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An experimental case study of the biofeedback treatment of a rape-induced psychophysiological cardiovascular disorder
BEHAVIOR THERAPY 7, 113-119 (1976)
An Experimental Case Study of the Biofeedback Treatment of a Rape-Induced Psychophysiological Cardiovascular Disorder E D W A R D B . BLANCHARD AND G E N E G . A B E L
University of Mississippi Medical Center A patient with a 15-year history of a rape-induced psychophysiologic cardiovascular disorder, episodic sinus tachycardia, and subsequent "blackout spells," was treated using a biofeedback procedure. The patient was taught to control her heart rate in the presence of audio tape descriptions of rape which earlier had instigated tachycardia episodes. Appropriate control phases in the treatment procedure helped to isolate the biofeedback training as responsible for the improvement.
Reports describing the treatment of cardiac arrhythmias through biofeedback (Weiss & Engel, 1971; Scott, Blanchard, Edmunson, & Young, 1973; Engel & Bleecker, 1974) hold out much promise. But problems in experimental design limit the inferences and conclusions which may be drawn (Blanchard & Young, 1974). The present report describes the biofeedback treatment of a patient with a rape-induced psychophysiologic cardiovascular disorder, namely a sinus tachycardia triggered by certain sexual cues. Care was taken to conduct the treatment of this case with appropriate control conditions (Barlow & Hersen, 1973) so as to isolate the therapeutic conditions. The idea of teaching a patient to control his heart rate through biofeedback training as a means of dealing with stressful situations is not new: Prigatano and Johnson (1972) and Sirota, Schwartz, and Shapiro (1974) have conducted analogue studies along these lines. However, in addition to not involving clinical patients, the latter two studies suffer from other problems: Prigatano and Johnson's subjects did not learn to control heart rate variability and showed no behavioral difference in comparison to an untreated group of spider-fearful subjects. In the study of Sirato et al., subjects were trained to increase or decrease heart rate while undergoing mildly aversive electrical shocks. While the evidence for the subjects' having learned to decrease their heart rate is somewhat questionable, due primarily to not having allowed for the decrease in heart rate because of This research was supported by National Heart and Lung Institute Grant, 1ROHL14906. Requests for reprints should be addressed to Edward B. Blanchard, 865 Poplar Av., Memphis, TN 38104. 113 Copyright © 1976by Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin any form reserved.
114
CASE REPORTS AND STUDIES
adaptation, this group of subjects did rate the shocks as less painful than subjects who were trying to increase heart rate.
CASE HISTORY The patient, a 30-year-old, married female with a history of "spells" since age 14, at which age she was raped by her sister's boyfriend. Repulsed by this event and feeling guilty, she concealed it from her family. T h e " spells" began shortly thereafter and, although having some variability, they generally were associated with a feeling of nausea and vomiting, a choking sensation with the onset of tachycardia, and a numbness of the extremities. The patient reported a vague sense of altered state of consciousness, had lost control of her bladder on one occasion, but had never lost control of bowels during a "spell." She reported no loss of consciousness, that is, she was able to hear what was occurring around her, but she was simply unresponsive for a minute or two. A number of months following the rape, the patient became aware that she was pregnant and concealed this from her parents until her seventh month of gestation. Great turmoil developed within the home, eventually leading to the patient's leaving town during the latter stages of pregnancy, delivering the child and giving it up for adoption. On returning to her home town, the patient perceived that others began thinking of her as the town slut. Her thoughts of guilt about the rape continued unabated, as did the spells. Her history from the age of 20 to her initial psychiatric contact with the experimenters was an endless repetition of numerous organic evaluations. She was followed for approximately 15 years as having a possible convulsive disorder. Four EEGs, numerous skull series, lumbar punctures, and pneumoencephaiograms were all within normal limits, and the frequency of the patient's spells was unaffected by anticonvulsant drugs (Mesantoin, Dilantin, phenobarbital). Her final neurological evaluation 2 years prior to initially being seen led to the conclusion that the patient's spells were psychogenic. Cardiovascular evaluations were likewise extensive with numerous possible diagnoses being entertained, but physical evaluations plus electrocardiograms (including a 10-hr, MoHetz II type) failed to confirm any specific cardiac disorder. The subject's extensive medical evaluations (running $3--4,000 per year) eventually led to her psychiatric referral. During the sessions which followed, she was able to identify the antecedents of her symptoms as thoughts and ruminations about having been raped, and more importantly, how individuals in her natural environment (especially her home town) might perceive her. Thoughts of returning home frequently preceded episodes oftachycardia. In the last 10 years, her fears were aggravated when she was propositioned by men in her home town, events she interpreted as directly resulting from her having been raped at age 14. The patient's therapy initially involved group therapy to increase her verbalization regarding chronic marital problems and her marked passivity regarding her symptomatology. In the course of therapy, the specific stimuli that elicited her spells became more apparent. Since they were rather easily circumscribed to the sexual area, and since the patient focused so strongly on her somatic problems, particularly the tachycardia episodes, a biofeedback treatment designed specifically to help the patient in this area was instituted. Throughout this treatment, the patient continued in group therapy and was stabilized on Dilantin, 100 mg twice per day.
