety and complained less of difficulties sleeping at 1 month postpartum. Although the positive effects of HRV biofeedback may be partly attributable to intervention effects, due to its clinical outcome, HRV biofeedback appears to be recommendable for many postpartum women as a feasible health-promoting measure after childbirth.

Predictors of anxiety among pregnant New Zealand women hospitalised for complications and a community comparison group

OBJECTIVE

to investigate predictors of anxiety for women experiencing hospitalisation during pregnancy and a comparison group of pregnant women (with or without medical complications) in the community.

DESIGN

correlational, cross-sectional observational questionnaire study.

SETTING

regional antenatal inpatient unit and community-based settings in New Zealand in 2009 and 2010.

PARTICIPANTS

118 pregnant women in hospital and 114 pregnant women in community.

MEASUREMENTS AND FINDINGS

women in hospital and community groups completed a battery of questionnaires on pregnancy and health history, life events, anxiety, optimism, coping, and relationship factors. Midwives caring for the women provided ratings of health status and psychological distress. Both groups of women had scores on state anxiety significantly above local norms; women in the hospital were significantly higher than those in the community on state anxiety and worry about their pregnancy. The groups did not differ on factors such as life events, optimism, and coping self-efficacy. Ratings of health and distress made by women and their midwives showed poor agreement. Predictors of acute anxiety differed across the groups: for hospitalised women, anxiety was predicted by their rating of their health and their dispositional optimism; for women in the community, anxiety was predicted by stressful life events, dispositional optimism, and coping self-efficacy.

KEY CONCLUSIONS

many women hospitalised during pregnancy are extremely anxious, and those most vulnerable are those who are less optimistic and see their health as poor. Health care professionals may not be aware of how anxious women are, and women and their hospital caregivers had poor agreement on ratings of the woman׳s health status.

IMPLICATIONS FOR RESEARCH AND PRACTICE

women hospitalised during pregnancy are at risk for high levels of anxiety. Midwives are well placed to help women by recognising their distress, supporting informed optimism, and guiding women toward realistic coping strategies and using existing social support networks. Research is needed on strategies for implementation and effectiveness of brief interventions to support women to manage anxiety and stress during pregnancy both in hospital and in the community.

Interoceptive dysfunction: toward an integrated framework for understanding somatic and affective disturbance in depression

Depression is characterized by disturbed sleep and eating, a variety of other nonspecific somatic symptoms, and significant somatic comorbidities. Why there is such close association between cognitive and somatic dysfunction in depression is nonetheless poorly understood. An explosion of research in the area of interoception-the perception and interpretation of bodily signals-over the last decade nonetheless holds promise for illuminating what have until now been obscure links between the social, cognitive-affective, and somatic features of depression. This article reviews rapidly accumulating evidence that both somatic signaling and interoception are frequently altered in depression. This includes comparative studies showing vagus-mediated effects on depression-like behaviors in rodent models as well as studies in humans indicating both dysfunction in the neural substrates for interoception (e.g., vagus, insula, anterior cingulate cortex) and reduced sensitivity to bodily stimuli in depression. An integrative framework for organizing and interpreting this evidence is put forward which incorporates (a) multiple potential pathways to interoceptive dysfunction; (b) interaction with individual, gender, and cultural differences in interoception; and (c) a developmental psychobiological systems perspective, emphasizing likely differential susceptibility to somatic and interoceptive dysfunction across the lifespan. Combined with current theory and evidence, it is suggested that core symptoms of depression (e.g., anhedonia, social deficits) may be products of disturbed interoceptive-exteroceptive integration. More research is nonetheless needed to fully elucidate the relationship between mind, body, and social context in depression.

