Carmen V. Russoniello, PhD

Posttraumatic stress disorder (PTSD) is a severe anxiety disorder whose symptoms emerge following exposure to extreme stress, such as those encountered in the battlefield or as a result of sexual abuse or natural disasters. The ability to employ coping mechanisms affects the disorder’s presentation as well as the frequency, intensity, and duration of the symptoms. The “Wounded Warrior” program at East Carolina University (Greenville, NC) was developed to promote the functional independence of US Marines, including those with PTSD.

STRESS RESPONSE: INTERACTION OF THE BRAIN AND IMMUNE SYSTEM

Walter Cannon coined the “flight or fight” response to stress in the early 20th century, in which he emphasized the importance of the parasympathetic system.¹ In 1988, Folkow clarified the description as an immune response to stress.² The stress response is now understood to be a neuroendocrine function that includes a feedback loop between the hypothalamus and the pituitary and adrenal glands; stimulation of the hypothalamus promotes secretion of corticotropin-releasing hormone (CRH) into the hypophyseal portal system, which supplies the anterior pituitarywith blood. CRH stimulates the secretion of adrenocorticotropic hormone into the bloodstream by the pituitary, prompting the adrenal glands to release the stress hormone cortisol.

Cortisol mobilizes the body’s defenses to meet the challenge of an adverse situation. It modulates the stress response by inhibiting the further release of CRH by the hypothalamus. Cortisol thus protects healthy cells and tissues by inhibiting an overreaction from the immune system. Without this protective effect, the interaction between the brain and the immune system can become dysregulated, increasing the risk of immune disorders.

THE CENTRAL AUTONOMIC NETWORK

The central nervous system that regulates the overall balance of the autonomic nervous system (ANS) has been called the central autonomic network (CAN).³ The CAN helps control executive, social, affective, attentional, and motivational functions. Therefore, the old paradigm of simply decreasing hyperarousal of the ANS to treat negative affective states and dispositions is inadequate. Instead, restoring the appropriate relationship between the ANS and the central nervous system is the aim behind interventions to treat PTSD.

Autonomic, cognitive, and affective functions assist humans in maintaining balance when confronted with external challenges. The CAN controls inhibitory or negative processes that permit specific behavior and redeploy resources needed elsewhere. When negative circuits are compromised, positive circuits develop, resulting in hypervigilance, the symptoms of which can be devastating and, if not ameliorated, can develop into permanent conditions. In one study,Vietnam veterans with PTSD had an 8% reduction in the volume of their right hippocampus compared with veterans without PTSD. Another study calculated a 26% reduction in the left hippocampus and a 22% reduction in the right in veterans with the most severe PTSD compared with veterans who were in combat but had no PTSD symptoms.⁴

A common subcortical neural system regulates defensive behavior, including autonomic, emotional, and cognitive behavior. When the prefrontal cortex is taken “off line” for whatever reason, parasympathetic inhibitory action is withdrawn, and relative sympathetic dominance, associated with defense, occurs.

CONFRONTING HYPERAROUSAL

The question then arises of how to train the ANS to avoid hypervigilance. Growing evidence supports the use of heart rate variability as a predictor of hypervigilance and inefficient allocation of attentional and cognitive resources.

The overall objective of heart rate variability training is to decrease ANS hyperarousal and to improve its balance. “Wounded warriors” learn to control ANS responses to stress-producing stimuli (eg, thoughts, memories, and images associated with combat). The goal of training is to decrease arousal and maintain ANS balance for increasing lengths of time.

Once it was observed that alpha waves were dysfunctional in vulnerable populations, protocols were developed to train alpha and theta waves as a method of improving function. Peniston and colleagues^5–9 showed that increased alpha and theta brain wave production resulted in normalized personality measures and prolonged the period of time before relapse in alcoholics. This protocol has also shown efficacy as an intervention in depression and PTSD.

