Listening to the heart: A meta-analysis of cognitive behavior therapy impact on the heart rate of patients with anxiety disorders

At the heart of the matter: how mental stress and negative emotions affect atrial fibrillation

Atrial fibrillation (AF) is the most common form of cardiac arrhythmia, affecting 2%-3% of the world's population. Mental and emotional stress, as well as some mental health conditions (e.g., depression) have been shown to significantly impact the heart and have been suggested to act both as independent risk factors and triggers in the onset of AF. In this paper, we review the current literature to examine the role that mental and emotional stress have in the onset of AF and summarise the current knowledge on the interaction between the brain and heart, and the cortical and subcortical pathways involved in the response to stress. Review of the evidence suggests that mental and emotional stress negatively affect the cardiac system, potentially increasing the risk for developing and/or triggering AF. Further studies are required to further understand the cortical and sub-cortical structures involved in the mental stress response and how these interact with the cardiac system, which may help in defining new strategies and interventions to prevent the development of, and improve the management of AF.

Adults with Animal Phobia: Systematic Replication of Clinical Cases

Animal phobia is common in children, but it is also frequent in adults who maintain the problem throughout their lives. Eleven cases of animal phobia that were treated with progressive multimedia exposure are presented. The participants were two men and nine women (aged 19–27 years), with anxiety and avoidance problems in relation to various animals. A single-case A-B-Follow-up design was carried out, with concurrent control of several baselines; and a systematic between-subjects replication, with the same treatment repeated across different participants and types of phobias. A behavioural interview, phobia questionnaires, and Multimedia Behavioural Avoidance Test (M-BAT) with pictures and videos of animals, as well as heart rate, were used for assessment purposes. The intervention was the progressive multimedia exposure in four phases (photographs, videos, simulated animals, and live exposure), in addition to diaphragmatic breathing, and homework assignments. The results replicate the same efficacy in each of the participants, with statistically significant and clinical changes in their daily lives. Also, the data as a group show this success with a high Cohen's d effect size (between −1.63 and −30.03). We conclude with an appraisal of the usefulness of the procedure for adults with phobias who do not tolerate direct exposure.

Anxiety disorders and age-related changes in physiology

BACKGROUND

Anxiety disorders are leading contributors to the global disease burden, highly prevalent across the lifespan and associated with substantially increased morbidity and early mortality.

AIMS

The aim of this study was to examine age-related changes across a wide range of physiological measures in middle-aged and older adults with a lifetime history of anxiety disorders compared with healthy controls.

METHOD

The UK Biobank study recruited >500 000 adults, aged 37-73, between 2006 and 2010. We used generalised additive models to estimate non-linear associations between age and hand-grip strength, cardiovascular function, body composition, lung function and heel bone mineral density in a case group and in a control group.

RESULTS

The main data-set included 332 078 adults (mean age 56.37 years; 52.65% females). In both sexes, individuals with anxiety disorders had a lower hand-grip strength and lower blood pressure, whereas their pulse rate and body composition measures were higher than in the healthy control group. Case-control group differences were larger when considering individuals with chronic and/or severe anxiety disorders, and differences in body composition were modulated by depression comorbidity status. Differences in age-related physiological changes between females in the anxiety disorder case group and healthy controls were most evident for blood pressure, pulse rate and body composition, whereas this was the case in males for hand-grip strength, blood pressure and body composition. Most differences in physiological measures between the case and control groups decreased with increasing age.

CONCLUSIONS

Findings in individuals with a lifetime history of anxiety disorders differed from a healthy control group across multiple physiological measures, with some evidence of case-control group differences by age. The differences observed varied by chronicity/severity and depression comorbidity.

