Psychological factors in exceptional, extreme and torturous environments

Environmental study and stress-related biomarkers modifications in a crew during analog astronaut mission EMMPOL 6

PURPOSE

Human presence in space is increasingly frequent, but we must not forget that it is a hostile environment. We aimed to study the characteristics of experimental scenarios, to obtain data on human response to isolation, disruption of circadian rhythm and high levels of psychophysical stress.

METHODS

In these experiments, we evaluated stress response in five young healthy subjects inside an earth-based moon-settlement-like habitat during a 1-week long analog astronaut mission. Wearable devices were used to monitor daily step count of the subjects, physical activity, heart rate during physical exercise and at rest, and sleep parameters. From saliva and urine samples collected every day at awakening, we studied oxy-inflammation biomarkers and hormones (stress and appetite) were studied too.

RESULTS

At the end of the week, all subjects revealed an increase in oxidative stress and cortisol levels but no inflammation biomarkers variations, in conjunction with increasing time/daily exercise. Furthermore, a significant decrease in hours of sleep/day, sleep quality, and REM phase of sleep was recorded and correlated with the increase of reactive oxygen species.

CONCLUSION

Oxidative stress increased in a short period of time and may be attributed to the influence of psychological stress during confinement, as well as increased exercise and decreased amount of sleep. On a long-term basis, this could impact performance.

Preventing retraumatisation in torture survivors during surgical care: results of a guideline-development project and qualitative study exploring healthcare providers' experiences

OBJECTIVES

Insufficient training and the absence of guidelines increase the risk of retraumatisation in torture survivors during surgical procedures. This study aims to develop guidelines to mitigate this risk and gather healthcare professionals' experiences treating torture survivors and insights on the guideline's feasibility and acceptability.

DESIGN

The study was conducted in two phases. Phase 'a' involved developing guidelines based on reviews of torture survivors' encounters in somatic care and potential retraumatisation triggers, as well as a qualitative study on survivors' experiences during surgical interventions. The development process adhered to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) principles and the Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument for methodological rigour. Phase 'b' involved focus groups and individual interviews with healthcare professionals to explore challenges in caring for torture survivors and to evaluate the guidelines.

SETTING

The study, conducted from May to August 2023, involved participants from surgical departments in three hospitals in southern and southeastern Norway.

PARTICIPANTS

Twenty-one healthcare professionals, including surgeons, anaesthesiologists, nurses and a dentist, participated in the study. Both focus group interviews and individual interviews were conducted.

RESULTS

Phase 'a': guidelines comprising six sections were developed: an introduction, general guidelines and four sections covering the preoperative, perioperative and postoperative surgical stages. Phase 'b': healthcare professionals struggled to understand torture's complexities and identify survivors' unique needs. They faced challenges using interpreters and assisting patients with strong reactions. While the guidelines were viewed as practical and useful for raising awareness, their length was questioned.

CONCLUSIONS

We provide recommendations for preventing retraumatisation in torture survivors undergoing surgical treatment. The guidelines may serve as a starting point for offering safe and individualised care to torture survivors. Teaching institutions and hospitals may incorporate the guidelines into healthcare professionals' education.

Exploring patients' and families' preferences for auditory stimulation in ICU delirium prevention: A qualitative study

OBJECTIVES

To explore the preferences of patients and families for delirium prevention by auditory stimulation in intensive care units.

RESEARCH METHODOLOGY

One-on-one, face-to-face, semistructured interviews with 17 participants (6 patients and 11 family members) were conducted at a step-down unit in a tertiary general hospital using a descriptive qualitative design. The data were analyzed via inductive thematic analysis.

RESULTS

Four major themes and ten subthemes emerged from the interviews: (1) reality orientation; (2) emotional support; (3) links to the outside; and (4) promising future.

CONCLUSIONS

The results in this qualitative study shed light on patients' and families' preferences for auditory stimulation in preventing ICU delirium. The participation of family members plays a crucial role in preventing ICU delirium. Family members can assist patients in reducing confusion about the situation by providing accurate and clear reality orientation. The emotional support and promising future provided by family members can help patients regain confidence and courage, which are often lacking in ICU patients. Linking patients to the outside world helps them stay connected, understand what is happening outside and reduce feelings of isolation.