BIOFEEDBACK TRAINING PROGRAM

The US Department of Defense is studying a combination of central nervous system biofeedback with ANS biofeedback, with the goal of restoring and maintaining tone between the systems.

The training program used in the study lasts 1 month, and starts with a session for preassessment, 16 biofeedback sessions (four per week), a postprogram evaluation, and a 3-month followup. Each week, participants are exposed to stress-producing stimuli that increase in intensity:

• Week 1: Stroop Color Word Test, math stressor, talk stressor/everyday events
• Week 2: Talk stressor, combat experiences
• Week 3: Images and sounds of combat
• Week 4: Virtual Baghdad or Afghanistan (virtual reality exposure)

Each biofeedback session consists of 5 minutes of baseline evaluation; 5 minutes in which the veteran is subjected to the weekly stressor; 20 minutes of heart rate variability and neurofeedback training; 5 more minutes of training with the weekly stressor; 20 more minutes of heart rate variability and neurofeedback training; and finally 5 minutes of recovery.

Preliminary clinical data indicate decreases in ANS hyperarousal and increases in parasympathetic activity (Figure). Reports on the Patient Health Questionnaire Short Form (PHQ SF-36) indicate positive changes in physical symptoms and decreases in symptoms of depression, panic, and anxiety. Outcome measurements will include changes from heart rate variability training; the Posttraumatic Stress Checklist; PHQ SF-36; Profile of Mood States; salivary alpha-amylase changes; a behavioral questionnaire assessing nutrition habits and alcohol, drug, and nicotine use; and the Self-Satisfaction Inventory.

SUMMARY

Dysfunction in the balance of both the ANS and central nervous system is associated with symptoms of PTSD in combat veterans. Methods that are designed to restore balance in these systems are needed to ameliorate these symptoms. Biofeedback and neurofeedback are safe methods with which to achieve these goals.

Posttraumatic stress disorder (PTSD) is a severe anxiety disorder whose symptoms emerge following exposure to extreme stress, such as those encountered in the battlefield or as a result of sexual abuse or natural disasters. The ability to employ coping mechanisms affects the disorder’s presentation as well as the frequency, intensity, and duration of the symptoms. The “Wounded Warrior” program at East Carolina University (Greenville, NC) was developed to promote the functional independence of US Marines, including those with PTSD.

STRESS RESPONSE: INTERACTION OF THE BRAIN AND IMMUNE SYSTEM

Walter Cannon coined the “flight or fight” response to stress in the early 20th century, in which he emphasized the importance of the parasympathetic system.¹ In 1988, Folkow clarified the description as an immune response to stress.² The stress response is now understood to be a neuroendocrine function that includes a feedback loop between the hypothalamus and the pituitary and adrenal glands; stimulation of the hypothalamus promotes secretion of corticotropin-releasing hormone (CRH) into the hypophyseal portal system, which supplies the anterior pituitarywith blood. CRH stimulates the secretion of adrenocorticotropic hormone into the bloodstream by the pituitary, prompting the adrenal glands to release the stress hormone cortisol.

Cortisol mobilizes the body’s defenses to meet the challenge of an adverse situation. It modulates the stress response by inhibiting the further release of CRH by the hypothalamus. Cortisol thus protects healthy cells and tissues by inhibiting an overreaction from the immune system. Without this protective effect, the interaction between the brain and the immune system can become dysregulated, increasing the risk of immune disorders.

THE CENTRAL AUTONOMIC NETWORK

The central nervous system that regulates the overall balance of the autonomic nervous system (ANS) has been called the central autonomic network (CAN).³ The CAN helps control executive, social, affective, attentional, and motivational functions. Therefore, the old paradigm of simply decreasing hyperarousal of the ANS to treat negative affective states and dispositions is inadequate. Instead, restoring the appropriate relationship between the ANS and the central nervous system is the aim behind interventions to treat PTSD.

