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Effect of autogenic training on cardiac autonomic nervous activity in high-risk fire service workers for posttraumatic stress disorder
Journal of Psychosomatic Research 60 (2006) 439 – 444
Effect of autogenic training on cardiac autonomic nervous activity in high-risk fire service workers for posttraumatic stress disorder Satoko Mitania,T, Masatoshi Fujitab, Satoko Sakamotob, Taro Shirakawa a
Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Public Health, Yoshida-Konoe cho, Sakyo-ku, Kyoto 606-8501, Japan b School of Health Sciences, Faculty of Medicine, Kyoto University, Yosida-Konoe cho, Sakyo-ku, Kyoto 606-8501, Japan Received 18 November 2004
Abstract Objective: We investigated the effect of autogenic training (AT) on cardiac autonomic nervous activity in fire services workers with the use of the questionnaire of the Japaneselanguage version of Impact of Event Scale-Revised (IES-R-J) and indexes of heart rate variability. Methods: We studied 22 male fire services workers who were divided into posttraumatic stress disorder (PTSD)-related stress group (n=10) and control group (n=12). They underwent AT twice or three times a week for 2 months. Results: Posttraumatic stress disorder-related stress group showed a significantly higher cardiac sympathetic nervous
activity and a significantly lower cardiac parasympathetic nervous activity than control group at baseline. Autogenic training significantly decreased cardiac sympathetic nervous activity and significantly increased cardiac parasympathetic nervous activity in both groups. These changes were accompanied by a significant decrease in the total points of IES-R-J. Conclusion: Autogenic training is effective for ameliorating the disturbance of cardiac autonomic nervous activity and psychological issues secondary to PTSD. D 2006 Elsevier Inc. All rights reserved.
Keywords: Autogenic training; Autonomic nervous activity; Heart rate variability; PTSD; Fire services workers
Introduction Paramedics, emergency medical technicians, rescue workers, and firefighters are often exposed to traumatic events associated with their occupation and have a higher prevalence of posttraumatic stress disorder (PTSD) than the general population. Between 10% and 30% of these fire services workers have been reported to suffer from PTSD-related symptoms, as assessed and diagnosed by the bImpact of Event Scale (IES)Q administered through a standard questionnaire [1 –3]. Autogenic training (AT) is a basic therapeutic technique, one of several psychophysiologically oriented approaches to the treatment of a variety of disorders. The theory of AT was established by Shultz and Luthe [4]. It involves the simultaneous modulation of mental and somatic functions. This technique is now widely used for the treatment of
T Corresponding author. Tel.: +81 75 753 4451; fax: +81 75 753 4452. 0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2005.09.005
headache [5,6], anxiety [7], chronic asthmatic disorder [8], and other stress-related disorders. In the present study, AT was applied to fire services workers to alleviate PTSD-related symptoms. Investigations of cardiovascular disorders have traditionally utilized heart rate and blood pressure to track responses. Some psychiatric PTSD literature has focused on autonomic nervous system measures, especially resting heart rate variability (HRV) patterns of low parasympathetic and elevated sympathetic activity [9 –11]. Power spectral analysis of HRV has successfully provided reliable and sensitive indices of cardiac autonomic nervous activity [12]. Using these indices, the effects of posture [13,14], drugs [15 –16], cognitive behavioral therapy [17], and exercise training [18] on HRV have been widely investigated. However, no studies have been conducted in which HRV analysis was applied for evaluating the beneficial effects of AT. Thus, the purpose of this study was to assess the effects of AT on PTSD-related symptoms of fire services workers
440
S. Mitani et al. / Journal of Psychosomatic Research 60 (2006) 439 – 444
by using the results of a self-administered questionnaire and analysis of HRV.
