Soothing the Sympathetic Nervous System with the REMAP process:
Results from Treating 8 Trauma (PTSD) Survivors
And Measuring Treatment Effect with Heart Rate Variability Analysis
By Steve B. Reed, LPC, LMSW, LMFT, Mary Ross, Ph.D., and Frances Mcmannemin, Ph.D. © 2006
Many people who have traumatic experiences, panic attacks, phobias, and general anxiety disorders experience a fight or flight reflex that will not shut off or that is repeatedly triggered by various signals that are interpreted as threatening even when there is no present danger. Subcortical activity in structures such as the amygdala (think of this as your body’s alarm system) has been implicated in the fight or flight reflex. When these subcortical circuits engage, the prefrontal cortex goes offline and the autonomic nervous system (ANS) reacts.
The autonomic nervous system, the part of you that is responsible for the non-voluntary control of all organs and systems of the body, is comprised of two primary branches: the sympathetic nervous system (SNS) and the parasympathetic nervous system (PNS).
The SNS’s role is to stimulate the body’s functioning which causes an increase in both the heart rate and stroke volume of the heart as well as a constriction of the blood vessels. This is what happens when the amygdala fires-up the fight or flight response. We are then ready to battle or run for our lives. You might think of this reflex as functioning like an automobile’s gas pedal.
In contrast, the PNS serves to calm the system. When the danger has passed, the PNS decreases the heart rate and stroke volume and dilates the blood vessels. This is more like a car’s brake system. Unfortunately, the PNS may not always work well for people with anxiety disorders and the SNS may be working overtime. This creates an unhealthy autonomic imbalance. Research is showing that this nervous system imbalance can be associated with emotional stress as well as cardiac disease.
Rather than relying solely on patient self-reports or psychological testing as a measure of that stress, there is now a “reliable method for quantifying autonomic nervous system (ANS) activity” (Akselrod et al. 1981). It is the analysis of heart rate variability (HRV).
“HRV analysis is a powerful tool in the assessment of the autonomic function. It is accurate, reliable, reproducible, yet simple to measure and process. The source information for HRV is a continuous beat-by-beat measurement of intervals between the heartbeats” (Pougatchev, et al 2004). This variability in the time between heartbeats can reveal information about the balance between the sympathetic and parasympathetic nervous systems.
When people have improved heart rate variability, it is because there is a better balance between the sympathetic and parasympathetic influences on the heart. Heart rate variability tends to improve when people are relaxed (better parasympathetic nervous system influence). Too much sympathetic nervous system activity (which causes a reduction in HRV) can be associated with stress, anxiety, and dysphoric mood (Fuller, BF 1992).
HRV appears to be very sensitive and responsive in measuring acute and possibly chronic stress (Vaccarino, V 2004). This can give us another measure of the effectiveness of energy psychology interventions upon the issues that need treatment.
Numerous studies have shown a relationship between emotional issues and reduced HRV. Some of those findings include:
- Offerhaus (1980) observed lower HRV in individuals who were “highly anxious” according to the Minnesota Multiphasic Personality Inventory (MMPI).
- Yeragani et al. (1990; 1993) who published a series of reports indicating reduced HRV (using both time domain and spectral measures) among DSM-III diagnosed panic disorder patients.
- Sloan et al. (1994) reported lower HRV as shown in reduced high-frequency power among 33 healthy volunteers who scored high on the Cooke-Medley Hostility scale.
- Kawachi et al. (1995) reported a cross-sectional association between anxiety and reduced HRV (as assessed by two time-domain measures) in 581 men.
- Thayer et al. (1996) and Friedman & Thayer (1998) who reported diminished HRV in anxiety disorders, especially in the High-Frequency band.
- Thayer et al. (1998) found reductions in HRV of people with depression.
- Cohen et al. (1999) reported that reductions in HRV were found in PTSD patients.
- Cohen et al. (2000) reported lower HRV was found in people with anxiety disorders.
- Murata et al. (2004), under lab conditions, showed that stressors (such as giving a public speech) lower HRV.
- Vaccarino (2004) reports that even low levels of depression compromised HRV. Severe symptoms of depression lowered HRV even more.
- Archives of Internal Medicine, June 2005 (regarding a sub-study of the Women’s Health Initiative) reported that a study at the University of Florida College of Medicine found that women with depressive symptoms tended to have lower heart rate variability and a higher average heart rate.
“HRV analysis enables clinicians and researchers to detect, quantify and trend changes in autonomic activity for patients” (De Jong et al. 2005).
This pilot study was an attempt to determine the feasibility to document changes that clients experience with a physiological measure, namely an ECG that measures heart rate variability. It involved 8 clients with a diagnosis of PTSD including one male and seven females ranging in age from 25 to 44. We found that the HRV measures greatly improved and correlated with client self-reports that presenting symptoms were significantly reduced after an average of 77.5 minutes of treatment. The improved HRV scores confirmed for us that it is possible to detect, quantify, and track changes in autonomic activity. It also suggests that the REMAP process can play a role in helping to shift the ANS back into a healthier balance by easing intense emotional stress.
The electrocardiograph (ECG) data were obtained using a Medicore SA 3000P Heart Rate Variability Analyzer. This is a new medical device that is in the final stage of FDA compliance approval. ECG is an electrical signal that is measured with special conductive electrodes that are placed (in this case) on both wrists and on one ankle. The electrodes pick up very small changes in the electrical field generated by the heart and the HRV analyzer is then able to break that information into 14 different measures of HRV.