METHOD
Apparatus The apparatus has been described in detail elsewhere (Scott et at., 1973). Briefly, it consisted of a polygraph and various electronic counters and timers by which (1) the patient's
CASE REPORTS AND STUDIES
1 15
heart rate could be measured and printed out on a minute-to-minute basis, and (2) the patient could be given binary visual feedback of heart rate on a beat-by-beat basis as to whether it was above or below a criterion level. All treatment sessions were conducted in an air conditioned, sound attenuated room. The patient sat in a recliner during sessions and was visually monitored via television. Procedure 1
All sessions lasted 40 rain. Each one was divided into four parts: The first 15 rain was devoted to adaptation of the patient to the laboratory situation; During the next 5 min the session, baseline heart rate was determined; and Finally, two consecutive 10-rain experimental trials were conducted. During the latter two trials, various experimental procedures, to be described, were introduced. Audio tapes. The patient's tachycardia episodes were instigated primarily by thoughts or other external cues related to sexual topics, especially rape. In the absence of these internal or external cues, her heart rate was usually in the normal range. To instigate the symptomatic behavior so that it could be treated, we played audio tape descriptions of scenes involving rape to the patient. The use of audio tape descriptions of sexual behavior for generating sexual arousal in patients has been described and demonstrated previously (Abel, Levis, &Clancy, 1970; Abel, Barlow, & Blanchard, Note 1). Three different 10-rain audio tape descriptions were developed, relying on the patient's history to determine which stimuli might provoke her episodes of tachycardia. The first description (Rape 1) was an explicit and detailed account of the actual rape episode. On listening to it, the patient later reported that although the description recounted the events of the actual rape, it failed to cause her emotional distress because the actual rape was less provocative than the attitudes of those in her environment who might know about the rape. The second and third descriptions (Rape 2 and Rape 3) subsequently were an elaboration of scenes in the patient's home town where she encountered the attitudes and opinions that she feared most, such as scenes of men calling her on the telephone to proposition her, neighbors talking about her illicit sexual activities when she was younger, etc. Two 10-rain audio tape descriptions of neutral scenes were also developed, scenes that were not emotionally charged for the patient, such as her fixing meals or going for a ride. These tapes were played to the patient during the experimental trials in a manner described below. Baseline 1. In the first four baseline sessions, no audio tapes were played and the patient continued to sit quietly. These sessions were designed to adapt the patient to the laboratory and to determine the degree of change in heart rate produced by continued adaptation within the session. Baseline 2. In the next two baseline sessions, tapes Rape 1 and Neutral were played in counterbalanced order for the experimental trials. When Rape 1 proved relatively ineffective in generating the symptomatic cardiac responses, Rape 2 was introduced. Rape 2 and Neutral were then presented for four sessions, with the order of presentation within a session counterbalanced across sessions. Feedback training. Next, the patient was taught to lower her heart rate, using the feedback and shaping procedure described in detail by Scott et al. (1973). Briefly, it consists of giving the patient binary feedback of heart rate on a beat-by-beat basis by means of a running time meter. The patient is instructed to try to lower her heart rate, and that when she is making the correct response, the meter is running. The criterion for feedback is changed according to a predetermined shaping schedule designed to keep the patient in fairly close contact with the criterion. In this phase of the treatment, the patient first received l0 rain of training with feedback only. This was followed by a second 10 rain in which she received feedback plus the neutral 1 The authors acknowledge the assistance of Mary R. Haynes in conducting the sessions.
1 16
CASE REPORTS AND STUDIES
audio tape so that she could learn to gain control of her heart rate while listening to an audio description. This phase of treatment was continued for eight sessions, until the patient was showing consistently good control of heart rate lowering. Feedback plus rape 2. Next, the patient was given an opportunity to apply her newly acquired ability in heart rate control. For the first l0 min she received only feedback of heart rate control. For the next 10 min she was instructed to listen to Rape 2, become involved in it, but still try to lower her heart rate using the feedback. This procedure was continued for 25 sessions until the patient had four consecutive sessions in which heart rate was lowered by at least two beats per minute (BPM). Baseline 2. The degree to which the patient had learned self-control of heart rate was assessed in the next phase by returning to baseline conditions: The patient again listened to tapes Rape 2 and Neutral in counterbalanced order, and controlled her heart rate without the assistance of feedback. Generalization. The final phase involved a test of generalization. An entirely new rape description, Rape 3, was introduced into the no-feedback trials in order to see how the patient could maintain control of heart rate, and continue to lower it, while listening to a novel stimulus. During the first four phases, sessions were usually held three or four times per week. During the last two phases, sessions were held only twice per week.
