Martin Sack

Low respiratory sinus arrhythmia and prolonged psychophysiological arousal in posttraumatic stress disorder: heart rate dynamics and individual differences in arousal regulation

BACKGROUND There is extensive evidence that the parasympathetic branch of the autonomic nervous system can modulate psychophysiological arousal. To date, no studies have investigated associations between cardiac vagal tone and the time course of arousal during exposure to trauma-related stimuli in posttraumatic stress disorder (PTSD). METHODS Thirty-one subjects, 29 with PTSD and 2 with partial PTSD, had electrocardiograms recorded during baseline and 2-minute traumatic and neutral script-driven imagery periods. Heart rate, respiratory sinus arrhythmia (RSA), and heart rate half-recovery to the trauma script were quantified, and subjects were divided into low and high baseline RSA groups. RESULTS Across all participants, heart rate significantly increased from the neutral to the trauma script and RSA significantly decreased from baseline to trauma script (p < .05). As predicted, low RSA subjects had more prolonged heart rate increases to the trauma script than high RSA subjects (p < .001), and heart rate half-recovery was negatively correlated to baseline RSA (r = -.50, p =.005). CONCLUSIONS This study is the first to find decreased RSA in response to a traumatic reminder and an association between low baseline RSA and sustained conditioned arousal in PTSD. Low vagal tone may account for deficient arousal and emotion regulation capacities often observed in PTSD.

Alterations in autonomic tone during trauma exposure using eye movement desensitization and reprocessing (EMDR)—Results of a preliminary investigation

EMDR combines stimuli that evoke divided attention--e.g. eye movements--with exposure to traumatic memories. Our objective was to investigate psycho-physiological correlates of EMDR during treatment sessions. A total of 55 treatment sessions from 10 patients with PTSD was monitored applying impedance cardiography. Onset of every stimulation/exposure period (n=811) was marked and effects within and across stimulation sets on heart rate (HR), heart rate variability (HRV), pre-ejection period (PEP) and respiration rate were examined. At stimulation onsets a sharp increase of HRV and a significant decrease of HR was noticed indicating de-arousal. During ongoing stimulation, PEP and HRV decreased significantly while respiration rate significantly increased, indicating stress-related arousal. However, across entire sessions a significant decrease of psycho-physiological activity was noticed, evidenced by progressively decreasing HR and increasing HRV. These findings suggest that EMDR is associated with patterns of autonomic activity associated with substantial psycho-physiological de-arousal over time.

Posttraumatic stress disorder revisited.

In this review we trace the history of and professional discussion on psychological traumatization due to “railroad spine syndrome,” “shell-shock syndrome,” and “war neuroses,” as well as the more or less endemic “posttraumatic stress disorder” of today. Psychological trauma engenders longlasting consequences in the biological, intrapsychic, and social organization of individuals. Medical experts have reported a shift in attention from exogenous to endogenous and back to exogenous causes, as indicated by new diagnostic systems (DSM-IV and ICD-10). As far as the relevant literature is concerned, the medical profession demonstrates the same partial amnesia as their patient counterparts. The purpose of this review is to overcome this fragmented memory and thus reach a more integrated view of what constitutes psychological trauma by reviewing trauma-related articles published in Psychosomatic Medicine. Moreover, we point out the direction in which research is desperately needed and ought to develop.

Event-related potentials and EMDR treatment of post-traumatic stress disorder

Ten patients suffering from post-traumatic stress disorder (PTSD) following a severe traumatic event, were assessed with event-related brain potentials (ERPs) in a modified oddball paradigm containing auditory standard, target, and novel tones. ERPs were assessed before and after a treatment session using the eye movement desensitization and reprocessing method. Compared to a control group that underwent sham treatment, ERPs of the patients showed a reduction of the P3a component in the post-treatment recording, suggesting a reduced orienting to novel stimuli and reduced arousal level after the treatment. Moreover, psychometric assessment revealed a marked improvement of the PTSD symptoms after treatment.

Trauma prevalence and somatoform symptoms: are there specific somatoform symptoms related to traumatic experiences?

There is still insufficient knowledge on the subject of possibly specific patterns of somatoform symptoms related to sexual or nonsexual traumatizations. Using standardized questionnaires, a sample of 892 patients consecutively admitted to a psychotherapy outpatient clinic were evaluated for psychological symptoms in general, for somatoform symptoms and for history of traumatizations. Any severe lifetime trauma was reported in 67.8% of the total sample. Somatoform symptoms were notably more prevalent in traumatized patients when compared with nontraumatized patients. Descriptive data analysis revealed specific elevations of symptom frequencies for pseudoneurological symptoms and for symptoms associated with discomfort or dysfunction in sexual organs.

Autonomic imbalance is associated with reduced facial recognition in somatoform disorders

OBJECTIVES Somatoform disorders are characterized by the presence of multiple somatic symptoms. While the accuracy of perceiving bodily signal (interoceptive awareness) is only sparely investigated in somatoform disorders, recent research has associated autonomic imbalance with cognitive and emotional difficulties in stress-related diseases. This study aimed to investigate how sympathovagal reactivity interacts with performance in recognizing emotions in faces (facial recognition task). METHODS Using a facial recognition and appraisal task, skin conductance levels (SCLs), heart rate (HR) and heart rate variability (HRV) were assessed in 26 somatoform patients and compared to healthy controls. Interoceptive awareness was assessed by a heartbeat detection task. RESULTS We found evidence for a sympathovagal imbalance in somatoform disorders characterized by low parasympathetic reactivity during emotional tasks and increased sympathetic activation during baseline. Somatoform patients exhibited a reduced recognition performance for neutral and sad emotional expressions only. Possible confounding variables such as alexithymia, anxiety or depression were taken into account. Interoceptive awareness was reduced in somatoform patients. CONCLUSIONS Our data demonstrate an imbalance in sympathovagal activation in somatoform disorders associated with decreased parasympathetic activation. This might account for difficulties in processing of sad and neutral facial expressions in somatoform patients which might be a pathogenic mechanism for increased everyday vulnerability.