IMPLICATIONS FOR CLINICAL PRACTICE

These findings can help health care staff gain insight into patients' and families' preferences and needs for auditory stimulation. Furthermore, these findings pave the way for crafting effective auditory interventions.

Effects of immersive virtual reality on sensory overload in a random sample of critically ill patients

Background

Sensory overload and sensory deprivation have both been associated with negative health outcomes in critically ill patients. While there is a lack of any clear treatment or prevention strategies, immersive virtual reality is a promising tool for addressing such problems, but which has not been repetitively tested in random samples. Therefore, this study aimed to determine how critically ill patients react to repeated sessions of immersive virtual reality.

Methods

This exploratory study was conducted in the mixed medical-surgical intermediate care unit of the University Hospital of Bern (Inselspital). Participants (N = 45; 20 women, 25 men; age = 57.73 ± 15.92 years) received two immersive virtual reality sessions via a head-mounted display and noise-canceling headphones within 24 h during their stay in the unit. Each session lasted 30-min and showed a 360-degree nature landscape. Physiological data were collected as part of the participants' standard care, while environmental awareness, cybersickness, and general acceptance were assessed using a questionnaire designed by our team (1 = not at all, 10 = extremely).

Results

During both virtual reality sessions, there was a significant negative linear relationship found between the heart rate and stimulation duration [first session: r(43) = -0.78, p < 0.001; second session: r(38) = -0.81, p < 0.001] and between the blood pressure and stimulation duration [first session: r(39) = -0.78, p < 0.001; second session: r(30) = -0.78, p < 0.001]. The participants had a high comfort score [median (interquartile range {IQR}) = 8 (7, 10); mean = 8.06 ± 2.31], did not report being unwell [median (IQR) = 1 (1, 1); mean = 1.11 ± 0.62], and were not aware of their real-world surroundings [median (IQR) = 1 (1, 5); mean = 2.99 ± 3.22].

Conclusion

The subjectively reported decrease in environmental awareness as well as the decrease in the heart rate and blood pressure over time highlights the ability of immersive virtual reality to help critically ill patients overcome sensory overload and sensory deprivation. Immersive virtual reality can successfully and repetitively be provided to a randomly selected sample of critically ill patients over a prolonged duration.

Psychological torture: definitions, clinical sequelae and treatment principles

Psychological torture, in its broadest sense, is the intentional infliction of suffering without resorting to direct physical violence, in what is known as 'no-touch' torture. While several other definitions of psychological torture have been suggested, there is no one precise definition. Given the rapidly evolving current global political climate and the intensification of conflict, war and asylum seeking, the need for better recognition of psychological torture among clinicians, followed by the provision of appropriate treatment support for victims, has become increasingly pertinent. This article raises awareness of the concept of psychological torture among clinicians, through an overview of its debated definitions, the modalities which constitute this form of torture, and its clinical sequelae and treatment approach.

The Syrian regime's apparatus for systemic torture: A qualitative narrative study of testimonies from survivors

BACKGROUND

Despite broad interest of the Syrian refugee plight in the academic and media circles, there are still limited studies analyzing the lived experiences of torture survivors under the Syrian regime. This qualitative study interviewed torture survivors to examine the form and function of the Syrian regime's security apparatus, and the personal aftermath of survivors.

METHODS

Thirteen in-depth interviews were conducted in Arabic with Syrian refugees who endured torture. Study participants were at least 19 years of age, resided as refugees in Jordan, and voluntarily agreed to participate in the study. Participation was anonymous and no incentives were provided. Only oral consent was required. Audio-recorded interviews were transcribed and translated to English, and then analyzed for repetitive themes utilizing the narrative approach.