Autonomic, cognitive, and affective functions assist humans in maintaining balance when confronted with external challenges. The CAN controls inhibitory or negative processes that permit specific behavior and redeploy resources needed elsewhere. When negative circuits are compromised, positive circuits develop, resulting in hypervigilance, the symptoms of which can be devastating and, if not ameliorated, can develop into permanent conditions. In one study,Vietnam veterans with PTSD had an 8% reduction in the volume of their right hippocampus compared with veterans without PTSD. Another study calculated a 26% reduction in the left hippocampus and a 22% reduction in the right in veterans with the most severe PTSD compared with veterans who were in combat but had no PTSD symptoms.⁴

A common subcortical neural system regulates defensive behavior, including autonomic, emotional, and cognitive behavior. When the prefrontal cortex is taken “off line” for whatever reason, parasympathetic inhibitory action is withdrawn, and relative sympathetic dominance, associated with defense, occurs.

CONFRONTING HYPERAROUSAL

The question then arises of how to train the ANS to avoid hypervigilance. Growing evidence supports the use of heart rate variability as a predictor of hypervigilance and inefficient allocation of attentional and cognitive resources.

The overall objective of heart rate variability training is to decrease ANS hyperarousal and to improve its balance. “Wounded warriors” learn to control ANS responses to stress-producing stimuli (eg, thoughts, memories, and images associated with combat). The goal of training is to decrease arousal and maintain ANS balance for increasing lengths of time.

Once it was observed that alpha waves were dysfunctional in vulnerable populations, protocols were developed to train alpha and theta waves as a method of improving function. Peniston and colleagues^5–9 showed that increased alpha and theta brain wave production resulted in normalized personality measures and prolonged the period of time before relapse in alcoholics. This protocol has also shown efficacy as an intervention in depression and PTSD.

BIOFEEDBACK TRAINING PROGRAM

The US Department of Defense is studying a combination of central nervous system biofeedback with ANS biofeedback, with the goal of restoring and maintaining tone between the systems.

The training program used in the study lasts 1 month, and starts with a session for preassessment, 16 biofeedback sessions (four per week), a postprogram evaluation, and a 3-month followup. Each week, participants are exposed to stress-producing stimuli that increase in intensity:

• Week 1: Stroop Color Word Test, math stressor, talk stressor/everyday events
• Week 2: Talk stressor, combat experiences
• Week 3: Images and sounds of combat
• Week 4: Virtual Baghdad or Afghanistan (virtual reality exposure)

Each biofeedback session consists of 5 minutes of baseline evaluation; 5 minutes in which the veteran is subjected to the weekly stressor; 20 minutes of heart rate variability and neurofeedback training; 5 more minutes of training with the weekly stressor; 20 more minutes of heart rate variability and neurofeedback training; and finally 5 minutes of recovery.

Preliminary clinical data indicate decreases in ANS hyperarousal and increases in parasympathetic activity (Figure). Reports on the Patient Health Questionnaire Short Form (PHQ SF-36) indicate positive changes in physical symptoms and decreases in symptoms of depression, panic, and anxiety. Outcome measurements will include changes from heart rate variability training; the Posttraumatic Stress Checklist; PHQ SF-36; Profile of Mood States; salivary alpha-amylase changes; a behavioral questionnaire assessing nutrition habits and alcohol, drug, and nicotine use; and the Self-Satisfaction Inventory.

SUMMARY

Dysfunction in the balance of both the ANS and central nervous system is associated with symptoms of PTSD in combat veterans. Methods that are designed to restore balance in these systems are needed to ameliorate these symptoms. Biofeedback and neurofeedback are safe methods with which to achieve these goals.

Posttraumatic stress disorder (PTSD) is a severe anxiety disorder whose symptoms emerge following exposure to extreme stress, such as those encountered in the battlefield or as a result of sexual abuse or natural disasters. The ability to employ coping mechanisms affects the disorder’s presentation as well as the frequency, intensity, and duration of the symptoms. The “Wounded Warrior” program at East Carolina University (Greenville, NC) was developed to promote the functional independence of US Marines, including those with PTSD.