Methods We distributed a questionnaire to each male fire services worker in a specific fire station, and each subject was asked to seal it in an envelope after completing it. We studied 22 fire services workers who were divided into a PTSDrelated stress (PS) group (n = 10) and a control group (n = 12), based on the results of the questionnaire. They were followed up over a 4 -month period. Subjects were also divided into two teams to avoid the time sequence effect. The effects of AT were assessed using both the questionnaire and the HRV analysis. The questionnaire: IES-R In all cases, the following self-administrated questionnaire was conducted before and after the AT application. The Japanese-language version of the Impact of Event Scale-Revised (IES-R-J) [19] was used to determine the frequency of self-reported posttraumatic symptoms of reexperiencing/intrusion, avoidance, and arousal symptoms, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria. This instrument contains 22 items (8 intrusion, 8 avoidance, and 6 hyperarousal items). Each question was scaled ranging from 0 (not at all) to 4 (yes, absolutely). Despite being developed before the formal introduction of PTSD within the diagnostic literature, the Horowitz’s IES [20] remains one of the most widely used self-reported measures of PTSD. Although not a PTSD diagnostic measure, the psychometric properties of the IES are satisfactory, and the use of IES as a measure of intrusion and avoidance, which are the core of PTSD symptomatology on DSM-III, was warranted [21]. Impact of Event Scale-Revised is the revised version of Horowitz’s IES, with additional questions on hyperarousal. By using the cutoff point of 24/25 on IES-R-J, the sensitivity was calculated to be 0.75– 0.89, the specificity 0.71–0.93, the positive predictive value 0.44 –0.80, and the negative predictive value 0.90–0.96 with regard to PTSD+partial PTSD vs. Normal [22]. Scoring high on the IES-R scale does not necessarily mean that the patient has PTSD; it may include neurosis, exPTSD, or various adjustment disorder patients as well [23]. In this study, our objective was not to determine whether subjects are PTSD patients. We defined empirically the subjects having above 18 points on the IES-R-J as the PS group. Heart rate variability analysis
repeated three times on November 2003, January 2004, and March 2004. We analyzed ECG data obtained between 9:00 a.m. and 10:00 a.m. after 30 min of bed rest. The complete recording was split into 5-min segments. We selected ECG recordings consisting predominantly of sinus rhythm. Recordings with frequent supraventricular or ventricular ectopic rhythms or atrial fibrillation were excluded from subsequent analysis. Heart rate and HRV parameters were computed for each segment. Spectral analysis was conducted by computing the following frequency domain variables for HRV by means of fast Fourier transformation. The direct current component was excluded in the calculation of the power spectrum to remove the nonharmonic components in the very low-frequency (LF) region (b 0.04 Hz). The area of spectral peaks within the whole range of 0.04 to 0.40 Hz was defined as total power (TP), the area of spectral peaks within the range of 0.04 to 0.15 Hz as LF power, and the area of spectral peaks within the range of 0.15 to 0.40 Hz as high-frequency (HF) power. The normalized HF power (= HF/TP) was used as an index of modulation of vagal activity [24]. The LF/HF power ratio was used as the index of sympathovagal balance [25 –27]. Autogenic training and procedure The first (heaviness of limbs) and second (warmth of limbs) standard mental exercise of the classical Schultz-type AT was utilized in the present study. The therapist was the same (S.M.) in all cases. The training was applied individually for a 60-min treatment session. Subjects were instructed to conduct AT by themselves twice or three times a week for 2 months. To avoid the time effect, we randomly divided the subjects into two teams. The first intervention team underwent AT from November 2003 to January 2004,
Table 1 Population characteristic and HRV baseline data of PS and the control groups
Number Age (meanFS.D., year) Frequency of AT per week Shift worker Daily worker Marriage No marriage Smoker Nonsmoker LF/HF
Total
PS group
Control group
22 42.2F9.7
10 43.6F8.9
12 41.1F10.6
2.8F2.0
3.0F2.3
8 2 9 1 6 4 4.25F1.85
10 2 11 1 9 3 1.70F0.56
0.21F0.07
0.39F0.08
18 4 20 2 16 6
HF/TP
The 24 -h Holter ECG recordings were obtained with a Spider View (ela Medical, France) and were analyzed with a Syne TEC (ela Medical). In all cases, ECG recordings were
Values are the meanFS.D. HF/TP, normalized HF power.
t test or v test t = 0.606, P = .551 t =0.219, P = .829 v 2 = 0.04 P = .63 v 2 = 0.02 P = .71 v 2 = 0.57 P = .38 t = 4.56, P b.001 t = 5.36, P b.001
S. Mitani et al. / Journal of Psychosomatic Research 60 (2006) 439 – 444
441
Table 2 Changes of LF/HF and HF/(HF+LF) on each intervention team
Values are the meanFS.D. Arrows indicate the time of the AT. HF/TP, normalized HF power.
and the second intervention team did AT from January 2004 to March 2004. Subjects were instructed to carry out AT at least two or three times per week. After the intervention periods, the number of AT training per week was assessed by the self-administered questionnaire. Before the study, all subjects gave written informed consent. The ethical committee at Kyoto University Graduate School of Medicine reviewed and approved the study protocol. Data analysis Demographic and physiological data are presented as the meanFS.D. The differences between the periods and between the groups and intervention teams were analyzed using the Student’s t test and the analytic software SPSS for Windows version 10.0.
