Peritraumatic Heart Rate and Posttraumatic Stress Disorder in Patients With Severe Burns
Abstract and Figures
Previous studies have suggested a link between heart rate (HR) following trauma and the development of posttraumatic stress disorder (PTSD). This study expands on previous work by evaluating HR in burn patients followed longitudinally for symptoms of acute stress disorder (ASD) and PTSD.
Data were collected from consecutive patients admitted to the Johns Hopkins Burn Center, Baltimore, Maryland, between 1997 and 2002. Patients completed the Stanford Acute Stress Reaction Questionnaire (n = 157) to assess symptoms of ASD. The Davidson Trauma Scale was completed at 1 (n = 145), 6 (n = 106), 12 (n = 94), and 24 (n = 66) months postdischarge to assess symptoms of PTSD. Heart rate in the ambulance, emergency room, and burn unit were obtained by retrospective medical chart review.
Pearson correlations revealed a significant relationship between HR in the ambulance (r = 0.32, P = .016) and burn unit (r = 0.30, P = .001) and ASD scores at baseline. Heart rate in the ambulance was related to PTSD avoidance cluster scores at 1, 6, 12, and 24 months. In women, HR in the ambulance was correlated with PTSD scores at 6 (r = 0.65, P = .005) and 12 (r = 0.78, P = .005) months. When covariates (gender, β-blockers, Brief Symptom Inventory Global Severity Index score) were included in multivariate linear regression analyses, ambulance HR was associated with ASD and PTSD scores at baseline and 1 month, and the interaction of ambulance HR and gender was associated with PTSD scores at 6 and 12 months. Multivariate logistic regression results were similar at baseline and 12 months, which included an HR association yet no interaction at 6 months and a marginal interaction at 1 month.
While peritraumatic HR is most robustly associated with PTSD symptom severity, HR on admission to burn unit also predicts the development of ASD. Gender and avoidance symptoms appear particularly salient in this relationship, and these factors may aid in the identification of subgroups for which HR serves as a biomarker for PTSD. Future work may identify endophenotypic measures of increased risk for PTSD, targeting subgroups for early intervention.
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... Prior literature has identified many preexisting and post hoc risk factors for development of PTSD (Ozer et al. 2003;Marmar et al. 2006;Cukor et al. 2011;Clark et al. 2013;Glatt et al. 2013;Eraly et al. 2014;Yurgil et al. 2014). However, limitations in the individual-based predictive value of these factors have prompted particular interest in the immediate peritraumatic response after trauma exposure as an individual specific robust predictor of PTSD development (McNally 2003;Ozer et al. 2003;Briere et al. 2005;Marmar et al. 2006;Breh and Seidler 2007;Lensvelt-Mulders et al. 2008;Bovin and Marx 2011;Gould et al. 2011) (Fig. 1). In particular, the first hours following the trauma may be a critical window for interventions aimed at the prevention or reduction of posttraumatic anxiety (Bryant 2003;Ehring et al. 2008) and have been characterized as the "golden hour(s)" after trauma (Zohar et al. 2009). ...
... Peritraumatic stress reactions refer to the specific stress-associated behavioral, emotional, cognitive, and physiological symptoms during and immediately following a traumatic event and include fear of dying, fear of losing emotional control, tachycardia, sweating, shaking, dizziness and dissociation symptoms, reduction of awareness, etc. (Fig. 2). These reactions have repeatedly demonstrated a strong and consistent association with the subsequent development of posttraumatic stress symptoms in prior research (McNally 2003;Ozer et al. 2003;Briere et al. 2005;Marmar et al. 2006;Breh and Seidler 2007;Lensvelt-Mulders et al. 2008;Bovin and Marx 2011;Gould et al. 2011). Peritraumatic panic symptoms are associated with activation of the sympathetic nervous system, with several studies showing that elevated heart rate during or immediately after the trauma is prospectively associated with an increased risk of developing PTSD symptoms (Fig. 2) (Shalev et al. 1998;Bryant et al. 2000Bryant et al. , 2007Birmes et al. 2003;Bryant 2003;Kassam-Adams et al. 2005). ...