RESULTS The values plotted in Fig. 1 were determined by subtracting the average heart rate for the 5-min session baseline from the average heart rate for the entire 10-min trial during which a rape audio tape was presented. During the Feedback Training phase, in which no rape descriptions were presented, heart rate from the trial during the Neutral tape was used. These difference values are presented as changes in heart rate, either an increase indicating arousal or a decrease indicating control. BASE- BASELINI -2 FEEDBACK FEEDBACK TRAINING + Rape - 2 LINE-I No TRAINING No Feeclba• Neut•
BASELINE GENERAL- FOLLOW IZATION -UP No No No
Tapes ~, iRaF
Feedbac~ Feedback Rape - 2 Rape.3
+1o--
m
8.1 2
+4-
" ~
Feedback
1 o
t
= -2:
I
I~
Z
1
4121
i
4
8
I,, ,,,,,,I,, 10 SESSIONS
20
25 I
6
'1
I
5
MONTHS
FIG. 1. Change in patient's average heart rate from session-baseline to experimental trial on a session by session basis for all phases of treatment.
CASE REPORTS A N D S T U D I E S
1 17
In Baseline 2, tape Rape 1 produced little arousal, whereas Rape 2 was very arousing (Fig. 1). In fact, during presentations, the patient's heart rate reached levels over 150 BPM for some periods of time. This high degree of arousal and the patient's tachycardia episode are somewhat masked by using the average heart rate for the entire 10 rain. There seemed little doubt that tape Rape 2 was arousing and instigated the tachycardia episodes. Moreover, there was no apparent habituation of this audio description during Baseline 2. During Feedback Training, the patient learned fairly quickly to lower her heart rate consistently while listening to an auditory stimulus. This newly acquired skill transferred fairly well in the next phase in which Rape 2 was reintroduced. Particularly noticeable is the sharp contrast in results for this phase with those of Baseline 2. The patient's performance in this phase was somewhat erratic, with several good performances being followed by a poor session. However, she eventually reached the criterion for termination of the phase. In the final experimental control phase, Baseline 3 and Generalization, the patient continued to show good control of heart rate in the absence of feedback. The failure to find a reversal in the heart rate data when feedback was withdrawn, while weakening the experimental analysis, was the desired clinical effect, and demonstrated the patient's ability to control heart rate in the absence of feedback. Follow-up sessions during which the patient received no feedback while listening to either Rape 2 or Rape 3 were held at 1, 3, and 4 months. The patient continued to maintain good heart rate control during these sessions. Clinical Course During the presentation of Rape 1, the patient reported minimal anxiety. During the presentation of Rape 2, however, concomitant with her sinus tachycardia in excess of 150 BPM, the patient reported marked anxiety to the cues presented in the tape. Following completion of such trials, the patient would frequently remain in the laboratory for 15 to 20 min crying excessively and discussing her guilt. During such episodes, she was allowed to ventilate, but the therapist was cautious to provide no more than minimal support. Her clinical course during feedback training using the neutral tapes was unremarkable. Feedback training with tape Rape 2 initially elicited some subjective discomfort, but as treatment progressed, the patient reported sustained reduction of anxiety while listening to it. The patient was most impressed during the generalization sessions. She spontaneously reported that this tape (Rape 3) was especially effective at eliciting those exact thoughts which, antecedent to treatment, had usually precipitated her tachycardia. She was surprised that her usual tachycardia was not elicited.
