An Exploration of Stress Reactivity, Stress Recovery, Mindfulness Meditation and Prayer with the use of Heart Rate Variability School of Kinesiology and Health Science Iqra Ashfaq A THESIS SUBMITTED TO THE FACULTY OF GRADUATE STUDIES IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE GRADUATE PROGRAM IN KINESIOLOGY & HEALTH SCIENCE YORK UNIVERSITY TORONTO, ONTARIO December 2016 © Iqra Ashfaq i" Abstract Heart rate variability (HRV) is a vagal nerve-mediated index of cardiac function, and is a useful tool in investigating the sympathetic and parasympathetic functions of the autonomic nervous system. This study investigated post-stress HRV changes during mindfulness meditation (MM) and while listening to a prayer passage from the Holy Quran, which comprise two stress reduction practices that are expected to elevate HRV and promote relaxation. Undergraduate Muslim students (N = 114; 65% female) were exposed to a lab- based assessment in which HRV was measured during: (1) a 5-minute baseline-resting phase; (2) a 5-minute cognitive stress-induction phase; and (3) a 10-minute post-stress phase. In the post-stress phase, participants were randomly assigned to one of the following four 10- minute audio conditions: (1) a meditation experimental (MExp) condition involving guided- MM; (2) a meditation control (MCon) condition involving a description of MM; (3) a prayer experimental (PExp) condition involving a prayer passage from the Holy Quran; or (4) a prayer control (PCon) condition involving a description of prayer. Results revealed that the mean HF-HRV was lower during the stress-induction phase, compared to mean HF-HRV at the baseline phase. Results for male participants revealed greater mean HF-HRV for participants in the MExp group than the MCon group at the 1–5 min and 6–10 min post- stress phases and results for female participants revealed greater mean HF-HRV for the MExp group than the MCon group only at the 1–5 min phase. Further analyses of females with self-reported dysphoric mood revealed greater mean HF-HRV for participants in the MExp group than the MCon group at the 1–5 min post-stress phase and it revealed greater mean HF-HRV for participants in the PExp group than the PCon group at the 6–10 min post- stress phase. These results suggest that while MM and listening to a prayer may be involved ii" in different processes, they both can promote relaxation following a cognitive stressor exposure for Muslim female participants with dysphoric mood. Keywords: heart rate variability, mindfulness meditation, prayer, Quran, stress, dysphoric mood " iii" Acknowledgement Alhamdu lillahil lathi hadana lihatha wama kunna linahtadiya laola an hadanallah (Praise be to Allah, who has guided us to this. Never could we have found guidance, had it not been for the guidance of Allah; Quran 7:43). All praise be to Allah, for guiding me to an idea and blessing me every step of the way until its final completion. I began as a young undergraduate student, desiring to explore religious practices through a scientific lens. My vision became a reality when Dr. Paul Ritvo agreed to supervise my research. At that moment I did not know he would not only become my supervisor, but one of my biggest supporters. Thank you Dr. Ritvo for believing in this study and encouraging me throughout the entirety of my academic journey. Thank you Dr. Joel Katz for your insightful suggestions and precise revisions from my proposal to my final thesis report. The endless support from my Health Behaviour Change lab mates began immediately and the members of this lab quickly went from lab mates to good friends. Thank you Kiara Clory for being by my side right from the beginning. Thank you Abid Azam and Saam Azargive for being great mentors and for spending your personal time to help me design my study. Thank you Arsh Randhawa, Sarah Pludwinski, Tina Changoor and Daniel Perez for all your valuable advice and support and thank you Dr. Noah Wayne for allowing me to share my final research with your students. The overly ambitious recruitment, data collection and data entry would not have been completed if it wasn’t for the help the Muslim Student Association (MSA) and the help from Vina Mohabir, Sawil Ghorany, Alex Mentis, Krista Walker, Maliha Syeda, and Alaa Youssef; thank you ladies for volunteering your time to help me reach my goals. I am forever grateful to Meysam Pirbaglou for selflessly spending endless nights helping me complete my analysis and reminding me of the importance of this research throughout. A special thanks goes to my family and friends for all their support and mostly importantly for their prayers. Thank you to my mom, Dilnaz Ashfaq, who inspired me to select Surah Rahman by emphasizing the blissful nature of the passage. Thank you to my dad, Mohammad Ashfaq, for