Perceptually Visible but Emotionally Subliminal Stimuli to Improve Exposure Therapies

Subliminal stimuli are gaining growing interest due to their capability to induce desensitization to pathologically feared (e.g., phobic) pictures without inducing exaggerated emotional reactions. However, unresolved methodological issues cast significant doubt on the reliability of these findings and their interpretation. The studies most robustly assessing stimulus detection found that ~30% of the supposed-to-be-subliminal stimuli were, in fact, detected, suggesting that the beneficial effects attributed to subliminal stimuli may result from those actually seen. Nevertheless, a deeper analysis of the data underlying this misinterpretation unveils theoretical and clinical implications. Since the purpose of subliminal stimulation is to reduce the aversiveness of exposure therapies while maintaining their efficacy, researchers should measure the emotional relevance of supposed-to-be-subliminal stimuli that are, in fact, detected. A distinction is needed between perceptually- and emotionally-subliminal stimuli: the former is not consciously detected; the latter just fails to elicit emotional reactions. Emotionally-subliminal stimuli could represent an intermediate step of exposure in addition to those involving perceptually subliminal or supraliminal stimuli. Importantly, emotionally subliminal stimuli could make patients able to sustain a conscious exposure to feared stimuli without exaggeratedly reacting to them: if confirmed by empirical data, this unexpected disconfirmation of patients' beliefs could pave the way for successful therapy while increasing their self-efficacy and compliance to treatment.

Emotion dysregulation and heart rate variability improve in US veterans undergoing treatment for posttraumatic stress disorder: Secondary exploratory analyses from a randomised controlled trial

BACKGROUND

Emotion regulation (ER) is a key process underlying posttraumatic stress disorder (PTSD), yet, little is known about how ER changes with PTSD treatment. Understanding these effects may shed light on treatment processes.

METHODS

We recently completed a non-inferiority design randomised controlled trial demonstrating that a breathing-based yoga practice (Sudarshan kriya yoga; SKY) was not clinically inferior to cognitive processing therapy (CPT) across symptoms of PTSD, depression, or negative affect. Here, in secondary exploratory analyses (intent-to-treat N = 85; per protocol N = 59), we examined whether self-reported ER (Difficulties in Emotion Regulation Scale; DERS) and physiological ER (heart rate variability; HRV) improved with treatment for clinically significant PTSD symptoms among US Veterans.

RESULTS

DERS-Total and all six subscales improved with small-to-moderate effect sizes (d = .24-.66) following CPT or SKY, with no differences between treatment groups. Following SKY (but not CPT), HR max-min (average difference between maximum and minimum beats per minute), LF/HF (low-to-high frequency) ratio, and normalised HF-HRV (high frequency power) improved (moved towards a healthier profile; d = .42-.55).

CONCLUSIONS

To our knowledge, this is the first study to demonstrate that a breathing-based yoga (SKY) improved both voluntary/intentional and automatic/physiological ER. In contrast, trauma-focused therapy (CPT) only reliably improved self-reported ER. Findings have implications for PTSD treatment and interventions for emotional disorders more broadly.

TRIAL REGISTRATION

Secondary analyses of ClinicalTrials.gov NCT02366403 .

Increased Vocalization of Rats in Response to Ultrasonic Playback as a Sign of Hypervigilance Following Fear Conditioning

We investigated the effects of prior stress on rats' responses to 50-kHz (appetitive) and 22-kHz (aversive) ultrasonic playback. Rats were treated with 0, 1, 6 or 10 shocks (1 s, 1.0 mA each) and were exposed to playbacks the following day. Previous findings were confirmed: (i) rats moved faster during 50-kHz playback and slowed down after 22-kHz playback; (ii) they all approached the speaker, which was more pronounced during and following 50-kHz playback than 22-kHz playback; (iii) 50-kHz playback caused heart rate (HR) increase; 22-kHz playback caused HR decrease; (iv) the rats vocalized more often during and following 50-kHz playback than 22-kHz playback. The previous shock affected the rats such that singly-shocked rats showed lower HR throughout the experiment and a smaller HR response to 50-kHz playback compared to controls and other shocked groups. Interestingly, all pre-shocked rats showed higher locomotor activity during 50-kHz playback and a more significant decrease in activity following 22-kHz playback; they vocalized more often, their ultrasonic vocalizations (USV) were longer and at a higher frequency than those of the control animals. These last two observations could point to hypervigilance, a symptom of post-traumatic stress disorder (PTSD) in human patients. Increased vocalization may be a valuable measure of hypervigilance used for PTSD modeling.

Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials.

OBJECTIVES

This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy.

DATA SOURCES

The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019.

REVIEW METHODS

Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality.

RESULTS

A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions.

LIMITATIONS

Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them.

CONCLUSION

Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes.