1 18
CASE REPORTS AND STUDIES
The patient continued to have episodes of sinus tachycardia and other aspects of her "spells" on about a once per week basis into the Feedback plus Rape 2 phase. During this phase the "spells" began to disappear. By the end of treatment the tachycardia episodes and "blackout spells" had virtually disappeared. During follow-up, 4 weeks after termination of the generalization sessions, the patient actually returned to her home town, and saw some of the men who had propositioned her in the past. Prior to treatment, such occurrences had always led to the development of her tachycardia and "spells." Further clinical support for the effectiveness of her treatment occurred when she was forced (due to some social obligations) to go into the home of one of the men who had propositioned her in the past. During the social encounter, she met and talked with one of the men, contact with whom, in the past, had routinely precipitated her spells. The patient was very pleased when no spell followed the social engagement. One element of her psychological symptoms was not altered by the treatment: depressive symptomatology and loss of appetite following conflicts with her husband. This symptomatology,which had always been present in her history, continued even following biofeedback training. DISCUSSION This case has several novel features: First, it represents a case of episodic sinus tachycardia treated by a biofeedback approach in which adequate baseline and control phases were included. A previous case reported by Engel and Bleecker (1974) showed a definite clinical effect; however, as noted by Blanchard and Young (1974), the experimental design of the latter study was such as to limit its scientific value. Secondly, it represents a wedding in a clinical case of biofeedback training with the use of audio tapes to generate arousal. With this particular patient, several alternative behavior therapy approaches were considered: both systematic desensitization (Wolpe, 1958) and flooding (Marks, 1972). These two were ruled out here for two reasons: The patient showed a great preoccupation with somatic complaints, particularly as related to her heart; and her episodic sinus tachycardia was, in and of itself, a decided problem. Thus, the decision was made to attack the problem behavior directly. It is possible that direct relaxation training could have been equally as effective as the biofeedback training in this case, or that the biofeedback procedure itself was only an elaborate means of teaching relaxation. Blanchard and Young (1974) have speculated that many of the clinical effects of biofeedback treatment, particularly with cardiovascular disorders, may be due to teaching the patient how to relax. Thus, it is not possible to rule out an explanation of present results based on relaxation; however, the design
CASE REPORTS AND STUDIES
1 19
u s e d d o e s e n a b l e us t o s a y t h a t the t o t a l b i o f e e d b a c k t r a i n i n g p a c k a g e , w h a t e v e r its u l t i m a t e m o d e o f a c t i o n , w a s r e s p o n s i b l e f o r the o b s e r v e d changes. F i n a l l y , this s t u d y d e m o n s t r a t e s c o n t r o l o f h e a r t r a t e in t h e a b s e n c e o f f e e d b a c k . M a n y s t u d i e s in t h e b i o f e e d b a c k a r e a h a v e d e m o n s t r a t e d feedback-assisted control of heart rate, but only a few have assessed the d e g r e e o f m a i n t e n a n c e o f this c o n t r o l in t h e a b s e n c e o f f e e d b a c k . S u c h c o n t r o l is n e c e s s a r y f o r a n y b i o f e e d b a c k t r a i n i n g to h a v e utility f o r t h e p a t i e n t in the n a t u r a l e n v i r o n m e n t .
REFERENCE NOTE 1. Abel, G. G., Barlow, D. H., & Blanchard, E. B. Developing heterosexual arousal by altering masturbatory fantasies: A controlled study. Paper presented to Annual Meeting of Association for Advancement of Behavior Therapy, Miami Beach, Florida, December 1973.
REFERENCES Abel, G. G., Levis, D., & Clancy, J. Aversion therapy applied to taped sequences of deviant behavior in exhibitionism and other sexual deviations: A preliminary report. Journal of Behavior Therapy and Experimental Psychiatry, 1970, 1, 58-66. Barlow, D. H., & Hersen, M. Single case experimental designs: Uses in applied clinical research. Archives o f General Psychiatry, 1973, 29, 319-325. Blanchard, E. B., & Young, L. D. Clinical applications of biofeedback training: A review of evidence. Archives of General Psychiatry, 1974, 30, 573-589. Engel, B. T., & Bleecker, E. R. Application of operant conditioning techniques to the control of the cardiac arrhythmias. In P. Obrist, A. H. Black, J. Brener, & L. V. DiCara (Eds.), Contemporary trends in cardiovascular psychophysiology, Chicago: Aldine-Atherton, 1974. Marks, I. M. Flooding (Implosion) and allied treatments. In Agras, W. S. (Ed.), Behavior Modification: Principles and Clinical Applications. Boston: Little, Brown & Co., 1972. Prigatano, G. P., & Johnson, H. J. Biofeedback control or heart rate variability to phobic stimuli: A new approach to treating spider phobia. Proceedings of Annual Convention, APA. Washington, DC, American Psychological Association, 1972, pp. 403-404. Scott, R. W., Blanchard, E. B., Edmunson, E. D., & Young, L. D. A shaping procedure for heart rate control in chronic tachycardia. Perceptual and Motor Skills, 1973, 37, 327-338. Sirota, A. D., Schwartz, G. E., & Shapiro, D. Voluntary control of human heart rate: Effect of reaction to aversive stimulation. Journal o f Abnormal Psychology, 1974, 83, 261-267. Weiss, T., & Engel, B. T. Operant conditioning of heart rate patients with premature ventricular contractions. Psychosomatic Medicine, 1971, 33, 301-321. Wolpe, J. Psychotherapy by Reciprocal Inhibition. Stanford, CA: Stanford University Press, 1958.
