Transcript Slow Breathing Slides - DBT Center of San Diego

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
Topics
1. Physiology of Emotion Dysregulation
2. Research Studies
3. Implementation of Paced Breathing
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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
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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
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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
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sustained attention
working memory
inhibition/flexibility (e.g., Stroop, Go-NoGo)
mental persistence (two studies)
during stressors (Hansen et al. 2009)
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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
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Goals of Relaxation Training
1. Reduce vulnerability to emotion triggers
2. 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
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
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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
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Randomized Studies of HRV
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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)
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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
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Implementation of
Paced Breathing
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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
12 breaths per minute
7 breaths per minute
5 breaths per minute
5 breaths/min. HR/BP Synchrony
Resonance Frequency Breathing
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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
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
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
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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
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
2 Minute Breathing Test
10 breath Pacing Test
10 bpm
8.5
7.5
7.0
6.5
6.0
5.5
5.0
4.5
60 s
1:10 min
1:20
1:25
1:30
1:40
1:50
2:00
2:13 min
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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)
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