advances in mind-body therapies...of mindfulness meditation; adapted for secular setting 10-step...
TRANSCRIPT
Advances in Mind-Body Therapies
Yoga Nidra, Neurofeedback, and HRV Biofeedback
COI
● The three presenters have no conflicts of interest to disclose
Mind Body Therapies
Impact of Mindfulness Meditation (Yoga Nidra) on Anger and Emotion
Regulation in Veterans
Lori A. Simms, Ph.D.Clinical Psychologist & Registered Yoga Teacher
(RYT)Department of Veterans Affairs
Nashville VA Medical Center
Yoga Nidra Meditation
Acknowledgement
This material is the result of work supported with resources and the use of facilities at the Nashville VA Medical Center (TVHS).
Special thanks to Megan Golla, Psy.D. and Stephanie Campbell, Ph.D. for assisting in this research project.
Topics Covered
●What is Yoga Nidra
●Irest Yoga Nidra
●Nashville VA Meditation Program
●Current study
●Summary
Yoga Nidra
● Yoga nidra is an ancient yogic practice of deep relaxation
● Form of meditation
● Similar to relaxation at the end of yoga class (Savasana)
● No physical postures in the practice of Yoga Nidra
Integrative Restoration or iRest
● iRest® is a form of yoga nidra and a type of mindfulness meditation; adapted for secular setting
● 10-step protocol developed by Richard Miller, Ph.D., psychologist and yoga teacher
● 1st study at Walter Reed Army Medical Center
● Now many groups at military and VA hospitals
Integrative Restoration or iRest
iRest has been shown to help with:
● PTSD
● Depression
● Anxiety
● Insomnia
● Chronic pain
● Chemical dependency
Intention
Heartfelt Desire
Breath
Physical Body
Inner Resource
Emotions
Beliefs
Joy
Awareness
Integration
iRest Yoga Nidra
Meditation ProgramNashville VAMC
● 8-week, closed group session
● Sessions are 75 minutes
● 6-10 veterans in each group
● Members provided 30-minute home practice CD
● Each session includes centering exercise, 15-20 min discussion of lesson, 30 minutes of guided meditation
“Water is fluid, soft, and yielding. But water will wear away rock, which is rigid and
cannot yield. As a rule, whatever is fluid, soft, and yielding will overcome whatever is
rigid and hard. This is another paradox: what is soft is strong.”
~ Lao Tzu
Current Study
● Looking at impact of meditation on emotion regulation and anger
● VA IRB approval
● Actively recruiting veterans; goal of obtaining 50 participants
● Participants complete informed consent; asked to complete 3 measures at the beginning and end of the group
Study Aim
●Aim: To investigate the effectiveness of iRest on emotion regulation and anger in a veteran population
●Transdiagnostic approach
Predicted the following at the end of 8-week group:● Reduction in overall self-reported anger
● Decrease in overall emotional dysregulation
● Increase in cognitive reappraisal● Diverse benefits reported via qualitative measure
Hypotheses
Measures
● State-Trait Anger Expression Inventory-2 (STAXI-2); subscales: State Anger, Trait Anger, and Anger Expression Index
● Difficulties in Emotion Regulation Scale (DERS); Total Scale Score
● Emotion Regulation Questionnaire (ERQ); Cognitive Reappraisal Scale
Initial Results
● 15 consented participants
● 10 participants completed group and all measures; 3 dropped out; 2 incomplete data
● Mean age = 48.5 years
● 7 males; 3 females
● 7 OEF/OIF/OND Era; 1 Vietnam Era; 1 Post Vietnam; 1 Other
Results - Demographics
Difficulties in Emotion Regulation (DERS) Mean Scores
ERQ– Reappraisal Scale Mean Scores
State Anger Mean Scores
Trait Anger Mean Scores
Anger Expression Index Mean Scores
Qualitative ResultsHow Practice Was Helpful for Veterans
● “Better able to control emotions.”
● “I see some of my emotional reactions as they are happening and can try to ‘invite’ accompanying thoughts in.”
● “Being able to step back and look at an emotion or feeling.”
● “How to meditate and relax after a stressful day.”
Limitations and Future Directions
Limitations
● Small sample size
● Difficult to determine mechanism of change
● Potential confounding variables
Future directions
● Replicate with larger sample (in process)
● Further examine mechanism of change; control for confounding variables
Summary
● Preliminary results show most hypotheses were confirmed with exception of trait anger
● Most participants reported overall decrease in anger and improved emotion regulation following group
● Yoga nidra meditation is a viable mind-body treatment option; conceptualize as bottom-up approach to healing
Training and Additional Resources
● Integrative Restoration Institute
● https://www.irest.us/
Mind Body Therapies
Neurofeedback
Pamela Drury, Ph.D., BCN.Clinical Neuropsychologist
Neurobehavioral Associates of Nashville
What is Neurofeedback?
