Heart Rate Variability Biofeedback (HRVB): A Physiological Approach to Stress

The Physiological Impact of Stress

In moments of stress, it is not uncommon for an individual to feel a sudden increase in heart rate, shortness of breath, sweaty palms, or tightening muscles. These physiological responses are part of the body’s natural reaction to stress. Common triggers for stress and anxiety may include external threats, such as upcoming work deadlines, interpersonal or romantic relationship difficulties, and financial pressures, or internal perceptions of threats, such as concerns about what others might think of oneself, how one may be perceived in different social circumstances, and onwards. While these reactions may occasionally be appropriate, when they become excessive they may contribute to further difficulties, including insomnia, persistent worry, racing thoughts, stomach pain, and light-headedness. If the body’s reaction to stress matches this pattern consistently, it may indicate that the body’s natural stress response is out of balance.

We can attempt to understand this pattern of physiological imbalance through biology.  In these moments, one’s sympathetic (“fight-or-flight”) nervous system (SNS) is activated, whereas their parasympathetic (“rest-and-digest”) nervous system (PNS) is withdrawn (Weissman & Mendes, 2021). At times, this can be quite adaptive. For example, if you are in the face of a genuine threat (i.e., a car is about to hit you), it is important for your body to react instinctively and prepare to get out of the way. With that being said, there are other times where this response can be maladaptive. For instance, if one is overwhelmed by cognitive and/or somatic symptoms of anxiety, whether that be over a looming deadline, romantic endeavor, or public speaking, their symptoms may inhibit them from engaging in these tasks, thus creating a self-fulfilling prophecy whereby they fall short.

To better understand your body’s inherent stress response from a biological perspective, let’s look at a hypothetical scenario:

Imagine that you hear a loud noise in your home in the middle of the night. In response, one might instinctively gasp (i.e., a sharp, shallow inhale) and prepare for conflict. One may think to themselves, “There’s an intruder in my home! I need to get ready to fight!” or “What if someone is hurt? I need to run and get help!” Physiologically, one’s heart might start racing, their muscles may begin to tense, and their senses may heighten. These immediate bodily reactions reflect the body’s natural “fight-or-flight” response, preparing your body to respond to a threat by either getting ready to fight or run away.

Now, let’s assume that the noise you heard was innocuous, such as a pet moving around, and was not a real threat. In this scenario, one might release a sigh of relief (i.e., a slow, measured exhale), feel their muscles begin to relax, and heart rate slow down. These reactions reflect the body’s natural “rest-and-digest” response, shifting the body from hypervigilance to return to a calmer state. For many people, this transition only takes a few minutes; however, some others might get stuck in this state of nervous system imbalance for significantly longer and struggle to fall back asleep.

Over time, prolonged stress, both psychologically and physiologically, can create a myriad of pathological symptoms. These include but are not limited to sleep disruptions (i.e., insomnia), difficulty sustaining attention, mood fluctuation, impaired gastric activity (i.e., stomach pain), and onwards (Shaffer & Ginsberg, 2017; Tiwari et al., 2021). Now that we understand how stress can impact the body, let’s review a non-invasive method of treatment.

Heart Rate Variability Biofeedback (HRVB)

Heart rate variability biofeedback (HRVB) training provides a behavioral, evidence-based way to regain balance in the nervous system, improve the body’s natural stress response, and ultimately facilitate more adaptive responses to the challenges of daily life (de Souza et al., 2022; Lalanza et al., 2023;). HRVB is a non-invasive, non-medication-based intervention, focused on training the body to calm itself down naturally rather than through pharmacological means. HRVB training works by teaching an individual to synchronize their breathing (i.e., respiratory rate) with their heart rhythm. In doing so, this synchrony can enhance the flexibility of the nervous system in response to stressors.