Results Twenty-two adult Japanese fire services workers with a mean age of 42.2F9.7 years participated in this study. Among these subjects, 10 persons who scored 18 points or more on the IES-R-J were designated as the PS group, and 12 persons with fewer than points served as the control group. We found that 18 of 22 (82%) worked on a 24 -h shift. Twenty persons were married. Sixteen were smokers and six were nonsmokers. There were no significant differences in age (t =0.606, P =.551) and the frequency of AT (t =0.219, P = .829) between the two groups. There were no significant differences between the two groups with respect to work shift, marriage, and smoking. At baseline (pre-AT), cardiac sympathetic nervous activity was significantly higher (t = 4.56, P b.001) in the PS group than the control group. In contrast, parasympathetic nervous activity was significantly lower (t =5.36, P b.001) in the PS group than the control group (Table 1).
Table 2 summarizes data on cardiac autonomic nervous activity in November, January, and March for each intervention team. In both the first and the second intervention teams, there were significant differences in cardiac nervous activity between pre- and post-AT. In the first intervention team, AT was applied from November 2003 to January 2004, the sympathetic nervous activity in January was significantly lower (t =3.86, P =.004), and the parasympathetic nervous activity in January was significantly higher (t = 2.86, P =.019) than those recorded in November. In the second intervention team, AT was applied from January 2004 to March 2004, the sympathetic nervous activity in March was significantly lower (t = 4.34, P = .001), and the parasympathetic nervous activity in March was significantly higher (t =4.05, P = .002) than those in January. Table 3 compares the effects of AT between the first and the second intervention teams. Low/high frequency decreased and HF/TP increased in both the first and second intervention teams, and there were no significant differences in the effect of AT between the first and the second intervention teams in terms of the effects of AT on sympathetic and parasympathetic nervous activities. Table 4 shows the effects of AT in the PS (n =10) and control (n = 12) groups. Low/high frequency significantly decreased in both the PS (t = 6.336, P b.001) and the control (t = 3.432, P = .006) groups after AT. High frequency/total power significantly increased in both the PS (t = 3.686, P =.005) and the control (t =3.269, P = .007) groups. In addition, in the PS group, the total scores on the IES-R-J Table 3 Comparison of the effects of AT between the first and the second intervention teams
Number LF/HF HF/TP
The first intervention team
The second intervention team
t
P
10 0.68F0.56 + 0.07F0.07
12 0.84F0.67 + 0.09F0.08
0.61 0.74
.55 .47
HF/TP, normalized HF power.
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Table 4 Comparison of the effects of AT in both PS group and the control groups PS group N
10
LF/HF
Control P group (paired t test) 12
Pre-AT 4.25F1.85 b.001 Post-AT 3.11F2.12 HF/TP Pre-AT 0.21F0.07 .005 Post-AT 0.30F0.13 Total points Pre-AT 26.30F16.47 .037 of IES-R Post-AT 10.30F10.49 Intrusion Pre-AT 8.30F5.98 .038 Post-AT 2.50F2.72 Hyperarousal Pre-AT 7.30F5.12 .065 Post-AT 3.50F3.60 Avoidance Pre-AT 10.0F6.82 .075 Post-AT 4.30F5.08
1.70F0.56 1.25F0.41 0.39F0.08 0.46F0.08 5.42F7.37 5.75F6.40 2.17F3.13 2.17F3.16 1.33F1.92 1.41F2.27 1.92F3.00 2.17F3.30
P (paired t test)
.006
.007
.887
1.000
.920
.768
Values are the meanFS.D.
markedly decreased (t = 2.453, P =.037). Among the three subscales of the IES-R-J, intrusion decreased significantly in the PS group (t = 2.437, P = .038); however, hyperarousal and avoidance did not change significantly (Table 4).
