Heart rate variability associated with posttraumatic stress disorder in victims' families of sewol ferry disaster

Attenuated peripheral oxygen extraction and greater cardiac output in women with posttraumatic stress disorder during exercise

Posttraumatic stress disorder (PTSD) is associated with an increased risk of developing cardiovascular disease, especially in women. Evidence indicates that men with PTSD exhibit lower maximal oxygen uptake (V̇o2max) relative to controls; however, whether V̇o2max is blunted in women with PTSD remains unknown. Furthermore, it is unclear what determinants (i.e., central and/or peripheral) of V̇o2max are impacted by PTSD. Therefore, we evaluated the central (i.e., cardiac output; Q̇c) and peripheral (i.e., arteriovenous oxygen difference) determinants of V̇o2max in women with PTSD; hypothesizing that V̇o2max would be lower in women with PTSD compared with women without PTSD (controls), primarily due to smaller increases in stroke volume (SV), and therefore Q̇c. Oxygen uptake (V̇o2), heart rate (HR), Q̇c, SV, and arteriovenous oxygen difference were measured in women with PTSD (n = 14; mean [SD]: 43 [11] yr,) and controls (n = 17; 45 [11] yr) at rest, and during an incremental maximal treadmill exercise test, and the Q̇c/V̇o2 slope was calculated. V̇o2max was not different between women with and without PTSD (24.3 [5.6] vs. 26.4 [5.0] mL/kg/min; P = 0.265). However, women with PTSD had higher Q̇c [P = 0.002; primarily due to greater SV (P = 0.069), not HR (P = 0.285)], and lower arteriovenous oxygen difference (P = 0.002) throughout exercise compared with controls. Furthermore, the Q̇c/V̇o2 slope was steeper in women with PTSD relative to controls (6.6 [1.4] vs. 5.7 [1.0] AU; P = 0.033). Following maximal exercise, women with PTSD exhibited slower HR recovery than controls (P = 0.046). Thus, despite attenuated peripheral oxygen extraction, V̇o2max is not reduced in women with PTSD, likely due to larger increases in Q̇c.NEW & NOTEWORTHY The current study indicates that V̇o2max is not different between women with and without PTSD; however, women with PTSD exhibit blunted peripheral extraction of oxygen, thus requiring an increase in Q̇c to meet metabolic demand during exercise. Furthermore, following exercise, women with PTSD demonstrate impaired autonomic cardiovascular control relative to sedentary controls. We interpret these data to indicate that women with PTSD demonstrate aberrant cardiovascular responses during and immediately following fatiguing exercise.

Can heart rate variability be a bio-index of hope? A pilot study

Background

Hope can affect the thinking habits, emotional regulations, and behaviors of individuals. Hope is considered as a positive trait by clinicians, who often assess the level of hope in psychological evaluations. Previous measurements of hope were largely based on self-reported questionnaires leading to the problem of subjectivity. Heart Rate Variability (HRV) is a bio index that is an objective, quick, cost effective, and non-invasive measurement. HRV has been used in the evaluation of physical health and some psychiatric conditions. However, it has not been tested for its potential to be a bio-index of the level of hope.

Method

This pilot cross-sectional observational study aimed to examine the relationships between HRV and the level of hope among adult Chinese people in Hong Kong. Convenience sampling was used and 97 healthy participants were recruited. Their level of hope was measured by the Dispositional Hope Scale-Chinese (DHS-C), and their HRV was quantified by emWave Pro Plus, a reliable sensor of HRV. Spearman's correlation coefficient analysis was performed on the HRV measurements and DHS-C.

Results

The DHS-C's overall mean score was 45.49. The mean scores of the subscale DHS-C (Agency) was 22.46, and the mean scores of DHS-C (Pathway) was 23.03. It was also revealed that there were significant, weak, and negative correlations between the level of hope and four out of ten HRV metrics. One HRV metric was found to have a significant, weak, and positive correlation with the level of hope.

Conclusion

This study provided initial evidence to support the use of HRV as a bio-index of hope. Implications of the current study and recommendations for future research directions are discussed.