EMDR Reprocessing of the Addiction Memory: Pretreatment, Posttreatment, and 1-Month Follow-Up

This randomized controlled study investigated the effects of eye movement desensitization and reprocessing (EMDR) in the treatment of alcohol dependency. EMDR was applied to reprocess the addiction memory (AM) in chronically dependent patients. The AM includes memories of preparatory behavior, drug effects (drug use), and loss of control (Wolffgramm, 2002). It is understood to involve extensive brain circuitry, drive part of conscious and unconscious craving, change environmental response at an organic level, and modify circuits that link to feelings of satisfaction, future planning, and hope. Thirty-four patients with chronic alcohol dependency were randomly assigned to one of two treatment conditions: treatment as usual (TAU) or TAU plus two sessions of EMDR (TAU+EMDR). The craving for alcohol was measured by the Obsessive–Compulsive Drinking Scale (OCDS) pre-, post-, and 1 month after treatment. The TAU+EMDR group showed a significant reduction in craving posttreatment and 1 month after treatment, whereas TAU did not. Results indicate that EMDR might be a useful approach for the treatment of addiction memory and associated symptoms of craving.

On the Interaction of Self-Regulation, Interoception and Pain Perception

Background: Interoceptive processes were found to be associated with better self-regulation capacities in healthy participants. Further empirical research suggests that interoceptive sensitivity is also important for the perception of pain both in healthy participants and in somatoform patients. Nevertheless, little is known about the interaction of interoceptive processes and self-regulation for pain. We therefore conducted a study examining the interaction of interoception and self-regulation in somatoform patients. Methods: We investigated interoceptive sensitivity and self-regulatory capacities in 30 somatoform patients and 30 healthy controls when experimentally assessing pain threshold and pain tolerance. Results: Interoceptive sensitivity was associated with better self-regulation capacities. Somatoform patients exhibited a significantly reduced interoceptive sensitivity and reduced self-regulatory capacities as assessed by self-report. Additionally, pain tolerance was significantly increased in somatoform patients as compared to controls. Conclusions: Our findings highlight that interoceptive sensitivity differentially interacts with pain and self-regulation both in healthy participants and somatoform patients. This might provide ideas for novel therapeutic interventions, e.g. a combined training of interoceptive sensitivity with certain aspects of self-regulation.

Assessment of Psychophysiological Stress Reactions During a Traumatic Reminder in Patients Treated With EMDR

This study investigates changes of stress-related psychophysiological reactions after treatment with EMDR. Sixteen patients with posttraumatic stress disorder (PTSD) following type I trauma underwent psychometric and psychophysiological assessment during exposure to script-driven imagery before and after EMDR and at 6-month follow-up. Psychophysiological assessment included heart rate (HR) and heart rate variability (HRV) during a neutral task and during trauma script listening. PTSD symptoms as assessed by questionnaire decreased significantly after treatment and during follow-up in comparison to pretreatment. After EMDR, stress-related HR reactions during trauma script were significantly reduced, while HRV indicating parasympathetic tone increased both during neutral script and during trauma script. These results were maintained during the follow-up assessment. Successful EMDR treatment may be associated with reduced psychophysiological stress reactions and heightened parasympathetic tone.

Blunted autonomic reactivity and increased pain tolerance in somatoform patients

Summary Autonomic measures were assessed during perception and imagination of pain in somatoform patients demonstrating an imbalance in sympathovagal activation and a hyposensitivity to pain stimuli. ABSTRACT Somatoform disorders are characterized by the presence of multiple somatic symptoms. Patients often experience different pain syndromes, and recent research suggests that sympathovagal balance is disturbed in somatoform patients, which could be related to alteration in pain sensitivity. This study analyzed how proposed sympathovagal imbalance interacts with objective pain assessment and the imagination of pain in somatoform disorders. Twenty‐one patients (4 men) with diagnosed multisomatoform disorder were included in the study and matched to healthy control subjects. Autonomic measures and heart rate variability were assessed during baseline; pain perception was assessed by means of a pressure algometer and pain imagination. We found evidence for a sympathovagal imbalance in somatoform disorders characterized by low parasympathetic activation and high sympathetic activation during all conditions. Additionally, somatoform patients had reduced pain tolerance. Vagal withdrawal during pain assessment was more pronounced for healthy control subjects and correlated positively with assessed pain tolerance. During imagination somatoform, patients reported higher pain unpleasantness and higher pain intensity as compared to control subjects. We conclude that our data demonstrate an imbalance in sympathovagal activation and a hyposensitivity to pain tolerance stimuli in somatoform disorders. Parasympathetic reactivity might form crucial information when judging pain‐associated affective‐motivational components. Our results might be attributable to a deficient detection of visceral signals and might be a pathogenetic mechanism for the development of emotional difficulties and increased everyday vulnerability in somatoform patients.