Discussion There were no significant differences in the effects of AT between the first and the second intervention teams, indicating that there was no time effect in the present study. Therefore, we can compare the AT effect accurately in the two groups with and without PS symptoms. Subjects with a higher score on the IES-R-J — that is, the PS group — revealed numerous symptoms of PTSD (intrusion, avoidance, and hyperarousal). This high scoring PS group showed a predominance of cardiac sympathetic nervous activity at baseline. By applying AT, the sympathetic nervous activity decreased, and the parasympathetic nervous activity increased in both the PS and the control groups. Autonomic nervous activity in the PS group changed to a greater extent than the control group; however, it did not reach the level observed in the control group. Moreover, AT reduced self-reported psychological dysfunction. The IESR-J score decreased significantly in the PS group. Among the three subscales of the IES-R-J, b intrusionQ decreased significantly, including bemotional flashback,Q bawakening from sleep,Q and bemotional welling up.Q These results reveal that psychological strain, which was caused by intrusion experiences, gave tense to autonomic nervous tone. The sympathetic branch is activated by any stimulus above an organismal threshold, and it functions to increase arousal, trigger an immediate anticipatory state, and rapidly mobilize in response to an appraised stressor [28]. People tend to present an oscillating pattern wherein intrusive symptoms are followed by avoidance. Intrusive experiences cannot, however, be warded off with avoidance behavior. Intrusion is the most characteristic symptom of PTSD from
a traumatic event. Thus, the results of this subscale reflected the efficacy of AT. The other two subscales (hyperarousal and avoidance) tended to decrease compared with pre-AT levels; however, they did not reach statistical significance, presumably due to the small sample size. Earlier studies of PTSD revealed a lower resting HRV in patients compared with controls, suggesting increased sympathetic and decreased parasympathetic tone [29 –31]. Our results are in agreement with earlier reports, implying that the PTSD-related symptoms are associated with disturbed cardiac autonomic nervous activity. Special treatment programs for PTSD, including psychodynamic reprocessing, behavioral therapy, cognitive psychotherapy, rapid eye-movement desensitization, pharmacotherapeutic approaches, preventative intervention, behavioral treatment, and medicinal treatments, have been proposed [32,33]; however, there have been few approaches that involve persons who were not yet diagnosed with psychiatric disorders, rather than those who were not yet diagnosed but at an elevated risk of PTSD. Although AT has been applied in the treatment of vehicle accident survivors [34], Japanese postwar high school students [35], and U.S. military prisoners in North Vietnam [36], the effects on autonomic nervous activity were not fully assessed. We have demonstrated, for the first time, the effect of AT on PS from the viewpoint of cardiac autonomic nervous activity.
Limitations to the study Several limitations to this study deserve comment. First, there is still a question as to whether IES-R-J is an appropriate means of assessing PTSD. In this study, it was used to measure PTSD symptoms, not establish a diagnosis of PTSD. Thus, the subjects of this study were not patients with a psychiatric diagnosis of PTSD. However, it is generally recognized that the psychometric properties of IES-R-J are satisfactory and available for epidemiological use [21]. Second, it remains controversial whether spectral analysis of HRV is really an appropriate index for autonomic nervous activity. Spectral analysis of HRV has recently gained recognition as a reliable noninvasive test for quantitative assessment of cardiovascular autonomic regulatory response. This technique also provides a dynamic map of sympathetic and parasympathetic tone and can thus be used to indicate the nature of sympathetic–parasympathetic interactions [37,38]. Third, it is necessary to confirm whether participants conducted AT properly. We recommended that they perform AT several times per week, as most of them were shift workers and were on duty two or three times a week, and carried out AT before taking a nap during their on-duty day. At the end of this study, the number of AT exercises was calculated based on the self-reported questionnaire.
S. Mitani et al. / Journal of Psychosomatic Research 60 (2006) 439 – 444
Finally, this study was limited by a small sample size. Therefore, future studies are necessary to elucidate the effect of AT in a large cohort of subjects. In conclusion, the findings reported here suggest that AT is effective for ameliorating the disturbance of cardiac autonomic nervous activity and psychological issues secondary to PTSD. These data also show that AT alleviates PS and psychological symptoms secondary to PTSD; however, we do not claim that AT is an effective treatment for PTSD.
