22 Spring 2008 Ô Biofeedback designed to respond to threatening situations (cf. LeDoux, (cf. situations threatening to respond to designed evolutionarily been has that system a of advantage taking builds on findings that the brain deals with novel dangers by methodologies neurobiological and cognitive-behavioral of our clinicalcasestudies. reinforce to trials controlled some from data preliminary have now We success. clinical considerable with therapies been using HRV biofeedback as an adjunct to exposure-type years,several last the in emerged havehas we that PTSD of (van derKolk, 2006, p. 289). people make of their experience—their narrative of the past” the on focusing than self- rather awareness, their increase and self-experience the physical on patient’s focus to useful be might it effective be to therapy For . . . past. the with associated emotions and sensations individuals are prone to experience the present with physical Traumatizeddisorder]: stress [posttraumatic PTSD in issue body oriented therapies can directly confront the core clinical dialectical and (ACT),behavioral therapy(vanderKolk, 2001, 2006). therapy (CBT), commitment therapy behavioral acceptance cognitive as cognitive such based techniques empirically the into techniques somatic work in the trauma field has pointed to the need to integrate Recent depression. including reduction symptoms, trauma-related the of for biofeedback HRV of use the explore to (Gevirtz,2007; Lehrer, 2007). recently,More havewe begun performance to aid an as and syndromes clinical of number Heart rate variability (HRV) biofeedback has been used for a a with together detailed casehistory. reported are results preliminary Some behavioral cognitive with techniques in the treatment of posttraumatic stress disorder. biofeedback variability rate In this article, an argument is made for integration of heart somatic techniques such as heart rate variability biofeedback. of inclusion the with treatment effective more of likelihood Recent research in the neurobiology of trauma supports the Keywords: posttraumatic stressdisorder, biofeedback, heartrate variability, cognitivetherapies CSPP at Alliant InternationalUniversity, SanDiego, CA Richard Gevirtz, PhD, andConstanceDalenberg, PhD Treatment of Trauma Symptoms Heart Rate Variability Biofeedbackinthe SPECIAL ISSUE Volume 36, Issue1, pp. 22–23 Biofeedback h cr ciia apoc t or rpsd integration proposed our to approach clinical core The model neurobiological the and experience our on Based “Interoceptive, has stated: field the in figure leading A meaning that that that nagrd B itgaig h nuoilgcl n the and neurobiological the integrating By endangered. feedback a still is body the that system cognitive the informs that loop create also changes physiological the known, entirely not are that processes complex However,through 2002). O’Keefe, & (Curtis disease heart in example, for as, exposure to these changes appears to be Prolonged problematic in itself, etc. variability, rate heart in decrease pressure, blood predetermined—changes in system are the of outputs the made, been has categorization danger the Once 2002). e a n dces i smtm ad a a ices in increase an had associated agoraphobia. and symptoms in decrease no had he months, 6 After symptoms. his alleviate to psychotherapy supportive attempted and abuse, substance by complicated PTSD, developed David precautions. safety proper not did follow who employees by caused explosion an of victim the been own had he job, his repair a During developing business. contracting craftsman 46-year-old a was David Case Study below. case the in illustrated are components basic The cutoffs. significant clinically below drop not did patients three additional and months, 3 an after goals their met patients two 3-month protocol, the within goals clinical their achieved patients significant 27 patients.the Twenty-two of consecutive (88%) 27 of clinically 24 clinic, for achieved our been have symptoms in PTSD in improvements trial 2003). ongoing al., an et CBT (Nishith In HRV effective increase example, to shown For been has components. other the of effectiveness the augments and reinforces component each that believed is it stated, Lehrer,As 2007).(cf. biofeedback HRV & and 2005), Riggs,Batten, & Rothbaum, (Orsillo ACT 1991), Foa, Murdock, 1997; Meadows, & (Foa CBT psychoeducation, components: four has PTSD of treatment the in acceptance ofthecognitivechanges. help physiology calmed the should so techniques, biofeedback the of As success simultaneously. the in output aids cognition and improved input both of hold grab metaphorically to techniques,hope cognitive-behavioral we In practice, the Trauma Research Institute protocol for for protocol Institute Research Trauma the practice, In ©Association for Applied Psychophysiology&Biofeedback

