Strategies against Burnout and Anxiety in Medical Education – Implementation and Evaluation of a New Course on Relaxation Techniques (Relacs) for Medical Students

Burnout and stress-related mental disorders (depression, anxiety) occur in medical students and physicians with a significantly higher prevalence than in the general population. At the same time, the learning of coping mechanisms against stress is still not an integral part of medical education. In this pilot study we developed an elective course for learning relaxation techniques and examined the condition of the students before and after the course. 42 students participated in the semester courses in 2012 and 2013 as well as in a survey at the start and end of each course. The students were instructed in autogenic training (AT) and progressive muscle relaxation according to Jacobsen (PMR) with the goal of independent and regular exercising. At the beginning and the end of the semester/course the students were interviewed using standardized, validated questionnaires on burnout (BOSS-II) and anxiety (STAI-G), depression (BDI), quality of life (SF-12) and sense of coherence (SOC-L9). We compared the results of our students participating in Relacs with results from eight semester medical students (n = 88), assessed with the same questionnaires at similar points of time within their semester. Participating students showed a significant decline in cognitive and emotional burnout stress and in trait anxiety. Furthermore, they showed a reduction in state anxiety and a conspicuous decrease in mean depression. The sense of coherence increased at the same time. A comparative cohort of medical students of 8^th semester students, showed lower values for the specified measurement parameters at the beginning, but showed no progressive changes. Our course introducing AT and PMR led to a significant reduction of burnout and anxiety within the participating group of medical students. Even the course attendance for just one semester resulted in significant improvements in the evaluated parameters in contrast to those students who did not attend the course.     

The influence of examination stress on psychophysiological characteristics and heart rate in students

With the aim to assess the influence of pre-examination psychoemotional stress on the level of centralization of the heart rate control, mathematical analysis of ECG of students was performed in normal condition (a common day of academic semester), before, and after an examination. The ECG was recorded and processed with the help of IBM-486 PC. R-R cardiointevalograms were processed by the method of variational pulsometry after Baevsky. Common quantitative heart rate indices were studied. The level of anxiety of students was assessed by Spilberger, and subjective estimations of general condition, activity and mood were obtained from the respective questionnaire. Three types of heart rate reactions on the examination stress were revealed. The reactions depended on the individual typological characteristics and the state of autonomic nervous system.     

The comparative effectiveness of heart rate biofeedback,speech skills training,and a combination of both in treating public-speaking anxiety

Forty-two speech-anxious undergraduate students (21 female, 21 male) were administered either heart rate biofeedback training, speech skills training, or a combination of both to aid in the alleviation of speech anxiety. Physiological (heart rate, tonic skin conductance level, systolic blood pressure, and diastolic blood pressure), overt motor, and self-report measures of anxiety were assessed during a pretreatment speech and two posttreatment speeches. Results indicated that all treatments were effective in lowering overt motor and self-report components of anxiety. However, only the biofeedback and combined group subjects demonstrated significantly less heart rate increase while speaking before an audience during the posttreatment assessment. Two individual difference variables examined in this study — cognitive/autonomic focus of anxiety and subjective confidence in treatment — were not found to significantly influence treatment effectiveness. Finally, factor analyses of the physiological data suggested that heart rate changes play a large role in the physiological component of anxiety.     

Physiological responses of mules on prolonged exposure to high altitude (3 650 m)

Eight healthy male animals were inducted and kept for 2 1/2 years at 3 650 m altitude and subjected to normal work schedules. Physiological measurements viz. heart rate, blood pressure, minute ventilation, oxygen consumption, respiration rate, hemoglobin, packed cell haematocrit volume and eosinophil count were made on these animals at periodic intervals. On acute induction to an altitude of 3 650 m these animals demonstrated a sudden increase in tidal volume, a decrease in Rf and no change in V_E, suggesting a decreased dead space/tidal volume ratio at altitude.However, all these changes stabilised within 3 weeks but on prolongation of stay, the physical state of these animals was adversely affected. The respiratory adjustments occurring on return to sea level appear to be a response to thermal stress. The initial increase in heart rate and blood pressure stabilised by the 2nd week.     