Acknowledgments The authors thank Dr. J Sugimoto for his invaluable knowledge and guidance on AT.
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Effect of autogenic training on cardiac autonomic nervous activity in high-risk fire service workers for posttraumatic stress disorder Satoko Mitania,T, Masatoshi Fujitab, Satoko Sakamotob, Taro Shirakawa a
Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Public Health, Yoshida-Konoe cho, Sakyo-ku, Kyoto 606-8501, Japan b School of Health Sciences, Faculty of Medicine, Kyoto University, Yosida-Konoe cho, Sakyo-ku, Kyoto 606-8501, Japan Received 18 November 2004
Abstract Objective: We investigated the effect of autogenic training (AT) on cardiac autonomic nervous activity in fire services workers with the use of the questionnaire of the Japaneselanguage version of Impact of Event Scale-Revised (IES-R-J) and indexes of heart rate variability. Methods: We studied 22 male fire services workers who were divided into posttraumatic stress disorder (PTSD)-related stress group (n=10) and control group (n=12). They underwent AT twice or three times a week for 2 months. Results: Posttraumatic stress disorder-related stress group showed a significantly higher cardiac sympathetic nervous
activity and a significantly lower cardiac parasympathetic nervous activity than control group at baseline. Autogenic training significantly decreased cardiac sympathetic nervous activity and significantly increased cardiac parasympathetic nervous activity in both groups. These changes were accompanied by a significant decrease in the total points of IES-R-J. Conclusion: Autogenic training is effective for ameliorating the disturbance of cardiac autonomic nervous activity and psychological issues secondary to PTSD. D 2006 Elsevier Inc. All rights reserved.
Keywords: Autogenic training; Autonomic nervous activity; Heart rate variability; PTSD; Fire services workers
Introduction Paramedics, emergency medical technicians, rescue workers, and firefighters are often exposed to traumatic events associated with their occupation and have a higher prevalence of posttraumatic stress disorder (PTSD) than the general population. Between 10% and 30% of these fire services workers have been reported to suffer from PTSD-related symptoms, as assessed and diagnosed by the bImpact of Event Scale (IES)Q administered through a standard questionnaire [1 –3]. Autogenic training (AT) is a basic therapeutic technique, one of several psychophysiologically oriented approaches to the treatment of a variety of disorders. The theory of AT was established by Shultz and Luthe [4]. It involves the simultaneous modulation of mental and somatic functions. This technique is now widely used for the treatment of
T Corresponding author. Tel.: +81 75 753 4451; fax: +81 75 753 4452. 0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved. doi:10.1016/j.jpsychores.2005.09.005
headache [5,6], anxiety [7], chronic asthmatic disorder [8], and other stress-related disorders. In the present study, AT was applied to fire services workers to alleviate PTSD-related symptoms. Investigations of cardiovascular disorders have traditionally utilized heart rate and blood pressure to track responses. Some psychiatric PTSD literature has focused on autonomic nervous system measures, especially resting heart rate variability (HRV) patterns of low parasympathetic and elevated sympathetic activity [9 –11]. Power spectral analysis of HRV has successfully provided reliable and sensitive indices of cardiac autonomic nervous activity [12]. Using these indices, the effects of posture [13,14], drugs [15 –16], cognitive behavioral therapy [17], and exercise training [18] on HRV have been widely investigated. However, no studies have been conducted in which HRV analysis was applied for evaluating the beneficial effects of AT. Thus, the purpose of this study was to assess the effects of AT on PTSD-related symptoms of fire services workers
440
S. Mitani et al. / Journal of Psychosomatic Research 60 (2006) 439 – 444
by using the results of a self-administered questionnaire and analysis of HRV.