An Experimental Case Study of the Biofeedback Treatment of a Rape-Induced Psychophysiological Cardiovascular Disorder E D W A R D B . BLANCHARD AND G E N E G . A B E L
University of Mississippi Medical Center A patient with a 15-year history of a rape-induced psychophysiologic cardiovascular disorder, episodic sinus tachycardia, and subsequent "blackout spells," was treated using a biofeedback procedure. The patient was taught to control her heart rate in the presence of audio tape descriptions of rape which earlier had instigated tachycardia episodes. Appropriate control phases in the treatment procedure helped to isolate the biofeedback training as responsible for the improvement.
Reports describing the treatment of cardiac arrhythmias through biofeedback (Weiss & Engel, 1971; Scott, Blanchard, Edmunson, & Young, 1973; Engel & Bleecker, 1974) hold out much promise. But problems in experimental design limit the inferences and conclusions which may be drawn (Blanchard & Young, 1974). The present report describes the biofeedback treatment of a patient with a rape-induced psychophysiologic cardiovascular disorder, namely a sinus tachycardia triggered by certain sexual cues. Care was taken to conduct the treatment of this case with appropriate control conditions (Barlow & Hersen, 1973) so as to isolate the therapeutic conditions. The idea of teaching a patient to control his heart rate through biofeedback training as a means of dealing with stressful situations is not new: Prigatano and Johnson (1972) and Sirota, Schwartz, and Shapiro (1974) have conducted analogue studies along these lines. However, in addition to not involving clinical patients, the latter two studies suffer from other problems: Prigatano and Johnson's subjects did not learn to control heart rate variability and showed no behavioral difference in comparison to an untreated group of spider-fearful subjects. In the study of Sirato et al., subjects were trained to increase or decrease heart rate while undergoing mildly aversive electrical shocks. While the evidence for the subjects' having learned to decrease their heart rate is somewhat questionable, due primarily to not having allowed for the decrease in heart rate because of This research was supported by National Heart and Lung Institute Grant, 1ROHL14906. Requests for reprints should be addressed to Edward B. Blanchard, 865 Poplar Av., Memphis, TN 38104. 113 Copyright © 1976by Associationfor Advancementof BehaviorTherapy. All rightsof reproductionin any form reserved.
114
CASE REPORTS AND STUDIES
adaptation, this group of subjects did rate the shocks as less painful than subjects who were trying to increase heart rate.
CASE HISTORY The patient, a 30-year-old, married female with a history of "spells" since age 14, at which age she was raped by her sister's boyfriend. Repulsed by this event and feeling guilty, she concealed it from her family. T h e " spells" began shortly thereafter and, although having some variability, they generally were associated with a feeling of nausea and vomiting, a choking sensation with the onset of tachycardia, and a numbness of the extremities. The patient reported a vague sense of altered state of consciousness, had lost control of her bladder on one occasion, but had never lost control of bowels during a "spell." She reported no loss of consciousness, that is, she was able to hear what was occurring around her, but she was simply unresponsive for a minute or two. A number of months following the rape, the patient became aware that she was pregnant and concealed this from her parents until her seventh month of gestation. Great turmoil developed within the home, eventually leading to the patient's leaving town during the latter stages of pregnancy, delivering the child and giving it up for adoption. On returning to her home town, the patient perceived that others began thinking of her as the town slut. Her thoughts of guilt about the rape continued unabated, as did the spells. Her history from the age of 20 to her initial psychiatric contact with the experimenters was an endless repetition of numerous organic evaluations. She was followed for approximately 15 years as having a possible convulsive disorder. Four EEGs, numerous skull series, lumbar punctures, and pneumoencephaiograms were all within normal limits, and the frequency of the patient's spells was unaffected by anticonvulsant drugs (Mesantoin, Dilantin, phenobarbital). Her final neurological evaluation 2 years prior to initially being seen led to the conclusion that the patient's spells were psychogenic. Cardiovascular evaluations were likewise extensive with numerous possible diagnoses being entertained, but physical evaluations plus electrocardiograms (including a 10-hr, MoHetz II type) failed to confirm any specific cardiac disorder. The subject's extensive medical evaluations (running $3--4,000 per year) eventually led to her psychiatric referral. During the sessions which followed, she was able to identify the antecedents of her symptoms as thoughts and ruminations about having been raped, and more importantly, how individuals in her natural environment (especially her home town) might perceive her. Thoughts of returning home frequently preceded episodes oftachycardia. In the last 10 years, her fears were aggravated when she was propositioned by men in her home town, events she interpreted as directly resulting from her having been raped at age 14. The patient's therapy initially involved group therapy to increase her verbalization regarding chronic marital problems and her marked passivity regarding her symptomatology. In the course of therapy, the specific stimuli that elicited her spells became more apparent. Since they were rather easily circumscribed to the sexual area, and since the patient focused so strongly on her somatic problems, particularly the tachycardia episodes, a biofeedback treatment designed specifically to help the patient in this area was instituted. Throughout this treatment, the patient continued in group therapy and was stabilized on Dilantin, 100 mg twice per day.