Change of cardiodynamic parameters and the heart rhythm in students under influence of the academic load

Dynamics psychological and cadriohemodynamical parameters and activity regulators mechanisms of a rhythm of heart of students in current of academic year is studied. It is shown, that process of adaptation of students to an academic load is accompanied by the periods of recession and a pressure parameters of hemodynamic, activity regulators mechanisms of a rhythm of heart and parameters of state of health, activity and mood. The periods of the highest pressure of physiological systems of an organism of students are the beginning of the first semester and the examination period. The adaptive changes of investigated parameters occurred in the course the academic year.     

Reaction of Cardiac Activity of Senior Pupils of Schools Providing Differentiated Education upon Examination Stress

Effects of examination stress on psychological characteristics and indices of the autonomic nervous system were studied in pupils of the eighth and tenth grades of high schools providing differential (test group, Neuron gymnasium) and general education (control group). General health state and levels of activity and mood (feeling, activity, mood; FAM) and neuroticism (according to Eysenck) were determined in both groups. Main hemodynamic indices (heart rate and blood pressure) were measured, and mathematical analysis of the heart rate by was performed according to Baevskii. Comparative analysis of psychophysiological tests and heart rate changes in the control and test groups points to a high tension in the cardiac rhythm regulation mechanisms and strong anxiety in schoolchildren in the differential education school. The character and depth of preexamination stress depended on the type of autonomic control of cardiac activity. Schoolchildren with sympathicotonic cardiac rhythm regulation showed the strongest emotional tension. Schoolchildren with the normotonic type of regulation were the most calm.     

Changes in pain perception and hormones pre- and post-kumdo competition

The psychological stress of competition is a powerful stimulus affecting numerous hormones, which in turn change how pain is perceived. This study investigated whether a kumdo (kendo) team competition may be related to changes in hormones and pain. Seventeen healthy male kumdo practitioners participated in this experiment. Pain experiments were conducted by applying noxious stimuli with a thermal stimulator 10 min before a kumdo competition and 30 min post-competition. Serum testosterone, cortisol, beta-endorphin levels, pain thresholds, pain ratings at 48 °C and during blood sampling (sampling pain), anxiety, blood pressure, and heart rate were measured pre- and post-competition. Anxiety, pain threshold, testosterone/cortisol ratio, and blood pressure were significantly higher pre-competition compared to post-competition, while cortisol and pain ratings were significantly lower pre-competition than post-competition. There were significant correlations between the number of previous competitions and testosterone levels both pre-competition and post-competition. In pre-competition measurements, sampling pain increased with an increase in systolic blood pressure, heart rate, and beta-endorphins, and a decrease in age. In post-competition measurements, sampling pain increased with an increase in diastolic blood pressure and a decrease in testosterone levels. These results indicate that severe psychological pre-competition stress was associated with reduced pain ratings, perhaps in order to improve athletic performance. This also suggests that competitors may be at risk of potential injury due to changes in pain perception, and careful consideration should be taken to avoid potential injury before and during competition.     

The Effects of Aroma Foot Massage on Blood Pressure and Anxiety in Japanese Community-Dwelling Men and Women: A Crossover Randomized Controlled Trial

Objectives

The aim of this study was to investigate the effects of aroma foot massage on blood pressure, anxiety, and health-related quality of life (QOL) in Japanese community-dwelling men and women using a crossover randomized controlled trial.

Methods

Fifty-seven eligible participants (5 men and 52 women) aged 27 to 72 were randomly divided into 2 intervention groups (group A: n = 29; group B: n = 28) to participate in aroma foot massages 12 times during the 4-week intervention period. Systolic and diastolic blood pressure (SBP and DBP, respectively), heart rate, state anxiety, and health-related QOL were measured at the baseline, 4-week follow-up, and 8-week follow-up. The effects of the aroma foot massage intervention on these factors and the proportion of participants with anxiety were analyzed using a linear mixed-effect model for a crossover design adjusted for participant and period effects. Furthermore, the relationship between the changes in SBP and state anxiety among participants with relieved anxiety was assessed using a linear regression model.