RESULTS

Major themes were observed across three experience-phases: pre-captivity, during captivity, and post-captivity. The pre-captivity phase included two sub-themes: the Syrian regime's initial detection and arrest system, and the intelligence system. The captivity phase was also divided into two sub-themes: environmental conditions in detention facilities, and torture methods including physical and psychological torture. Some of the environmental conditions in detention facilities included lack of sanitation, crowding, starvation, and withholding of medical care. Torture methods encompassed beatings, electric shocks, nail-pulling, hanging, drowning, suffocation, rape, and the witnessing of killing, sexual assault, or torture of others. The post-captivity phase included their release from captivity, escaping Syria, and post-displacement conditions and activism.

CONCLUSIONS

The Syrian regime employs a vast security apparatus to track, detain, interrogate, torture, and subjugate its civilian population. A systematic mechanism commences even before captivity and continues for years after release, with negative implications on the well-being of survivors, their families, and the Syrian people as a collective community. The Syrian war saw a shift toward mass detention, torture as a form of social punishment, subjugation, and indeterminate imprisonment. Intervention agencies, host countries, and policymakers must be informed of survivors' experiences to better address their needs. Moreover, the international community must advocate for a firm stance against torture, demand justice, and prosecute all parties engaged in perpetuating such extreme forms of suffering and trauma.

Visual and auditory stimulation for patients in the intensive care unit: A mixed-method study

OBJECTIVES

To determine what type (e.g., television, photographs, music, etc), content (e.g., nature scenes, family members, etc), and duration of visual and auditory stimuli should be provided to intensive care unit patients during their hospitalisation.

RESEARCH METHODOLOGY AND DESIGN

This mixed-methods study followed an exploratory-descriptive design. In total, 31 participants were interviewed: 19 were former critically ill patients in the intensive care unit and 12 were nursing experts, all from a university hospital in Switzerland. Based on current practice, patients and nurses were familiar with receiving and providing television, photographs, radio, and musical stimuli, with no specific exposure to virtual reality, aside from that in their personal lives. Data were collected from the former patients using structured interviews, whereas semi-structured interviews were used for the nursing experts.

FINDINGS

Overall, patient and expert opinions aligned well; both groups agreed that receiving visual and/or auditory stimuli would benefit patients. Photographs, television, and virtual reality were the visual stimuli most chosen by the patients, with an emphasis on nature-focused content. When appropriate, audio matching the content should be provided alongside the visual stimuli to act as a distraction from the hospital environment. Visual stimuli should not exceed 10-15 min, while auditory stimuli should not exceed one hour.

CONCLUSION

Sensory overload and deprivation are common problems in the intensive care unit with negative effects on patient outcomes. Based on patient and expert opinions, visual and auditory stimuli are desired by patients and could help address these issues.

Affective health and countermeasures in long-duration space exploration

Background

Space research is shifting attention toward interplanetary expeditions. Therefore, whether long-duration spaceflight may influence affective health is becoming an urgent issue.

Method

To this end, we undertook a literature search and reviewed several behavioral simulation studies on Earth that focused on affective components in space. We concluded with studies showing how spaceflight can impact on affective health of astronauts with a positively laden trajectory.

Results

By analyzing the multifaceted theoretical concept of affective health, we show that there is a variety of affective states (e.g., stress, coping, adaptation, and resilience) that can be differently affected by spaceflight.

Conclusions

Countermeasures geared toward promoting positive emotions could play a key role in positive adaptation to extreme environments and thus during long-duration space missions may benefit. Subjective resilience plays a mediating role in adaptation, but its definition needs to be deepened in order to develop robust countermeasures that may prevent the onset of emotional disorders.

Torture exposure and the functional brain: investigating disruptions to intrinsic network connectivity using resting state fMRI

