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  • Writer's pictureBrian Lissak

Heart Rate Variability (HRV) Biofeedback Training

Updated: Feb 7, 2023

HRV Biofeedback training is a method to interact directly with your nervous system to down regulate the stress response and allow the sympathetic-parasympathetic balance to be restored.


Table of Contents

  • What is Biofeedback?

  • What is Heart Rate Variability?

  • What is HRV Biofeedback Training?

  • HRV training as an adjunct to talk therapy

  • HRV training as a standalone practice

  • HRV training for athletes

  • Additional Resources


What is Biofeedback?

Biofeedback is a way in which to gain control over some of your body's functions. It is based on the Learning Theory of Operant Conditioning (think Pavlov’s dogs). The best way to explain biofeedback is through some practical examples.


To best explain biofeedback, I will describe a scenario that uses EMG Biofeedback, as I find it to be the easiest to understand. Imagine someone has a sports injury and partially tears some muscle in their shoulder. The body’s natural response is inflammation and a general tensing of the area. That’s a supportive and useful physiological response.


Now let’s say its a year later. The muscle tear has healed, but the area around the shoulder is still tense. Those muscles have habituated themselves to this state, even though the reason they tensed up is no longer present.


Biofeedback training can be very useful here. We would attach some sensors (in this case, EMG sensors) to the shoulder muscles that are habitually tense, and they would be connected to a computer. On the computer screen is a red ball. As the muscles tense, the ball increases in size. As the muscles relax, the ball decreases. Your goal is to keep the ball as small as possible. You don’t need to know how to do that. Rather, through rapid, subconscious trial and error, you will learn - just like Pavlov’s dogs - that when you relax the muscles around your shoulder, the ball shrinks. If you do that enough times, you will learn how to relax those muscles without needing the biofeedback, which is the ultimate goal.


What is Heart Rate Variability?

Heart Rate Variability refers to the variations in average heart rate from beat to beat. Don’t worry if this sounds confusing - it’s not how we generally think of heart rate. Normally we think of heart rate as being steady across time, because we are used to thinking of the overall average, such as “my resting heart rate is _____.” However, that’s a very large grain perspective. Our heart rate is constantly increasing and decreasing from beat to beat. At least, it should be.


Every time you inhale, your sympathetic nervous system is activated. This is commonly referred to as the “fight or flight” system. Every time you exhale, your parasympathetic nervous system is activated. This is commonly referred to as the “rest and digest” system. (This is of course a gross simplification of the nervous system, but for our purposes, it’s sufficient). Therefore, every time you inhale, your heart rate should increase, and every time you exhale, your heart rate should decrease, as your sympathetic and parasympathetic nervous systems are alternatingly activated by the breath. This is called Respiratory Sinus Arrhythmia. Having high levels of heart rate variability - meaning a large range from breath to breath - is a sign of physiological health.


Now let’s look at someone who is in a stress state, like anxiety. When you are anxious, your parasympathetic nervous system is inhibited. On a nervous system level, you are existentially threatened - a lion is stalking you through the jungle and wants to eat you. Obviously, resting and digesting are of no concern in that moment.


When you are stressed, you actually have very little heart rate variability. You inhale, and your sympathetic (fight or flight) nervous system is activated; you exhale, and…your sympathetic nervous system is still activated. The parasympathetic is inhibited because the things it enables your body to do are of secondary importance when you are existentially threatened.


This is one way of understanding anxiety: you are in a constant state of existential threat. As often happens in our modern world, that anxiety becomes generalized. It ceases to be an appropriate stress response to an acute external factor (like a lion trying to eat you) and permeates your life until it is just a way of being. The psychophysiological toll this takes is immense.


What is Heart Rate Variability (HRV) Biofeedback Training?

HRV Biofeedback training is a method to interact directly with your nervous system to down regulate the stress response and allow the sympathetic-parasympathetic balance to be restored.


We do this through the breath. The client wears two biometric sensors: respiration and heart rate. These sensors are hooked up to a computer program with a specific HRV algorithm.

The client follows a breath pacer, which is generally set somewhere between five to seven breaths per minute. Sound slow? It is. This is not a natural respiration rate. It is specific for the training, which is only supposed to occur in short bursts of time - between 5-20 minutes per continuous session.


As the client follows the breath pacer - breathing abdominally (belly breaths) instead of using the trapezius muscles (chest breathing) - certain physiological mechanisms are triggered that allow the sympathetic-parasympathetic balance to occur. This is called coherence or phase (see image below). On the screen, you can see your respiration as a rising and falling line that looks like peaks and valleys (blue line). As you get into coherence, your heart rate (red line) will begin to synchronize to your breath - increasing as you inhale, decreasing as you exhale. By training this daily - only 5-20 minutes per day - you strengthen autonomic nervous system balance.