Methods We distributed a questionnaire to each male fire services worker in a specific fire station, and each subject was asked to seal it in an envelope after completing it. We studied 22 fire services workers who were divided into a PTSDrelated stress (PS) group (n = 10) and a control group (n = 12), based on the results of the questionnaire. They were followed up over a 4 -month period. Subjects were also divided into two teams to avoid the time sequence effect. The effects of AT were assessed using both the questionnaire and the HRV analysis. The questionnaire: IES-R In all cases, the following self-administrated questionnaire was conducted before and after the AT application. The Japanese-language version of the Impact of Event Scale-Revised (IES-R-J) [19] was used to determine the frequency of self-reported posttraumatic symptoms of reexperiencing/intrusion, avoidance, and arousal symptoms, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), criteria. This instrument contains 22 items (8 intrusion, 8 avoidance, and 6 hyperarousal items). Each question was scaled ranging from 0 (not at all) to 4 (yes, absolutely). Despite being developed before the formal introduction of PTSD within the diagnostic literature, the Horowitz’s IES [20] remains one of the most widely used self-reported measures of PTSD. Although not a PTSD diagnostic measure, the psychometric properties of the IES are satisfactory, and the use of IES as a measure of intrusion and avoidance, which are the core of PTSD symptomatology on DSM-III, was warranted [21]. Impact of Event Scale-Revised is the revised version of Horowitz’s IES, with additional questions on hyperarousal. By using the cutoff point of 24/25 on IES-R-J, the sensitivity was calculated to be 0.75– 0.89, the specificity 0.71–0.93, the positive predictive value 0.44 –0.80, and the negative predictive value 0.90–0.96 with regard to PTSD+partial PTSD vs. Normal [22]. Scoring high on the IES-R scale does not necessarily mean that the patient has PTSD; it may include neurosis, exPTSD, or various adjustment disorder patients as well [23]. In this study, our objective was not to determine whether subjects are PTSD patients. We defined empirically the subjects having above 18 points on the IES-R-J as the PS group. Heart rate variability analysis
repeated three times on November 2003, January 2004, and March 2004. We analyzed ECG data obtained between 9:00 a.m. and 10:00 a.m. after 30 min of bed rest. The complete recording was split into 5-min segments. We selected ECG recordings consisting predominantly of sinus rhythm. Recordings with frequent supraventricular or ventricular ectopic rhythms or atrial fibrillation were excluded from subsequent analysis. Heart rate and HRV parameters were computed for each segment. Spectral analysis was conducted by computing the following frequency domain variables for HRV by means of fast Fourier transformation. The direct current component was excluded in the calculation of the power spectrum to remove the nonharmonic components in the very low-frequency (LF) region (b 0.04 Hz). The area of spectral peaks within the whole range of 0.04 to 0.40 Hz was defined as total power (TP), the area of spectral peaks within the range of 0.04 to 0.15 Hz as LF power, and the area of spectral peaks within the range of 0.15 to 0.40 Hz as high-frequency (HF) power. The normalized HF power (= HF/TP) was used as an index of modulation of vagal activity [24]. The LF/HF power ratio was used as the index of sympathovagal balance [25 –27]. Autogenic training and procedure The first (heaviness of limbs) and second (warmth of limbs) standard mental exercise of the classical Schultz-type AT was utilized in the present study. The therapist was the same (S.M.) in all cases. The training was applied individually for a 60-min treatment session. Subjects were instructed to conduct AT by themselves twice or three times a week for 2 months. To avoid the time effect, we randomly divided the subjects into two teams. The first intervention team underwent AT from November 2003 to January 2004,
Table 1 Population characteristic and HRV baseline data of PS and the control groups
Number Age (meanFS.D., year) Frequency of AT per week Shift worker Daily worker Marriage No marriage Smoker Nonsmoker LF/HF
Total
PS group
Control group
22 42.2F9.7
10 43.6F8.9
12 41.1F10.6
2.8F2.0
3.0F2.3
8 2 9 1 6 4 4.25F1.85
10 2 11 1 9 3 1.70F0.56
0.21F0.07
0.39F0.08
18 4 20 2 16 6
HF/TP
The 24 -h Holter ECG recordings were obtained with a Spider View (ela Medical, France) and were analyzed with a Syne TEC (ela Medical). In all cases, ECG recordings were
Values are the meanFS.D. HF/TP, normalized HF power.
t test or v test t = 0.606, P = .551 t =0.219, P = .829 v 2 = 0.04 P = .63 v 2 = 0.02 P = .71 v 2 = 0.57 P = .38 t = 4.56, P b.001 t = 5.36, P b.001
S. Mitani et al. / Journal of Psychosomatic Research 60 (2006) 439 – 444
441
Table 2 Changes of LF/HF and HF/(HF+LF) on each intervention team
Values are the meanFS.D. Arrows indicate the time of the AT. HF/TP, normalized HF power.
and the second intervention team did AT from January 2004 to March 2004. Subjects were instructed to carry out AT at least two or three times per week. After the intervention periods, the number of AT training per week was assessed by the self-administered questionnaire. Before the study, all subjects gave written informed consent. The ethical committee at Kyoto University Graduate School of Medicine reviewed and approved the study protocol. Data analysis Demographic and physiological data are presented as the meanFS.D. The differences between the periods and between the groups and intervention teams were analyzed using the Student’s t test and the analytic software SPSS for Windows version 10.0.