METHOD
Apparatus The apparatus has been described in detail elsewhere (Scott et at., 1973). Briefly, it consisted of a polygraph and various electronic counters and timers by which (1) the patient's
CASE REPORTS AND STUDIES
1 15
heart rate could be measured and printed out on a minute-to-minute basis, and (2) the patient could be given binary visual feedback of heart rate on a beat-by-beat basis as to whether it was above or below a criterion level. All treatment sessions were conducted in an air conditioned, sound attenuated room. The patient sat in a recliner during sessions and was visually monitored via television. Procedure 1
All sessions lasted 40 rain. Each one was divided into four parts: The first 15 rain was devoted to adaptation of the patient to the laboratory situation; During the next 5 min the session, baseline heart rate was determined; and Finally, two consecutive 10-rain experimental trials were conducted. During the latter two trials, various experimental procedures, to be described, were introduced. Audio tapes. The patient's tachycardia episodes were instigated primarily by thoughts or other external cues related to sexual topics, especially rape. In the absence of these internal or external cues, her heart rate was usually in the normal range. To instigate the symptomatic behavior so that it could be treated, we played audio tape descriptions of scenes involving rape to the patient. The use of audio tape descriptions of sexual behavior for generating sexual arousal in patients has been described and demonstrated previously (Abel, Levis, &Clancy, 1970; Abel, Barlow, & Blanchard, Note 1). Three different 10-rain audio tape descriptions were developed, relying on the patient's history to determine which stimuli might provoke her episodes of tachycardia. The first description (Rape 1) was an explicit and detailed account of the actual rape episode. On listening to it, the patient later reported that although the description recounted the events of the actual rape, it failed to cause her emotional distress because the actual rape was less provocative than the attitudes of those in her environment who might know about the rape. The second and third descriptions (Rape 2 and Rape 3) subsequently were an elaboration of scenes in the patient's home town where she encountered the attitudes and opinions that she feared most, such as scenes of men calling her on the telephone to proposition her, neighbors talking about her illicit sexual activities when she was younger, etc. Two 10-rain audio tape descriptions of neutral scenes were also developed, scenes that were not emotionally charged for the patient, such as her fixing meals or going for a ride. These tapes were played to the patient during the experimental trials in a manner described below. Baseline 1. In the first four baseline sessions, no audio tapes were played and the patient continued to sit quietly. These sessions were designed to adapt the patient to the laboratory and to determine the degree of change in heart rate produced by continued adaptation within the session. Baseline 2. In the next two baseline sessions, tapes Rape 1 and Neutral were played in counterbalanced order for the experimental trials. When Rape 1 proved relatively ineffective in generating the symptomatic cardiac responses, Rape 2 was introduced. Rape 2 and Neutral were then presented for four sessions, with the order of presentation within a session counterbalanced across sessions. Feedback training. Next, the patient was taught to lower her heart rate, using the feedback and shaping procedure described in detail by Scott et al. (1973). Briefly, it consists of giving the patient binary feedback of heart rate on a beat-by-beat basis by means of a running time meter. The patient is instructed to try to lower her heart rate, and that when she is making the correct response, the meter is running. The criterion for feedback is changed according to a predetermined shaping schedule designed to keep the patient in fairly close contact with the criterion. In this phase of the treatment, the patient first received l0 rain of training with feedback only. This was followed by a second 10 rain in which she received feedback plus the neutral 1 The authors acknowledge the assistance of Mary R. Haynes in conducting the sessions.
1 16
CASE REPORTS AND STUDIES
audio tape so that she could learn to gain control of her heart rate while listening to an audio description. This phase of treatment was continued for eight sessions, until the patient was showing consistently good control of heart rate lowering. Feedback plus rape 2. Next, the patient was given an opportunity to apply her newly acquired ability in heart rate control. For the first l0 min she received only feedback of heart rate control. For the next 10 min she was instructed to listen to Rape 2, become involved in it, but still try to lower her heart rate using the feedback. This procedure was continued for 25 sessions until the patient had four consecutive sessions in which heart rate was lowered by at least two beats per minute (BPM). Baseline 2. The degree to which the patient had learned self-control of heart rate was assessed in the next phase by returning to baseline conditions: The patient again listened to tapes Rape 2 and Neutral in counterbalanced order, and controlled her heart rate without the assistance of feedback. Generalization. The final phase involved a test of generalization. An entirely new rape description, Rape 3, was introduced into the no-feedback trials in order to see how the patient could maintain control of heart rate, and continue to lower it, while listening to a novel stimulus. During the first four phases, sessions were usually held three or four times per week. During the last two phases, sessions were held only twice per week.
