enhancing emotional regulation with resonance frequency paced breathing training milton z. brown,...

Enhancing Emotional Regulation With Resonance Frequency Paced Breathing

Training

Milton Z. Brown, Ph.D.

Alliant International UniversityDBT Center of San Diegowww.dbtsandiego.com

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1. Physiology of Emotion Dysregulation2. Research Studies3. Implementation of Paced Breathing

Topics

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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

Emotion DysregulationAutonomic Nervous System

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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

Emotion Dysregulation in BPDAutonomic Nervous System

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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)

Problems Associated with Low HRV

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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

DBT Strategies

Goals of Relaxation Training

1. Reduce vulnerability to emotion triggers2. 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

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Goal 1: Increase general levels of HRVGoal 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

Goals of Relaxation Training

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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

Heart Rate Variability

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Randomized Studies of HRV

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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)

Randomized Studies of HRV

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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

Needed HRV Studies

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Implementation ofPaced Breathing

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

• 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 Breathing

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

BPD RF Breathing Feasibility Study

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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

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10 bpm 60 s8.5 1:10 min7.5 1:207.0 1:256.5 1:306.0 1:405.5 1:505.0 2:004.5 2:13 min

10 breath Pacing Test

Slow Breathing TrainingProblems• 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)

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

References