STRESS RESPONSE: INTERACTION OF THE BRAIN AND IMMUNE SYSTEM

Walter Cannon coined the “flight or fight” response to stress in the early 20th century, in which he emphasized the importance of the parasympathetic system.¹ In 1988, Folkow clarified the description as an immune response to stress.² The stress response is now understood to be a neuroendocrine function that includes a feedback loop between the hypothalamus and the pituitary and adrenal glands; stimulation of the hypothalamus promotes secretion of corticotropin-releasing hormone (CRH) into the hypophyseal portal system, which supplies the anterior pituitarywith blood. CRH stimulates the secretion of adrenocorticotropic hormone into the bloodstream by the pituitary, prompting the adrenal glands to release the stress hormone cortisol.

Cortisol mobilizes the body’s defenses to meet the challenge of an adverse situation. It modulates the stress response by inhibiting the further release of CRH by the hypothalamus. Cortisol thus protects healthy cells and tissues by inhibiting an overreaction from the immune system. Without this protective effect, the interaction between the brain and the immune system can become dysregulated, increasing the risk of immune disorders.

THE CENTRAL AUTONOMIC NETWORK

The central nervous system that regulates the overall balance of the autonomic nervous system (ANS) has been called the central autonomic network (CAN).³ The CAN helps control executive, social, affective, attentional, and motivational functions. Therefore, the old paradigm of simply decreasing hyperarousal of the ANS to treat negative affective states and dispositions is inadequate. Instead, restoring the appropriate relationship between the ANS and the central nervous system is the aim behind interventions to treat PTSD.

Autonomic, cognitive, and affective functions assist humans in maintaining balance when confronted with external challenges. The CAN controls inhibitory or negative processes that permit specific behavior and redeploy resources needed elsewhere. When negative circuits are compromised, positive circuits develop, resulting in hypervigilance, the symptoms of which can be devastating and, if not ameliorated, can develop into permanent conditions. In one study,Vietnam veterans with PTSD had an 8% reduction in the volume of their right hippocampus compared with veterans without PTSD. Another study calculated a 26% reduction in the left hippocampus and a 22% reduction in the right in veterans with the most severe PTSD compared with veterans who were in combat but had no PTSD symptoms.⁴

A common subcortical neural system regulates defensive behavior, including autonomic, emotional, and cognitive behavior. When the prefrontal cortex is taken “off line” for whatever reason, parasympathetic inhibitory action is withdrawn, and relative sympathetic dominance, associated with defense, occurs.

CONFRONTING HYPERAROUSAL

The question then arises of how to train the ANS to avoid hypervigilance. Growing evidence supports the use of heart rate variability as a predictor of hypervigilance and inefficient allocation of attentional and cognitive resources.

The overall objective of heart rate variability training is to decrease ANS hyperarousal and to improve its balance. “Wounded warriors” learn to control ANS responses to stress-producing stimuli (eg, thoughts, memories, and images associated with combat). The goal of training is to decrease arousal and maintain ANS balance for increasing lengths of time.

Once it was observed that alpha waves were dysfunctional in vulnerable populations, protocols were developed to train alpha and theta waves as a method of improving function. Peniston and colleagues^5–9 showed that increased alpha and theta brain wave production resulted in normalized personality measures and prolonged the period of time before relapse in alcoholics. This protocol has also shown efficacy as an intervention in depression and PTSD.

BIOFEEDBACK TRAINING PROGRAM

The US Department of Defense is studying a combination of central nervous system biofeedback with ANS biofeedback, with the goal of restoring and maintaining tone between the systems.