Results

Aroma foot massage significantly decreased the mean SBP (p = 0.02), DBP (p = 0.006), and state anxiety (p = 0.003) as well as the proportion of participants with anxiety (p = 0.003). Although it was not statistically significant (p = 0.088), aroma foot massage also increased the score of mental health-related QOL. The change in SBP had a significant and positive correlation with the change in state anxiety (p = 0.01) among participants with relieved anxiety.

Conclusion

The self-administered aroma foot massage intervention significantly decreased the mean SBP and DBP as well as the state anxiety score, and tended to increase the mental health-related QOL scores. The results suggest that aroma foot massage may be an easy and effective way to improve mental health and blood pressure.

Trial Registration

University Hospital Medical Information Network 000014260     

EEG Based Evaluation of Examination Stress and Test Anxiety Among College Students

BackgroundAdolescence is a crucial chapter in life and the presence of stress, depression, and anxiety at this stage is a great concern. Prolonged stress is one of the risk factors that may induce suicidal thoughts, destructive ideation, abuse of alcohol, and drugs in adulthood. Based on a record from National Crime Records Bureau, In India over 2320 children were committed suicide per year because of failure in examinations. This raised number implies the severity of this issue and its major impact on society.ObjectivesThe main objective of this paper is to analyze the cognitive stress in students during examination period using EEG biomarkers.Methods and ResultsEEG signal was acquired in two different test conditions such as before examination with 12 minutes and after examination with 3 minutes from 14 subjects with eight electrodes located using wireless Enobio device (Neuro electrics) with 10-20 international lead system. The three brain waves such as theta, alpha, beta relative band energies were considered, and EEG band ratios such as heart rate, neural activity, arousal index, vigilance index and cognitive performance attentional resource index extracted between before and after examination condition using db4 wavelet family with 6 level decomposition. The statistical results suggest that after examination the relative sub-band energies α, β, and θ were decreased significantly (p < 0.05) as compared to before examination. Also, the EEG band ratio such as heart rate and vigilance index shows significant (p < 0.05) decrease after the examination as compared to before examination. It was found that there was a significant (p < 0.05) rise in the arousal index, Cognitive performance attentional resource index (CPARI), and neural activity after the examination as compared to before examination.ConclusionThe experimental results found that the memory and concentration were high before examination, which concludes that adolescence group examination stress was high before examination period as compared to after examination. In the case of gender group comparison, theta energy band for male students was found high compared to female students in before examination state such that it concludes that male students were highly stressed (before examination) than female students. Overall, our results suggest that after examination male students with lower heart rate index than female students which implies the male students control their stress levels as compared to females in the same stress situation.     

Classification of oscillatory states of blood pressure after bleeding in cats (author's transl)]

Blood pressure and heart rate responses were recorded on bleeding of blood volume of 1 ml/kg body weight (test input) from the abdominal aorta of cat. Forward path gain, backward path gain and minification were determined from blood pressure responses to test input. Oscillations in blood pressure were elicited spontaneously or artificially after bleeding of blood volume of 5 ml/kg body weight (conditioning input). The oscillatory states are classified into latent state, underdamped oscillatory state and harmonic oscillatory state. Open loop gain decreased in the latent state but increased in the other states. Therefore, oscillation was hard to elicit in the latent state. Minification, however, enlarged in the latent state, making the system irritable to disturbances and reducing its control accuracy. In the latent state, an insensible disturbance increased backward path gain and open loop gain to induce the oscillations. There was an increase of heart rate at an elicitation of oscillation in any state and a decrease of heart rate made it damped. Therefore, the heart rate regulatory system plays a main role in the feedback path of the blood pressure regulatory system and an increase of heart rate by an insensible disturbance or test input increases backward path gain.     