Results Twenty-two adult Japanese fire services workers with a mean age of 42.2F9.7 years participated in this study. Among these subjects, 10 persons who scored 18 points or more on the IES-R-J were designated as the PS group, and 12 persons with fewer than points served as the control group. We found that 18 of 22 (82%) worked on a 24 -h shift. Twenty persons were married. Sixteen were smokers and six were nonsmokers. There were no significant differences in age (t =0.606, P =.551) and the frequency of AT (t =0.219, P = .829) between the two groups. There were no significant differences between the two groups with respect to work shift, marriage, and smoking. At baseline (pre-AT), cardiac sympathetic nervous activity was significantly higher (t = 4.56, P b.001) in the PS group than the control group. In contrast, parasympathetic nervous activity was significantly lower (t =5.36, P b.001) in the PS group than the control group (Table 1).
Table 2 summarizes data on cardiac autonomic nervous activity in November, January, and March for each intervention team. In both the first and the second intervention teams, there were significant differences in cardiac nervous activity between pre- and post-AT. In the first intervention team, AT was applied from November 2003 to January 2004, the sympathetic nervous activity in January was significantly lower (t =3.86, P =.004), and the parasympathetic nervous activity in January was significantly higher (t = 2.86, P =.019) than those recorded in November. In the second intervention team, AT was applied from January 2004 to March 2004, the sympathetic nervous activity in March was significantly lower (t = 4.34, P = .001), and the parasympathetic nervous activity in March was significantly higher (t =4.05, P = .002) than those in January. Table 3 compares the effects of AT between the first and the second intervention teams. Low/high frequency decreased and HF/TP increased in both the first and second intervention teams, and there were no significant differences in the effect of AT between the first and the second intervention teams in terms of the effects of AT on sympathetic and parasympathetic nervous activities. Table 4 shows the effects of AT in the PS (n =10) and control (n = 12) groups. Low/high frequency significantly decreased in both the PS (t = 6.336, P b.001) and the control (t = 3.432, P = .006) groups after AT. High frequency/total power significantly increased in both the PS (t = 3.686, P =.005) and the control (t =3.269, P = .007) groups. In addition, in the PS group, the total scores on the IES-R-J Table 3 Comparison of the effects of AT between the first and the second intervention teams
Number LF/HF HF/TP
The first intervention team
The second intervention team
t
P
10 0.68F0.56 + 0.07F0.07
12 0.84F0.67 + 0.09F0.08
0.61 0.74
.55 .47
HF/TP, normalized HF power.
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Table 4 Comparison of the effects of AT in both PS group and the control groups PS group N
10
LF/HF
Control P group (paired t test) 12
Pre-AT 4.25F1.85 b.001 Post-AT 3.11F2.12 HF/TP Pre-AT 0.21F0.07 .005 Post-AT 0.30F0.13 Total points Pre-AT 26.30F16.47 .037 of IES-R Post-AT 10.30F10.49 Intrusion Pre-AT 8.30F5.98 .038 Post-AT 2.50F2.72 Hyperarousal Pre-AT 7.30F5.12 .065 Post-AT 3.50F3.60 Avoidance Pre-AT 10.0F6.82 .075 Post-AT 4.30F5.08
1.70F0.56 1.25F0.41 0.39F0.08 0.46F0.08 5.42F7.37 5.75F6.40 2.17F3.13 2.17F3.16 1.33F1.92 1.41F2.27 1.92F3.00 2.17F3.30
P (paired t test)
.006
.007
.887
1.000
.920
.768
Values are the meanFS.D.
markedly decreased (t = 2.453, P =.037). Among the three subscales of the IES-R-J, intrusion decreased significantly in the PS group (t = 2.437, P = .038); however, hyperarousal and avoidance did not change significantly (Table 4).