Torture has profound psychological and physiological consequences for survivors. While some brain structures and functions appear altered in torture survivors, it is unclear how torture exposure influences functional connectivity within and between core intrinsic brain networks. In this study, 37 torture survivors (TS) and 62 non-torture survivors (NTS) participated in a resting-state fMRI scan. Data-driven independent components analysis identified active intrinsic networks. Group differences in functional connectivity in the default mode network (DMN), salience network (SN) and central executive network (CEN) of the triple network model, as well any prefrontal network, were examined while controlling for PTSD symptoms and exposure to other potentially traumatic events. The analysis identified 25 networks; eight comprised our networks of interest. Within-network group differences were observed in the left CEN (lCEN), where the TS group showed less spectral power in the low-frequency band. Differential internetwork dynamic connectivity patterns were observed, where the TS group showed stronger positive coupling between the lCEN and anterior dorsomedial and ventromedial DMN, and stronger negative coupling between a lateral frontal network and the lCEN and anterior dorsomedial DMN (when contrasted with the NTS group). Group differences were not attributed to torture severity or dissociative symptoms. Torture survivors showed disrupted dynamic functional connectivity between a laterally-aligned lCEN that serves top-down control functions over external processes and the midline DMN that underpins internal self-referential processes, which may be an adaptive response to mitigate the worst effects of the torture experience. This study provides a critical step in mapping the neural signature of torture exposure to guide treatment development and selection.

Exploration of Psychological Resilience during a 25-Day Endurance Challenge in an Extreme Environment

Psychological resilience is the ability to use personal qualities to withstand pressure, consisting of the interaction between the individual and the environment over time. It is essential when operating in extreme environments which are typically characterised by a complex combination of stressors with increased elements of risk and adversity. Psychological resilience has never been investigated “live” (e.g., in the moment) throughout the duration of an extreme endurance challenge, despite anecdotal accounts of the need for resilience to successfully function in such environments. The aim of the study was to explore psychological resilience with challenge team members (n = 4, mean age = 46.0 years) involved in a 25-day extreme endurance challenge. The object of the challenge was to ‘TAB’ (Tactical Advance to Battle, fast marching with weighted packs) 100 peaks in the UK in 25 days and complete long-distance bike rides between base camps. A mixed-methods approach with a focus on qualitative methods was utilised. Specifically, individual reflective video diaries (n = 47) and focus groups (n = 4) were completed and analysed using interpretative phenomenological analysis (IPA). At the same time, the 10-item Connor Davidson Resilience Scale was employed to measure resilience, which highlighted the individualised and dynamic nature of resilience. Two superordinate themes were identified from the video diaries and focus groups, namely, the identification of the stressors within extreme environments and strategies to maintain functioning. Stressors were split into subordinate themes of significant and every day, and collectively, they created a cluster effect which contributed to pressure associated with operating in these environments. Challenge team members employed various strategies to maintain functioning, including using a challenge mindset to positively appraise pressure as a challenging learning experience. Further research should continue to develop an understanding of how participants completing challenges within extreme environments utilise and develop personal qualities to maintain functioning.

Overview and Strategy Analysis of Technology-Based Nonpharmacological Interventions for In-Hospital Delirium Prevention and Reduction: Systematic Scoping Review

BACKGROUND

Delirium prevention is crucial, especially in critically ill patients. Nonpharmacological multicomponent interventions for preventing delirium are increasingly recommended and technology-based interventions have been developed to support them. Despite the increasing number and diversity in technology-based interventions, there has been no systematic effort to create an overview of these interventions for in-hospital delirium prevention and reduction.

OBJECTIVE

This systematic scoping review was carried out to answer the following questions: (1) what are the technologies currently used in nonpharmacological technology-based interventions for preventing and reducing delirium? and (2) what are the strategies underlying these currently used technologies?

METHODS

A systematic search was conducted in Scopus and Embase between 2015 and 2020. A selection was made in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Studies were eligible if they contained any type of technology-based interventions and assessed delirium-/risk factor-related outcome measures in a hospital setting. Data extraction and quality assessment were performed using a predesigned data form.

RESULTS

A total of 31 studies were included and analyzed focusing on the types of technology and the strategies used in the interventions. Our review revealed 8 different technology types and 14 strategies that were categorized into the following 7 pathways: (1) restore circadian rhythm, (2) activate the body, (3) activate the mind, (4) induce relaxation, (5) provide a sense of security, (6) provide a sense of control, and (7) provide a sense of being connected. For all technology types, significant positive effects were found on either or both direct and indirect delirium outcomes. Several similarities were found across effective interventions: using a multicomponent approach or including components comforting the psychological needs of patients (eg, familiarity, distraction, soothing elements).