Heart and brain traumatic stress biomarker analysis with and without machine learning: A scoping review

The enigma of post-traumatic stress disorder (PTSD) is embedded in a complex array of physiological responses to stressful situations that result in disruptions in arousal and cognitions that characterise the psychological disorder. Deciphering these physiological patterns is complex, which has seen the use of machine learning (ML) grow in popularity. However, it is unclear to what extent ML has been used with physiological data, specifically, the electroencephalogram (EEG) and electrocardiogram (ECG) to further understand the physiological responses associated with PTSD. To better understand the use of EEG and ECG biomarkers, with and without ML, a scoping review was undertaken. A total of 124 papers based on adult samples were identified comprising 19 ML studies involving EEG and ECG. A further 21 studies using EEG data, and 84 studies employing ECG meeting all other criteria but not employing ML were included for comparison. Identified studies indicate classical ML methodologies currently dominate EEG and ECG biomarkers research, with derived biomarkers holding clinically relevant diagnostic implications for PTSD. Discussion of the emerging trends, algorithms used and their success is provided, along with areas for future research.

Association of Autonomic Activation with traumatic reminder challenges in posttraumatic stress disorder: A co-twin control study

Post-traumatic stress disorder (PTSD) has been associated with cardiovascular disease (CVD), but the mechanisms remain unclear. Autonomic dysfunction, associated with higher CVD risk, may be triggered by acute PTSD symptoms. We hypothesized that a laboratory-based trauma reminder challenge, which induces acute PTSD symptoms, provokes autonomic dysfunction in a cohort of veteran twins. We investigated PTSD-associated real-time physiologic changes with a simulation of traumatic experiences in which the twins listened to audio recordings of a one-minute neutral script followed by a one-minute trauma script. We examined two heart rate variability metrics: deceleration capacity (DC) and logarithmic low frequency (log-LF) power from beat-to-beat intervals extracted from ambulatory electrocardiograms. We assessed longitudinal PTSD status with a structured clinical interview and the severity with the PTSD Symptoms Scale. We used linear mixed-effects models to examine twin dyads and account for cardiovascular and behavioral risk factors. We examined 238 male Veteran twins (age 68 ± 3 years old, 4% black). PTSD status and acute PTSD symptom severity were not associated with DC or log-LF measured during the neutral session, but were significantly associated with lower DC and log-LF during the traumatic script listening session. Long-standing PTSD was associated with a 0.38 (95% confidence interval, -0.83,-0.08) and 0.79 (-1.30,-0.29) standardized unit lower DC and log-LF, respectively, compared to no history of PTSD. Traumatic reminders in patients with PTSD lead to real-time autonomic dysregulation and suggest a potential causal mechanism for increased CVD risk, based on the well-known relationships between autonomic dysfunction and CVD mortality.

Comparative Analysis of the Psychosocial Symptoms and Experiences of Bereaved Parents and Parents of Children Who Survived the Sewol Ferry Accident After 5 Years: A Qualitative Interview Study

BACKGROUND

This study aimed to investigate the psychosocial symptoms and experiences of bereaved parents of victims and parents of survivors of the Sewol Ferry accident five years after the accident.

METHODS

In-depth interviews of 186 bereaved parents of victims or survivors of the Sewol Ferry accident were conducted. We elicited and categorized meaning units relevant to the psychological, cognitive, and physical traits of the participants from these interviews. Differences in responses between bereaved parents and survivors' parents and between genders were examined using frequency analyses and χ² tests.

RESULTS

Data were organized under seven headings: observed attitude and impression of participants, difficulties due to mental health problems, difficulties due to physical pain, difficulties in relationships, negative changes following the incident, positive changes following the incident, and help needed. Within these headings, 27 themes, 60 sub-themes, and 80 meaning units were elicited.

CONCLUSION

This study explored the psychiatric, physical, and relational problems reported by bereaved parents and those of survivors as well as major changes in their personal and social lives after the Sewol Ferry accident. Differences in responses according to gender were also identified. The results from this study could inform and facilitate the implementation of intervention measures, such as long-term psychological evaluation, to bereaved parents of victims or survivors of disasters.

Disaster Resilience Differs between Survivors and Victims’ Families: A Semantic Network Analysis

The main purpose of this study is to clarify the difference in disaster resilience between survivors and victims’ families by analyzing the language used in popular literature on disaster cases. The results showed that there were differences in emotions, behaviors, attitudes, role perceptions, etc., between survivors and victims’ families in dealing with a disaster. In particular, survivors remember and think about the situation that occurred at the time of the disaster, which creates resilience to the incident, while victims’ families attempt to establish resilience to the incident by investigating the facts and government countermeasures. While survivors were focused on building their own resilience, victims’ families were more focused on improving government countermeasures to prevent such accidents from recurring. This can be considered as social or national resilience. Based on this comparative analysis, it is necessary to prepare various theoretical foundations for disaster preparedness and resilience, while further elaborating the theory.