The postwar fiscal burden for treatment of posttraumatic stress disorder (PTSD) and PTSD-related mental, physical, and social outcomes can be high, and the liability can persist for decades post-armistice. Thus, any advancement in early detection and prevention of PTSD promise substantial benefits. There is strong confirmation that peritraumatic stress reactions are robust posttrauma predictors of PTSD development. This fact provides evidence to warrant training for the recognition and evaluation of peritraumatic stress. However, although instruments for measuring peritraumatic symptoms exist, they were not specifically developed to assess combat-related peritraumatic reactions and may insufficiently capture the wide range of possible reactions in the immediate aftermath of a combat-related trauma. In addition, these measures also all rely on subjective, retrospective self-report. To redress this problem, we developed the Peritraumatic Behavior Questionnaire (PBQ). The ultimate goal was to generate a military-specific observer-rating scale for corpsman and medics in theater to facilitate the early detection of combat-related peritraumatic distress symptoms in actively deployed service members and to unify underlying peritraumatic symptom dimensions to reliably assess combat-related peritraumatic reactions as a general construct. Before assessing an observer-rated version of the PBQ (PBQ – Observer Rated, PBQ-OR), we initially investigated the psychometric and predictive properties of the self-rated PBQ version (PBQ – Self Report, PBQ-SR). We considered that the establishment of good psychometric properties for the SR version would be important before introducing the additional complexities of observer ratings. Here we report the development of the PBQ and summarize the recently reported psychometric properties of the PBQ-SR, as well as our findings and conclusions from the in-theater evaluation procedure of the PBQ-OR. Our data confirm the ability of the PBQ to unify the underlying peritraumatic symptom dimensions and reliably assess combat-related peritraumatic reactions as a general construct. Both PBQ-SR and PBQ-OR showed high correlation to various PTSD-specific as well as PTSD-related symptoms and demonstrated promise as a potential standard screening measure in military clinical practice.
... e., dissociation around the time of trauma; for a review see Cardeña & Classen, in press) predicted acute stress and higher scores on the SASRQ (Hunt et al., 2008). Furthermore, higher heart rate during a stressful event was associated with later acute stress and high scores on the SASRQ (Gould et al., 2011). One study indicated that participants who believed that a certain event would have a big impact on the future tended to score higher on the SASRQ (Maldonado et al., 2002) Gelkopf, Berger andRoe (2016). ...
The fourth edition of the Diagnostic and Statistical Manual introduced the diagnosis of Acute Stress Disorder (ASD) for acute pathological reactions including dissociative ones, following a traumatic event. Various measures of ASD have been developed, with the Stanford Acute Stress Reaction Questionnaire (SASRQ) being one of the most commonly used across the world. This paper systematically covers more than 20 years of research with it and 90 papers in different languages. The main conclusion is that the SASRQ and its translations to other languages have consistently shown convergent, divergent, and predictive validity, besides exhibiting good reliability. We finish the paper by advancing suggestions for future development including the use a new SASRQ version that follows DSM-5 criteria, evaluating whether distinct items or subscales differentially predict different types of acute- and long-term posttraumatic symptomatology, and assessing its clinical usefulness.
... Previous work also suggests that cardiovascular arousal plays an important role in PTSD symptom development [27]. In particular, clinical studies revealed that PTSD was associated with increases in heart rate (HR), as an indicator of psychophysiological arousal, shortly after trauma (i.e. in ambulance/emergency room after major burn injuries) [28] and in response to trauma-related stimuli [29]. Similarly, decreases in heart rate variability (HRV), as an indicator of elevated sympathetic activity relative to parasympathetic activity, were associated with PTSD diagnosis in veterans [30]. ...
The angiotensin-II antagonist losartan is a promising candidate that has enhanced extinction in a post-traumatic stress disorder (PTSD) animal model and was related to reducing PTSD symptom development in humans. Here, we investigate the neurocognitive mechanisms underlying these results, testing the effect of losartan on data-driven and contextual processing of traumatic material, mechanisms proposed to be relevant for PTSD development. In a double-blind between-subject design, 40 healthy participants were randomised to a single oral dose of losartan (50 mg) or placebo, 1 h before being exposed to distressing films as a trauma analogue while heart rate (HR) was measured. Peritraumatic processing was investigated using blurry picture stimuli from the films, which transformed into clear images. Data-driven processing was measured by the level of blurriness at which contents were recognised. Contextual processing was measured as the amount of context information retrieved when describing the pictures’ contents. Negative-matched control images were used to test perceptual processing of peripheral trauma-cues. Post-traumatic stress symptoms were assessed via self-report questionnaires after analogue trauma and an intrusion diary completed over 4 days following the experiment. Compared to placebo, losartan facilitated contextual processing and enhanced detail perception in the negative-match pictures. During the films, the losartan group recorded lower HR and higher HR variability, reflecting lower autonomic stress responses. We discuss potential mechanisms of losartan in preventing PTSD symptomatology, including the role of reduced arousal and increased contextual processing during trauma exposure, as well as increased threat-safety differentiation when encountering peripheral trauma-cues in the aftermaths of traumatic events.
