Emotion regulation and heart rate variability may identify the optimal posttraumatic stress disorder treatment: analyses from a randomized controlled trial

Abstract

Introduction: High variability in response and retention rates for posttraumatic stress disorder (PTSD) treatment highlights the need to identify "personalized" or "precision" medicine factors that can inform optimal intervention selection before an individual commences treatment. In secondary analyses from a non-inferiority randomized controlled trial, behavioral and physiological emotion regulation were examined as non-specific predictors (that identify which individuals are more likely to respond to treatment, regardless of treatment type) and treatment moderators (that identify which treatment works best for whom) of PTSD outcome.

Methods: There were 85 US Veterans with clinically significant PTSD symptoms randomized to 6 weeks of either cognitive processing therapy (CPT; n = 44) or a breathing-based yoga practice (Sudarshan kriya yoga; SKY; n = 41). Baseline self-reported emotion regulation (Difficulties in Emotion Regulation Scale) and heart rate variability (HRV) were assessed prior to treatment, and self-reported PTSD symptoms were assessed at baseline, end-of-treatment, 1-month follow-up, and 1-year follow-up.

Results: Greater baseline deficit in self-reported emotional awareness (similar to alexithymia) predicted better overall PTSD improvement in both the short- and long-term, following either CPT or SKY. High self-reported levels of emotional response non-acceptance were associated with better PTSD treatment response with CPT than with SKY. However, all significant HRV indices were stronger moderators than all self-reported emotion regulation scales, both in the short- and long-term. Veterans with lower baseline HRV had better PTSD treatment response with SKY, whereas Veterans with higher or average-to-high baseline HRV had better PTSD treatment response with CPT.

Conclusions: To our knowledge, this is the first study to examine both self-reported emotion regulation and HRV, within the same study, as both non-specific predictors and moderators of PTSD treatment outcome. Veterans with poorer autonomic regulation prior to treatment had better PTSD outcome with a yoga-based intervention, whereas those with better autonomic regulation did better with a trauma-focused psychological therapy. Findings show potential for the use of HRV in clinical practice to personalize PTSD treatment.

Clinical trial registration: ClinicalTrials.gov identifier, NCT02366403.

Keywords: cognitive processing therapy; emotion regulation; heart rate variability; moderator; posttraumatic stress disorder; precision medicine; predictor; yoga.

Figure 1

Baseline DERS-Awareness (where “low”/”high” refer to ±1SD from the mean) as a non-specific predictor of both (A) short-term and (B) long-term PTSD treatment outcome, regardless of group.

Figure 2

Baseline DERS indices (where “low”/”high” refer to ±1SD from the mean) as moderators of PTSD treatment outcome over the short-term: (A) DERS-Total, (B) DERS-Non-Acceptance, (C) DERS-Impulse, (D) DERS-Awareness, (E) DERS-Strategy, (F) DERS-Clarity. Note that points are used to differentiate lines rather than to represent data plotting. Open points (1 and 3) represent high baseline DERS, and enclosed points (2 and 4) represent low baseline DERS. Solid lines/square points represent CPT, and dotted lines/diamond points represent SKY.

Figure 3

Baseline HRV indices (where “low”/”high” refer to ±1SD from the mean) as moderators of PTSD treatment outcome over the short-term: (A) SDNN, (B) RMSSD, (C) HF-HRV. Note that points are used to differentiate lines rather than to represent data plotting. Open points (1 & 3) represent high baseline HRV, enclosed points (2 & 4) represent low baseline HRV. Solid lines/square points represent CPT, dotted lines/diamond points represent SKY.