正念冥想对妇科肿瘤手术患者应激反应的影响

目的:探讨正念冥想对妇科肿瘤手术患者应激反应的效果。方法:将70例手术患者分为试验组(正念冥想组)、对照组(空白对照组),各35例。采用焦虑自评量表(SAS)对两组患者不同时间点的焦虑水平进行测试,比较两组患者不同时间点的心率和血压,静脉采血测定去甲肾上腺素(NE)、皮质醇(COS)。结果:两组不同测量时间及组间的焦虑评分、血压、心率比较,差异均有统计学意义(P0.05);试验组患者血浆NE值明显降低(P0.05),COS值亦有所下降(P0.05)。结论:正念冥想能有效减轻妇科肿瘤手术患者的焦虑,稳定血压和心率,减轻应激反应。     

Dbh(-/-) mice are hypotensive,have altered circadian rhythms,and have abnormal responses to dieting and stress

We used mice deficient in dopamine beta-hydroxylase [Dbh(-/-)] and their littermate controls [Dbh(+/-)] to examine the role of epinephrine (Epi) and norepinephrine (NE) in the maintenance of cardiovascular parameters during 7 days of caloric restriction and acute exposure to environmental stress. Cardiovascular parameters of the mice were monitored using blood pressure radiotelemeters at an ambient temperature of 29 degrees C. Under normal conditions, Dbh(-/-) mice had a low heart rate, were severely hypotensive, and displayed an attenuated circadian blood pressure rhythm. Upon 50% caloric restriction, Dbh(+/-) mice exhibited decreases in heart rate and mean blood pressure. However, the blood pressures of Dbh(-/-) mice did not fall significantly in response to caloric restriction, and the bradycardia associated with caloric restriction was attenuated in these mice. In response to an open-field test, the blood pressure and heart rate of Dbh(+/-) mice increased substantially and rapidly, whereas Dbh(-/-) mice had blunted changes in blood pressures and no change in heart rate. These data suggest a primary role of Epi and NE in mediating the hypotension induced by dieting. Furthermore, Epi and NE play a smaller, but still significant, role in the bradycardia induced by caloric restriction. In contrast, Epi and NE are required for the tachycardia in an open field but are not required for the increase in blood pressure.     

Ordinary and Recurrent Dream Recall of Active, Past and Non-recurrent Dreamers During and After Academic Stress

The role of stress in the onset and frequency of recurrent dreams was investigated by comparing dream recall of students undergoing naturalistic stress conditions. Thirty nine students in active, past and non-recurrent dream groups (n = 13) recorded frequency of nights per week involving overall and recurrent dream recall in the week prior to mid-term examinations and in a neutral study week in second semester. Self-report measures of everyday hassles and uplifts, anxiety and positive and negative affect experienced during these conditions were also collected. Anxiety and negative affect were reported as significantly higher in the pre-examination week. Overall the groups reported dreams on significantly more nights in the pre-examination week than the post examination week. Recurrent dream nights increased during the stress week for the active recurrent dream group but there was no change in recurrent dream recall for the other groups. These findings are consistent with theories that the experience of emotional stress is a critical factor in the onset and persistence of recurrent dreams.     

Circadian Time Structure of Cardiovascular Characteristics in Human Pregnancy

Conventional time-unspecified single measurements of blood pressure and heart rate may be misleading because they may be influenced, among other factors, by the patient's emotional state, position, diet, and external stimuli. All of these effects depend on the stages of a (mathematical) spectrum of rhythms and trends with age. The evaluation of predictable variability in blood pressure and heart rate by (a) the use of fully ambulatory devices, and (b) chronobiologic data processing, assesses early cardiovascular disease risk, e.g., in pregnancy. We have used this approach to quantify changes in 24-h synchronized (circadian) characteristics of cardiovascular variables in two consecutive pregnancies of a clinically healthy woman. Blood pressure and heart rate were automatically monitored, with few interruptions, at I-h intervals, each time for at least 48 consecutive h, and for a total of 76 days of monitoring in each pregnancy. Circadian parameters of those circulatory variables were computed for each single day of measurement by the least-squares fit of a 24-h cosine curve. Regression analysis of parameters thus obtained revealed patterns of variation of circadian-rhythm-adjusted means and amplitudes with gestational age. In both pregnancies, the predictable variability of the circadian-rhythm-adjusted mean of blood pressure can be approximated by a second-order polynomial model on gestational age: a steady linear decrease in systolic, diastolic, and mean arterial blood pressure up to the 22nd week of pregnancy is followed by an increase in blood pressure up to the day of delivery. This longitudinal study confirms and extends to ambulatory everyday life conditions the predictable pregnancy-associated variability in blood pressure and heart rate and also allows the establishment of prediction and confidence limits for cardiovascular parameters in a healthy pregnancy.     

