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Journal of Traumatic Stress June 2012, 25, 348–352 BRIEF REPORT Measures of Psychophysiological Arousal Among Resettled Traumatized Iraqi Refugees Seeking Psychological Treatment Shameran Slewa-Younan,1 Kerenze Chippendale,1 Andreea Heriseanu,1 Sanja Lujic,2 John Atto,3 and Beverley Raphael4,5 1 Mental Health, School of Medicine, The University of Western Sydney, Sydney, New South Wales, Australia Population Health, School of Medicine, The University of Western Sydney, Sydney, New South Wales, Australia 3 Ware St. Medical Centre, Fairfield, New South Wales, Australia 4 Disaster Response and Resilience Research Group, School of Medicine, The University of Western Sydney, Sydney, New South Wales, Australia 5 Medical School, Australian National University, Canberra, Australian Capital Territory, Australia 2 Resettled refugees living in Western countries frequently report high levels of posttraumatic stress disorder (PTSD) and depression. This study sought to measure levels of physiological arousal in a group of resettled Iraqi refugees in Australia receiving psychological treatment. A continuous recording of electrocardiogram (ECG) data was used to examine baseline heart rate (HR) and heart rate variability (HRV) in refugees (n = 25) and healthy age- and sex-matched controls (n = 23). Descriptively, PTSD (48%) was the most commonly noted disorder followed equally by major depressive episode (36%) and dysthymia (36%) in the refugees. Examination of the physiological data indicated that the refugee group had increased resting HR compared with healthy controls (78.84 vs. 60.08 beats per minute, p < .001). No significant differences were noted in the HRV data with age, gender, and years of education included in the model. This finding highlights the importance of examining levels of arousal in refugees presenting with mental health complaints to provide appropriate treatment strategies. The United Nations Human Rights Commission (UNHRC, 2010) reported that in 2009 there were 15.2 million refugees worldwide with a majority of these located in developing countries. Research into refugee mental health has demonstrated a strong relationship between exposure to traumatic events and psychological distress, with a recent systematic review indicating the two most commonly reported disorders being posttraumatic stress disorder (PTSD; 30.6%) and depression (30.8%; Steel et al., 2009). Research also indicates that exposure to traumatic events can produce abnormalities in physiological measures (Orr & Roth, 2000). A meta-analysis of the psychophysiology of PTSD noted that increased heart rate (HR) is one of the most robust correlates of PTSD (Pole, 2007). Furthermore, heart rate variability (HRV) research has consistently demonstrated an imbalance of sympathetic and parasympathetic inputs present in PTSD (Cohen et al., 1998), in addition to providing a promising objective measure of treatment outcome (Ginsberg, Berry, & Powell, 2010). Refugee mental health research is often complex and findings are conflicting. Variations in reported prevalence rates of disorders, the impact of cultural/ethnic differences in psychological presentations, and the influence of sociodemographic and/or resettlement issues are all thought to contribute to these differences (Steel et al., 2009). In contrast, examinations of physiological measures of traumatized refugees, although scarce, have replicated results found in other PTSD populations. For example, studies among Cambodian refugees have noted elevated HR, skin conductance, and blood pressure (Kinzie et al., 1998). Refugees are a heterogeneous group, and differences in patterns of civil conflict and systematic torture and terror in the country of origin may result in different patterns of mental health disorders (Nicholl & Thompson, 2004). Factors associated with higher psychiatric morbidity were exposure to prolonged conflict, ongoing conflict in country of origin, and exposure to cumulative traumatic events (Steel et al., 2009). In recent times, Iraq has suffered from a long period of violence and Correspondence concerning this article should be addressed to Shameran Slewa-Younan, Mental Health, School of Medicine, University Of Western Sydney, Locked Bag 1797, Penrith, NSW, 2751. E-mail: s.slewayounan@uws.edu.au C 2012 International Society for Traumatic Stress Studies. View Copyright  this article online at wileyonlinelibrary.com DOI: 10.1002/jts.21694 348 Psychophysiology of Trauma in Refugees human rights violations (Jamil et al., 2007). Research by Wood and Gibney (2010) indicates that tortures, murders, and disappearances have become a common part of Iraqi life. Furthermore, a study of Iraqi refugees resettled in the United States revealed a high incidence of depression (22.4%) and PTSD (28.4%) compared to the general population (Jamil et al., 2007), although the generalizability of this finding is limited due to the use of self-report measures. This study sought to examine levels of arousal, measured by HR and HRV, in a group of resettled Iraqi refugees presenting for psychological treatment compared with healthy age- and sex-matched controls to expand on the understanding of psychiatric symptoms in refugees. Furthermore, the influence of a diagnosis of PTSD on arousal levels was investigated by comparing HR and HRV of refugees with PTSD versus refugees with all other diagnoses. 