... The Pearson product-moment correlation (r) was used to determine the strength and direction of the relation between acute posttraumatic risk markers and PTSD symptoms or disorder. For studies reporting data for pairings of continuous and dichotomous variables, including presence or absence of PTSD diagnosis at follow-up (Bryant et al., 2008;Coronas et al., 2011;De Young et al., 2007;Shalev & Freedman, 2005;Yehuda et al., 1998), PTSD symptom cutoff scores (Alarcon et al., 2011;Gould et al., 2011), or cut-off scores for risk markers (Bryant et al., 2008;Zatzick et al., 2005), formulas were used to impute point-biserial correlations (Lipsey & Wilson, 2001). All r values were transformed using the Fisher's Z r transform (Hedges & Olkin, 1985) and associated standard errors and inverse variance weights were computed for each effect size. ...
Individuals with posttraumatic stress disorder (PTSD) typically exhibit altered hypothalamic–pituitary-adrenal (HPA) function and sympathetic nervous system (SNS) activity. The goals of this study were to determine whether HPA and SNS alterations in the immediate aftermath of trauma predict subsequent PTSD symptom development and whether inconsistencies observed between studies can be explained by key demographic and methodological factors. This work informs secondary prevention of PTSD by identifying subgroups of trauma survivors at risk for PTSD. This meta-analysis (26 studies, N = 5186 individuals) revealed that higher heart rate measured soon after trauma exposure was associated with higher PTSD symptoms subsequently (r = 0.13). Neither cortisol (r = − 0.07) nor blood pressure (diastolic: r = − 0.01; systolic: r = 0.02) were associated with PTSD symptoms which may be influenced by methodological limitations. Associations between risk markers (heart rate, cortisol, systolic blood pressure) and PTSD symptoms were in the positive direction for younger samples and negative direction for older samples. These findings extend developmental traumatology models of PTSD by revealing an age-related shift in the presentation of early risk markers. More work will be needed to identify risk markers and pathways to PTSD while addressing methodological limitations in order to shape and target preventive interventions.
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.
Psychiatric problems frequently occur during burn treatment and can complicate recovery. In addition, preexisting psychiatric disorders are often present and sometimes will have contributed to the burn injury. Pain, itching, and stress during burn recovery can complicate treatment and recovery. It is therefore essential that members of the burn treatment team recognize, assess, and treat psychiatric problems in patients with burn injury. More severe psychiatric disorders in patients may result from the injury and treatment, such as posttraumatic stress disorder and depression. It is useful to have mental health professionals as part of the treatment team. Quick detection and treatment of psychiatric problems contribute to overall recovery and reduce complications.
Patient-reported outcome measures (PROMs) are vital for evaluating patient needs and therapeutic progress. This review aimed to identify the PROMs used in adult burn care and establish their quality. Computerized bibliographic searches of Psychinfo, Social Sciences Citation Index, Cinahl, Psycharticles, AMED, Medline, and HAPI were used to find English-language articles using English-language PROMs from January 2001 to September 2016. Psychometric quality assessment of the PROMs was conducted. A total of 117 studies achieved the entry criteria and reported using 77 different PROMs (71 generic and 6 burn-specific). Overall, the psychometric quality of the PROMs was low; only 17 (13 generic and 4 burn-specific) had psychometric evidence appropriate to adults with burn injuries completing an English language version of the PROM. Although this review identified a number of generic and burn-specific PROMs that have some psychometric evidence with adult burn patients, research is still needed to further examine these preexisting measures and validate them in different languages. This will enable researchers and clinicians to better understand the potential impact of a burn injury on adults, and evaluate the effectiveness of therapeutic interventions.