Recordings were made while each client sat upright and was comfortably at rest. They were requested to breathe normally and avoid movement or talking during the 5-minute measurements. Three recordings were made. A baseline assessment was taken while each patient focused on neutral or positive thoughts. A pre-treatment reading was taken while they focused on their painful memories. After 20 to 45 minutes of energy psychology treatment with the REMAP process (a comprehensive meridian-based, psycho-sensory therapy) each patient was requested to think again about their traumatic experience while a post-treatment recording was taken. All three recordings were made within 80 minutes of each other. The results of these recordings were then compared to assess whether there were any quantifiable changes in the sympathetic and parasympathetic nervous system activity as revealed through the HRV measures. A follow-up recording was also made between one and four weeks after the initial treatment session.
Below is a summary of the key HRV components utilized and a comparison between the pre-treatment and post-treatment measurements including the percentage of change.
Heart Rate figures represent the mean (average) heart rate as measured in beats per minute (bpm) during the five-minute recordings. A normal heart rate is 60 to 90 beats per minute. Bradycardia is below 50 bpm. Tachycardia is above 100 bpm. When under physical or emotional stress, the heart rate will increase. It decreases when the stress is eased.
Root Means Squared (RMS-SD) This measure estimates high-frequency variations in the heart rate during short-term recordings. It reflects an estimate of the parasympathetic regulation of the heart. The more PNS activity there is (higher numbers), then the greater the calming effect. The less PNS activity there is (lower numbers) and/or the more SNS activity, then the greater the activation of the fight or flight reflex.
Standard Deviation (SDNN) is the standard deviation of the beat to beat intervals. The clinical meaning of a decrease in SDNN is a weakening in the autonomic nervous system’s ability to keep homeostasis in the face of internal/external environmental challenges and lowered coping ability to various emotional stressors. In this measure, smaller numbers are worse and larger numbers are better.
The similarity in baseline and pre-treatment data for the SDNN and PSI measures may suggest that the background stress level of the participants was high on the day of the initial recordings and that their ability to compartmentalize their stress during the baseline recording was low. They also may have been experiencing some anticipatory anxiety.
Physical Stress Index (PSI) represents accumulated physical load. Higher numbers in the PSI reading indicates that there is pressure on the body’s regulation system. Lower numbers would represent an improvement.
Total Successive R-R Interval Difference (TSRD) is a comparison of SDNN results between the current and the last HRV test. If the TSRD in the current recording is higher than the previous recording, then the SDNN of the patient has increased (better result). If the TSRD is lower in the current test, then it is a worse result.
Low Frequency / High-Frequency Normalized Ratio (LF/HF Ratio) is used to indicate a balance between sympathetic and parasympathetic tone. This is frequently used to measure physiological changes caused by various interventions. A lower ratio represents a better result and a higher ratio a worse result.
One to four weeks after treatment, two follow-up HRV recordings were completed. They included another baseline recording (while thinking about neutral to positive thoughts) and another recording while the clients focused on their traumas.
It may be important to note that baseline data is not a static or constant number. It will vary over time. It even fluctuates between different hours of the day. As a result, the follow-up recordings were taken at approximately the same time of day as the initial recordings in order to prevent hourly variances.
Still, these measures are so sensitive that they will vary over time as a result of a person’s current stress level. Recent unrelated stress (e.g. just had an argument with one’s spouse) may have an influence on all current recordings. This may explain the differences between the original baseline and follow-up baseline.
A comparison of the follow-up HRV data (traumatic memory vs. baseline) showed an improvement over the baseline recordings in every category measured. This could suggest that the clients may now be less stressed by thoughts of their treated traumatic memories than by their current background stress level as reflected in the baseline data.
The following is a comparison of the group averages:
As a result of REMAP treatment (averaging 77.5 minutes), the clients were able to think of their traumatic events and their autonomic nervous systems were as calm or calmer than when thinking about neutral/relaxing thoughts. One conclusion is that this physiological data provides support that the traumas were desensitized. This coincided with client self-reports that:
- Their over-all stress level had eased,
- They had a dissipation of physical tension,
- Changes occurred in the visual representation of their traumas (e.g. the mental picture of the incident had shifted to appear more distant and less in focus),
- There was a dissipation of negative thoughts about their incidents and
- Their experience of distress about their traumas had eased by 87.4%
The Subjective Units of Distress Scale (SUD) (Wolpe, 1959) is a rating of symptom intensity from 0 to 10 with 10 representing something that bothers you as bad as it can and 0 not bothering you at all. Below you will find the group averages for the SUD scale and information regarding the length of treatment in sessions and in minutes of treatment.
Five of eight clients reported that the incident no longer disturbed them and that they were ready to focus on a new issue at their next appointment. The remainder (3 of 8 clients) felt significantly better after their REMAP session than they did before it (fewer symptoms) but believed that they could benefit from additional treatment on their issue.
Based on the initial results, we believe that we have obtained useful data that illustrates that positive changes in symptoms are reflected physically in the autonomic nervous system. We further believe that it is possible for future studies to show that the REMAP process can be empirically and objectively documented (both quantitatively and qualitatively). More formal studies are needed that would include:
- A control group,
- A comparison group using a different treatment method (e.g. cognitive therapy),
- Pre, post and follow-up measures using self-reports and psychological tests, and
- Two physical indicators of change (e.g. HRV, the BIS Index Monitor, or qEEG).
We are in the beginning stages of designing a new study that we hope to conduct with participants suffering from PTSD who would be drawn primarily from a veteran’s population. We are planning to improve that study by adding some of these additional elements.
Steve B. Reed, is a psychotherapist and innovator of the REMAP process.
Marry Ross, Ph.D. is a psychologist and an affiliate faculty in the Neurotherapy program in the Department of Rehabilitation, Social Work and Addictions (DRSWA) at the University of North Texas.
The late Frances Mcmanemin, Ph.D. was a psychologist and neurotherapy expert who worked in a medical setting.
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