(Blue line - respiration ; Red line - heart rate)


HRV Biofeedback Training as an Adjunct to Talk Therapy

Many of my clients come to me with a presenting problem of anxiety. In my experience, anxiety is present in almost all cases of someone seeking therapy, even if it is not the most pressing issue. What very often happens, especially in the clients who have severe anxiety, is that three people will be in the therapy room: myself, the client, and their anxiety. Their anxiety exists as a defensive buffer between them and the potentially harmful external world. It blocks all attempts to access the clients inner world.


This is where HRV training comes in. In cases like this, you will not be able to think your way out. The anxious voice is the loudest and drowns out all other perspectives. For the moment, we can just leave that to the side. The anxious voice can scream its head off, for now. As anyone who has suffered with anxiety can tell you, it is not just a negative thought process. It is a terrible physical experience as well.


HRV training gets directly at this physiological process and interrupts that negative feedback loop. When anxiety goes from an appropriate response to an acute situation, like having a stress response while being mugged, and generalizes itself to a constant state not related to anything external, like being anxious every time you go outside and being fearful of walking past alleys, this is when we can call it a disorder. What happens here is that a feedback loop is created wherein there is an anxious thought, which causes a physiological stress response (fight/flight) from the body.


When there is no acute situation in which you can fight or flee, the energy (adrenaline, cortisol, etc.) that was summoned up sits in the body. When that isn’t properly discharged and re-regulated, then a message is sent from the body up to the brain saying, “something’s wrong - danger!” which causes more anxious thoughts as the mind tries to make sense of the stress response that the body is in. As the brain continues scanning for threats, now at a slightly higher level, it sends a message down to the body saying “hey, we are scanning for threats, be ready to deal with it when we find it” and so another stress response is triggered, so more adrenaline, cortisol, etc. are dumped into the body, which causes the body to….


You can see how this perpetuates itself in a terrible feedback loop, one which you cannot generally think yourself out of because it is not solely being caused by thoughts. HRV training avoids the cognitive side of this loop and gets directly at the physiological expression of anxiety, disrupting that feedback loop and creating a new, positive feedback loop. Once your body is regulated through the breath to a state of sympathetic-parasympathetic balance, signals are sent to your brain saying “we’re safe.” This begins a positive feedback loop of safety and balance.


I’ll often have clients say to me, shocked, “I’m having the anxious thoughts but they have no power - I don’t feel them in my body the way I usually do!” Once you have the experience of separation from these anxious thoughts, and you begin to experience the truth that they are not indicative of reality and you don’t need to identify with them, an opening is created where talk therapy can become really useful. Training the nervous system into a state of coherence, so it knows another way of being besides anxiety, is one of the most powerful tools I have as a therapist.



HRV Training as a Standalone Practice

Even if you are not in talk therapy, and don’t feel the need to be, HRV Biofeedback Training can still be useful to you. Our modern culture is designed to be hyper-stimulating. On a technical level, this means it is designed to excite your nervous system, to trigger constantly small doses of that “fight/flight” response. The news is structured this way; social media is structured this way; even our smartphones are designed this way (the red icon when you have a notification is received as a warning signal by the brain, which is why stop signs and red lights are red - it’s not coincidental, its neurophysiological).


When we are constantly being stimulated, our systems become strained and can slowly teeter off kilter. This affects our sleep, mood, cognitive abilities, sexual performance, sexual desire, athletic performance, immune response, recovery rates, digestion, auditory functioning…the list goes on and on. HRV Biofeedback Training can help keep you balanced.



HRV Biofeedback Training for Athletes

One of the biggest concerns for high level athletes is burnout: physical, mental, and emotional. Physical activity is stressful on the body. Stress isn’t a bad thing - it helps cardiovascular health, brain function, and everything else. But it needs to be balanced by proper recovery and the ability to quickly and efficiently transition from the stress state of athletic activity to a recovery state. Achieving respiratory sinus arrhythmia, which is what HRV training does, puts your body in the optimal physiological state to recover from stressful activity, capitalizing on the workout you just did and preparing you for the next one, as well as helping you transition back into the normal periods of life in between intense athletic performance.


HRV Biofeedback Training done shortly after intense physical activity also has the added benefit of teaching your nervous system to self regulate. By using the artificially created stress response from the exercise, which is comparable physiologically to a psychologically induced stress response, you can build resilience in your nervous system to be able to quickly and efficiently self regulate. So even if you are in what would normally be a high anxiety situation, your nervous system has the experience of down regulating out of it, allowing you to be calm, cool and collected while everyone else freaks out.


Additional Resources

The first 2 links are videos explaining HRV training.

The 3rd link is an article explaining what HRV is.

The 4th link is for at home HRV training device.

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