Objectives: While mortality rates after burn are low, physical and psychosocial impairments are common. Clinical research is focusing on reducing morbidity and optimizing quality of life. This study examines self-reported Satisfaction With Life Scale scores in a longitudinal, multicenter cohort of survivors of major burns. Risk factors associated with Satisfaction With Life Scale scores are identified. Methods: Data from the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Burn Model System (BMS) database for burn survivors greater than 9 years of age, from 1994 to 2014, were analyzed. Demographic and medical data were collected on each subject. The primary outcome measures were the individual items and total Satisfaction With Life Scale (SWLS) scores at time of hospital discharge (pre-burn recall period) and 6, 12, and 24 months after burn. The SWLS is a validated 5-item instrument with items rated on a 1-7 Likert scale. The differences in scores over time were determined and scores for burn survivors were also compared to a non-burn, healthy population. Step-wise regression analysis was performed to determine predictors of SWLS scores at different time intervals. Results: The SWLS was completed at time of discharge (1129 patients), 6 months after burn (1231 patients), 12 months after burn (1123 patients), and 24 months after burn (959 patients). There were no statistically significant differences between these groups in terms of medical or injury demographics. The majority of the population was Caucasian (62.9%) and male (72.6%), with a mean TBSA burned of 22.3%. Mean total SWLS scores for burn survivors were unchanged and significantly below that of a non-burn population at all examined time points after burn. Although the mean SWLS score was unchanged over time, a large number of subjects demonstrated improvement or decrement of at least one SWLS category. Gender, TBSA burned, LOS, and school status were associated with SWLS scores at 6 months; scores at 12 months were associated with LOS, school status, and amputation; scores at 24 months were associated with LOS, school status, and drug abuse. Conclusions: In this large, longitudinal, multicenter cohort of burn survivors, satisfaction with life after burn was consistently lower than that of non-burn norms. Furthermore mean SWLS scores did not improve over the two-year follow-up period. This study demonstrates the need for continued efforts to improve patient-centered long term satisfaction with life after burn.
The elderly as a general population are frequently understudied for both diagnostic criteria and responses to therapeutic interventions. When it comes to medications, the pharmacokinetic (e.g., medication concentration) and pharmacodynamic
(e.g., receptor affinity) properties are often different for the elderly which at times may limit how effective medications are as well as side effects experienced. In addition, geriatric patients’ brains
are undergoing loss of neuronal reserve related to aging and increased prevalence of neurodegenerative diseases. In short, the elderly are a unique population when it comes to susceptibility of side effects from medications. This chapter reviews how these factors impact the prescribing of medications for PTSD in the elderly as well as potential complications which can occur.
Posttraumatic stress disorder (PTSD) is a common reaction to traumatic events. Many people recover in the ensuing months, but in a significant subgroup the symptoms persist, often for years. A cognitive model of persistence of PTSD is proposed. It is suggested that PTSD becomes persistent when individuals process the trauma in a way that leads to a sense of serious, current threat. The sense of threat arises as a consequence of: (1) excessively negative appraisals of the trauma and/or ist sequelae and (2) a disturbance of autobiographical memory characterised by poor elaboration and contextualisation, strong associative memory and strong perceptual priming. Change in the negative appraisals and the trauma memory are prevented by a series of problematic behavioural and cognitive strategies. The model is consistent with the main clinical features of PTSD, helps explain several apparently puzzling phenomena and provides a framework for treatment by identifying three key targets for change. Recent studies provided preliminary support for several aspects of the model.