your words of wisdom. Thank you to my sister and brother, Sana and Ahsan Ashfaq, for listening to me speak about each step of the study. Thank you to Nadia Husain not only for your amazing graphic design skills, but for being one of my biggest cheerleaders. Thank you Sanum Baig, Lauren Chan and Sarah Sartaj for your constant support and understanding of my unpredictable schedule. Thank you to all my family, friends and additional volunteers who took the time to express their experience of listening to Surah Rahman for 7 consecutive days and thank you to everyone who constantly inquired about the study; your pure excitement was the fuel to my motivation. This study would not have been successful without all the participants who volunteered their time—I am sorry that you had to go through the deceiving stress task. Finally, thank you Qari Ziyaad Patel for your beautiful recitation and words of encouragement. Rabbana taqabbal minna innaka anta alssameeAAu alAAaleemu (Our Lord, accept [this] from us. Indeed You are the Hearing, the Knowing; Quran 2:127) " iv" Table of Contents Abstract .................................................................................................................................... ii Acknowledgement .................................................................................................................. iv 1.0 Introduction ................................................................................................................... 1 2.0 Literature Review ............................................................................................................. 3 2.1 The Autonomic Nervous System and Stress ............................................................................ 3 2.2 Heart Rate Variability and Stress ............................................................................................ 6 2.3 Heart Rate Variability Mechanisms & Measurement ............................................................ 8 2.4 Psychophysiological Theories of Heart Rate Variability ...................................................... 11 2.5 Heart Rate Variability as a Marker of Psychopathological Risk ........................................ 13 2.6 Heart Rate Variability as a Marker of Physical Illnesses .................................................... 16 2.7 Mindfulness Meditation (MM) ................................................................................................ 17 2.8 Physiological and Relaxation effects of Meditation .............................................................. 19 2.9 Physiological and Relaxation effects of Spiritual and Religious Practices ......................... 20 3.0 Methods ............................................................................................................................ 22 3.1 Participants ............................................................................................................................... 22 3.2 Materials ................................................................................................................................... 24 3.3 Measures ................................................................................................................................... 25 3.4 Procedure .................................................................................................................................. 28 3.5 Data Extraction and Pre-processing of Physiological Measures ......................................... 34 3.6 Hypotheses ................................................................................................................................ 34 3.7 Statistical Analyses ................................................................................................................... 37 4.0 Results .............................................................................................................................. 38 4.1 Outline of Results Section ........................................................................................................ 38 4.2 Participant Recruitment and Flow ......................................................................................... 38 4.3 Group characteristics ............................................................................................................... 41 4.4 Hypothesis Testing ................................................................................................................... 51 5.0 Discussion ........................................................................................................................ 78 5.1 Summary of Findings and Measures ...................................................................................... 