● Focus on the central nervous system and brain
● Trained through operant conditioning
● Self-regulation of brain activity
Quantifying the EEG
19-channel EEG
QEEG-Derived Brain Maps
Physiological Measures Used in Neurofeedback
● Amplitude
● Surface Z-scores
● Coherence
● Low Resolution Electroencephalogram Tomography Analysis (LORETA) Z-scores
Amplitude Training
Amplitude Training
Live Z-Score Training
Live Z-Score Training
Live Z-Score Training
Coherence Training
Delta Theta Alpha Beta Beta2
Coherence Training
Delta Theta Alpha Beta Beta2
Coherence Training
Before
After
Delta Theta Alpha Beta Beta2
sLORETA
Specific Brodmann Areas
Cortical Networks
Break Time!
“Mr. Osborne, may I
be excused? My
brain is full.”
Neurofeedback and ADHD●Peer reviewed scientific article or PhD Thesis
●Subjects had primary dx of ADD/ADHD
●Controlled between subject design with passive or active control group (randomized or not)
OR●Prospective within subject design
OR●Retrospective within subject design with N>500
Neurofeedback and ADHD
●Standard Administration
●Pre- and Post- means and standard deviations for hyperactivity, impulsiveness, or a CPT
●15 studies were included in the meta-analysis
Neurofeedback and ADHD
Steiner et al, 2014
40 sessions
3 times per week
Over 5 months
Measured by parent
ratings
Case Study - ADHD Diagnosed with ADHD,
Specific Learning Disorders in Math and Written Expression
Academically read below grade level and struggled with math.
Parents wanted to avoid medications if possible
9 year-old male
Presented with emotional dysregulation, attention problems in school, hyperactivity, anxiety, and oppositional defiant behaviors
“I feel stupid”
Case Study - ADHD
He met his Accelerated Reading goal for the first time, “I can read anything”
Teacher reported he made the second highest score in the class on a TCAP prep math test
Underwent 20 sessions of neurofeedback, two times per week for 10 weeks
Mother reported changes in behavior, calmer and having more conversations.
Case Study - ADHD
●Pre-training ●Post-20 sessions
Case Study - ADHD
●Pre-training ●Post-20 sessions
Neurofeedback & Anxiety
0
10
20
30
40
50
60
Pre Treatment Post Treatment
Zung
0
10
20
30
40
50
60
Pre Treatment Post Treatment
SCARED
Neurofeedback & Anxiety
Neurofeedback & Anxiety
Case Study – Depression & Anxiety
• 24-yo female
• Presented with diagnosis of bipolar disorder,
depression, and recent pain onset
• History of social anxiety and sensory integration
problems
Case Study – Depression & Anxiety• QEEG guided sLORETA z-score training plus HRV
• By 6th session she was reporting improvements in mood
and pain, began PT for pelvic pain after 10th session
• Session 15 – “more emotionally stable”, “able to step
back, notice, and manage emotions”
• After 20 sessions, felt she had met mood and anxiety
goals, and wanted to continue work on longstanding
language and working memory problems.
Case Study – Depression & Anxiety
●Pre-training ●Post-20 sessions
Case Study – Depression &Anxiety
55
60
65
70
75
80
Depression Anxiety
BEFOREBEFORE
AFTER
AFTER
Personality Assessment Inventory
Neurofeedback versus Meds for Migraine Headaches
0
10
20
30
40
50
60
70
Cessation for1 year
>50%Reduction
<50%Reduction
No Change
% Responders
QEEG Drug
Case Study -Migraine
●35 yo female
●Tried all other standard treatment options
●15 headaches per month
●Most brain activity was outside the normal range, including excessive fast and hyper-coherence in fast activity
Case Study -Migraine
●Underwent 19 sessions amplitude training
●Headaches decreased to less than one per month, and responded to OTC or imitrexquickly
●Anxiety improved, went off anxiolytic and started psychotherapy
Case Study - Migraine
Before After
Neurofeedback and TBI
20
40
60
80
100
120
Cognitive Scores
Pre Treatment Post Treatment
Case Study - TBI●Pre-training ●Post-40 sessions
0
10
20
30
40
50
60
70
80
90
100
Case Study - TBI
Case Study - Remote TBI• 66 year old male
• Presented >20 yrs post TBI
• Poor attention
• Highly agitated
• Low frustration tolerance
• Disinhibited
• Couldn’t use remote control
Case Study - Remote TBI
Z-Score
Neurofeedback
115 sessions
Was able to sit for 1 ½
hour computerized
assessment
Attention, frustration
tolerance improved
greatly
Becoming a Neurofeedback Provider
● Licensed health services provider
● Board certification in neurofeedback (BCN)
● Specialized training in brain-behavior relationships, such as a neuropsychologist or psychologist
● For those providers who use QEEG to guide treatment, additional training in QEEG assessment is essential.