The reliability and validity of the Brief Symptom Inventory (BSI) was examined for a group of 501 forensic psychiatric inpatients and outpatients. Alpha coefficients for the 9 primary symptom dimensions revealed a high degree of consistency among the items that compose each scale. Scores on the 9 BSI dimensions were found to correlate with both analogous and nonanalogous measures of the Minnesota Multiphasic Personality Inventory (MMPI), indicating a limited convergent validity and a poor discriminant validity for the instrument. Reactivity to response bias was demonstrated by prominent correlations between the BSI dimensions and the MMPI validity scales. The significant intercorrelations among the BSI symptom subscales indicated the inappropriateness of BSI profile analysis in this sample. The BSI may hold some promise as a general indicator of psychopathology but further research is needed to justify its use as a clinical psychiatric screening tool. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Defines posttraumatic stress disorder (PSD), which has been used to circumscribe the varied symptoms reported by combatants, and briefly presents a conditioning model for the development of PSD. The model explains PSD as a combination of high-order conditioning and stimulus generalization. The benchmark symptoms for a diagnosis of PSD are (1) intrusive thoughts regarding the traumatic event, (2) vivid recollections of the traumatic event wherein the individual reports that he/she feels that the trauma is actually reoccurring, and (3) terrifying nightmares that contain specific details of the event. A previous study by the authors (unpublished) is reported in which several symptoms were assessed by evaluating Ss' performance on cognitive and behavioral tasks and by questionnaires selected for their relationship to specific symptoms to the disorder. Responses of PSD veterans on these tasks were compared to those of well-adjusted Vietnam combat veterans without PSD. Results show that performance on 5 of the 6 tasks was effective in distinguishing Vietnam veterans with PSD from those who were well adjusted: PSD Ss demonstrated increased physiological arousal; motoric agitation; intrusive, combat-related cognitions when exposed to cues resembling the original traumatic event; poor concentration; and poor performance on emotion identification. (26 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Posttraumatic stress disorder (PTSD) is a psychiatric condition that is directly precipitated by an event that threatens a person's life or physical integrity and that invokes a response of fear, helplessness, or horror. In recent years it has become clear that only a proportion of those exposed to fear-producing events develop or sustain PTSD. Thus, it seems that an important challenge is to elucidate aberrations in the normal fear response that might precipitate trauma-related psychiatric disorder. This paper summarizes the findings from recent studies that examined the acute and longer term biological response to traumatic stress in people appearing to the emergency room immediately following trauma exposure. In the aggregate, these studies have demonstrated increased heart rate and lower cortisol levels at the time of the traumatic event in those who have PTSD at a follow-up time compared to those who do not. In contrast, certain features associated with PTSD, such as intrusive symptoms and exaggerated startle responses, are only manifest weeks after the trauma. The findings suggest that the development of PTSD may be facilitated by an atypical biological response in the immediate aftermath of a traumatic event, which in turn leads to a maladaptive psychological state.
A reliable and valid measure is needed for assessing the psychological symptoms experienced in the aftermath of a traumatic event. Previous research suggests that trauma victims typically experience dissociative, anxiety and other symptoms, during or shortly after a traumatic event. Although some of these symptoms may protect the trauma victim from pain, they may also lead to acute stress, posttraumatic stress, or other disorders. The Stanford Acute Stress Reaction Questionnaire (SASRQ) was developed to evaluate anxiety and dissociation symptoms in the aftermath of traumatic events, following DSM-IV criteria for acute stress disorder. We present data from multiple datasets and analyses supporting the reliability and construct, convergent, discriminant, and predictive validity of the SASRQ.
10.1176/appi.ajp.160.4.636
This study was presented in part at the 42nd Annual Scientific Session of the American College of Cardiology, Anaheim, California, March 1993. Dr. Molnar is a visiting research fellow from the State Hospital for Cardiology, Balatonfured, Hungary and was supported by a grant from Marquette Electronics, Inc., Milwaukee, Wisconsin. This study was supported in part by the Reingold Estate and the Cooley Charitable Trust, Chicago, Illinois. Dr. Rosenthal is a member of the Feinberg Cardiovascular Research Institute, Northwestern University Medical School, Chicago, Illinois.
Substantial evidence from animal studies suggests that enhanced memory associated with emotional arousal results from an activation of beta-adrenergic stress hormone systems during and after an emotional experience. To examine this implication in human subjects, we investigated the effect of the beta-adrenergic receptor antagonist propranolol hydrochloride on long-term memory for an emotionally arousing short story, or a closely matched but more emotionally neutral story. We report here that propranolol significantly impaired memory of the emotionally arousing story but did not affect memory of the emotionally neutral story. The impairing effect of propranolol on memory of the emotional story was not due either to reduced emotional responsiveness or to nonspecific sedative or attentional effects. The results support the hypothesis that enhanced memory associated with emotional experiences involves activation of the beta-adrenergic system.
We discuss the gender-specific differences for traumatic events and Post-Traumatic Stress Disorder (PTSD) as found in the epidemiological literature. Recent research literature consistently reports three interesting findings: 1) men experience traumatic events more often, 2) women and men differ in the type of traumatic experiences they experience, and 3) women more often develop PTSD after the experience of a traumatic event. In the second part of the present article we provide some explanations for these differences. The reported higher vulnerability of women for PTSD could be due to the methodology used, the higher prevalence of childhood sexual abuse and rape in women, the different coping styles of women and men, or the more limited socio-economic resources of women. Depression and Anxiety 17:130–139, 2003. © 2003 Wiley-Liss, Inc.