Alliant International University Enhancing Emotional Regulation With Resonance Frequency Paced Breathing Training Milton Z. Brown, Ph.D. Alliant International University DBT Center of San Diego www.dbtsandiego.com Prefrontal cortex is taken “offline” during emotional stress to let automatic, prepotent processes regulate behavior. In modern society inhibition, delayed response, and cognitive flexibility are vital for successful adjustment and self-regulation, and prolonged prefrontal inactivity can lead to hypervigilance, defensiveness, and perseveration. Autonomic dysregulation contributes to deficits in attention and cognitive performance, such as selective attention, response selection, inhibition of prepotent responses, and executive control, all of which depend upon working memory.

Topics Physiology of Emotion Dysregulation Research Studies Implementation of Paced Breathing Impulsive behavior directly elicited by emotions or they function to reduce them 2

Emotion Dysregulation Autonomic Nervous System When a threat is perceived: sympathetic arousal parasympathetic/vagal withdrawal (reduced HRV) When the threat has passed: parasympathetic re-activation (vagal brake) Low parasympathetic activity (low HRV) increases emotional reactivity/sensitivity In BPD: more vagal withdrawal, more often (low HRV) slower vagal re-activation => emotions linger 3

Emotion Dysregulation in BPD Autonomic Nervous System Austin et al. (2007) N=20 baseline HRV: BPD = control (low power) HRV after emotion films: BPD < control Kuo & Linehan (2009) N=60 baseline HRV: BPD < social anxiety HRV after emotion films: BPD = control the films may not have been effective enough Weinberg et al. (2009) N = 40 baseline HRV: BPD < control HRV after social stressor: BPD = control Weinberg et al. (2009) dx was not done 5

Problems Associated with Low HRV Higher levels of stress reactivity cortisol reactivity (Johnson et al. 2002) startle potentiation (Ruiz-Padial et al. 2003) Worse executive function performance sustained attention working memory inhibition/flexibility (e.g., Stroop, Go-NoGo) mental persistence (two studies) during stressors (Hansen et al. 2009) Between subjects-correlations Low HRV people reacted to cognitive tests as if they were aversive (Johnson et al. 2002) Low HRV people reacted to aversive stimuli as if they were aversive (Ruiz-Padial et al. 2003) 6

Focus on Emotion Regulation DBT Strategies Focus on Emotion Regulation Reduce vulnerability to emotion triggers exercise, and balanced eating and sleep exposure therapy Reduce intensity of emotion episodes more than distraction is needed Increase emotional tolerance mindfulness block avoidance Act effectively despite emotional arousal 7

Goals of Relaxation Training Reduce vulnerability to emotion triggers Skills for regulating emotions when triggered reduce emotional arousal feel better activate parasympathetic system emotion tolerance more capacity for effective behavior sustained effort (“will power”) problem-solving cognitive abilities 8 8

Goals of Relaxation Training Goal 1: Increase general levels of HRV Goal 2: Increase ability to reverse vagal withdrawal (recover from stressors) Activities that strengthen baroreflexes: increase HRV in general improve recovery from vagal withdrawal improve executive functioning improve mood incongruent behaviors improve mood incongruent behaviors = sustained effort 9

Heart Rate Variability HRV-linked self-regulation is like a muscle: Regular HRV training increases ability to activate HRV in specific situations HRV-linked emotion coping behaviors are effortful and hard to sustain for long periods become less effective after prolonged use HRV “depletes” and improves with rest 10

Randomized Studies of HRV 11

Randomized Studies of HRV HRV manipulations Two experiments failed to worsen HRV Exercise improved HRV and execute function tasks (Hansen et al. 2004) RF breathing => calm, HRV (Vaschillo, 2006) HRV-BF (RCTs were HRV-BF home practice) 15 min. => calm, HRV (Sherlin, 2009) 4 wks (20 min 5x/wk) => HRV and BDI (Zucker, 2009) 8 wks (15 min/wk) => HRV/BDI (Brown et al., 2009) reduction in PTSD symptoms (White, 2008) Sherlin (2009): 5 bpm HR reduction lasted for 10 after RF breathing - passive biofeedback control group (Sherlin, et al., 2009). StressEraser vs. sham. The HRV-BF group showed a significantly greater reduction in state anxiety and HR during the Stroop task. The sham was to “watch the wave” and “let go” of stressful thoughts to put their mind “in sync with their blood circulation” Zucker (2009): HRV-BF home practice 20 minutes 5x/wk => resting HRV and BDI-II - both groups reduced PTSD symptoms; but the BF group reported greater reductions in depressive symptoms and greater increase in HRV than those in the PMR group. Brown, Chaudri, Gevirtz (2009): abt 15min/wk of practice recovery phase HRV and BDI-II 12