349 of very low frequency (VLF; ≤ 0.04 Hz), low frequency (LF; 0.04–0.15 Hz), and high frequency (HF; 0.15–0.4 Hz), and the LF/HF ratio by applying a fast Fourier transform software program to resample data via a Welch window with 50% overlap. For clinical significance of the bands, please refer to the standards of HRV measures developed by the Task Force of the European Society of Cardiology (1996). Diagnoses. The Mini-International Neuropsychiatric Inventory V.5.0.0 (MINI; Sheehan et al., 1998) is a brief structured diagnostic interview for the major Axis I psychiatric disorders in the DSM-IV and ICD-10. It has sound psychometric properties with the diagnostic interrater reliability for the English and Arabic versions respectively as (k = .95) and (k = .80; Kadri et al., 2005; Sadek, 2000; Sheehan et al., 1998). This scale was used to determine current diagnoses and administered to both patients and healthy controls. Method Participants A convenience sample of 25 resettled Iraqi refugees referred for treatment of psychological disorders was recruited and assessed at first presentation to a private clinic located in metropolitan Sydney, staffed primarily by Iraqi clinicians. Iraq comprises of multiple religious and ethnic groups. Study participants comprised the Assyrian/Chaldean/Syriac group or Christian Iraqis, considered to be among the most vulnerable populations in Iraq (UNHCR, 2009). Twenty-three healthy age- and sex-matched controls were volunteers from the staff of the University of Western Sydney. Exclusion criteria for both groups were a history of cardiovascular disease, diabetes, neurological disorders and related medications, mental retardation, or head injury. Controls additionally were required to have absence of any current psychological disorders, screened for using the MiniInternational Neuropsychiatric Inventory (MINI V5.0; Sheehan et al., 1998). Approval for the study was obtained from the university human research ethics committee and written informed consent was obtained from all participants. Measures Heart rate and HRV recording and data processing. Following a short rest deactivation period of approximately 5 minutes, a 15-minute recording of electrocardiographic (ECG) R data was recorded via ADInstruments Powerlab system (MLS060; ADInstruments Pty Ltd, Bella Vista, New South Wales, Australia) on all participants conducted in supine position, who were instructed to close their eyes and rest. This provided a measure of average resting HR. The HRV analyses were performed using the HRV module of ADInstruments LabChart (V6.1.1) software. The signal was processed with a band pass filter before R-R intervals were identified automatically. Anomalous beats were then reprocessed manually and true ectopic beats excluded from further analysis. Spectral analysis was performed to calculate the frequency bands PTSD exposure and symptoms. The Harvard Trauma Questionnaire (HTQ) is a cross-cultural checklist enquiring about a variety of trauma events and PTSD symptoms (Mollica et al., 1992). This scale evidences excellent psychometric properties, with high test-retest reliability (r = .89) and internal consistency (α = .90; Mollica et al., 1992). In this study, Part 1 (assessing types of trauma events experienced and/or witnessed) and Part 4 (examining PTSD symptoms and severity) were utilized. The HTQ and the MINI were administered to the refugee group in Arabic by a bilingual interviewer. Coefficient α was .93 in these data. Statistical Analyses With 25 patients per group the study had 80% power to detect a difference of 345 ms2 in LF, 170 ms2 in HF, and 840 ms2 in total power, and 10.5 beats per minute in heart rate, using a 5% level of significance and standard deviations of 415, 205, 1015, and 12 respectively. Demographic data were analyzed to provide a comparison between the patient group and controls using independent samples t test, chi-square, or Fisher’s exact test, as appropriate. Normal Gaussian distribution of the continuous data (HR, HRV, HTQ) was