Autonomic dysfunction and cardiovascular risk in post-traumatic stress disorder

BACKGROUND

Patients with post-traumatic stress disorder (PTSD) have an increased risk for cardiovascular disease. The underlying mechanisms are unclear but impaired autonomic function may contribute. However, research in this field has shown contradictory results and the causal links between PTSD, autonomic dysfunction, and cardiovascular risk remain unknown. This brief review summarizes the current knowledge on alterations in autonomic function and cardiovascular risk in patients with PTSD.

LITERATURE SEARCH STRATEGY

A PubMed search of the literature was performed using the following keywords: autonomic function, heart rate variability, blood pressure variability, sympathetic activity, baroreflex function, and cardiovascular risk in combination with PTSD. Evidence-based studies conducted between 2000 and 2021 were selected.

RESULTS

In total 1221 articles were identified and of these, 61 (48 original research papers, 13 review articles) were included in this review. Many, though not all, studies have reported increased activity of the sympathetic nervous system and decreased activity of the parasympathetic nervous system (namely, autonomic imbalance) in PTSD patients. There seems to be enough evidence to suggest impairments in baroreflex function in PTSD, leading to blood pressure dysregulation. It appears that the chronicity of PTSD diagnosis and symptom severity are independent risk factors for cardiovascular disease, which may be linked with impaired autonomic function.

CONCLUSIONS

Increased cardiovascular risk may be associated with autonomic dysfunction in PTSD. Whether autonomic dysfunction can serve as a biomarker for the onset and progression of PTSD remains to be determined. It also needs to determine if autonomic imbalance increases the risk of developing PTSD.

Autonomic dysfunction in posttraumatic stress disorder indexed by heart rate variability: a meta-analysis

BACKGROUND

Changes in autonomic nervous system (ANS) function have been observed in a variety of psychological disorders, including posttraumatic stress disorder (PTSD). Analysis of heart rate variability (HRV) provides insight into the functioning of the ANS. Previous research on PTSD found lower HRV in PTSD patients compared to controls, indicating altered sympathetic and parasympathetic activity, but findings are inconsistent. The purpose of this meta-analysis was to examine differences in HRV indices between individuals with PTSD and healthy controls at baseline and during stress.

METHODS

The included primary studies present an aggregate of studies analyzing different HRV indices. Examined HRV indices were standard deviation of the normalized NN-intervals (SDNN), root mean square of successive differences (RMSSD), low-frequency (LF) and high-frequency (HF) spectral components, LF/HF ratio, and heart rate (HR). Moderating effects of study design, HRV and PTSD assessment, and sample characteristics were examined via subgroup-analyses and meta-regressions.

RESULTS

Random-effects meta-analyses for HRV parameters at rest revealed significant group differences for RMSSD and HF-HRV, suggesting lower parasympathetic activity in PTSD. The aggregated effect size for SDNN was medium, suggesting diminished total variability in PTSD. A small effect was found for LF-HRV. A higher LF/HF ratio was found in the PTSD sample as compared to controls. Individuals with PTSD showed significantly higher HR. During stress, individuals with PTSD showed higher HR and lower HF-HRV, both indicated by small effect sizes.

CONCLUSIONS

Findings suggest that PTSD is associated with ANS dysfunction.

Toward a Taxonomy for Analyzing the Heart Rate as a Physiological Indicator of Posttraumatic Stress Disorder: Systematic Review and Development of a Framework

BACKGROUND

Posttraumatic stress disorder (PTSD) is a prevalent psychiatric condition that is associated with symptoms such as hyperarousal and overreactions. Treatments for PTSD are limited to medications and in-session therapies. Assessing the way the heart responds to PTSD has shown promise in detecting and understanding the onset of symptoms.

OBJECTIVE

This study aimed to extract statistical and mathematical approaches that researchers can use to analyze heart rate (HR) data to understand PTSD.