The training program used in the study lasts 1 month, and starts with a session for preassessment, 16 biofeedback sessions (four per week), a postprogram evaluation, and a 3-month followup. Each week, participants are exposed to stress-producing stimuli that increase in intensity:

• Week 1: Stroop Color Word Test, math stressor, talk stressor/everyday events
• Week 2: Talk stressor, combat experiences
• Week 3: Images and sounds of combat
• Week 4: Virtual Baghdad or Afghanistan (virtual reality exposure)

Each biofeedback session consists of 5 minutes of baseline evaluation; 5 minutes in which the veteran is subjected to the weekly stressor; 20 minutes of heart rate variability and neurofeedback training; 5 more minutes of training with the weekly stressor; 20 more minutes of heart rate variability and neurofeedback training; and finally 5 minutes of recovery.

Preliminary clinical data indicate decreases in ANS hyperarousal and increases in parasympathetic activity (Figure). Reports on the Patient Health Questionnaire Short Form (PHQ SF-36) indicate positive changes in physical symptoms and decreases in symptoms of depression, panic, and anxiety. Outcome measurements will include changes from heart rate variability training; the Posttraumatic Stress Checklist; PHQ SF-36; Profile of Mood States; salivary alpha-amylase changes; a behavioral questionnaire assessing nutrition habits and alcohol, drug, and nicotine use; and the Self-Satisfaction Inventory.

SUMMARY

Dysfunction in the balance of both the ANS and central nervous system is associated with symptoms of PTSD in combat veterans. Methods that are designed to restore balance in these systems are needed to ameliorate these symptoms. Biofeedback and neurofeedback are safe methods with which to achieve these goals.

Question from audience: Why does the Cleveland Clinic start its healing services program preoperatively rather than postoperatively?

Dr. Gillinov: We have a fairly well defined preoperative set of medical tests, and during this process nurses present patients with materials that explain the experience, and nurses and doctors make themselves available in special classes to answer patients’ questions. In doing so, we have increasingly identified patients preoperatively who have stress or problems.

Last week I saw a woman who had a leaking mitral valve, but her symptoms were out of proportion to her disease. She had loss of energy and appetite, and she wasn’t eating much. She was depressed and our team picked that up. She actually never had to undergo surgery. We referred her to a psychologist and, according to her son, she started to feel better. By starting preoperatively, we’re sometimes able to pick out things that we should treat instead of heart disease.

We also provide guided imagery and massage preoperatively.

Dr. Duffy: Healing services is on standing preoperative orders at the hospital. The team goes in proactively and asks, “In addition to your open heart surgery on Wednesday, is there anything we can do to support your emotional and spiritual journey here today?”

Terminology also matters. The term “healing services” is a safe umbrella under which we include biofeedback as one of the services, but it encompasses pastoral care, hospice care, and palliative care. The way it’s integrated into a care model is important. If it’s reserved for end of life, it might be viewed as defective or as a death sentence, so we want the healing services team to be proactive.

Question from audience: How does the primary care physician fit into all of this? I believe that if the physicians in the hospital want to gain patient confidence, they’ll show that they’re communicating well with the primary care physician.

Dr. Gevirtz: The primary care physicians are incredibly open to this idea. They have 12 minutes to deal with people with fibromyalgia, irritable bowel syndrome, chronic pain, noncardiac chest pain, etc. What are they going to do in 12 minutes? They’re grateful if they have a handoff, especially if it’s in the Clinic itself.

Question from audience: Are there any thoughts on making biofeedback part of general training rather than using it just for patients who’ve already experienced trauma?

Dr. Gevirtz: We did a study in which we showed that a biofeedback technician in the primary care setting saved the health maintenance system quite a lot of money, but the administration couldn’t decide whose territory to take to give us an office, so it ended the program.

Dr. Russoniello: How we enable greater access to our intervention is an important question. I see people quit the program if they can’t get access to biofeedback. In an effort to enhance compliance, we’ve incorporated biofeedback into video games, working with a couple of private companies to develop them.The idea is that persons playing the video game can accrue points to enhance their overall score if they perform paced breathing or some other form of biofeedback. Early indications from focus groups are that people will like this.

We have already shown in randomized controlled clinical studies of depression and anxiety that certain video games can improve mood and decrease stress.There is a big movement to get products in people’s hands to help them manage their health.