verified by examination of distributional histograms. To decrease the influence of outlying observations, data were trimmed to the 90th percentile prior to statistical testing. Linear regression analyses were used to model differences between the refugee and control groups, with age, gender, and years of education in the model. Estimated marginal means are reported for each group, using average age of 46.33 years and average years of education of 14.64. A separate analysis examined differences between PTSD and non-PTSD patients with age and gender included in the model. Estimated marginal means were calculated using average age of 46.20 years. Bonferroni adjusted p-values were used to control for multiple comparisons. Analyses were carried out using SPSS Version 17.0 software (SPSS, Inc., 2008). Journal of Traumatic Stress DOI: 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. 350 Slewa-Younan et al. Table 1 Demographic Characteristics of the Iraqi Refugee and Healthy Control Groups Iraqi refugee (n = 25) PTSD Variable Gender Male Female Employment Employed Homemakers Unemployed Retired Other disorders All Healthy control (n = 23) n % n % n % χ2 n % χ2 5 7 41.7 58.3 8 5 61.5 38.5 13 12 52.0 48.0 0.99 13 10 56.5 43.5 0.10 15.4 7.7 76.9 2 2 21 – 8.0 8.0 84.0 – 2.01 22 – – 1 95.6 – – 4.35 37.98∗∗∗ 8.3 91.7 2 1 10 1 11 Note. PTSD = Posttraumatic stress disorder. Employed group includes fulltime students as well. ∗∗∗ p < .001. Results Table 2 reports differences in the average physiological measures and psychological scales between patients with PTSD versus patients with other disorders and between all patients versus controls, following multiple linear regression modeling, where appropriate. When examining physiological measures between patients and healthy controls, a statistically significant difference was noted on resting HR, with refugee patients demonstrating higher resting HR compared with controls, t(46) = 4.87, p < .001. There were no differences between refugees and controls in any frequency domain. Similarly, there was no difference between the groups on the LF/HF ratio. Mean PTSD symptom scores from the HTQ were statistically significantly different within the patient group, with an average score of 3.39 (SE = 0.17) in PTSD patients compared to 2.31 (SE = 0.17) in those patients with other disorders, t(21) = 4.05, p = .001. Similarly, patients with PTSD reported significantly more trauma events (10.86, SE = 0.80) compared to those without PTSD (4.83, SE = 0.78), t(21) = 4.90, p < .001. There Table 1 presents the study characteristics of the refugee and control groups. There were no differences on demographic characteristics between the two samples except for years of education, t(46) = 6.16, p < .001, and employment status, χ2 (2, N = 48) = 37.98, p < .001. The Iraqi refugees had spent an average of 29.24 (SD = 18.55) months as externally displaced persons and had been living in Australia on average 58.32 (SD = 45.32) months. Assyrian followed by Arabic were the two most commonly spoken languages. As expected, all refugee patients met criteria for at least one type of mental disorder as determined by the MINI. The most common presentation was for PTSD (48%) followed equally by a major depressive episode (36%) and dysthymia (36%). Of those with current PTSD, 75% had a depressive disorder, and 8% of patients with PTSD reported a comorbid substance use disorder. Table 2 Differences in Arousal Between Refugees with PTSD Versus Other Disorders and Refugees Versus Healthy Controls PTSD patients vs. other patients PTSD (n = 12) Variable Heart rate LF power HF power Total power LF/HF ratio Refugees vs. Controls Other (n = 13) Refugees (n = 25) Controls (n = 23) M SE M SE t M SE M SE 79.25 353.76 324.08 1,539.27 2.25 2.94 77.55 98.95 298.76 0.50 77.26 526.95 507.89 1,915.54 1.56 2.84 75.06 95.78 289.18 0.48 0.44 −1.46 −1.21 −0.82 0.90 78.74 558.13 418.94 1,947.26 2.01 2.19 164.01 131.21 438.56 0.38 60.08 1,060.27 875.70 3,646.20 1.61 2.25 168.62 134.90 450.88 0.39 t 4.87∗∗ −1.75 −1.99 −2.21 0.61 Note. Heart rate is measured in beats per minute. LF power, HR power, total power, and LF/HF ratio are all indices of heart rate variability. PTSD = Posttraumatic stress disorder; LF = low frequency (ms2 ); HF = high frequency (ms2 ). ∗∗ p < .001, alpha value adjusted to p < .006 to account for multiple comparisons. Journal of Traumatic Stress DOI: 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. 