FUTURE WORK

Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42017078690.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 9. See the NIHR Journals Library website for further project information.

Cognitive behavioural therapy for insomnia does not appear to have a substantial impact on early markers of cardiovascular disease: A preliminary randomized controlled trial

According to the World Health Organization, cardiovascular diseases are the leading cause of death in the world. Therefore, early prevention of these diseases is a public health priority. Epidemiological data suggest that insomnia may be a modifiable risk factor for cardiovascular diseases. A randomized controlled trial in a sample of insomnia patients without cardiovascular disease was conducted to investigate the effects of insomnia treatment on early markers of cardiovascular diseases assessed by 24-hr ambulatory blood pressure, heart rate and heart rate variability monitoring, and morning fasting blood samples. Forty-six patients with insomnia disorder were randomized to cognitive behavioural therapy for insomnia (CBT-I; n = 23) or a waitlist control condition (n = 23). Contrary to the hypothesis, intention-to-treat analyses did not show any significant treatment effects on early markers of cardiovascular disease (d = 0.0-0.6) despite successful insomnia treatment (d = 1.3). Potential methodological and conceptual reasons for these negative findings are discussed. Future studies might include larger sample sizes that are at risk of cardiovascular diseases and focus on other cardiovascular markers.

Experience Versus Report: Where Are Changes Seen After Exposure-Based Cognitive-Behavioral Therapy? A Randomized Controlled Group Treatment of Childhood Social Anxiety Disorder

A considerable number of children and adolescents with social anxiety disorder (SAD) do not benefit from treatment as much as expected. However, treatment success should not be measured with social anxiety reports alone; the cognitive, behavioral, and physiological components of social stress should also be assessed. The authors examined an exposure-based SAD-specific group cognitive behavioral therapy (CBT) in a randomized controlled trial (N = 67, age 9-13 years, blind randomized allocation to treatment [CBT; n = 31] and waitlist control [WLC; n = 36] groups). Success was operationalized as a clinically significant reduction of symptoms measured with SAD-specific questionnaires, structured interviews, and changes in response to the Trier Social Stress Test (TSST). In the CBT group, there was a trend toward a significant increase in positive cognitions in the TSST after treatment (d = 0.37), whereas these positive cognitions decreased in the WLC group (d = 0.40). No significant results involving group appeared for negative cognitions, behavior and physiology. Children in the CBT group, but not parents, further reported less social anxiety in one questionnaire from pre- to post-treatment (d = 0.89). A structured interview confirmed a decrease in severity of SAD in the CBT group. While the gold standard of a blind interview showed efficacy of treatment, not all trait and state measures demonstrated similar success patterns.Trial registration Eligibility criteria and some of the dependent variables (cognitions, physiology) for treatment success were registered with the German Research Foundation (TU 78/5-2, HE 3342/4-2) prior to recruitment. Clinical assessment of diagnosis and behavioral data were not a priori planned as outcome measures for this trial and therefore analyzed in a post-hoc approach.

Psychophysiological Markers of Fear and Anxiety

PURPOSE OF REVIEW

The purpose of this paper is to provide a current review of the recent literature (2015-2018) on psychophysiological markers of fear and anxiety.

RECENT FINDING

Relative to healthy controls, fear-based disorders are characterised by heightened physiological reactivity to circumscribe threat salient stimuli, whereas anxiety-related disorders are associated with a more blunted pattern of physiological reactivity. Fear and anxiety disorders are marked by abnormal patterns of physiological reactivity, characterised by hyper- and hypo-reactivity in response to stimuli varying in threat salience.

Study protocol for a non-inferiority randomised controlled trial of SKY breathing meditation versus cognitive processing therapy for PTSD among veterans

INTRODUCTION

Post-traumatic stress disorder (PTSD) is a debilitating, highly prevalent condition. Current clinical practice guidelines recommend trauma-focused psychotherapy (eg, cognitive processing therapy; CPT) as the first-line treatment for PTSD. However, while these treatments show clinically meaningful symptom improvement, the majority of those who begin treatment retain a diagnosis of PTSD post-treatment. Perhaps for this reason, many individuals with PTSD have sought more holistic, mind-body, complementary and integrative health (CIH) interventions. However, there remains a paucity of high-quality, active controlled efficacy studies of CIH interventions for PTSD, which precludes their formal recommendation.