Discussion There were no significant differences in the effects of AT between the first and the second intervention teams, indicating that there was no time effect in the present study. Therefore, we can compare the AT effect accurately in the two groups with and without PS symptoms. Subjects with a higher score on the IES-R-J — that is, the PS group — revealed numerous symptoms of PTSD (intrusion, avoidance, and hyperarousal). This high scoring PS group showed a predominance of cardiac sympathetic nervous activity at baseline. By applying AT, the sympathetic nervous activity decreased, and the parasympathetic nervous activity increased in both the PS and the control groups. Autonomic nervous activity in the PS group changed to a greater extent than the control group; however, it did not reach the level observed in the control group. Moreover, AT reduced self-reported psychological dysfunction. The IESR-J score decreased significantly in the PS group. Among the three subscales of the IES-R-J, b intrusionQ decreased significantly, including bemotional flashback,Q bawakening from sleep,Q and bemotional welling up.Q These results reveal that psychological strain, which was caused by intrusion experiences, gave tense to autonomic nervous tone. The sympathetic branch is activated by any stimulus above an organismal threshold, and it functions to increase arousal, trigger an immediate anticipatory state, and rapidly mobilize in response to an appraised stressor [28]. People tend to present an oscillating pattern wherein intrusive symptoms are followed by avoidance. Intrusive experiences cannot, however, be warded off with avoidance behavior. Intrusion is the most characteristic symptom of PTSD from
a traumatic event. Thus, the results of this subscale reflected the efficacy of AT. The other two subscales (hyperarousal and avoidance) tended to decrease compared with pre-AT levels; however, they did not reach statistical significance, presumably due to the small sample size. Earlier studies of PTSD revealed a lower resting HRV in patients compared with controls, suggesting increased sympathetic and decreased parasympathetic tone [29 –31]. Our results are in agreement with earlier reports, implying that the PTSD-related symptoms are associated with disturbed cardiac autonomic nervous activity. Special treatment programs for PTSD, including psychodynamic reprocessing, behavioral therapy, cognitive psychotherapy, rapid eye-movement desensitization, pharmacotherapeutic approaches, preventative intervention, behavioral treatment, and medicinal treatments, have been proposed [32,33]; however, there have been few approaches that involve persons who were not yet diagnosed with psychiatric disorders, rather than those who were not yet diagnosed but at an elevated risk of PTSD. Although AT has been applied in the treatment of vehicle accident survivors [34], Japanese postwar high school students [35], and U.S. military prisoners in North Vietnam [36], the effects on autonomic nervous activity were not fully assessed. We have demonstrated, for the first time, the effect of AT on PS from the viewpoint of cardiac autonomic nervous activity.
Limitations to the study Several limitations to this study deserve comment. First, there is still a question as to whether IES-R-J is an appropriate means of assessing PTSD. In this study, it was used to measure PTSD symptoms, not establish a diagnosis of PTSD. Thus, the subjects of this study were not patients with a psychiatric diagnosis of PTSD. However, it is generally recognized that the psychometric properties of IES-R-J are satisfactory and available for epidemiological use [21]. Second, it remains controversial whether spectral analysis of HRV is really an appropriate index for autonomic nervous activity. Spectral analysis of HRV has recently gained recognition as a reliable noninvasive test for quantitative assessment of cardiovascular autonomic regulatory response. This technique also provides a dynamic map of sympathetic and parasympathetic tone and can thus be used to indicate the nature of sympathetic–parasympathetic interactions [37,38]. Third, it is necessary to confirm whether participants conducted AT properly. We recommended that they perform AT several times per week, as most of them were shift workers and were on duty two or three times a week, and carried out AT before taking a nap during their on-duty day. At the end of this study, the number of AT exercises was calculated based on the self-reported questionnaire.
S. Mitani et al. / Journal of Psychosomatic Research 60 (2006) 439 – 444
Finally, this study was limited by a small sample size. Therefore, future studies are necessary to elucidate the effect of AT in a large cohort of subjects. In conclusion, the findings reported here suggest that AT is effective for ameliorating the disturbance of cardiac autonomic nervous activity and psychological issues secondary to PTSD. These data also show that AT alleviates PS and psychological symptoms secondary to PTSD; however, we do not claim that AT is an effective treatment for PTSD.
Acknowledgments The authors thank Dr. J Sugimoto for his invaluable knowledge and guidance on AT.
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