CONCLUSIONS

Technology-based interventions have a high potential when multidimensional needs of patients (eg, physical, cognitive, emotional) are incorporated. The 7 pathways pinpoint starting points for building more effective technology-based interventions. Opportunities were discussed for transforming the intensive care unit into a healing environment as a powerful tool to prevent delirium.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020175874; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=175874.

Psychological torture: Characteristics and impact on mental health

Torture has been illegal in most of Europe and the United States for over a century but persisted in other parts of the world. The changing geopolitical landscape has led to its resurgence in recent years. The public rejection of traditional forms of torture that rely on the infliction of physical pain has paradoxically increased the reliance on psychological methods of torture. This critical commentary aims to define and characterize psychological torture (PT) while exploring practical, legal, ethical and therapeutic implications relevant to clinicians and policymakers. Psychological torture comes in a range of forms. It is being increasingly justified and adopted by legitimate authorities in the name of national security. The emphasis on the avoidance of physical pain leads to the assumption that PT does not produce the levels of suffering and harm that are associated with physically violent forms of torture. This same assumption has allowed for the implication of mental health professionals in theorizing and providing legitimacy for the actions of perpetrators. Psychological torture is still poorly defined with limited understanding of its long-term psychiatric impact on those who are subjected to it. The role of mental health professionals in preventing or addressing psychological torture remains ambiguous and needs to be reinforced.

Psychological Screening for Exceptional Environments: Laboratory Circadian Rhythm and Sleep Research

Selecting participants who constitute a representative sample while protecting them from potential adverse outcomes is a concern for clinical researchers. Our research group conducts deep phenotyping studies of the circadian timing system and sleep–wake regulation in long (up to 3 months) laboratory experiments, similar in many ways to “exceptional environment” conditions. Here, we describe the psychological screening process we have used for more than 30 years. We outline our “Select In” and “Select Out” measures within three major categories: psychological, psychophysiological, and psychosocial factors. We describe the screening process, inclusion–exclusion criteria on standard questionnaires, and clinical interview questions. We also describe how we manage the exclusion process during screening, ensure continued psychological health during the laboratory study, and manage study terminations. We present data from one recent study, outlining the number of individuals excluded at each stage of the process and present subjective mood data from the included individuals, showing the trajectory of mood across the five-week laboratory study and the end-of-study debriefing, during which the participants rated their comfort with various aspects of the study and their willingness to return for a future study. While designed for our inpatient research studies, elements of these procedures may also be useful for selecting individuals for other exceptional environments.

Perception and Performance on a Virtual Reality Cognitive Stimulation for Use in the Intensive Care Unit: A Non-randomized Trial in Critically Ill Patients

Background: Newly acquired long-term cognitive impairments are common among survivors of critical illness. They have been linked to the stressful situation that patients experience in the intensive care unit (ICU). In this paper we use virtual reality (VR) technology to comfort critically ill patients and reduce stress during their ICU stay. We investigate the acceptance, comfort, recollection, and visual perception of VR stimulation and how it affects physiological parameters.

Methods: A VR head-mounted display was used to present immersive nature scenes to 33 critically ill cardiac surgery patients [mean age 63 years (range 32–83)]. Data was collected with an eye tracker fitted inside the VR head-mounted display to measure eye movements (250 Hz) and sensors to record physiological parameters (240 Hz). Patients received VR stimulation (for 5 min.) prior to ICU admission, during ICU stay, and 3 months after discharge. Acceptance, recollection and comfort were assessed with validated questionnaires.

Results: The number of gazed meaningful objects per minute was significantly lower during the ICU session compared to pre- and follow-up sessions, whereas mean duration of fixation on meaningful moving objects did not differ between the sessions. While respiratory rate decreased significantly during VR stimulation, heart rate and blood pressure remained constant. Post-ICU rating of VR acceptance during ICU stay was moderate to high and discomfort low. Recollection of VR was high [28/33 patients (84.8%)], while recollection of ICU stay was low [10/33 patients (30.3%)].