The level of anxiety and state of autonomic regulation depending on the predicted examination grades in students living under unfavorable environmental conditions

The examination situation evokes psychoemotional and autonomic reactions with different degrees of intensity depending on the predicted grades in first-year students living under unfavorable conditions of the middle Ob’ River basin. All the examined students (residents of the middle Ob’ River basin) were found to have a high or super high level of trait and state anxiety. The unfavorable emotional state was accompanied by different degrees of the strengthening of parasympathetic effects on cardiac activity and the tension of regulatory systems that were at a maximum in students who expected a C grade. Irrespective of the predicted result, the highest levels of anxiety and increase in the stress of regulatory systems were observed in female students.     

Circadian Time Structure of Cardiovascular Characteristics in Human Pregnancy

Conventional time-unspecified single measurements of blood pressure and heart rate may be misleading because they may be influenced, among other factors, by the patient's emotional state, position, diet, and external stimuli. All of these effects depend on the stages of a (mathematical) spectrum of rhythms and trends with age. The evaluation of predictable variability in blood pressure and heart rate by (a) the use of fully ambulatory devices, and (b) chronobiologic data processing, assesses early cardiovascular disease risk, e.g., in pregnancy. We have used this approach to quantify changes in 24-h synchronized (circadian) characteristics of cardiovascular variables in two consecutive pregnancies of a clinically healthy woman. Blood pressure and heart rate were automatically monitored, with few interruptions, at I-h intervals, each time for at least 48 consecutive h, and for a total of 76 days of monitoring in each pregnancy. Circadian parameters of those circulatory variables were computed for each single day of measurement by the least-squares fit of a 24-h cosine curve. Regression analysis of parameters thus obtained revealed patterns of variation of circadian-rhythm-adjusted means and amplitudes with gestational age. In both pregnancies, the predictable variability of the circadian-rhythm-adjusted mean of blood pressure can be approximated by a second-order polynomial model on gestational age: a steady linear decrease in systolic, diastolic, and mean arterial blood pressure up to the 22nd week of pregnancy is followed by an increase in blood pressure up to the day of delivery. This longitudinal study confirms and extends to ambulatory everyday life conditions the predictable pregnancy-associated variability in blood pressure and heart rate and also allows the establishment of prediction and confidence limits for cardiovascular parameters in a healthy pregnancy.     

Dynamics of the integrated characteristics of heart rate variability and psychophysiological parameters of students under the conditions of daily and weekly academic loads

The effects of daily and weekly academic loads on the psychological and cardio-and hemodynamic characteristics of students were analyzed. The self-estimated state of health, activity, and mood were evaluated with the use of the HAM (Health-Activity-Mood) questionnaire; the introversion and extraversion, neuroticism, and intelligence of the subjects were determined according to Eysenck; and the self-estimate the personal anxiety according to Spielberger, was evaluated. The main hemodynamic parameters (heart rate and arterial blood pressure) were measured and the systolic and minute blood volumes were calculated. The comparison of the dynamics of the parameters studied showed that there were two types of response of the students’ cardio-and hemodynamic parameters to academic load: sympathetic and parasympathetic. The parasympathetic response was found to be more adequate because the sympathetic response entailed the risk of overstrain and adaptation failure.     