Heart Rate Variability: New Perspectives on Physiological Mechanisms, Assessment of Self-regulatory Capacity, and Health risk

Heart rate variability, the change in the time intervals between adjacent heartbeats, is an emergent property of interdependent regulatory systems that operates on different time scales to adapt to environmental and psychological challenges. This article briefly reviews neural regulation of the heart and offers some new perspectives on mechanisms underlying the very low frequency rhythm of heart rate variability. Interpretation of heart rate variability rhythms in the context of health risk and physiological and psychological self-regulatory capacity assessment is discussed. The cardiovascular regulatory centers in the spinal cord and medulla integrate inputs from higher brain centers with afferent cardiovascular system inputs to adjust heart rate and blood pressure via sympathetic and parasympathetic efferent pathways. We also discuss the intrinsic cardiac nervous system and the heart-brain connection pathways, through which afferent information can influence activity in the subcortical, frontocortical, and motor cortex areas. In addition, the use of real-time HRV feedback to increase self-regulatory capacity is reviewed. We conclude that the heart's rhythms are characterized by both complexity and stability over longer time scales that reflect both physiological and psychological functional status of these internal self-regulatory systems.

Biofeedback for psychiatric disorders: a systematic review

Biofeedback potentially provides non-invasive, effective psychophysiological interventions for psychiatric disorders. The encompassing purpose of this review was to establish how biofeedback interventions have been used to treat select psychiatric disorders [anxiety, autistic spectrum disorders, depression, dissociation, eating disorders, schizophrenia and psychoses] to date and provide a useful reference for consultation by clinicians and researchers planning to administer a biofeedback treatment. A systematic search of EMBASE, MEDLINE, PsycINFO, and WOK databases and hand searches in Applied Psychophysiology and Biofeedback, and Journal of Neurotherapy, identified 227 articles; 63 of which are included within this review. Electroencephalographic neurofeedback constituted the most investigated modality (31.7%). Anxiety disorders were the most commonly treated (68.3%). Multi-modal biofeedback appeared most effective in significantly ameliorating symptoms, suggesting that targeting more than one physiological modality for bio-regulation increases therapeutic efficacy. Overall, 80.9% of articles reported some level of clinical amelioration related to biofeedback exposure, 65.0% to a statistically significant (p < .05) level of symptom reduction based on reported standardized clinical parameters. Although the heterogeneity of the included studies warrants caution before explicit efficacy statements can be made. Further development of standardized controlled methodological protocols tailored for specific disorders and guidelines to generate comprehensive reports may contribute towards establishing the value of biofeedback interventions within mainstream psychiatry.

Cardiac coherence, self-regulation, autonomic stability, and psychosocial well-being

The ability to alter one’s emotional responses is central to overall well-being and to effectively meeting the demands of life. One of the chief symptoms of events such as trauma, that overwhelm our capacities to successfully handle and adapt to them, is a shift in our internal baseline reference such that there ensues a repetitive activation of the traumatic event. This can result in high vigilance and over-sensitivity to environmental signals which are reflected in inappropriate emotional responses and autonomic nervous system dynamics. In this article we discuss the perspective that one’s ability to self-regulate the quality of feeling and emotion of one’s moment-to-moment experience is intimately tied to our physiology, and the reciprocal interactions among physiological, cognitive, and emotional systems. These interactions form the basis of information processing networks in which communication between systems occurs through the generation and transmission of rhythms and patterns of activity. Our discussion emphasizes the communication pathways between the heart and brain, as well as how these are related to cognitive and emotional function and self-regulatory capacity. We discuss the hypothesis that self-induced positive emotions increase the coherence in bodily processes, which is reflected in the pattern of the heart’s rhythm. This shift in the heart rhythm in turn plays an important role in facilitating higher cognitive functions, creating emotional stability and facilitating states of calm. Over time, this establishes a new inner-baseline reference, a type of implicit memory that organizes perception, feelings, and behavior. Without establishing a new baseline reference, people are at risk of getting “stuck” in familiar, yet unhealthy emotional and behavioral patterns and living their lives through the automatic filters of past familiar or traumatic experience.