Question from audience: How much overlap is there between biofeedback methodologies—enhancing heart rate variability, vagal withdrawal, neurofeedback, and electroencephalographic feedback—in the systems you’re targeting and what are the unique contributions of each?

Dr. Gevirtz: We follow a stepped-care model. We start with the simplest and move on to the more complicated technologies. Two published studies with long-term followup showed the effectiveness of a learned breathing technique in alleviating noncardiac chest pain. Simple biofeedback wasn’t even needed. Three years later, the patients were better than they were at the end of the actual training. If you can do it simply, then you do it, and if it doesn’t work, then move on to more and more complicated techniques, with neurofeedback being the last resort.

Question from audience: Has anybody measured the physical impact of stimulating multiple systems on the study subject? In other words, can it be damaging to overstimulate these systems at the same time?

Dr. Gevirtz: We’ve been trying to do that. Recurrent abdominal pain or functional abdominal pain is the most common complaint to pediatric gastroenterologists. We have 1,800 patients a year who make it to the children’s hospital level with this complaint. These are kids who are suffering with very great pain and we we’re pretty sure it’s an autonomically mediated kind of phenomenon. We’re able to measure vagal activity in these kids in ambulatory settings at school and have found very little vagal activity before treatment. After training, they were able to restore vagal activity, and it correlated at the level of 0.63 with a reduction of symptoms. I think it’s important to try to tie the physiology to symptoms. It’s not always easy to do but we’re trying.

Question from audience: I’d like to pick up on two topics that Dr. Duffy raised: the business of medicine and the proposal for informed hope rather than an informed consent before surgery. Something that I see with patients and families at times is this magical expectation promoted by the business side that medicine can do these amazing and wonderful things and doesn’t have any sort of weaknesses. I wonder what role unrealistic expectations promoted by the media, advertising, and others may play in the stress of patients, caregivers, and physicians who need to try to meet the expectations of infallible medicine?

Dr. Duffy: We’ve spun so far the other way with our advanced technology that we’ve lost the human side, especially the concept of a relationship and giving people hope even though they have a terminal condition. It’s a balance between the art and the business of medicine. It’s about setting realistic expectations and realistic hope.

Question from audience: Why does the Cleveland Clinic start its healing services program preoperatively rather than postoperatively?

Dr. Gillinov: We have a fairly well defined preoperative set of medical tests, and during this process nurses present patients with materials that explain the experience, and nurses and doctors make themselves available in special classes to answer patients’ questions. In doing so, we have increasingly identified patients preoperatively who have stress or problems.

Last week I saw a woman who had a leaking mitral valve, but her symptoms were out of proportion to her disease. She had loss of energy and appetite, and she wasn’t eating much. She was depressed and our team picked that up. She actually never had to undergo surgery. We referred her to a psychologist and, according to her son, she started to feel better. By starting preoperatively, we’re sometimes able to pick out things that we should treat instead of heart disease.

We also provide guided imagery and massage preoperatively.

Dr. Duffy: Healing services is on standing preoperative orders at the hospital. The team goes in proactively and asks, “In addition to your open heart surgery on Wednesday, is there anything we can do to support your emotional and spiritual journey here today?”

Terminology also matters. The term “healing services” is a safe umbrella under which we include biofeedback as one of the services, but it encompasses pastoral care, hospice care, and palliative care. The way it’s integrated into a care model is important. If it’s reserved for end of life, it might be viewed as defective or as a death sentence, so we want the healing services team to be proactive.

Question from audience: How does the primary care physician fit into all of this? I believe that if the physicians in the hospital want to gain patient confidence, they’ll show that they’re communicating well with the primary care physician.

Dr. Gevirtz: The primary care physicians are incredibly open to this idea. They have 12 minutes to deal with people with fibromyalgia, irritable bowel syndrome, chronic pain, noncardiac chest pain, etc. What are they going to do in 12 minutes? They’re grateful if they have a handoff, especially if it’s in the Clinic itself.