Certification in Neurofeedback
Mind Body Therapies
HRV Biofeedback
Adriana Kipper-Smith, Ph.D., HSPAssistant Professor of Clinical Psychiatry
Vanderbilt UniversityPCC
Biofeedback
● Promotes physiological self-regulation, which takes place with the improvement of the perception of visceral events
● Through the process of interoceptive exposure, BF promotes greater sensitivity of afferent physiological stimuli and corrects for inaccurate perceptions, not uncommon within individuals struggling with anxiety disorders
(Moss, 2002; Schwartz & Olson, 2003, Yucha & Gilbert, 2004)
Self-regulation
Respiration
●Dysfunctional breathing can interfere with HRV
biofeedback training, electrodermal biofeedback,
neurofeedback,
and temperature biofeedback training
●Effortless breathing is Erik Peper’s term for healthy
abdominal or diaphragmatic breathing
(Peper et al., 2008).
Respiration
● Overbreathing lowers CO2 in the blood more
subtly than hyperventilation
● Resulting behaviors: gasping, sighing, yawning
● Moderate overbreathing can reduce oxygen
delivery to the brain by 30%‐40%
● Severe overbreathing can reduce it by 60%
Respiration
●Overbreathing lowers CO2 in the blood more
subtly than hyperventilation
●Resulting behaviors: gasping, sighing, yawning(Khazan, 2013)
HRVB
● HRV is considered a measure of neurocardiacfunction, reflecting heart-brain interactions and ANS dynamics
● HRV is a technique that measures heart beat-to-beat activity, assessing the influences of sympathetic and vagal branches of the ANS
(Brunoni et al., 2013)
HRVB
● HRV provides an index of autonomic signals to the heart
● Low HRV → decreased vagal nerve activity and increased sympathetic activity → Associated with multiple physiopathologies including fetal distress, diabetic autonomic neuropathy, hypertension, stroke, higher risk of mortality after myocardial infarction, immune system dysfunction, etc.
(Henriques, Keffer, Abrahamson, & Horst, 2011)
HRVB
● The natural logarithm of the ratio of LF to HF power is the main indicator of autonomic balance between the sympathetic and parasympathetic systems
HRVB
● Recent studies have shown that HRV is associated with emotion recognition—the higher the HRV the easier to recognize emotions
(Brunoni et al., 2013; Peira, Fredrikson, & Pourtois, 2014)
● Age-adjusted low HRV has been considered a predictor of future health problems and mortality –it suggests reduced regulatory capacity and executive functions (decrease cognitive performance) in the pre-frontal cortex
(McCraty & Shaffer, 2015)
Psychophysiological Coherence
● Psychophysiological coherence is a state of calm alertness that occurs naturally with sustained positive emotions and can be induced by slow, deep breathing
● More subtle reductions in this ratio occur with activities that increase efferent parasympathetic activity such as when relaxing, sleeping, or with positive moods states
(Zohar, Cloninger, & McCraty, 2013)
Resonant Frequency
Respiratory Sinus Arrhythmia
Effortless diaphragmatic breathing produces a synchrony between the
rhythms of the breathing and rhythms of the heart. This
cardiorespiratory synchrony is called Respiratory Sinus Arrhythmia
(RSA)-- RSA means the respiration waveform co-varies with the heart
rate
Polyvagal Theory
● Vagus: 10th Cranial Nerve: The vagus nerve (wandering from Latin) is the body's longest pair of nerves, starting in the brain and winding through the digestive system
● New Vagus: Consisting of a fast-acting, myelinated vagus that can rapidly withdraw and reinstate its inhibitory influence on the heart
Polyvagal Theory
● A key premise of the polyvagal theory is that the new vagus has control over facial expression, head turning, vocalization, listening, and other socially relevant behaviors
● The connection of the new vagus and cranial nerves provides a mechanism by which cardiac states can be coordinated with social behaviors (Porges, 1997, 2001)
Stress & HRV
● Stress → low HRV → high cortisol concentrations → impairments in working memory and greater error-related brain activity
● Greater HRV → Increased executive functioning → faster reaction + more correct responses to cognitive tasks
(Prinsloo, Rauch, Lambert, Muench, Noakes, & Derman, 2011)
Depression/Mood
◦ Voluntary control of breath patterns affects:
◦ ANS functions via the vagal afferents to brainstem nuclei (nucleus tractus sollitarius, parabrachial nucleus, and locus coeruleus)
◦ Vagal afferents activate hypothalamic vigilance areas and enhance attention and alertness, whereas pathways through the thalamus quiet frontal cortical activity and reduce worrying
(Gerbarg and Brown, J. of Family Practice, 4, 2005)
Implications to clinical practice
By adding biopsychosocial to cognitive factors, we will improve our model of various
anxiety disorders
● Both prevention and treatment should emphasize measures that reduce chronic sympathetic tone, increase parasympathetic tone, as well as traditional risk factors
● HRV biofeedback, regular meditation(respiration), yoga, neurofeedback, exercise, social support, regular therapies, etc. offer promise in this regard
Research initiativesVanderbilt Psychological & Counseling Center
Psychopathology in Counseling Centers
5-session BF Protocol
● Our center’s Biofeedback Clinic sees an average of 25 students per month (approximately 100 appointments monthly), comprising approximately 3.5% of the total number of students utilizing the Center’s services
5-session BF Protocol
● Focus is on respiration and HRV training
● Students are evaluated pre-treatment (initial interview, BAI, and Nijmegen Questionnaire) and post-treatment (BAI and written feedback)
Data Analysis
● Our sample: 111 Students (Data from April 2013 through January 2014)
● We had a total of 60 completed BF protocols (pre and post BAIs)
● Mean age of all students who began the protocol: 25.3 (SD 6.5) →Undergraduate and graduate students
Data Analysis
● Results showed a significant reduction in BAI score: [t (59) = 8.49; p < .001], with an effect size of 1.1
Data Analysis
● Females: 79
● Males: 32
● Race
81% White
7.2 % Black
4.5% Asian
2.7% Latino
4.5% multiple
Data Analysis
Diagnoses Percent
Anxiety Disorders 84.68
Depressive Disorders 30.63
Adjustment Disorders 7.2
V-Codes 9.9
Protocol Effectiveness
● Results from the 60 students who completed their BF protocol
● Scores were reduced by an average of 8.18 per client
Mean Std Deviation
BAI Pre 16.950 8.6816
BAI Post 8.767 6.0123
Protocol Effectiveness
Statistics
BAI pre BAI post
N Valid111 60
Missing0 51
Mean18.162 8.767
Median17.000 8.000
Std. Deviation9.2585 6.0123
Protocol EffectivenessWritten feedback
● Ability to watch physiological response in real time
“Being able to see my progress through different types of exercises made me believe it works!“
“Being able to physically see the changes in my breath was very helpful”
"Seeing my breathing and heart rate on the screen and the effects of breath work physiologically was most helpful”
“ The visual games helped me to control my breathing while under a stressful experience"
Protocol EffectivenessWritten feedback
● Most significant symptom reduction: Anxiety in general, hyperventilation, insomnia, tingling
● Several students reported performance improvement (presentations, test taking, sleep quality, etc.)
Ongoing study
● “Effects of Biofeedback on distress at the Vanderbilt PCC”
● This study will analyze symptom data that is collected in the
context of routine care to determine if Biofeedback (BF) is
more effective than treatment as usual in reducing
psychological distress
Ongoing study
● Students are randomized to one of the following
conditions:
● (1) TAU
● (2) BF
● (3) TAU + BF
BCIA HRV Certificate
● HRV Certificate of completion
● Approved and standardized didactic workshop based on fundamental science that meets rigorous academic standards
● Plus…
BCIA HRV Certificate (bcia.org)
● File an application● Agree to abide by BCIA’s Professional Standards and
Ethical Principles (PSEP)● Complete a BCIA-approved HRV biofeedback
didactic program● Document completion of 3 hours of ethics● Pass a nationally-standardized online exam based on
the 15-hour Blueprint of Knowledge
Acknowledgments
● This work has been possible thanks to the collaboration and valuable suggestions of our PCC BF team, Jay Tift, LPC, and David Sacks, PCC Associate Director
● I’d also like to recognize Tony Hughes, Ph.D., BCB, who helped us to develop our 5-session protocol
“It is very important to generate a good attitude, a good heart (e.g., exhibiting resonant frequency), as much as possible. From this, happiness in both the short term and the long term for both yourself and
others will come.” Dalai Lama
Questions?