Conclusion: Eye movements indicate that patients were able to perceive and process cognitive stimulation during their ICU stay. VR was recalled better than the rest of the ICU stay and well accepted. Decreased respiratory rate during stimulation indicate a relaxing effect of VR.

Comparing the Relaxing Effects of Different Virtual Reality Environments in the Intensive Care Unit: Observational Study

Background

After a prolonged intensive care unit (ICU) stay, approximately 50%-75% of all critically ill patients suffer from neurocognitive late effects and a reduction of health-related quality of life. It is assumed that the noisy and stressful ICU environment leads to sensory overload and deprivation and potentially to long-term cognitive impairment.

Objective

In this study, we investigated three different virtual reality environments and their potentially restorative and relaxing effects for reducing sensory overload and deprivation in the ICU.

Methods

A total of 45 healthy subjects were exposed to three different environments, each 10 minutes in length (dynamic, virtual, natural, and urban environments presented inside the head-mounted display, and a neutral video on an ICU TV screen). During the study, data was collected by validated questionnaires (ie, restoration and sickness) and sensors to record physiological parameters (240 hertz).

Results

The results showed that the natural environment had the highest positive and restorative effect on the physiological and psychological state of healthy subjects, followed by the urban environment and the ICU TV screen.

Conclusions

Overall, virtual reality stimulation with head-mounted display using a dynamic, virtual and natural environment has the potential, if directly used in the ICU, to reduce sensory overload and deprivation in critically ill patients and thus to prevent neurocognitive late effects.

Impact of a Nurse Intervention to Improve Sleep Quality in Intensive Care Units: Results From a Randomized Controlled Trial

BACKGROUND

Patients of adult intensive care units (ICUs) often suffer from a lack of sleep. Reducing anxiety by promoting adaptation to the ICU prior to admission may be an appropriate way to increase sleep quality.

OBJECTIVE

The aim of this study was to evaluate the impact on sleep quality of a brief nurse intervention.

METHODS

This was a pilot randomized controlled trial in Spain. Forty patients admitted in hospital for valve cardiac surgery were randomly allocated to (1) control group (n = 20), receiving usual care, and to (2) experimental group (EG, n = 20), receiving a nurse intervention the day before surgery and admission in the ICU. The intervention was based on Roy Adaptation Model. A trained nurse anticipated the stressful stimulus to patients in order to develop functional adaptive behaviors. A set of photographs and videos was used to illustrate the environment and assistance in the ICU. Sleep quality in the ICU was measured with the Richards-Campbell Sleep Questionnaire and usual sleep quality with the Pittsburgh Sleep Quality Index.

RESULTS

After the intervention, sleep quality was lower in the EG compared with the control group (-4 points in Richards-Campbell Sleep Questionnaire, P = .69). Adjustment for main confounders led this reduction to -1.9 points (P = .87) among patients in EG. Stratified analyses shown a positive impact for people who usually slept well (+5.2 points, P = .77), but negative for those who had previous poor sleep quality (-20.0 points, P = .24).

CONCLUSION

A nurse intervention prior to ICU admission did not increase patients' sleep quality. In addition, the intervention could have incremented anxiety over the patients who used to sleep poorly at their homes.

The influence of hypoxia and prolonged exercise on attentional performance at high and extreme altitudes: A pilot study

Introduction

Exposure to hypoxic conditions is reported to impair cognitive performance. Further, moderate physical exercise improves cognitive function, but little is known about the influence of exercise on cognitive function in hypoxia. Therefore, the current study aimed to examine the influence of hypoxia (HYP) and prolonged exercise (EX) on attentional performance.

