Bridging the gap between emotion and health

Bridging the gap from emotion to health:
A synthesis on vagal function
Dr Andrew Kemp, PhD
Associate Professor, University of Sydney
Visiting Professor, University of São Paulo
Editor, PLOS ONE, Frontiers in Psychology
email: andrew.kemp@sydney.edu.au; twitter: @andrewhkemp

The Devastating Impact of Mental Illness
The cost of mental & physical illness is increasing
› Cost of mental illness alone – $2.5T in 2010 – estimated to increase
to $6T by 2030
› But what do these figures mean?
- Entire global health spending in 2009 was $5.1T
- Annual GDP for low income countries is less than $1T
- Entire overseas development aid over the past 20 years is less than $2T
› Cost of mental health, cardiovascular disease, chronic respiratory
disease, cancer, & diabetes over next two decades estimated at:
- cumulative output loss of $47T
- or 75% of global GDP in 2010
NIMH Director, Tom Insel: http://www.nimh.nih.gov/about/director/2011/the-global-cost-of-mental-illness.shtml

Intimate Relationship
bw Mental & Physical Health
› Participants were photographed before and after a 30-day meditation
retreat against a consistent background
› Day 1: each person was asked to consider what they were looking for
in the practice period ahead
› Meditation practice:
- practice continues all morning, afternoon, & evening until about 9 or 10 p.m.
- centered on mindfulness meditation (‘shamatha’ meditation)
- alternating sitting and walking meditation in the meditation hall
- mindful eating (inc Japanese Zen practice called oryoki)
› After 30-days of meditation: each participant in the project was asked
to consider what the experience of mediation retreat had been for
them
http://shambhalatimes.org/2011/10/20/before-and-after-portraits-from-dathun/
3

Before vs after 30 day meditation retreat
4
Peter Seidler, Before and After Project, 2011

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6

7

8

9

Medical consequences of Depression
Gold & Chrousos, Molecular Psychiatry, 2002, 7: 254-75 10
Abnormalities
Typical symptoms (& more
commonly researched)
Increasing knowledge on
other abnormalities
including autonomic
function, metabolic
syndrome & morbidity

Reduced Bone Density in Depression
 Osteoporosis
Trabeculations
(spongy bone) are
Gold & Chrousos, Molecular Psychiatry, 2002, 7: 254-75
11
reduced
Cortical bone
is also thinner

Coronary Heart Disease
ELSA-Brasil is the first large multi-centre cohort study of adult health conducted in
Brazil and is funded by its Ministries of Health, and Science and Technology.
Kemp & colleagues, under review

Relationship bw Depression & Cardiac Mortality
› N=2847, 55 – 85 years
› Followed-up over 4 yrs
› Finding observed after adjustment for
confounders
- smoking, alcohol, BP, BMI & antidepressants
› Depression increases relative risk of
cardiac mortality 3-4 fold
› Mechanisms proposed:
- Decreased heart rate variability
- Impaired platelet functions
- Hypercortisolemia
- Lifestyle factors
Penninx et al.., 2001. Arch Gen Psychiatry.
Without CVD (n=2397)
With CVD (n=450)

Psychological Distress  Mortality
N=65,000 people from
the general population
free of CVD & cancer at
study baseline.
Dose–response
association bw
psychological distress &
increased risk of
mortality over 8 years
Russ et al., 2012, BMJ

Summary of Talk: From Neuroscience to Public
Health
› Neuroscience of emotion
- basic emotion theorists vs psychological constructionists
- neuroscience research is at a cross-roads
› Bridging the gap from emotion to health
- neurovisceral integration & importance of the vagus nerve (Thayer)
- polyvagal theory (Porges, 2011): implications for emotion & mental health
- cholinergic anti-inflammatory reflex (Tracey, 2002): mechanism linking impaired
vagal function to physical health
- vagal function: the structural link?
› Frontiers Research Topic: call for contributions

Charles Darwin on Emotion (1872)
› The Expression of Emotions in Man and Animals
- facial expressions reflect actions necessary for life
- emotions are ‘hardwired’, innate & universal
- similarities across different cultures & species
e.g. anger/aggression
- Frowning: protects eyes
in anticipation of attack
Ref: Darwin, 1872; Dalgleish, 2004