Question from audience: Are there any thoughts on making biofeedback part of general training rather than using it just for patients who’ve already experienced trauma?

Dr. Gevirtz: We did a study in which we showed that a biofeedback technician in the primary care setting saved the health maintenance system quite a lot of money, but the administration couldn’t decide whose territory to take to give us an office, so it ended the program.

Dr. Russoniello: How we enable greater access to our intervention is an important question. I see people quit the program if they can’t get access to biofeedback. In an effort to enhance compliance, we’ve incorporated biofeedback into video games, working with a couple of private companies to develop them.The idea is that persons playing the video game can accrue points to enhance their overall score if they perform paced breathing or some other form of biofeedback. Early indications from focus groups are that people will like this.

We have already shown in randomized controlled clinical studies of depression and anxiety that certain video games can improve mood and decrease stress.There is a big movement to get products in people’s hands to help them manage their health.

Question from audience: How much overlap is there between biofeedback methodologies—enhancing heart rate variability, vagal withdrawal, neurofeedback, and electroencephalographic feedback—in the systems you’re targeting and what are the unique contributions of each?

Dr. Gevirtz: We follow a stepped-care model. We start with the simplest and move on to the more complicated technologies. Two published studies with long-term followup showed the effectiveness of a learned breathing technique in alleviating noncardiac chest pain. Simple biofeedback wasn’t even needed. Three years later, the patients were better than they were at the end of the actual training. If you can do it simply, then you do it, and if it doesn’t work, then move on to more and more complicated techniques, with neurofeedback being the last resort.

Question from audience: Has anybody measured the physical impact of stimulating multiple systems on the study subject? In other words, can it be damaging to overstimulate these systems at the same time?

Dr. Gevirtz: We’ve been trying to do that. Recurrent abdominal pain or functional abdominal pain is the most common complaint to pediatric gastroenterologists. We have 1,800 patients a year who make it to the children’s hospital level with this complaint. These are kids who are suffering with very great pain and we we’re pretty sure it’s an autonomically mediated kind of phenomenon. We’re able to measure vagal activity in these kids in ambulatory settings at school and have found very little vagal activity before treatment. After training, they were able to restore vagal activity, and it correlated at the level of 0.63 with a reduction of symptoms. I think it’s important to try to tie the physiology to symptoms. It’s not always easy to do but we’re trying.

Question from audience: I’d like to pick up on two topics that Dr. Duffy raised: the business of medicine and the proposal for informed hope rather than an informed consent before surgery. Something that I see with patients and families at times is this magical expectation promoted by the business side that medicine can do these amazing and wonderful things and doesn’t have any sort of weaknesses. I wonder what role unrealistic expectations promoted by the media, advertising, and others may play in the stress of patients, caregivers, and physicians who need to try to meet the expectations of infallible medicine?

Dr. Duffy: We’ve spun so far the other way with our advanced technology that we’ve lost the human side, especially the concept of a relationship and giving people hope even though they have a terminal condition. It’s a balance between the art and the business of medicine. It’s about setting realistic expectations and realistic hope.

Question from audience: Why does the Cleveland Clinic start its healing services program preoperatively rather than postoperatively?

Dr. Gillinov: We have a fairly well defined preoperative set of medical tests, and during this process nurses present patients with materials that explain the experience, and nurses and doctors make themselves available in special classes to answer patients’ questions. In doing so, we have increasingly identified patients preoperatively who have stress or problems.

Last week I saw a woman who had a leaking mitral valve, but her symptoms were out of proportion to her disease. She had loss of energy and appetite, and she wasn’t eating much. She was depressed and our team picked that up. She actually never had to undergo surgery. We referred her to a psychologist and, according to her son, she started to feel better. By starting preoperatively, we’re sometimes able to pick out things that we should treat instead of heart disease.

We also provide guided imagery and massage preoperatively.

