COLLINEARITY BETWEEN MILITARY SEXUAL TRAUMA AND POSTTRAUMATIC STRESS

COLLINEARITY BETWEEN MILITARY SEXUAL TRAUMA AND POSTTRAUMATIC STRESS DISORDER IN MEASURING HEART RATE VARIABILITY Elizabeth Ann Davis Lee Ph. D, APN, ACNS-BC University of Arkansas at Little Rock

Purpose � � Review collinearity between military sexual trauma (MST) and posttraumatic stress disorder (PTSD) and discuss implications and limitations in using heart rate variability (HRV) to measure cardiac function in women who experienced MST Conduct secondary evaluation of the risk of lower HRV in women veterans with MST controlling for covariates of PTSD, depression, age, coronary artery disease, diabetes mellitus, and smoking tobacco

Women Veterans at Risk � 400, 000 women in active duty, National Guard or Reserves with 280, 000 women in OEF/OIF (Do. D & Coast Guard, 2011) � Military sexual trauma (MST) during OEF/OIF deployment: 51% harassed and 25% assaulted (Street et al. , 2013) � � � 31% of OEF/OIF women veterans with PTSD had MST in 2006 -2009 (Maguen et al. , 2012) 50% increase in sexual assault 2012 -2013 (Do. D, 2014) Dose response to level/frequency of MST and frequency and risk of PTSD (Kang et al. , 2005)

Long Term Health � PTSD 5 -9 times greater risk with MST (Suris et al. , 2004, Kimerling et al. , 2007) compared to fourfold risk with combat trauma (Kang et al. , 2005) � � Disability for PTSD: 71% reported MST (Murdock et al. , 2004) Homeless women veterans 40% had MST (Pavao et al. , 2013) Declining physical and psychological health (Street et al. , 2008; Suris et al. , 2004) including cardiovascular disorders (Kubzansky et al. , 2007; Boscarino, 2008; Frayn et al. , 1999) Preliminary findings of significant relationship between decreased HRV and MST/PTSD (Lee et al. , 2013; Lee & Theus, 2012)

Methods � Medical Records of cohort of 126 female veterans � Holters & EKGs January 2007 -December 2010 � Setting: Central Arkansas Veterans Healthcare System � IRB approval of CAVHS and the University of Tennessee Health Science Center

Methods � Measures: � SDNN and RMSSD with regular respirations � MST universal screening for harassment & assault � PTSD Checklist-Civilian � Depression PHQ-9 � Age in years � Coronary artery disease, diabetes mellitus, smoking tobacco

Results Covariate Military sexual trauma Posttraumatic stress disorder Depression Coronary artery disease Diabetes mellitus Cigarette smoking 65 years or older n 27 37 74 3 20 28 10 % 21 29 59 2 16 22 8 MST (N=27) � � AGE (M=41 years) PTSD (80%) SDNN (M=32 ms) RMSSD (M=37 ms) NO MST (N=99) � � AGE (M=51 years) PTSD (15%) SDNN (M=49 ms) RMSSD (M=51 ms)

Sample Characteristics of Female Veterans (n = 126) Examined by Electrocardiogram and Holter following Cardiology Consult 2007 -2010 at CAVHS Variables Skew M SD 25% 75% AGE 0. 07 48. 59 14. 12 21 -36 37 -86 LOGS 0. 24 3. 64 0. 58 2. 85 -3. 20 3. 21 -5. 27 LOGR 0. 39 3. 73 0. 51 3. 10 -3. 34 3. 11 -5. 18 M, mean; SD, standard deviation; 25%, lower quartile range; 75%, upper three quartile range; LOGS, log transformation of standard deviation of all normal sinus R-R intervals; LOGR, log transformation of square root of the mean of the sum of the squares of differences between adjacent normal to normal intervals; AGE, age in years.

Crude Relative Risk of Association of Variables with Lower Heart Rate Variability by Chi-square Tests Variable Lower quartile SDNN Lower quartile RMSSD n RR 95% LCI 95% UCI MST 27 2. 51 1. 43 4. 40 1. 50 0. 78 2. 87 PTSD 37 2. 12 1. 19 3. 79 1. 32 0. 71 2. 48 Depression 74 1. 34 0. 71 2. 54 0. 85 0. 46 1. 57 Age ≥ 65 10 2. 15 1. 06 4. 34 2. 23 1. 10 4. 52 DM 20 1. 00 0. 43 2. 24 1. 55 0. 77 3. 09 Smoker 28 0. 98 0. 47 2. 02 1. 02 0. 49 2. 12 SDNN, standard deviation of normal sinus rhythm R-R intervals; RMSSD, square root of the mean of the sum of squared differences of successive normal sinus rhythm R-R intervals; MST, military sexual trauma; PTSD, posttraumatic stress disorder; DM, diabetes mellitus; Smoker, tobacco smoking; BB, beta blocker treatment, n, number; RR, relative risk; LCI, lower confidence interval; UCI, upper confidence interval.

Unadjusted and Adjusted Odds of Having a Lower Quartile Standard Deviation of Normal Sinus R-R intervals (SDNN) associated with Military Sexual Trauma or Posttraumatic Stress Variable OR 95% CI χ2 p AOR 95% CI χ2 p MST 4. 18 1. 68 -10. 48 10. 27 . 001 4. 49 1. 77 -11. 44 9. 94 . 002 ≥ 65 4. 38 1. 10 -17. 48 5. 01 . 025 4. 45 1. 13 -17. 48 4. 58 . 032 PTSD 3. 11 1. 33 -7. 28 7. 17 . 007 3. 45 1. 43 -8. 33 7. 59 . 006 ≥ 65 3. 46 0. 93 -12. 88 3. 78 . 052 4. 71 1. 19 -18. 59 4. 89 . 027 OR, unadjusted or crude odds ratio; AOR, adjusted odds ratio obtained from a multiple logistic regression model; CI, confidence interval; p, p-value; MST, military sexual trauma; PTSD, posttraumatic stress disorder.

ANCOVA: Log(SDNN) on Age MST (P =. 0001) PTSD (P =. 0002)

Discussion � � Lower HRV with MST and PTSD in younger women veterans Treatments for PTSD that increase HRV � CBT � Biofeedback � Hatha yoga � Self-compassion � Exercise � HRV a potential measure to identify individuals at risk, monitor treatment compliance, and modify treatments based on response (via tele-health? )

Limitations � � 10 -second ECG and Holter recordings Historical cohort design Smaller sample size (n=126) Limited to female veterans at VA

Future Research � � Improving the health and health care of women veterans is a priority (Bastain et al. , 2013) Repetitive 5 -minute segments free of artifact and ectopic beats monitoring respirations need to be used for evaluating HRV in larger samples of both genders HRV needs to be measured pre and post MST/PTSD interventions Tele-health reporting of self-monitored HRV could promote involvement of veterans in their own care and provide a physiological measure of treatment response

Theory Implications Allostatic loading � Mc. Ewen & Seeman (1999) � Sterling & Eyer (1988) � Groer & Burns (2009)

Acknowledgements � Professional: � Study was conducted with support and resources of CAVHS; opinions are that of the author � Veterans who protect our nation � Dissertation Committee

Questions

ANCOVA: RMSSD on AGE MST (P =. 001) PTSD (FLAT LINES)

2. png ANCOVA � � � Log(SDNN) on Age by MST Significant difference in means between MST (M= 3. 25, SD= 0. 11) and no MST (M= 3. 74, SD= 0. 06) The SDNN of a 25 year old with MST exposure is comparable to that of a 69 year old without MST