Paul Ekman’s 6 Basic Emotions
Anger Disgust Fear Happiness Sadness Surprise
Carroll Izard: distinct emotions appear within the first months of life

Emotions as ‘Natural Kinds’
Disgust: insula
Fear:
amygdala
From: Lindquist et al., 2013
Anger: OFC
Sadness: ACC

But are emotions a construct of social reality?
What emotion is expressed here?
Ref: Barrett, 2012

Social reality?
Ref: Barrett, 2012
And now?

Emotions as Psychological Constructions
From: Lindquist et al., 2013
Emotion are made
up of elements:
Core affect
Conceptualisation
Language
Executive attention

The Emotional Brain
LeDoux: Research on emotion
has increased exponentially over
the last decade, yet ‘emotion’
remains ill-defined, leading to an
“intellectual stalemate”
Lindquist: “Over the last century,
the emotion debate has been
fought like a series of battles that
resemble something like the
Hundred Years’ War between
England and France.”
LeDoux, 1998, 2012; Lindquist et al., 2013

William James on Emotion (1884)
“Does your heart pound
because you are
afraid... Or are you
afraid because you
feel your heart
pounding?”

Modern neuroscience is ‘neurocentric’
“Unfortunately, most researchers in psychiatry and psychology express little interest in the mapping
of autonomic regulation as a “vulnerability” dimension for various disorders and behavioural
problems, although visceral features are often symptoms of the disorders they are treating.”
25
- Stephen Porges, The Polyvagal Theory, 2011, page 261
“Techniques such as human neuroimaging permit valuable insights into the brain basis of
perceptions, thoughts, feelings, and actions, yet these mental functions are for the most part
considered in isolation from the physiological state of the body.”
- Critchley & Harrison, 2013. Neuron

Bodily Maps of Emotions
In five experiments,
participants (n = 701)
were shown two
silhouettes of bodies
alongside emotional
words, stories, movies, or
facial expressions.
Nummenmaa et al., 2013. PNAS.

Culturally universal categorical somatotopic maps

Neurovisceral Integration & Emotion
Nucleus Tractus Solitarius: a site of
anatomical convergence of visceral inputs,
which projects to regions contributing to
coordinated autonomic, hormonal &
immune output
Thayer et al. (2009). Neurovisceral Integration Model Porges, 2011. The Polyvagal Theory

Depression & CVD: Potential Mechanisms?
› Increased HPA-axis activity
› Increased sympatho-adrenomedullary
activity
› Increased inflammation
› Increased platelet activation and
aggregation
› and reduced vagal function
(heart rate variability, or HRV)
Musselman, D. L. et al. 1998. Archives of General Psychiatry; Nemeroff, C. B., & Goldschmidt-Clermont, P. J. 2012. Nat. Rev. Cardiol

The Vagus Nerve
Bonaz et al., Neurogastroenterol Motil (2013) 25, 208–221

Vagus Nerve: A Structural Link?
› Vagal function is associated with:
- psychological resilience
- psychophysiological flexibility & response to environmental challenge
- emotion capacity & social engagement
- glucose regulation
- inhibition of hypothalamic-pituitary-adrenal (HPA) axis
- regulation of immune function
› Chronic decreases reflect impairment of the cholinergic anti-inflammatory
reflex 
- immune dysfunction and inflammation 
- CVD, diabetes, osteoporosis, arthritis, Alzheimer's disease, periodontal
disease, and certain types of cancers as well as declines in muscle strength
and increased frailty and disability
Kemp & Quintana, 2013; Thayer & Sternberg, 2006; Thayer et al., 2010; Kashdan & Rottenberg, 2010; Porges (2011); Tracey (2002)

Heart Rate Variability (HRV)
• HRV relates to analyses on the R – R interval
• QRS complex – ventricle depolarization
• T wave – ventricle repolarization
• P wave – depolarisation of the atria prior to contraction
Mechanical events of the cardiac cycle lag slightly behind the
electrical signals; thus, the contraction of the cardiac muscle
comes just after the corresponding electrical signal