Methods

A total of 80 participants (female: n = 29; male: n = 51) were assigned to four groups: HYP + EX (n = 15), HYP (n = 25), EX (n = 21) and normoxia (NOR) (n = 21). The Frankfurt Attention Inventory—2 (FAIR-2) was performed at four testing points (day 1, 14, 16 and 18) to assess attentional performance. All groups completed a pretest (D1) and a follow-up test (D18). In HYP + EX conditions, the cognitive task was performed in a hypoxic state after prolonged exercise (D14: 3950 m, D16: 5739 m) during a mountain climb on Mt. Kilimanjaro. Participants in HYP were tested under intermittent hypoxia at rest in a hypoxic chamber (D14: 3500 m, D16: 5800 m), and those in EX were tested under normoxia after prolonged exercise during a 7-day backcountry ski hiking tour. NOR was a control group, and participants completed all tests under normoxia and at rest.

Results

Hypoxia impaired the attentional functions performance value (PV) and continuity value (CV) for the HYP + EX (p = 0.000) and HYP (L: p = 0.025; K: p = 0.043) groups at 5739 m and 5800 m, respectively, but not the function quality value (QV). In contrast, the EX group did not exhibit changes in attentional function.

Conclusion

The current results suggest that attentional performance is impaired during extreme normobaric and hypobaric hypoxic exposure. We further conclude that greater cognitive impairment under hypobaric hypoxia during a mountain climb compared with normobaric hypoxia at rest is not caused by prolonged exercise, but may be influenced by other factors (e.g. low temperatures, dehydration, or sleep deprivation) that remain to be verified.

Monitoring daily events, coping strategies, and emotion during a desert expedition in the Middle East

Personnel operating in extreme environmental conditions are exposed to a variety of stressors. Whether a person adjusts to the conditions and is able to cope has implications for their psychological health. In previous extreme-environment work, temporal changes in stress, coping, and emotion have been reported. Building on previous studies, we used a diary methodology to explore temporal changes in and associations between daily events, coping strategies, and affect during a unique hyperarid desert expedition. Four participants undertaking a crossing of the Empty Quarter desert were recruited to the study. Participants completed pre-expedition, postexpedition, and 4-month follow-up questionnaires. A daily self-report diary was used to collect situational data. Time-based changes were analysed before testing predictive models linking events and coping strategies with affective responses. Findings suggest that participants had an overall positive experience. There were changes in both the events experienced and coping strategies used during the expedition. Variation in events and coping strategies significantly predicted fluctuations in positive and negative affect. Results offer valuable mechanistic information that could inform monitoring systems aimed at tracking psychological variables during operations in extreme environments. Results are discussed in relation to the novel context, diary methodology, and implications for those operating in extremes.

Lost at sea: the medicine, physiology and psychology of prolonged immersion

In most countries, immersion represents the second most common cause of accidental death in children and the third in adults. Between 2010 and 2013, 561 deaths worldwide involving recreational divers were recorded by the Divers Alert Network. Consequently, there is no room for complacency when diving. Being lost at sea is a diver's worst nightmare. In 2006, a diver was lost at sea off the coast of New Zealand for 75 hours. It is unprecedented that, after such a long time immersed in temperate (16-17°C) waters, he was found and survived. His case is presented and utilised to illustrate the many physiological and psychological factors involved in prolonged immersion and what might determine survival under such circumstances. We also briefly review options for enhancing diver location at sea and a few issues related to search and rescue operations are discussed.

Visuo-acoustic stimulation that helps you to relax: A virtual reality setup for patients in the intensive care unit

After prolonged stay in an intensive care unit (ICU) patients often complain about cognitive impairments that affect health-related quality of life after discharge. The aim of this proof-of-concept study was to test the feasibility and effects of controlled visual and acoustic stimulation in a virtual reality (VR) setup in the ICU. The VR setup consisted of a head-mounted display in combination with an eye tracker and sensors to assess vital signs. The stimulation consisted of videos featuring natural scenes and was tested in 37 healthy participants in the ICU. The VR stimulation led to a reduction of heart rate (p = 0. 049) and blood pressure (p = 0.044). Fixation/saccade ratio (p < 0.001) was increased when a visual target was presented superimposed on the videos (reduced search activity), reflecting enhanced visual processing. Overall, the VR stimulation had a relaxing effect as shown in vital markers of physical stress and participants explored less when attending the target. Our study indicates that VR stimulation in ICU settings is feasible and beneficial for critically ill patients.