RESULTS The values plotted in Fig. 1 were determined by subtracting the average heart rate for the 5-min session baseline from the average heart rate for the entire 10-min trial during which a rape audio tape was presented. During the Feedback Training phase, in which no rape descriptions were presented, heart rate from the trial during the Neutral tape was used. These difference values are presented as changes in heart rate, either an increase indicating arousal or a decrease indicating control. BASE- BASELINI -2 FEEDBACK FEEDBACK TRAINING + Rape - 2 LINE-I No TRAINING No Feeclba• Neut•
BASELINE GENERAL- FOLLOW IZATION -UP No No No
Tapes ~, iRaF
Feedbac~ Feedback Rape - 2 Rape.3
+1o--
m
8.1 2
+4-
" ~
Feedback
1 o
t
= -2:
I
I~
Z
1
4121
i
4
8
I,, ,,,,,,I,, 10 SESSIONS
20
25 I
6
'1
I
5
MONTHS
FIG. 1. Change in patient's average heart rate from session-baseline to experimental trial on a session by session basis for all phases of treatment.
CASE REPORTS A N D S T U D I E S
1 17
In Baseline 2, tape Rape 1 produced little arousal, whereas Rape 2 was very arousing (Fig. 1). In fact, during presentations, the patient's heart rate reached levels over 150 BPM for some periods of time. This high degree of arousal and the patient's tachycardia episode are somewhat masked by using the average heart rate for the entire 10 rain. There seemed little doubt that tape Rape 2 was arousing and instigated the tachycardia episodes. Moreover, there was no apparent habituation of this audio description during Baseline 2. During Feedback Training, the patient learned fairly quickly to lower her heart rate consistently while listening to an auditory stimulus. This newly acquired skill transferred fairly well in the next phase in which Rape 2 was reintroduced. Particularly noticeable is the sharp contrast in results for this phase with those of Baseline 2. The patient's performance in this phase was somewhat erratic, with several good performances being followed by a poor session. However, she eventually reached the criterion for termination of the phase. In the final experimental control phase, Baseline 3 and Generalization, the patient continued to show good control of heart rate in the absence of feedback. The failure to find a reversal in the heart rate data when feedback was withdrawn, while weakening the experimental analysis, was the desired clinical effect, and demonstrated the patient's ability to control heart rate in the absence of feedback. Follow-up sessions during which the patient received no feedback while listening to either Rape 2 or Rape 3 were held at 1, 3, and 4 months. The patient continued to maintain good heart rate control during these sessions. Clinical Course During the presentation of Rape 1, the patient reported minimal anxiety. During the presentation of Rape 2, however, concomitant with her sinus tachycardia in excess of 150 BPM, the patient reported marked anxiety to the cues presented in the tape. Following completion of such trials, the patient would frequently remain in the laboratory for 15 to 20 min crying excessively and discussing her guilt. During such episodes, she was allowed to ventilate, but the therapist was cautious to provide no more than minimal support. Her clinical course during feedback training using the neutral tapes was unremarkable. Feedback training with tape Rape 2 initially elicited some subjective discomfort, but as treatment progressed, the patient reported sustained reduction of anxiety while listening to it. The patient was most impressed during the generalization sessions. She spontaneously reported that this tape (Rape 3) was especially effective at eliciting those exact thoughts which, antecedent to treatment, had usually precipitated her tachycardia. She was surprised that her usual tachycardia was not elicited.