HRV: Time domain
 Measures the temporal variation between heart beats (i.e., R-R waves)
 Common measures include:
 Standard deviation of normal to normal (or N-N) intervals (SDNN)
 Root mean square successive differences (RMSSD): mediated by the PNS
Kleiger, R., Stein, P., & Bigger, J. (2005). Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and
Noninvasive Electrocardiology, Inc, 10(1); Appelhans & Luecken, 2006

 Frequency domain: decomposes HRV
signal into magnitude & frequency of
multiple sinusoidal waves
 A Fast Fourier transform (FFT) transforms
the signal from time- to frequency-domain
 High frequency (HF) power: reflects
cardiac parasympathetic influence due
to respiratory sinus arrhythmia
 Low frequency (LF) power reflects
baroreflex function, a homeostatic
mechanism for maintaining blood
pressure
HRV: Frequency domain
Saul, 1990; Kleiger, R., Stein, P., & Bigger, J. (2005); Goldstein, Bentho, Park & Sharabi, 2011; Appelhans &
Luecken, 2006

Impact of Anxious Anticipation vs Slow Breathing
Ruth Wells, 2011, Honors student. Kemp & colleagues, 2012. Matter Over Mind: A Randomised-Controlled Trial of Single-Session
Biofeedback Training on Performance Anxiety and Heart Rate Variability in Musicians. PLoS ONE 7(10): e46597.
doi:10.1371/journal.pone.0046597

 Provides additional information to more
traditional measures, e.g.
 Poincaré plot
 Measures the complexity and
predictability of heartbeats
 less linearity – more variability
HRV: Non-linear Domain
Fig: The Poincaré graph plots each R-R interval as
a function of the next R-R interval
Kleiger, R., Stein, P., & Bigger, J. (2005). Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and
Noninvasive Electrocardiology, Inc, 10(1)

HRV Poincaré graph: Impact of age
Healthy, young participant Older participant with CVD
Lopes & White, book chapter

HRV & respiratory sinus arrhythmia
 HR decelerates with expiration & accelerates with inspiration
 Phasic changes in HRV: increases when calm, and decreases with
stress
 Resting state HRV: a marker of mental & physical health

Impact of Intensive 10-day Meditation Course
Jonathan Krygier, 2011- present, PhD student. Kemp & colleagues, 2013. Int J Psychophysiol
40

HRV biofeedback &
Performance Anxiety in Musicians
Ruth Wells, Honours student, 2011; Kemp & colleagues, 2012. PLOS ONE

HRV biofeedback & anxious anticipation
Impact of breathing intervention on RR
intervals: Normal breathing during
anticipation stress (left fig; 12
breaths/min) vs HRV biofeedback (right
fig; 6 breaths/min)
Experimental induction of
performance anxiety (anxious
anticipation) in professional
musicians

Anxiety Decreased &
HRV increased in Intervention Group
43

The traditional view of the autonomic nervous
system
• Two systems:
• the sympathetic (red)
• parasympathetic (blue)
› 2 behavioural patterns:
› ‘Fight or flight’: dependent on the SNS
› ‘Rest & digest’: dependent on the PNS

Polyvagal Theory
Porges (2011). The Polyvagal Theory
Stephen Porges John Hughlings Jackson
1835-1911
Polyvagal Theory is a phylogenetically ordered,
hierarchical model that draws on the Jacksonian
principle of ‘dissolution’
John Hughlings Jackson (1858): ‘‘when the higher
[phylogenetically newer neural circuits] are suddenly
rendered functionless, the lower rise in activity’’

Polyvagal Theory: Implications for Emotion
Porges (2011). The Polyvagal Theory
Myelinated vagus: originates
from nucleus ambiguus;
supports social
communication &
psychophysiological flexibility;
activity explicitly linked to HRV
Sympathetic nervous
system: supports mobilisation
behaviours, e.g. fight, fight,
play
Unmyelinated vagus: dorsal
vagal complex; most
phylogenetically primitive;
responsible for immobilisation
behaviours, e.g. extreme
terror, bradycardia, vasovagal
syncope, reproduction,
nursing, pair-bonding