METHODS

A scoping literature review was conducted to extract HR models. A total of 5 databases including Medical Literature Analysis and Retrieval System Online (Medline) OVID, Medline EBSCO, Cumulative Index to Nursing and Allied Health Literature (CINAHL) EBSCO, Excerpta Medica Database (Embase) Ovid, and Google Scholar were searched. Non-English language studies, as well as studies that did not analyze human data, were excluded. A total of 54 studies that met the inclusion criteria were included in this review.

RESULTS

We identified 4 categories of models: descriptive time-independent output, descriptive and time-dependent output, predictive and time-independent output, and predictive and time-dependent output. Descriptive and time-independent output models include analysis of variance and first-order exponential; the descriptive time-dependent output model includes a classical time series analysis and mixed regression. Predictive time-independent output models include machine learning methods and analysis of the HR-based fluctuation-dissipation method. Finally, predictive time-dependent output models include the time-variant method and nonlinear dynamic modeling.

CONCLUSIONS

All of the identified modeling categories have relevance in PTSD, although the modeling selection is dependent on the specific goals of the study. Descriptive models are well-founded for the inference of PTSD. However, there is a need for additional studies in this area that explore a broader set of predictive models and other factors (eg, activity level) that have not been analyzed with descriptive models.

An Exploration of Discrepancies and Concordances Between Hospital Disaster Directors and General Health Care Providers in Gyeonggi Province, South Korea: Quantitative Analysis of a Multicenter Cross-Sectional Survey Study

OBJECTIVE

The purpose of this study was to investigate differences in the perception of disaster issues between disaster directors and general health care providers in Gyeonggi Province, South Korea.

METHODS

The Gyeonggi provincial committee distributed a survey to acute care facility personnel. Survey topics included awareness of general disaster issues, hospital preparedness, and training priorities. The questionnaire comprised multiple choices and items scored on a 10-point Likert scale. We analyzed the discrepancies and characteristics of the responses.

RESULTS

Completed surveys were returned from 43 (67%) of 64 directors and 145 (55.6%) of 261 health care providers. In the field of general awareness, the topic of how to triage in disaster response showed the greatest discrepancies. In the domain of hospital level disaster preparedness, individual opinions varied most within the topics of incident command, manual preparation. The responses to "accept additional patients in disaster situation" showed the biggest differences (> 21 versus 6~10).

CONCLUSIONS

In this study, there were disaster topics with discrepancies and concordances in perception between disaster directors and general health care providers. The analysis would present baseline information for the development of better training programs for region-specific core competencies, knowledge, and skills required for the effective response.

Acute Physiological Responses Following a Bout of Vigorous Exercise in Military Soldiers and First Responders with PTSD: An Exploratory Pilot Study

Post-traumatic stress disorder (PTSD) is a prevalent and debilitating condition associated with psychological conditions and chronic diseases that may be underpinned by dysfunction in the autonomic nervous system (ANS), the hypothalamic-pituitary-adrenal (HPA) axis and chronic systemic low-grade inflammation. The objective of this pilot study was to determine psychological, ANS [heart rate variability (HRV)], HPA (salivary cortisol) and inflammatory (salivary C-Reactive Protein) responses to a bout of vigorous exercise in male first responders, military veterans and active duty personnel with (n = 4) and without (n = 4) PTSD. Participants (50.1 ± 14.8 years) performed a thirteen-minute, vigorous intensity (70%–80% of heart rate max), one-on-one boxing session with a certified coach. Physiological and psychological parameters were measured before, during, immediately after to 30 min post-exercise, and then at 24 h and 48 h post. The effect sizes demonstrated large to very large reductions in HRV that lasted up to 48 h post-exercise in the PTSD group compared with unclear effects in the trauma-exposed control (TEC) group. There were unclear effects for depression, anxiety and stress as well as salivary biomarkers for both groups at all time-points. Findings may reflect stress-induced changes to the ANS for PTSD sufferers.

Posttraumatic Stress Disorder and Alterations in Resting Heart Rate Variability: A Systematic Review and Meta-Analysis

OBJECTIVE

The functions of both the central and peripheral autonomic nervous system, indexed by heart rate variability (HRV), are affected by psychology and physiology. This review summarizes the results of studies comparing the evaluation of HRV parameters between individuals with posttraumatic stress disorder (PTSD) and healthy controls.