METHODS AND ANALYSES

We present the protocol for an ongoing non-inferiority parallel group randomised controlled trial (RCT) comparing the efficacy of a breathing meditation intervention (Sudarshan Kriya Yoga [SKY]) to a recommended evidence-based psychotherapy (CPT) for PTSD among veterans. Assessors are blinded to treatment group. The primary outcome measure is the PTSD Checklist-Civilian Version and a combination of clinical, self-report, experimental and physiological outcome measures assess treatment-related changes across each of the four PTSD symptom clusters (re-experiencing, avoidance, negative cognitions or mood and hyperarousal/reactivity). Once the RCT is completed, analyses will use both an intent-to-treat (using the 'last observation carried forward' for missing data) and a per-protocol or 'treatment completers' procedure, which is the most rigorous approach to non-inferiority designs.

ETHICS AND DISSEMINATION

To the best of our knowledge, this is this first non-inferiority RCT of SKY versus CPT for PTSD among veterans. The protocol is approved by the Stanford University Institutional Review Board. All participants provided written informed consent prior to participation. Results from this RCT will inform future studies including larger multi-site efficacy RCTs of SKY for PTSD and other mental health conditions, as well as exploration of cost-effectiveness and evaluation of implementation issues. Results will also inform evidence-based formal recommendations regarding CIH interventions for PTSD.

TRIAL REGISTRATION NUMBER

NCT02366403; Pre-results.

Biobehavioral assessment of the anxiety disorders: Current progress and future directions

It is difficult to accurately assess and differentially diagnose the anxiety disorders. The current system of assessment relies heavily on the subjective measures of client self-report, clinical observation, and clinical judgment. Fortunately, recent technological advances may enable practitioners to utilize objective, biobehavioral measures of assessment in a clinical setting. The current body of literature on two of these biobehavioral tools (eye-tracking and electrocardiogram devices) is promising, but more validation and standardization research is needed to maximize the utility of these devices. Eye-tracking devices are uniquely capable of providing data that can be used to differentially diagnose anxiety disorders from both other commonly comorbid and misdiagnosed disorders. Both eye-tracking and electrocardiogram devices are able to provide change-sensitive assessment information. This objective, real-time feedback can assist clinicians and researchers in assessing treatment efficacy and symptom fluctuation. Recently developed wearable and highly portable electrocardiogram devices, like the wearable fitness and behavior tracking devices used by many consumers, may be particularly suited for providing this feedback to clinicians. Utilizing these biobehavioral devices would supply an objective, dimensional component to the current categorical diagnostic assessment system. We posit that if adequate funding and attention are directed at this area of research, it could revolutionize diagnostic and on-going assessment practices and, in doing so, bring the field of diagnosis out of the 20th century.

Empirically supported psychological treatments and the Research Domain Criteria (RDoC)

BACKGROUND

The Research Domain Criteria (RDoC) has been developed as an alternative approach to studying psychiatric disorders. The RDoC constructs and units of analysis, from genes up through paradigms, are intended to describe a hierarchy of priority measurements. Several of these have been investigated in the context of empirically-supported treatments, as either moderators or mediators of outcome.

METHOD

This review considers the available research on the moderating and mediating role of genes, molecules, circuits and physiology in cognitive-behavior therapy (CBT) outcome studies for negative valence system conditions.

FINDINGS

Based on the review, research has aspired to identify candidate genes, molecules, circuits and physiological moderators or mediators of treatment, but no definitive tests have been conducted. Instead, several candidate variables have been found that deserve further investigation.

LIMITATIONS

The available research is based on diagnoses from the DSM, whereas the RDoC initiative endeavors to determine empirically valid taxonomic signs.

CONCLUSIONS

The results of this review are discussed in the joint context of developments in empirically-supported psychological therapy and the specific aims of the RDoC initiative, and conclude with recommendations for future research.