HRV & Oxytocin
• Oxytocin (OT) plays a key
regulatory role in social behaviour
• We examined the impact of OT on
resting-state HRV, an index of
motivation & capacity for social
behaviour
• Standard dose of 24 intranasal units
(IU) (3 puffs per nostril, each puff
containing 4 IU) of either OT or
placebo
• OT increases HRV, larges using the
DFA non-linear measure of HRV
• DFA decreases  more random
Kemp et al. (2012). PLOS ONE
signal

Heart Rate, HRV & Stress
 Heart rate and it’s variability is very sensitive to stress
 Under resting state: large beat to beat variability
 Stress condition: decreases HRV (& HR increase)
Rest Stress: Task instructions followed by task
(serial 13’s task with social pressure)
Sasha Saunders, Honours student, 2011

Heart Rate, HRV, Stress & Escitalopram
- Single dose escitalopram (20mg)
49
- N=44, healthy females, cross-over
design
Under Stress:
- HR increased - HRV (HF nu;
0.15-0.4Hz) decreased
- large effect sizes observed
Under Treatment:
- HR decreased - HRV (HF nu;
0.15-0.4Hz) increased
- large effect sizes observed
Sasha Saunders, Honours student, 2011, Kemp & colleagues, 2013,
Psychopharm, Dec 15. [Epub ahead of print]

Interaction with Age
50
Findings
- Effects found to be specific to
those >25yrs
- No beneficial cardiac effects for
those <25yrs
Interpretation?
- Black box warnings for young
adults
- Maturational differences in PFC
Framework
- Theoretical framework for
understanding treatment-emergent
suicidality was
proposed
Sasha Saunders, Honours student, 2011, Kemp & colleagues, 2013,
Psychopharm, Dec 15. [Epub ahead of print]

HRV & emotion recognition
Daniel Quintana, 2010-2013, PhD Student. Kemp & colleagues, 2012. International Journal of Psychophysiology

HRV is reduced in depression
Kemp et al.., 2010, 2011, 2012.. Biological Psychiatry.
Hedges's g and 95% CI
p-Value
0.312
0.340
0.001
0.124
1.000
0.040
0.744
0.009
1.000
0.869
0.607
0.828
0.686
0.731
0.027
-2.00 -1.00 0.00 1.00 2.00
Reduced HRV Increased HRV
frequency HRV
Reduced HRV
Unmedicated depressed patients
without CVD display reduced HRV
(relative to controls)
Small effect size of HRV in time &
frequency domain (Hedges g: ~0.3)
Large effect size of HRV in non-linear
domain (Hedges g: 1.9)

Reduced HRV is a trait marker of depression
Brunoni, Kemp, et al. (2013). The International Journal of
Neuropsychopharmacology

Depression & anxiety comorbidity
Method: Case-control
Sample:
CTLS: n=94
MDD alone: n=24
MDD+PD/PTSD: n=14
MDD+GAD: n=24
› Major depressive disorder (MDD) with generalised anxiety
disorder (GAD) display greatest reductions in HRV relative to
CTLS
› Findings were NOT able to be explained by increased
depression severity
Kemp et al.., 2012. PLoS ONE.

HRV & Generalised Anxiety Disorder
MDD with
GAD
Worry &
hyper –
vigilance
Unable to
disengage
threat
detection
Chronic
withdrawal of
PNS
long term
reductions in
HRV
Increased
risk for CVD
& SCD
Kemp et al.., 2012. PLoS ONE.