78 5.2 Discussion of Results ................................................................................................................ 80 5.3 Implications .............................................................................................................................. 92 5.4 Strengths and Limitations ....................................................................................................... 94 5.5 Future Research Directions ..................................................................................................... 95 6.0 Conclusion ....................................................................................................................... 97 References .............................................................................................................................. 99 Appendix A – Systematic Review ...................................................................................... 129 Appendix B – Randomization Sheet .................................................................................. 152 Appendix C – Problem Sets for Pattern Recognition Task (PRT) ................................. 153 Appendix D – Questionnaires ............................................................................................ 154 The Centrality of Religiosity Scale-15 (CRS-15; Huber & Huber, 2012) ..................................... 155 Supplementary Questionnaire ........................................................................................................ 159 Post-Pattern Recognition Task (PRT) Questionnaire .................................................................... 166 Post-Listening Intervention Questionnaire: Experience ................................................................ 167 " v" Post-Listening Intervention Questionnaire: Understanding Meaning ............................................ 168 Appendix E – Debriefing Statement .................................................................................. 171 " vi" 1.0 Introduction The common everyday challenges of prolonged stress can lead to the onset and progression of physical and mental health disorders (McEwen & Stellar, 1993; Steptoe, 1991). In 2013, 23% of Canadians (~ 6.6 million), 15 years or older, rated most days as ‘extremely stressful’ or ‘quite a bit stressful’ (Statistics Canada, 2014). In addition, a variety of studies together suggest that 60–90% of primary care visits are related to stress issues (Puchalski, 2001). Thus the stress reduction methods utilized by individuals and their effectiveness for health enhancement and/or health sustainability is a central public health concern. In the healthy management of stress, the autonomic nervous system (ANS) regulates visceral body functions and, in this way, plays a key role in preventing mental and physical disease (Battipaglia & Lanza, 2015; Thayer & Brosschot, 2005). The dynamic equilibrium of individuals can be deranged by the stress experienced under conditions of perceived physical or psychological threat (Chrousos, 2009; Thayer, Ahs, Fredrikson, Sollers III &Wager, 2012). The stress response can be prolonged or excessive (i.e., an exaggerated cardiac response to mild-moderate stress), delaying the reinstatement of homeostasis. This excess stress, associated with sympathetic-parasympathetic imbalance (SPI), may lead to both mental (Hovey & King, 1996) and physical dysfunctions (e.g., hypertension and myalgic pain; Fechir et al., 2008), while contributing to or exacerbating diagnosable chronic diseases (Kiecolt-Glaser et al., 2003). Flexible ANS regulation is essential for dealing with rapidly changing environmental demands (Thayer & Brosschot, 2005; Thayer et al., 2012) and is reflected in heart rate variability (HRV) defined as the variation in the time intervals between heartbeats (Thayer et 1" al., 2012; Thayer, Hansen, Saus-Rose, & Johnsen, 2009). HRV is a useful tool in investigating the sympathetic and parasympathetic function and balance in the ANS (Karim, Hasan, & Ali, 2011; Thayer, Yamamoto, & Brosschot, 2009). HRV has been used to index autonomic function in relation to (but not limited to) acute stress (Fabes & Eisenberg, 1997; Pattyn, Migeotte, Neyt, den Nest, & Cluydts, 2010; Radespiel-Tröger, Rauh, Mahlke, Gottschalk, & Mück-Weymann, 2003), cardiovascular diseases (Chida & Steptoe, 2010; Kemp, Quintana, Felmingham, Matthews, & Jelinek, 2012; Stein & Kleiger, 1999) such as hypertension (Masi et al., 2007; Thayer & Lane, 2007) and coronary artery disease (Carney et al., 1988); diabetes (Ewing et al., 1981; Maser, Mitchell, Vinik, & Freeman, 2003); psychopathology (Lyonfields, Borkovec, & Thayer, 1995; Marano et al., 2009; Miu, Heilman, & Miclea, 2009; Thayer, Friedman, & Borkovec, 1996) such as major depression (Chambers & Allen, 2002; Rottenberg, 