Psychophysiological reactivity of currently dental phobic-, remitted dental phobic- and never-dental phobic individuals during exposure to dental-related and other affect-inducing materials

Psychophysiological responses indicating the preparation of defensive behaviour, such as heart rate (HR)-increase and startle-response (SR) potentiation, have often been reported amongst individuals suffering from phobic disorders when exposed to phobia-related information. Although exposure is widely considered the 'gold standard' for treatment of Specific Phobia, it is unclear to what extent psychophysiological defensive response patterns change following treatment, and whether any changes are maintained. We assessed the acoustic SR- and HR-response to neutral, positive, negative and phobia-related pictures and sounds in 41 individuals currently suffering from dental phobia, 22 formerly dental phobic individuals who had remitted following an exposure-based treatment eight months prior to assessment, and 29 control individuals with no history of dental phobia. We observed SR-potentiation to dental-related stimuli in controls combined with HR-deceleration. In contrast, amongst phobic individuals SR-potentiation was accompanied by HR-acceleration to dental pictures. Successfully treated individuals showed inhibited startle reactivity in combination with HR-deceleration to dental related materials of both modalities. Our findings suggest inappropriate fight-flight preparation amongst individuals with dental phobia, reflecting overactivation of the defensive system. However, successful treatment results in inhibited physiological defence preparation, with remitted individuals displaying a response pattern that differed from that of phobic individuals and controls.

Heart rate variability predicts therapy outcome in pain-predominant multisomatoform disorder

BACKGROUND

Autonomic imbalance establishes an important model to understand organically unexplained physical complaints. Our study aimed to investigate whether the functioning of the autonomous nervous system corresponds with somatoform symptoms and predicts the outcome of brief psychotherapy in these patients.

METHOD

As a part of multicenter study assessing effects of brief psychodynamic interpersonal therapy on multisomatoform disorder (PISO-study), 106 patients participated in a stress experiment investigating autonomic reactivity during application of the Stroop-test. Patients were randomized receiving either enhanced medical care (EMC, N=49) or psychotherapy (N=57). Autonomic baseline functioning as well as stress reactivity of heart rate (HR) and heart rate variability (HRV) were analyzed in their relation to symptom measures and as potential predictors of the primary outcome (Physical Component Score of the SF-36) during 9-month follow-up.

RESULTS

After therapy patients markedly and sustainably improved in physical quality of life, and this long-term improvement was predicted by baseline HR and HRV. HRV also predicted change in pain symptoms following psychotherapy. A responder analysis revealed a significant better treatment outcome in patients with high pre-treatment HRV (OR 3.4, CI: 1.2-9.9, p=.0035). No significant associations between HR or HRV and outcome measures were found in the EMC group.

CONCLUSION

In our study, the adaptability of the autonomous nervous system as indicated by low pretreatment HR and high HRV was associated with a more pronounced benefit from psychotherapy. This finding can be explained by a possible association between autonomic self-regulation and emotional learning capacities.

TAKING THE PULSE OF PROLONGED EXPOSURE THERAPY: PHYSIOLOGICAL REACTIVITY TO TRAUMA IMAGERY AS AN OBJECTIVE MEASURE OF TREATMENT RESPONSE

BACKGROUND

Physiological reactivity to trauma-related cues is a primary symptom of PTSD and can be assessed objectively using script-driven imagery paradigms. However, subjective self-reported symptom measures are the most common outcome indices utilized in PTSD treatment trials and clinic settings. We examined physiological reactivity during a short trauma imagery task as an objective index of response to PTSD treatment, optimized for use in routine clinical care settings.

METHODS

Participants were 35 male combat veterans receiving prolonged exposure (PE) therapy in a Veterans Affairs outpatient clinic. In addition to traditional subjective self-reported and clinician-rated symptom measures, patients also completed a script-driven imagery task in which heart rate (HR) and skin conductance (SC) were recorded at three assessment points across treatment. We examined changes in subjective symptom measures and objective trauma-specific physiological reactivity over the course of PE, and investigated the association between pretreatment physiological reactivity and treatment response.

RESULTS

Patients who completed PE showed significantly diminished HR and SC reactivity to trauma imagery across therapy. Additionally, individuals showing greater trauma-specific HR reactivity at pretreatment showed greater reductions in subjectively reported PTSD symptoms at posttreatment.

CONCLUSIONS

Findings support the utility of physiological reactivity during trauma imagery as an objective outcome measure that has the potential to be incorporated into evidence-based PTSD treatment in routine clinical settings, or prospective studies related to the individualization of care at pretreatment.