Impact of past anxiety disorder
Past – but not current anxiety – adversely impacts HRV
› Method: case – control
› Sample: Women with hx of
anxiety (n=22) versus
women w/out (n=34)
› Resting state HRV is
reduced in mothers with hx
of anxiety disorder in first
trimester
Braeken, Van Den Bergh, Kemp, PLOS
ONE, 2013

› Method: case – control
› Sample: Infants of women with past
anxiety (n=16) versus infants of
women w/out (n=28)
› History of maternal psychopathology
impacts on HRV in mother and infant
› Implications: reduced HRV in
infants may predispose them to
future psychiatric illness & reduced
longevity
RMSSD Child
Healthy
Lifetime Anxiety
4
3
2
1
0
Healthy
p=.048, Hg=.63 Lifetime Anxiety
RMSSD Child
Impact of past anxiety disorder on offspring
Braeken, Van Den Bergh, Kemp, PLOS
ONE, 2013

What is the impact of antidepressants on HRV?
No difference with SSRIs
Increased HRV with rTMS
Reduced HRV with TCAs
No difference in HRV
Kemp et al.., 2010. Biological Psychiatry.
Method: Meta-analysis
Sample: N=186

No impact of tDCS or sertraline on HRV… even in
treatment responders!
Brunoni, Kemp, et al. (2013). The International Journal of
Neuropsychopharmacology

Longitudinal findings (2-yrs): all classes of a/deps
affect HRV
› 2-year changes in HRV in
different antidepressant groupings
› respiratory sinus arrhythmia
(RSA) = measure of HRV
› All classes of antidepressants
adversely affect HRV
› TCA > SNRI > SSRI
Epidemiological findings: TCAs increase risk of CVD over 8 yrs by 35%.
Other findings indicate that antidepressant use (inc SSRI) increases risk of
SCD 3.34-fold.
Licht et al.., 2011. Biological Psychiatry; Hamer et al., 2010. Eur Heart J; Whang et al.,
2009. JACC

Cholinergic Anti-Inflammatory Reflex
Vagal function plays
critical role in
inflammation (hence
CAR)
Nicotinic acetylcholine
receptor α7 subunit is an
essential regulator of
inflammation
Dysregulation  excess
of cytokines, impaired
fasting glucose & HPA-axis
dysregulation
(neurosurgeon) Kevin Tracey & colleagues, 2002 – 2012; Wang et al. 2003. Nature; Thayer & Sternberg,
2010

HRV & components of the metabolic syndrome
› N=228, participants aged
18 – 21yrs
› SBP, hs-CRP associated with
decreases HRV
› MVPA associated with increases
WC: waist circumference in HRV
MVPA: moderate-to-vigorous physical activity
SBP: systolic blood pressure
Trg: triglycerides
Glu: glucose
HDL: high-density lipoprotein
hs-CRP: C-reactive protein
Soares-Miranda et al., 2012. Diabetes Metab Res
Rev

Cortical structures
Amygdala
Nucleus
Ambiguus
Vagus
Decreased HRV
Nucleus Tractus Solitarius
Increased HRV
Response to
environmental
challenge
Nucleus Tractus Solitarius
Social behaviour
Chronic reductions in HRV Chronic elevation in HRV
Psychophysiological rigidity Psychophysiological flexibility
Morbidity, mortality Health, longevity
Phasic change:
normal
response
to environment
Chronic
change:
implications
for mortality /
longevity

Vagal nerve
function
Behavioural
response strategies
Emotion
Psychophysiological
flexibility
Control of inflammatory
Psychiatric
Illness
Resilience
Wellbeing
processes
Physical disease
Mortality Longevity
Vagal nerve
dysfunction,
psychiatric
illness, ill-health
Healthy vagal
nerve function,
well-being,
longevity

Call for Contributions
http://www.frontiersin.org/emotion_science/researchtopics/mechanisms_underpinning_the_li/2668

Acknowledgements & Thanks
Dan Quintana
PhD Student, 2010-2013
Prof Gin Malhi
University of Sydney
Prof Richard Bryant
University of NSW
Prof Paulo Lotufo
USP
A/Prof Isabela Benseñor
USP
Dr Andre Brunoni
USP
Prof Bea Van Den Bergh
Tilburg University
Ruth Wells
Honors Student, 2011
Jonathan Krygier
PhD Student, 2011-

Acknowledgements
Paulo Lotufo Isabela Benseñor Andre Brunoni
… and the team at Centro de Pesquisa Clinica e Epdemiológica

Bridging the gap between emotion and health

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