Circadian and short-term regulation of blood pressure and heart rate in transgenic mice with cardiac overexpression of the beta1-adrenoceptor

Congestive heart failure is associated with a loss of circadian and short-term variability in blood pressure and heart rate. In order to assess the contribution of elevated cardiac sympathetic activity to the disturbed cardiovascular regulation, we monitored blood pressure and heart rate in mice with cardiac overexpression of the β₁-adrenoceptor prior to the development of overt heart failure. Telemetry transmitters for continuous monitoring of blood pressure and heart rate were implanted in 8 to 9-week-old wildtype and transgenic mice, derived from crosses of heterozygous transgenic (line β₁TG4) and wildtype mice. Cardiovascular circadian patterns were analyzed under baseline conditions and during treatment with propranolol (500 mg/L in drinking water). Short-term variability was assessed by spectral analysis of beat-to-beat data sampled for 30 min at four circadian times. Transgenic β₁TG4 mice showed an increase in 24 h heart rate, while blood pressure was not different from wildtype controls. Circadian patterns in blood pressure and heart were preserved in β₁TG4 mice. Addition of propranolol to the animals' drinking water led to a reduction in heart rate and its 24 h variation in both strains of mice. Short-term variability in blood pressure was not different between wildtype and β₁TG4 mice, but heart rate variability in the transgenic animals showed a rightward shift of the high-frequency component in the nocturnal activity period, suggesting an increase in respiratory frequency. In conclusion, the present study shows that both the circadian and the short-term regulation of blood pressure and heart rate are largely preserved in young, nonfailing β₁-transgenic mice. This finding suggests that the loss of blood pressure and heart rate variability observed in human congestive heart failure cannot be attributed solely to sympathetic overactivity but reflects the loss of adrenergic responsiveness to changes in the activity of the autonomic nervous system.     

Acupuncture effects on reflex responses to mental stress in humans

In animal studies, acupuncture has been shown to be sympathoinhibitory, but it is unknown if acupuncture is sympathoinhibitory in humans. Nineteen healthy volunteers underwent mental stress testing pre- and postacupuncture. Muscle sympathetic nerve activity (MSNA), blood pressure, and heart rate during mental stress were compared pre- and postacupuncture. Control acupuncture consisted of acupuncture at nonacupoints and "no-needle" acupuncture. Acupuncture had no effect on resting MSNA, blood pressure, or heart rate. After real acupuncture, the increase in mean arterial pressure (pre- vs. postacupuncture 4.5 vs. 1.7 mmHg, P < 0.001), but not MSNA or heart rate, was blunted during mental stress. Similarly, following nonacupoint acupuncture, the increase in mean arterial pressure was blunted during mental stress (5.4 vs. 2.9 mmHg, P < 0.0003). No-needle acupuncture had no effect on these variables. In conclusion, acupuncture at traditional acupoints, nonacupoints, and no-needle acupuncture does not modulate baseline MSNA or MSNA responses to mental stress in normal humans. Acupuncture significantly attenuates the increase in blood pressure during mental stress. Needling nonacupoints, but not "no-needle" acupuncture, have a similar effect on blood pressure.     

Social technology restriction alters state-anxiety but not autonomic activity in humans

Social technology is extensively used by young adults throughout the world, and it has been suggested that interrupting access to this technology induces anxiety. However, the influence of social technology restriction on anxiety and autonomic activity in young adults has not been formally examined. Therefore, we hypothesized that restriction of social technology would increase state-anxiety and alter neural cardiovascular regulation of arterial blood pressure. Twenty-one college students (age 18-23 yr) were examined during two consecutive weeks in which social technology use was normal or restricted (randomized crossover design). Mean arterial pressure (MAP), heart rate, and muscle sympathetic nerve activity (MSNA) were measured at rest and during several classic autonomic stressors, including isometric handgrip, postexercise muscle ischemia, cold pressor test, and mental stress. Tertile analysis revealed that restriction of social technology was associated with increases (12 ± 2 au; range 5 to 21; n = 7), decreases (-6 ± 2 au; range -2 to -11; n = 6), or no change (0 ± 0 au; range -1 to 3; n = 8) in state-anxiety. Social technology restriction did not alter MAP (74 ± 1 vs. 73 ± 1 mmHg), heart rate (62 ± 2 vs. 61 ± 2 beats/min), or MSNA (9 ± 1 vs. 9 ± 1 bursts/min) at rest, and it did not alter neural or cardiovascular responses to acute stressors. In conclusion, social technology restriction appears to have an interindividual influence on anxiety, but not autonomic activity. It remains unclear how repeated bouts, or chronic restriction of social technology, influence long-term psychological and cardiovascular health.