In HRVB training, an important physiological marker of treatment effectiveness is heart rate variability (HRV). Unlike average heart rate, which is a measure of one’s heartbeats per minute (bpm), HRV looks at the difference in timing between each individual heartbeat (Shaffer & Ginsberg, 2017). Generally speaking, higher HRV means that one can better adapt to stressors as they arise (i.e., the fluctuation between SNS and PNS activation is flexible and adaptive), whereas lower HRV is associated with a fight-or-flight response and stress (i.e., primarily SNS activation; Hughes, 2025). Research has demonstrated that healthy adult populations typically have an average HRV of around 42 milliseconds (ms), within a range of 19-75ms. At times, this range can even extend to 120ms, particularly in athletes (Tiwari et al., 2021). Moreover, a collection of data tracking HRV in adults on a regular basis found that the median HRV is 35ms for healthy adult women and 34.2ms for healthy adult men (Hughes, 2025). With this in mind, the focus of HRVB training is less on attaining a specific HRV number, as each individual’s body is unique, and more on improving one’s specific body’s natural response to stress over time.

A key goal of HRVB training is to strengthen a physiological state called respiratory sinus arrhythmia (RSA). In scientific terms, RSA is a measure of cardiac vagal modulation. More specifically, it is a measure of the variability in the natural rise in heart rate when you inhale, driven by the SNS (i.e., the “fight-or-flight” system), and the corresponding fall in heart rate when you exhale, moderated by the PNS (i.e., the “rest-and-digest” system). This may sound familiar, as HRV is a measure of the difference between individual heart beats.

RSA is important because it reflects the functioning of the vagus nerve, the main part of the PNS responsible for regulating involuntary functions such as heart rate, digestion, and breathing. A healthy RSA indicates that your body can shift more easily between states of relaxation and stress via the PNS’ control of the vagus nerve (Munafò et al, 2016; Weissman & Mendes, 2021). Research has found that paced, diaphragmatic breathing at a rate of between 4.5 and 6.5 cycles per minute can stimulate one’s cardiovascular system in a way that leads to higher HRV and a variety of physiological and mental health benefits (Riberio et al., 2023).

A pivotal aspect of HRVB is that it provides an individualized window into the body’s natural stress response. When engaging in this intervention, one can see the subtle timing differences between their heartbeats, showing how effectively their SNS and PNS interact with one another in real time. HRVB training has been reliably demonstrated in relevant research to help prevent excessive or prolonged SNS activation, promote resilience and emotional regulation, and enhance physical and psychological well-being (Pizzoli et al., 2021).

Clinical Applications and Benefits of HRVB

Research findings support the effectiveness of HRVB treatment for a variety of cognitive and behavioral concerns, including but not limited to:

• Reduced symptoms of depression and anxiety (Lehrer et al, 2020; Park & Roth, 2023; Pizzoli et al., 2021).

• Enhanced emotional regulation and attention, persisting 4-5 weeks after the end of the intervention (de Souza et al., 2022; Shaffer & Ginsberg, 2017;).

• Improved sleep and reduced insomnia, even after as little as two sessions (Hasuo et al., 2020).

• Increased self-regulation, adaptability, and resilience (Shaffer & Ginsberg, 2017).

• Improved athletic and artistic performance (Lehrer et al., 2020).

• Reducing susceptibility to stress-related cardiovascular disorders (Munafò et al, 2016).

Integration with Psychotherapy

HRVB can be used as a stand-alone intervention, with training typically lasting 2-5 sessions until a patient gains mastery over the technique, or as an adjunct to psychotherapy treatment, such as cognitive behavioral therapy (CBT), mind-body therapies (MBT), or acceptance and commitment therapy (ACT). Integrating HRVB into psychotherapy treatment has been found to improve several treatment outcomes. In particular, adding HRVB to psychotherapy has been shown to promote improvement in depressive symptoms, PTSD, and generalized anxiety disorder, among other conditions (Caldwell & Steffen, 2018; Criswell et al., 2018; Park & Roth, 2023).

Anecdotally, when integrated with behavioral therapy, HRVB can help reduce physiological symptoms of anxiety that may interfere with behavioral interventions, such as during exposure and response prevention exercises. For example, a patient that practices biofeedback before, after, or during a session may notice reduced muscle tension, anxiety, and a calmer heart rate. In turn, this may make it easier to identify and challenge unhelpful thoughts, engage with exposure exercises, and implement coping strategies more effectively.

Similarly, when combined with ACT or MBT, HRVB can support mindfulness-based interventions by helping patients stay grounded in the present moment, tolerate difficult emotions, and redirect their attention toward value-driven behaviors. For instance, a patient who learns to notice their stress responses during HRVB practice may be better equipped to accept uncomfortable emotions without judgment. In doing so, they may be better able to choose behaviors that align with their personal values, even in the presence of anxiety or fear.