www.aapb.org Gevirtz, Dalenberg

In David’s initial five sessions, he told his story and We hope that the recently created spate of trauma analyzed the triggers leading to his traumatic reexperiencing victims from our occupation in the Middle East will spur on of the event. He recognized his substance abuse as an attempt research that will enable us to better treat the devastating at avoidance. Using the principles of ACT, he was encouraged symptoms associated with trauma exposure, or even better, to accept his anxiety rather than attempt to suppress it (or to find out what skills might protect our personnel before drink it away). Psychoeducation regarding the biology of they experience the symptoms that are so personally and PTSD aided David in seeing the process as normal, rather financially costly. than as a failure of will. At the end of the initial five sessions, David and his References therapist developed a series of bullet points representing his Briere, J. (1995). Manual for the Trauma Symptom Inventory. story. These bullet points were used in two ways. First, David Odessa, FL: Psychological Assessment Resources. Curtis, B. M., & O’Keefe, J. H., Jr. (2002). Autonomic tone as a made a tape of the bullet points that he could replay, and he cardiovascular risk factor: The dangers of chronic fight or flight. used the tape as he practiced breathing with a StressEraser, Mayo Clinic Proceedings, 77, 45–54. a handheld HRV biofeedback device. Second, he read and Foa, E. B., & Meadows, E. A. (1997). Psychosocial treatments for reread a written version of the bullet points in his therapist’s posttraumatic stress disorder: A critical review. Annual Review office while being monitored by HRV monitoring (in this of Psychology, 48, 449–480. Foa, E. B., Rothbaum, B. O., Riggs, D. S., & Murdock, T. B. (1991). Treat- case the Freeze-Framer by HeartMath, Boulder Creek, CA) ment of posttraumatic stress disorder in rape victims: A comparison for the last 15 minutes of each session. between cognitive-behavioral procedures and counseling. Journal of David also was asked to tell his story in the classic manner Consulting and Clinical Psychology, 59, 715–723. of in vivo exposure, with emotional content and present tense. Gevirtz, R. N. (2007). Psychophysiological perspectives on stress- When David paused in his narrative, the therapist noted related and anxiety disorders. In P. M. Lehrer, R. L. Woolfolk, & the content of the story. After the narrative was concluded, W. E. Sime (Eds.), Principals and practice of stress management (3rd ed.). New York: Guilford Press. David was taken back to the pause points and was asked for LeDoux, J. E. (2002). The synpatic self. New York: Viking Press. his cognitions. David’s most problematic cognitions centered Lehrer, P. M. (2007). Biofeedback training to increase heart rate on the degree to which he felt that he could not trust others variability. In P. M. Lehrer, R. L. Woolfolk, & W. E. Sime (Ed.), and could not control his own destiny. These cognitions were Principles and practice of stress management (3rd ed.). New recognized as relevant to his prior attachment history and York: Guilford Press. Nishith, P., Duntley, S. P., Domitrovich, P. P., Uhles, M. L., Cook, B. were processed using ACT principles (i.e., by acceptance, J., & Stein, P. K. (2003). Effect of cognitive behavioral therapy on understanding, and recognition of what behavioral actions heart rate variability during REM sleep in female rape victims could be taken to improve his safety). with PTSD. Journal of Traumatic Stress, 16, 247–250. David’s PTSD symptoms dropped from T scores above 75 Orsillo, S. M., & Batten, S. V. (2005). Acceptance and commitment on Hyperarousal, Defensive Avoidance, and Re-Experiencing, therapy in the treatment of posttraumatic stress disorder. scales in the Trauma Symptom Inventory (Briere, 1995), to Behavior Modification, 29, 95–129. van der Kolk, B. A. (2001). The psychobiology and psycho- T scores under 50 in 3 months. He was no longer troubled by pharmacology of PTSD. Human Psychopharmacology, 16, agoraphobia and reported that his drinking was back under S49–S64. control. He chose to complete another 6 months of therapy van der Kolk, B. A. (2006). Clinical implications of neuroscience to focus on attachment-related distrust before termination. research in PTSD. Annals of the New York Academy of Sciences, 1071, 277–293.

Conclusion Though more research is badly needed in this area, our preliminary findings seem to indicate that adding HRV biofeedback to multicomponent, trauma-focused

CBT delivers a clinically meaningful gain in treatment effectiveness. In another trial in our lab, Brooke White is Biofeedback finding that adding a StressEraser to supportive therapy

Richard Gevirtz Constance Dalenberg for trauma symptoms in military veterans is producing noticeable gains beyond those produced by a progressive Correspondence: Richard Gevirtz, PhD, 10455 Pomerado Road, San Diego CA 92131, email: [email protected]. muscle relaxation intervention. Ô

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