Needed HRV Studies There are NO randomized studies of HRV-BF or exercise for BPD Studies need to confirm improvements in: Resting HRV and global symptoms When stressors occur: HRV vagal withdrawal recovery subjective arousal/tolerance executive functioning abilities effort persistence Sherlin (2009) N=43: 5 bpm HR reduction lasted for 10 after RF breathing Zucker (2009) N=38: HRV-BF home practice 20 minutes 5x/wk => resting HRV and BDI-II Brown, Chaudri, Gevirtz (2009) N=60: recovery phase HRV and BDI-II 13

Implementation of Paced Breathing 14

Resonance Frequency Breathing slow pace: about 5-6 breaths per minute breathing synchronized with RSA oscillations in HR and blood pressure (~5-6 cycles/min.) largest possible HR decrease on each exhale smooth/coherent HR oscillations (waves) need to verify with visual HR feedback Prolonged RF breathing may create better autonomic balance better than PMR 15

12 breaths per minute

7 breaths per minute E = start of exhale

5 breaths per minute

5 breaths/min. HR/BP Synchrony E = start of exhale

Resonance Frequency Breathing primarily the lower abdomen (diaphragm) exhale longer than inhale (4 sec in, 6 sec out) pursed lips to slow down the exhale exhaling slows HR (vagal break) exhaling at RF pace activates most vagal break visual feedback can maximize RSA HRV and breathing-HR synchrony biofeedback may maximize placebo effect Resonance frequency is like the natural speed of a swing in motion (HR), exhaling is pushing the swing, breathing at resonance is like pushing the swing right as it starts to move away from you 20

BPD RF Breathing Feasibility Study Design N = 15 BPD participants Single-group pre-post design 8-10 biofeedback sessions (1 hr) asked to practice for 20 min. per day PANAS, BSL, BAI, BDI, DERS, HRV Resonance frequency is like the natural speed of a swing in motion (HR), exhaling is pushing the swing, breathing at resonance is like pushing the swing right as it starts to move away from you 21

BPD RF Breathing Feasibility Study Outcomes (N = 15) 80% (12) easily mastered breathing by 2nd session; without pacer by 3rd or 4th session 1 had a few more sessions to develop mastery 20% (3 of 15) did not achieve mastery 2 dropped out (did not like breathing) Among the 13 completers: 62% (8) practiced consistently 62% (8) liked breathing and reported it helpful 8% (1) did not like the breathing 23% (3) did not report whether it was helpful 22

Impulsive behavior directly elicited by emotions or they function to reduce them 23

Impulsive behavior directly elicited by emotions or they function to reduce them 24

Slow Breathing Training Phase 1: assess baseline RSA HRV and resonance frequency (RF) Phase 2: practice breathing at RF pace with pacing stimulus, visual feedback, or counting Phase 3: breathe at RF pace autonomously Phase 4: quickly engage RF breathing when distressed (during or immediately following emotion triggers) Phase 5: confirm quick RSA HRV recovery Imagine accepting Fully accept for one moment 25

Slow Breathing Training Phase 1: Assessment baseline RSA HRV at rest when attempting to relax when attempting to recover from stressor determine resonance frequency (RF) 2 minute recordings of HR oscillations at each pace record size of HR reductions on exhale at each pace 7 bpm, 6.5, 6.0, 5.5, 5.0, 4.5, and 4.0 bpm 26

Impulsive behavior directly elicited by emotions or they function to reduce them

2 Minute Breathing Test 28

10 breath Pacing Test 10 bpm 60 s 8.5 1:10 min 7.5 1:20 7.0 1:25 7.5 1:20 7.0 1:25 6.5 1:30 6.0 1:40 5.5 1:50 5.0 2:00 4.5 2:13 min Impulsive behavior directly elicited by emotions or they function to reduce them 29

Slow Breathing Training Problems Patient cannot breathe slowly enough take a more gradual approach take in more air with each breath Patient gets light-headed or dizzy and stops slow breathing take in less air Patient breathes primarily from upper chest lay down with book on abdomen Patient cannot engage RF breathing without prompts or heart rate feedback much more practice (e.g., 20 min/day) Patient cannot engage RF breathing when distressed practice in context (e.g., during exposure therapy) 30

References Weinberg, Klonsky, Hajcak (2009). Autonomic impairment in borderline personality disorder. Brain and Cognition. Austin, Riniolo, Porges (2007). Borderline personality disorder and emotion regulation. Brain and Cognition Kuo & Linehan (2009). Disentangling emotion processes in borderline personality disorder. Journal of Abnormal Psychology Segerstrom & Solberg (2007). Heart rate variability reflects self-regulatory strength, effort, and fatigue. Psychological Science Reynard, Gevirtz, Brown, Boutelle, Berlow (2011). Heart rate variability as a marker of self-regulation. Applied Psychophysiology and Biofeedback Sherlin, Gevirtz, Wyckoff, Muench (2009). Effects of respiratory sinus arrhythmia biofeedback versus passive biofeedback control. International Journal of Stress Management

References Dale, Carroll, Galen, Hayes, Webb, Porges (2009). Abuse history is related to autonomic regulation to mild exercise and psychological wellbeing. Applied Psychophysiology and Biofeedback, 34(4), 299-308