Evaluating the clinical effectiveness of a specialized perinatal psychiatry inpatient unit

Women experiencing severe perinatal mental illness during pregnancy or postpartum have unique needs when psychiatric hospitalization is indicated. Although many countries have established mother-baby psychiatric units, similar facilities have not been available in the US. In 2011, the University of North Carolina at Chapel Hill inaugurated the first Perinatal Psychiatry Inpatient Unit in the US. We describe the unique characteristics of the patient population and report clinical outcomes guiding development and refinement of treatment protocols. Ninety-two perinatal patients were admitted between September 2011 and September 2012, and 91 completed self-report measures at admission and discharge. Perinatal unipolar mood disorder was the most frequent primary diagnosis (60.43 %), and 11 patients (12 %) were admitted with psychosis. The data document clinically and statistically significant improvements in symptoms of depression, anxiety, and active suicidal ideation between admission and discharge (p < 0.0001), as assessed by the Edinburgh Postnatal Depression Scale, Patient Health Questionnaire, and Generalized Anxiety Disorder Scale. Overall functioning was also improved, demonstrated by a significant mean difference of -10.96 in total scores of the Work and Social Adjustment Scale (p < 0.0001). Data suggest that delivering specialized and targeted interventions for severe maternal mental illness in a safe and supportive setting produces positive patient outcomes.

Pilot study employing heart rate variability biofeedback training to decrease anxiety in patients with eating disorders

Heart rate variability (HRV) biofeedback, a technique which encourages slow meditative breathing, was offered to 25 in-patients with various eating disorder diagnoses-anorexia nervosa, bulimia nervosa and binge eating disorder. We found that this modality had no serious side effects, and was subjectively useful to most participants. An enhanced ability to generate highly coherent HRV patterns in patients with recent onset anorexia nervosa was observed.

Negative mood and alcohol problems are related to respiratory dynamics in young adults

This study examined the relationship of negative affect and alcohol use behaviors to baseline respiration and respiratory response to emotional challenge in young adults (N = 138, 48 % women). Thoracic-to-abdominal ratio, respiratory frequency and variability, and minute volume ventilation were measured during a low-demand baseline task, and emotional challenge (viewing emotionally-valenced, emotionally-neutral, and alcohol-related pictures). Negative mood and alcohol problems principal components were generated from self-report measures of negative affect and mood, alcohol use, and use-related problems. The negative mood component was positively related to a thoracic bias when measured throughout the study (including baseline and picture exposure). There was generally greater respiratory activity in response to the picture cues, although not specifically in response to the content (emotional or alcohol-related) of the picture cues. The alcohol problems component was positively associated with respiratory reactivity to picture cues, when baseline breathing patterns were controlled. Self-report arousal data indicated that higher levels of negative mood, but not alcohol problems, were associated with greater arousal ratings overall. However, those with alcohol problems reported greater arousal to alcohol cues, compared to emotionally neutral cues. These results are consistent with theories relating negative affect and mood to breathing patterns as well as the relationship between alcohol problems and negative emotions, suggesting that the use of respiratory interventions may hold promise for treating problems involving negative affect and mood, as well as drinking problems.

Dynamic processes in regulation and some implications for biofeedback and biobehavioral interventions

Systems theory has long been used in psychology, biology, and sociology. This paper applies newer methods of control systems modeling for assessing system stability in health and disease. Control systems can be characterized as open or closed systems with feedback loops. Feedback produces oscillatory activity, and the complexity of naturally occurring oscillatory patterns reflects the multiplicity of feedback mechanisms, such that many mechanisms operate simultaneously to control the system. Unstable systems, often associated with poor health, are characterized by absence of oscillation, random noise, or a very simple pattern of oscillation. This modeling approach can be applied to a diverse range of phenomena, including cardiovascular and brain activity, mood and thermal regulation, and social system stability. External system stressors such as disease, psychological stress, injury, or interpersonal conflict may perturb a system, yet simultaneously stimulate oscillatory processes and exercise control mechanisms. Resonance can occur in systems with negative feedback loops, causing high-amplitude oscillations at a single frequency. Resonance effects can be used to strengthen modulatory oscillations, but may obscure other information and control mechanisms, and weaken system stability. Positive as well as negative feedback loops are important for system function and stability. Examples are presented of oscillatory processes in heart rate variability, and regulation of autonomic, thermal, pancreatic and central nervous system processes, as well as in social/organizational systems such as marriages and business organizations. Resonance in negative feedback loops can help stimulate oscillations and exercise control reflexes, but also can deprive the system of important information. Empirical hypotheses derived from this approach are presented, including that moderate stress may enhance health and functioning.