2007) and anxiety (Friedman, 2007); and emotion regulation (Calkins & Johnson, 1998; Quintana, Guastella, Outhred, Hickie, & Kemp, 2012). For the purposes of studying behavioural interventions to help recover from stress, HRV was measured to index the flexible control of the ANS via peripheral physiology (Thayer et al., 2012). In addition, HRV has been used to examine autonomic function in relation to attentional regulation (Porges, 1992). Attentional regulation involves recognizing relevant information and inhibiting inappropriate responses to maintain health in complex environments (Sarter, Givens, & Bruno, 2001; Thayer & Brosschot, 2005; Thayer & Lane, 2000). Deficits in sustained attention are detrimental to health—as they are present in mental illnesses such as depression and anxiety (Hammar et al., 2003; Sheppes, Luria, Fukuda, & Gross, 2013). It has been suggested that the decline in attention and in other cognitive " 2" functions due to stress is related to autonomic dysfunction. With the use of HRV, the parasympathetic activity involved in top down attention regulation can be inferred (Applehans & Luecken, 2006). Therefore, it is essential to study practices that deem to improve attention regulation via cardiac autonomic response modulation, promoting healthy stress reactivity. Together, these findings justified the importance of examining the physiological effects (sympathetic-parasympathetic activity) of stress-reduction practices (i.e., mindfulness meditation (MM) and listening to a prayer passage from the Quran) in the aftermaths of a stress response (stimulated by a stress-induction task). The following literature review begins with a summary of the effect of stress on the autonomic nervous system. Next, there is a summary of HRV, including it as a marker of psychophysiological responses and stress-related illnesses, and the psychopathological theories underlying HRV. Furthermore the review includes the evidence-based benefits of MM and spiritual/religious practices. The study’s rationale and hypotheses are supported by the following review. Section 3 depicts the methods of the study, including participant recruitment, the inclusion- exclusion criteria, data acquisition equipment, self-report measures, procedures, and statistical analysis. Section 4 describes the final results of this study and section 5 discusses the study’s clinical implications and limitations. 2.0 Literature Review 2.1 The Autonomic Nervous System and Stress The autonomic nervous system (ANS) is central as it controls visceral body functions (e.g., heart activation), and plays a key role in preventing mental and physical disease (Battipaglia & Lanza, 2015; Thayer & Brosschot, 2005). The ANS consists of regions in the " 3" central nervous system and associated peripheral nerves that anatomically and functionally divide into the excitatory sympathetic (i.e., energy mobilization, “fight or flight”) and inhibitory parasympathetic (i.e., vegetative and restorative function, “rest and digest”) subsystems (Appelhans & Luecken, 2006; Battipaglia & Lanza, 2015; Thayer, Yamamoto, & Brosschot, 2009). The sympathetic fibers exit thoracic and lumbar segments of the spinal cord whereas parasympathetic fibers exit the brainstem and sacral segments of the spinal cord (Porges, 2003). The dynamic equilibrium of individuals can be deranged by the stress experienced under conditions of perceived physical or psychological threat (Chrousos, 2009; Thayer, Ahs, Fredrikson, Sollers III &Wager, 2012). Physical or psychological stressors trigger a “stress response” that activates physiological arousal via the sympathetic nervous system (e.g., increasing glucose, heart rate (HR) and blood pressure; Appelhans & Luecken, 2006; Chrousos & Gold, 1992; De Kloet, Joëls, & Holsboer, 2005), which is then terminated by the activation of the parasympathetic nervous system (De Kloet, Joëls, & Holsboer, 2005). When confronting stressors, an effective system involves the rapid activation of the stress response followed by efficient termination—reinstating homeostasis. However, if the stress response is prolonged or inadequate, it becomes difficult to reinstate homeostasis and leads to risk factors for cardiovascular disorder and psychiatric illness (Brosschot, Gerin, & Thayer, 2006; Verkuil, Brosschot, de Beurs, & Thayer, 2009). Stress responses reflected in a hyperactive sympathetic system dominating a hypoactive parasympathetic system result in elevated risks for mental and physical pathology (Thayer & Brosschot, 2005). The excess stress associated with autonomic imbalance have been proposed to lead to eating disorders, substance abuse, excess smoking/alcohol consumption (Ferguson, Willemsen, & Castañeto, 2010), suicidal ideation; autonomic imbalance can also lead to depression (Hovey & King, " 4"