How is HRVB Different From Other Breathing Techniques?

Unlike standard, “one-size-fits-all” breathing exercises, HRVB is individualized and data driven. Of course, many mindful breathing techniques promote general relaxation. What separates HRVB from other breathing techniques is the in-the-moment monitoring of one’s heart rhythms to identify the specific breathing rate and pattern that maximizes RSA, unique to each individual. This allows the intervention to be tailored to your specific physiology, making it more effective than a generalized approach.

How Does HRVB Look In-Practice?

In-Office Sessions:

• Several non-invasive sensors (usually on the fingertip, hand, and stomach) track your heart rhythm, respiration rate, and skin conductance, shown on a visual display in real time.

• A heart rate monitor is placed on your fingertip or earlobe, tracking your heartbeat moment-to-moment and facilitating calculation of HRV.

• Two sensors are placed on your hand that measure galvanic skin response (GSR), the electrical conductance of your skin, which increases with stress and decreases with relaxation.

• A respiration band, resembling a seat belt, rests on your stomach and measures respiration rate to ensure paced, diaphragmatic breathing that optimizes RSA.

• Guided by your clinician, you practice paced diaphragmatic breathing, receiving immediate feedback on how your nervous system responds in order to create an individualized breathing technique that works best for your body.

At-Home Practice:

• Use of a smartphone app measures heart rate and moment-to-moment variation in heartbeats via the phone’s camera.

• An app, or smart watch, guides you through paced breathing exercises, providing visual or auditory feedback. Alternatively, one can keep pace themselves.

• Short daily sessions, about 2-5 minutes per day, help reinforce skills learned in the office and generalize them to everyday stressors.

During an in-office session, you and your clinician will monitor how your heart rhythm, GSR, and respiration rate respond on the visual display as you experiment with slightly faster or slower breaths, finding the precise pace that works best for you. At home, the use of a smartphone app that tracks moment-to-moment heartbeats can help guide you through the same tailored breathing technique, providing real-time feedback and reinforcing the skills built in the office.

Case Examples

In one case, a 39-year-old female was referred for a seven-week HRVB adjunctive treatment for comorbid generalized anxiety disorder and depression. After completing the assigned treatment protocol, their reported anxiety improved from severe to mild, and their depression improved from mild to minimal. These improvements were sustained at a four-week follow-up. After eight weeks, the patient reported that their anxiety was no longer a concern (Park & Roth, 2023).

In another case, a 41-year-old medical receptionist experiencing shoulder and arm pain learned to pair HRVB with ACT-based mindfulness skills. Importantly, her reported frustration with co-workers and her work environment heightened her physiological stress response. Through HRVB and mindfulness practice, she was better able to manage these reactions when imagining stressful work scenarios. At follow-up, she reported only occasional pain and stiffness, which she could manage effectively with her newly learned HRVB technique (Gevirtz, 2024).

Overall, by integrating HRVB with psychotherapy, patients can gain the behavioral tools needed to better regulate their body’s inherent stress response alongside the cognitive strategies to promote psychological flexibility, resilience, and facilitate living a value-driven life.

Summary

HRVB is a non-invasive, behavioral, evidence-based approach that teaches an individual to train their nervous system to respond more flexibly and adaptively to stress.

Unlike standard breathing exercises, HRVB is individualized and data-driven, working to identify the specific breathing technique, rate, and pattern that best supports each patient’s unique physiology.

By optimizing respiratory sinus arrhythmia (RSA), the natural rise and fall of heart rate with breathing, HRVB strengthens the balance between the sympathetic (“fight-or-flight”) and parasympathetic (“rest-and-digest”) branches of the autonomic nervous system, supporting recovery from stress, improved emotional regulation, and a variety of other beneficial mental and physical health factors.

In-office sessions provide real-time feedback to help patients discover their optimal breathing rhythm and rate. At-home practice reinforces the skills learned in the office and promotes the generalization of the benefits of HRVB to everyday stressors. Paired with psychotherapies such as CBT and ACT, HRVB has been found to reduce excessive anxiety, enhance mindfulness, and strengthen adaptive responses to the challenges of daily life. 

References

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