1. 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
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.

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

3. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. Randomized Studies of HRV11

12. 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

13. 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

14. Implementation of
Paced Breathing 14

15. 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

16. 12 breaths per minute

17. 7 breaths per minute
E = start of exhale

18. 5 breaths per minute

19. 5 breaths/min. HR/BP Synchrony
E = start of exhale

20. 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

21. 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

22. 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

23. Impulsive behavior directly elicited by emotions or they function to reduce them23

24. Impulsive behavior directly elicited by emotions or they function to reduce them24

25. 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

26. 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

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

28. 2 Minute Breathing Test 28

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

30. 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

31. 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

32. 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),