1 18
CASE REPORTS AND STUDIES
The patient continued to have episodes of sinus tachycardia and other aspects of her "spells" on about a once per week basis into the Feedback plus Rape 2 phase. During this phase the "spells" began to disappear. By the end of treatment the tachycardia episodes and "blackout spells" had virtually disappeared. During follow-up, 4 weeks after termination of the generalization sessions, the patient actually returned to her home town, and saw some of the men who had propositioned her in the past. Prior to treatment, such occurrences had always led to the development of her tachycardia and "spells." Further clinical support for the effectiveness of her treatment occurred when she was forced (due to some social obligations) to go into the home of one of the men who had propositioned her in the past. During the social encounter, she met and talked with one of the men, contact with whom, in the past, had routinely precipitated her spells. The patient was very pleased when no spell followed the social engagement. One element of her psychological symptoms was not altered by the treatment: depressive symptomatology and loss of appetite following conflicts with her husband. This symptomatology,which had always been present in her history, continued even following biofeedback training. DISCUSSION This case has several novel features: First, it represents a case of episodic sinus tachycardia treated by a biofeedback approach in which adequate baseline and control phases were included. A previous case reported by Engel and Bleecker (1974) showed a definite clinical effect; however, as noted by Blanchard and Young (1974), the experimental design of the latter study was such as to limit its scientific value. Secondly, it represents a wedding in a clinical case of biofeedback training with the use of audio tapes to generate arousal. With this particular patient, several alternative behavior therapy approaches were considered: both systematic desensitization (Wolpe, 1958) and flooding (Marks, 1972). These two were ruled out here for two reasons: The patient showed a great preoccupation with somatic complaints, particularly as related to her heart; and her episodic sinus tachycardia was, in and of itself, a decided problem. Thus, the decision was made to attack the problem behavior directly. It is possible that direct relaxation training could have been equally as effective as the biofeedback training in this case, or that the biofeedback procedure itself was only an elaborate means of teaching relaxation. Blanchard and Young (1974) have speculated that many of the clinical effects of biofeedback treatment, particularly with cardiovascular disorders, may be due to teaching the patient how to relax. Thus, it is not possible to rule out an explanation of present results based on relaxation; however, the design
CASE REPORTS AND STUDIES
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u s e d d o e s e n a b l e us t o s a y t h a t the t o t a l b i o f e e d b a c k t r a i n i n g p a c k a g e , w h a t e v e r its u l t i m a t e m o d e o f a c t i o n , w a s r e s p o n s i b l e f o r the o b s e r v e d changes. F i n a l l y , this s t u d y d e m o n s t r a t e s c o n t r o l o f h e a r t r a t e in t h e a b s e n c e o f f e e d b a c k . M a n y s t u d i e s in t h e b i o f e e d b a c k a r e a h a v e d e m o n s t r a t e d feedback-assisted control of heart rate, but only a few have assessed the d e g r e e o f m a i n t e n a n c e o f this c o n t r o l in t h e a b s e n c e o f f e e d b a c k . S u c h c o n t r o l is n e c e s s a r y f o r a n y b i o f e e d b a c k t r a i n i n g to h a v e utility f o r t h e p a t i e n t in the n a t u r a l e n v i r o n m e n t .
REFERENCE NOTE 1. Abel, G. G., Barlow, D. H., & Blanchard, E. B. Developing heterosexual arousal by altering masturbatory fantasies: A controlled study. Paper presented to Annual Meeting of Association for Advancement of Behavior Therapy, Miami Beach, Florida, December 1973.
REFERENCES Abel, G. G., Levis, D., & Clancy, J. Aversion therapy applied to taped sequences of deviant behavior in exhibitionism and other sexual deviations: A preliminary report. Journal of Behavior Therapy and Experimental Psychiatry, 1970, 1, 58-66. Barlow, D. H., & Hersen, M. Single case experimental designs: Uses in applied clinical research. Archives o f General Psychiatry, 1973, 29, 319-325. Blanchard, E. B., & Young, L. D. Clinical applications of biofeedback training: A review of evidence. Archives of General Psychiatry, 1974, 30, 573-589. Engel, B. T., & Bleecker, E. R. Application of operant conditioning techniques to the control of the cardiac arrhythmias. In P. Obrist, A. H. Black, J. Brener, & L. V. DiCara (Eds.), Contemporary trends in cardiovascular psychophysiology, Chicago: Aldine-Atherton, 1974. Marks, I. M. Flooding (Implosion) and allied treatments. In Agras, W. S. (Ed.), Behavior Modification: Principles and Clinical Applications. Boston: Little, Brown & Co., 1972. Prigatano, G. P., & Johnson, H. J. Biofeedback control or heart rate variability to phobic stimuli: A new approach to treating spider phobia. Proceedings of Annual Convention, APA. Washington, DC, American Psychological Association, 1972, pp. 403-404. Scott, R. W., Blanchard, E. B., Edmunson, E. D., & Young, L. D. A shaping procedure for heart rate control in chronic tachycardia. Perceptual and Motor Skills, 1973, 37, 327-338. Sirota, A. D., Schwartz, G. E., & Shapiro, D. Voluntary control of human heart rate: Effect of reaction to aversive stimulation. Journal o f Abnormal Psychology, 1974, 83, 261-267. Weiss, T., & Engel, B. T. Operant conditioning of heart rate patients with premature ventricular contractions. Psychosomatic Medicine, 1971, 33, 301-321. Wolpe, J. Psychotherapy by Reciprocal Inhibition. Stanford, CA: Stanford University Press, 1958.