Effects of heart rate variability biofeedback during exposure to fear-provoking stimuli within spider-fearful individuals: Study protocol for a randomized controlled trial

Sarah K. Schäfer, Frank R. Ihmig, Karen A. Lara H., Frank Neurohr, Stephan Kiefer, Marlene Staginnus, Johanna Lass-Hennemann, Tanja Michael

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12 Citations (SciVal)


Background: Specific phobias are among the most common anxiety disorders. Exposure therapy is the treatment of choice for specific phobias. However, not all patients respond equally well to it. Hence, current research focuses on therapeutic add-ons to increase and consolidate the effects of exposure therapy. One potential therapeutic add-on is biofeedback to increase heart rate variability (HRV). A recent meta-analysis shows beneficial effects of HRV biofeedback interventions on stress and anxiety symptoms. Therefore, the purpose of the current trial is to evaluate the effects of HRV biofeedback, which is practiced before and utilized during exposure, in spider-fearful individuals. Further, this trial is the first to differentiate between the effects of a HRV biofeedback intervention and those of a low-load working memory (WM) task. Methods: Eighty spider-fearful individuals participate in the study. All participants receive a training session in which they practice two tasks (HRV biofeedback and a motor pseudo-biofeedback task or two motor pseudo-biofeedback tasks). Afterwards, they train both tasks at home for 6 days. One week later, during the exposure session, they watch 16 1-min spider video clips. Participants are divided into four groups: group 1 practices the HRV biofeedback and one motor pseudo-task before exposure and utilizes HRV biofeedback during exposure. Group 2 receives the same training, but continues the pseudo-biofeedback task during exposure. Group 3 practices two pseudo-biofeedback tasks and continues one of them during exposure. Group 4 trains in two pseudo-biofeedback tasks and has no additional task during exposure. The primary outcome is fear of spiders (measured by the Fear of Spiders Questionnaire and the Behavioral Approach Test). Secondary outcomes are physiological measures based on electrodermal activity, electrocardiogram and respiration. Discussion: This RCT is the first one to investigate the effects of using a pre-trained HRV biofeedback during exposure in spider-fearful individuals. The study critically contrasts the effects of the biofeedback intervention with those of pseudo-tasks, which also require WM capacity, but which do not have a physiological base. If HRV biofeedback is effective in reducing fear of spiders, it would represent an easy-to-use tool to improve exposure-therapy outcomes.

Original languageEnglish
Article number184
Issue number1
Publication statusPublished - 16 Mar 2018

Bibliographical note

Funding Information:
(Bundesministerium für Bildung und Forschung) for funding this study with an applied research grant. We thank any individual taking part in our study for contributing to our research. Moreover, we thank all Master’s students and student assistants who supported the trial.

Funding Information:
Funding for this trial was kindly provided by the German Federal Ministry of Education and Research through an applied research grant (contract numbers 13GW0158B and 13GW0158C) within the program “Medical technology solutions for the digital healthcare” (German: “Medizintechnische Lösungen für die digitale Gesundheitsversorgung”). Members of the project “DigiPhobie – Digital Therapy for the Treatment of Specific Phobia at Home” (German: “DigiPhobie – Digitale Therapie zur häuslichen Behandlung von spezifischen Phobien”) are the Department of Clinical Psychology and Psychotherapy, Fraunhofer Institute for Biomedical Engineering, Saarland University Medical Center, and Promotion Software GmbH. The founders had no role in the development and the design of the trial. It had also no influence in the preparation or approval of the manuscript.

Publisher Copyright:
© 2018 The Author(s).

Copyright 2019 Elsevier B.V., All rights reserved.


  • Biofeedback
  • Exposition therapy
  • Exposure therapy
  • Fear of spiders
  • Heart rate variability
  • HRV biofeedback
  • Spider phobia

ASJC Scopus subject areas

  • Medicine (miscellaneous)
  • Pharmacology (medical)


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