Dr. Duffy: Healing services is on standing preoperative orders at the hospital. The team goes in proactively and asks, “In addition to your open heart surgery on Wednesday, is there anything we can do to support your emotional and spiritual journey here today?”

Terminology also matters. The term “healing services” is a safe umbrella under which we include biofeedback as one of the services, but it encompasses pastoral care, hospice care, and palliative care. The way it’s integrated into a care model is important. If it’s reserved for end of life, it might be viewed as defective or as a death sentence, so we want the healing services team to be proactive.

Question from audience: How does the primary care physician fit into all of this? I believe that if the physicians in the hospital want to gain patient confidence, they’ll show that they’re communicating well with the primary care physician.

Dr. Gevirtz: The primary care physicians are incredibly open to this idea. They have 12 minutes to deal with people with fibromyalgia, irritable bowel syndrome, chronic pain, noncardiac chest pain, etc. What are they going to do in 12 minutes? They’re grateful if they have a handoff, especially if it’s in the Clinic itself.

Question from audience: Are there any thoughts on making biofeedback part of general training rather than using it just for patients who’ve already experienced trauma?

Dr. Gevirtz: We did a study in which we showed that a biofeedback technician in the primary care setting saved the health maintenance system quite a lot of money, but the administration couldn’t decide whose territory to take to give us an office, so it ended the program.

Dr. Russoniello: How we enable greater access to our intervention is an important question. I see people quit the program if they can’t get access to biofeedback. In an effort to enhance compliance, we’ve incorporated biofeedback into video games, working with a couple of private companies to develop them.The idea is that persons playing the video game can accrue points to enhance their overall score if they perform paced breathing or some other form of biofeedback. Early indications from focus groups are that people will like this.

We have already shown in randomized controlled clinical studies of depression and anxiety that certain video games can improve mood and decrease stress.There is a big movement to get products in people’s hands to help them manage their health.

Question from audience: How much overlap is there between biofeedback methodologies—enhancing heart rate variability, vagal withdrawal, neurofeedback, and electroencephalographic feedback—in the systems you’re targeting and what are the unique contributions of each?

Dr. Gevirtz: We follow a stepped-care model. We start with the simplest and move on to the more complicated technologies. Two published studies with long-term followup showed the effectiveness of a learned breathing technique in alleviating noncardiac chest pain. Simple biofeedback wasn’t even needed. Three years later, the patients were better than they were at the end of the actual training. If you can do it simply, then you do it, and if it doesn’t work, then move on to more and more complicated techniques, with neurofeedback being the last resort.

Question from audience: Has anybody measured the physical impact of stimulating multiple systems on the study subject? In other words, can it be damaging to overstimulate these systems at the same time?

Dr. Gevirtz: We’ve been trying to do that. Recurrent abdominal pain or functional abdominal pain is the most common complaint to pediatric gastroenterologists. We have 1,800 patients a year who make it to the children’s hospital level with this complaint. These are kids who are suffering with very great pain and we we’re pretty sure it’s an autonomically mediated kind of phenomenon. We’re able to measure vagal activity in these kids in ambulatory settings at school and have found very little vagal activity before treatment. After training, they were able to restore vagal activity, and it correlated at the level of 0.63 with a reduction of symptoms. I think it’s important to try to tie the physiology to symptoms. It’s not always easy to do but we’re trying.

Question from audience: I’d like to pick up on two topics that Dr. Duffy raised: the business of medicine and the proposal for informed hope rather than an informed consent before surgery. Something that I see with patients and families at times is this magical expectation promoted by the business side that medicine can do these amazing and wonderful things and doesn’t have any sort of weaknesses. I wonder what role unrealistic expectations promoted by the media, advertising, and others may play in the stress of patients, caregivers, and physicians who need to try to meet the expectations of infallible medicine?

Dr. Duffy: We’ve spun so far the other way with our advanced technology that we’ve lost the human side, especially the concept of a relationship and giving people hope even though they have a terminal condition. It’s a balance between the art and the business of medicine. It’s about setting realistic expectations and realistic hope.