351 Psychophysiology of Trauma in Refugees were no statistically significant differences between the two patient subgroups on any of the physiological measures. Discussion This study sought to examine differences in physiological arousal in a group of resettled Iraqi refugees compared to controls and as a function of type of symptom profile. Results indicated that refugees demonstrated significantly elevated resting HR when compared to controls. Interestingly, no significant differences were noted on the HRV measures between these two groups. Furthermore, no significant differences were found between those refugees with PTSD versus refugees with other disorders on any of the arousal measures. Resting HR has been noted to be one of the most robust indices of the physiological reactivity demonstrated in PTSD (Pole, 2007). Our findings seem to suggest that although elevated HR is representative (sensitive) of a traumatized population (distinguishing Iraqi refugees from the controls) it is not specific, given the lack of significance noted in the resting HR of those refugees with PTSD versus all other disorders. Although this appears different to Kinzie et al. (1998) who noted that Cambodian refugees with PTSD demonstrated greatest physiological reactivity following exposure to trauma cues, a number of factors should be noted. First, this reactivity in the refugees with PTSD was in response to trauma stimuli only. Their analysis of resting HR failed to find a significant difference between any of the five subject groups; however, similar to our study, both the Cambodian refugees with PTSD and those without had higher resting HR than healthy American controls. This seems to indicate that elevated physiological arousal in refugees may be present regardless of meeting criteria for PTSD. Discordance between psychophysiological estimates of PTSD to gold standard self-report measures of PTSD has been the subject of great debate within the wider PTSD research community (Orr & Roth, 2000). Given the controversy surrounding the use of standardized measures in refugee research (Nicholl & Thompson, 2004), this can only be more significant. Although refugees with PTSD had significantly more exposure to trauma events and higher symptom scores, PTSD mean symptom scores among those refugees with other disorders was still high. Indeed, eight of the 13 refugee patients with other disorders reported a mean HTQ symptom score of greater than 2.2 indicating the possible presence of subthreshold PTSD and thus driving this group’s elevated resting HR. Research suggests that such discordance may represent individuals who have demonstrated sufficient recovery so that a diagnosis of PTSD is no longer appropriate, but who still have significant functional impairments (Orr & Roth, 2000). Given that only current PTSD was assessed in this study, this explanation cannot be ruled out. Referring to HRV data, no statistically significant findings were noted within the refugee group and between the refugee and control groups. This lack of significance precludes discussion of HRV results. A number of limitations are noted in this study. First, the relatively small sample size limits the generalizability and power of the findings. Moreover, the fact that Iraqi refugees and controls were recruited through nonrandom sampling methods means that they may not be entirely representative of the wider community. Future research that includes recruiting a larger random sample of participants would be beneficial. Additionally, this study was limited to baseline measures of arousal; it would be worthwhile to examine response to trauma cues among refugees to better understand the physiology of trauma in this population. In conclusion, our findings indicate that refugees demonstrate increased measures of arousal in the form of elevated resting HR, regardless of whether they met criteria for PTSD or not. An examination of physiological arousal pre- and postintervention using specific strategies targeted at reduction of anxiety and stress levels may be an important part of a comprehensive approach to diagnosis and treatment in this group of patients. References Cohen, H., Kotler, M., Matar, M. A., Kaplan, Z., Loewenthal, U., Miodownik, H., & Cassuto, Y. (1998). Analysis of heart rate variability in posttraumatic stress disorder patients in response to a trauma-related reminder. Biological Psychiatry, 44, 1054–1059. doi:10.1016/S0006-3223(97)00475-7 Ginsberg, J. P., Berry, M. E., & Powell, D. A. (2010). Cardiac coherence and posttraumatic stress disorder in combat veterans. Alternative Therapies in Health and Medicine, 16, 52–60. 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Human Rights Quarterly, 32, 367–400. doi:10.1353/hrq.0.0152 Journal of Traumatic Stress DOI: 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies. Copyright of Journal of Traumatic Stress is the property of John Wiley & Sons, Inc. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.