METHODS

Eligible studies (n=499) were identified through literature searches of the EMBASE, Medline, PubMed and Web of Science databases. Nineteen studies met our inclusion criteria. A random effects model was used, and standardized mean differences for highfrequency HRV(HF-HRV), low-frequency HRV(LF-HRV) and the root mean square of successive R-R interval differences (RMSSD) were calculated.

RESULTS

Significant effects were found for HF-HRV [p<0.0001, Z=4.18; Hedges'g=-1.58, 95% confidence interval (CI) (-2.32, -0.84); k=14] and RMSSD [p<0.00001, Z=4.80; Hedges'g=-1.96, 95% CI (-2.76, -1.16); k=9] relative to healthy controls. Considerable heterogeneity was revealed, but the main effects for HF-HRV and RMSSD were robust in subsequent meta-regression and subgroup analyses.

CONCLUSION

Given the relationships among low vagal state, inflammation, and alterations in brain structure and function, including executive function and emotion regulation, reduced HRV may be regarded as an endophenotype in PTSD research.

Cardiovascular Events after the Sewol Ferry Disaster, South Korea

BACKGROUND

Major incidents affecting large numbers of people may increase the rate of acute cardiovascular events, even among those who are not directly involved in the incident. It is hypothesized that the MV Sewol ferry disaster (South Korea) would increase the incidence of cardiovascular events nation-wide.

METHODS

Data on all adult patients (&gt;18 years) who were diagnosed with acute cardiovascular events, including acute myocardial infarction (MI), angina, and cardiac arrhythmias, were extracted from the National Emergency Department Information System (NEDIS) from March 15 through June 17, during the years 2011-2014 (four weeks before to eight weeks after the event date). Poisson regression models were used to calculate the incidence rate ratios (IRRs) comparing the weekly changes in the occurrences of cardiovascular events from the week of the Sewol event (April 16-22, 2014) to eight weeks after the disaster (June 11-17, 2014), using the one-month period before Sewol as a reference period (March 15-April 15), adjusting for calendar years (years 2011-2014) and environmental factors.

RESULTS

During the study periods, cardiovascular events were identified in 73,823 patients. Compared to the reference period, the week of the Sewol disaster and the three weeks after the disaster showed a significant increase in the number of acute cardiovascular events, IRRs of 1.09 (95% CI, 1.03-1.15) and 1.08 (95% CI, 1.02-1.15), respectively (P &lt;.01 for both). In particular, there was 21% increase in incidence of arrhythmia (IRR = 1.21; 95% CI, 1.02-1.44; P = .03) during the week of the Sewol disaster compared with the reference period.

CONCLUSION

This study showed a significant increase in the incidence of acute cardiovascular events during the week of, and the three weeks after, the Sewol ferry disaster in 2014. These additional cardiac emergencies may be triggered by emotional stressors related to the event, highlighting the public health importance of indirect exposure to a tragic catastrophe.Kong SY, Song KJ, Shin SD, Ro YS. Cardiovascular events after the Sewol ferry disaster, South Korea. Prehosp Disaster Med. 2019;34(2):142-148.

Social support moderates association between posttraumatic growth and trauma-related psychopathologies among victims of the Sewol Ferry Disaster

Disasters have numerous harmful effects on the mental health status of trauma-exposed people. We investigated the differences in the association between trauma-related psychopathologies and posttraumatic growth according to the perceived social support level among victims of the Sewol Ferry disaster on April 16, 2014, in South Korea. Data from 241 bereaved family members, survivors, and family members of survivors were used. The Duke-UNC Functional Social Support Questionnaire, Posttraumatic Growth Inventory, PTSD Checklist-5, Posttraumatic Embitterment Disorder Self-Rating Scale, Patient Health Questionnaire-9, and Generalized Anxiety Disorder-7 were used to evaluate perceived social support, posttraumatic growth, and trauma-related psychopathologies. We found that the severity of depression and anxiety showed inverse correlations with posttraumatic growth only in the low-social support group, while they did not demonstrate significant correlations in the high-social support group. The social support level had correlations with posttraumatic growth and the severity of posttraumatic stress disorder and posttraumatic embitterment disorder only in female respondents. Furthermore, there was a mediation pathway from social support level to posttraumatic growth through depressive symptoms. This study explored the complex relationship between social support, posttraumatic growth, trauma-related psychopathologies, and gender among trauma-exposed individuals in the aftermath of the Sewol Ferry disaster.