C 2006)

Journal of Traumatic Stress, Vol. 19, No. 5, October 2006, pp. 735740 (

BRIEF REPORT

Heart Rate of Motor Vehicle Accident Survivors

in the Emergency Department, Peritraumatic
Psychological Reactions, ASD, and PTSD Severity:
A 6-Month Prospective Study
Eric Kuhn
Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Sierra Pacic Mental Illness,
Research, Education, and Clinical Center, Palo Alto, CA; and Stanford University School
of Medicine, Palo Alto, CA

Edward B. Blanchard, Tiffany Fuse, and Edward J. Hickling

Center for Stress and Anxiety Disorders, University at Albany, Albany, NY

John Broderick
Adirondack Medical Center, Saranac Lake, NY
This small-scale study investigates the relationships between the heart rate of motor vehicle accident
survivors presenting in the emergency department (ED) and acute stress disorder (ASD) and posttraumatic
stress disorder (PTSD) symptom severity. It also examines the relationships between the survivors heart
rate in the ED and peritraumatic dissociation and peritraumatic distress reported 2 weeks posttrauma.
Fifty motor vehicle accident (MVA) survivors were assessed 2 weeks, 1 (N = 42), 3 (N = 37), and
6 months (N = 37) post-MVA. The heart rate in the ED predicted self-reported ASD symptom severity
and clinician-rated PTSD symptom severity at 6 months but not at 1 or 3 months. Survivors heart rate
in the ED was signicantly correlated with peritraumatic dissociation but not peritraumatic distress.
These ndings support the role of elevated ED heart rate as a predictor of both ASD and chronic PTSD
symptom severity and may help to clarify the discrepant ndings of previous research.

For both acute stress disorder (ASD) and posttraumatic

stress disorder (PTSD), the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV; American
Psychiatric Association, 1994) requires that an individual
has experienced a trauma; however, this requisite alone
does not account fully for who develops these conditions.
For example, after serious motor vehicle accidents (MVA),
only 1314% of survivors develop ASD (Harvey &
Bryant, 1998) and 1545% develop PTSD (Blanchard &
Hickling, 2004). Thus, identifying and understanding psychological and physiological mechanisms that mediate the

relationship between experiencing trauma and developing

ASD or PTSD are of paramount importance.
Sympathetic arousal during and immediately after
trauma (i.e., peritraumatic) has been posited as one physiological mechanism that strengthens the consolidation
of emotional memories (McCleery & Harvey, 2004) and
enhances fear conditioning (Pittman, 1989) resulting in
many symptoms of ASD and PTSD (e.g., intrusive recollections, cued sympathetic arousal). To date, only one
study (Bryant, Harvey, Guthrie, & Moulds, 2000) has
examined the relationship between heart rate (HR)an

Correspondence concerning this article should be addressed to: Eric Kuhn, VA Palo Alto Health Care System, 334PTSD, Menlo Park, CA 94025. E-mail: ekuhn@stanford.edu.


C 2006 International Society for Traumatic Stress Studies. Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/jts.20150

735

736

Kuhn et al.

indicator of sympathetic arousalshortly after trauma and

ASD. In that study, early HR was not higher in those diagnosed with ASD versus those with sub-ASD (all criteria
met except dissociative symptoms) or no ASD. In fact,
the sub-ASD group had higher HR than the ASD and
non-ASD groups. However, in that study, HR was assessed
about 6 days post-MVA so it remains unknown if elevated
peritraumatic HR would predict ASD.
To date, six studies have examined the relationship between HR soon after trauma and later PTSD. These studies produced inconsistent ndings with four reporting a
positive relationship (Bryant et al., 2000; Kassam-Adams,
Garcia-Espana, Fein, & Winston, 2005; Shalev et al., 1998;
Zatzick et al., 2005), one reported a negative relationship
(Blanchard, Hickling, Galovski, & Veazey, 2002), and one
reported no relationship (Buckley et al., 2004). A possible reason for these mixed ndings is the methodological
heterogeneity across studies. This is particularly true with
respect to symptom assessment methods (interviews vs.
self-report), samples (e.g., treatment seeking for PTSD vs.
all available trauma patients), and timing of PTSD assessments (1 month vs. >4 months).
Surprisingly the relationships between survivors heart
rate in the emergency department (ED) and other peritraumatic factors have largely been neglected. In only two
of these studies (Delahanty, Royer, & Raimonde, 2003;
Shalev et al., 1998) was the relationship between HR and
peritraumatic dissociation studied and in both, survivors
ED heart rate was not related to peritraumatic dissociation.
Likewise, the relationship between HR and peritraumatic
distress was examined in only one of these studies (Shalev
et al., 1998), with immediate response (a composite measure of physical, emotional, and negative cognitive experiences during the trauma) correlating with survivors ED
heart rate.
Despite this paucity of research, these relationships are
nonetheless important to consider. For example, peritraumatic dissociation has long been assumed to reduce the
overwhelming distress and arousal created by traumatic experiences (van der Kolk, van der Hart, & Marmar, 1996).
Thus, higher peritraumatic dissociation might be expected
to be related to lower HR. Indirect evidence for this hy-

pothesis is provided by a nding of lower HR in female rape

victims who had high peritraumatic dissociation compared
with those who had low peritraumatic dissociation when
later recounting their rape (Grifn, Resick, & Mechanic,
1997). However, a recent attempt to replicate this nding
with MVA and assault survivors failed; instead the results
suggested that those high in dissociation might have (i.e.,
approached signicance) higher HR than survivors low
in dissociation (Nixon, Bryant, Moulds, Felmingham, &
Mastrodomenico, 2005). The relationship between peritraumatic distress and physiological arousal is also important to consider because DSM-IV requires subjective
responses of fear, helplessness, or horror for an event to be
considered a trauma. Understanding how these responses
relate to objective indicators of physiological distress might
provide useful information to promote our understanding
of the etiology of PTSD.
Given the state of this literature, we examined the relationship between ED heart rate and subsequent ASD
and PTSD symptom severity in a sample of injured MVA
survivors. We hypothesized that elevated ED heart rate in
MVA survivors would predict ASD and PTSD symptom
severity. Unlike previous studies, we examined the association of ED heart rate with both acute (<3 months) and
chronic (>3 months) PTSD symptom severity making it
possible to evaluate if timing of the assessment could help
account for the discrepant ndings of previous research. We
also examined the relationships between ED heart rate in
MVA survivors and peritraumatic dissociation and distress.

METHOD
Participants
The participants were 50 (20 men, 30 women) MVA survivors recruited from a U.S. Level 1 trauma center ED.
Eighteen participants were hospitalized (M = 8.7 days,
SD = 6.2) and 32 were discharged directly from the ED.
There were 41 White, 8 African American, and 1 Latino individual with ages ranging from 18 to 67 years (M = 38.6,
SD = 13.6). Initially, 90 patients were approached, 15
declined, and 25 consented but failed to complete the

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Victims Heart Rate in the Emergency Department, ASD, and PTSD

rst interview. These patients did not signicantly differ

in age, gender, and the percentage hospitalized compared
to participants. During the study, 13 participants dropped
out. They were younger, t(48) = 2.2 p = <.05, than completers, but did not differ in gender, percentage hospitalized, ED heart rate, and ASD symptom severity.

737

envelope a week before the assessment time point. Because

of possible travel limitations (e.g., physical injury, lack of
transportation, distance), most interviews (93%) were conducted by phone. Participants received $10 for the 2-week
assessment and $20 for each of the follow-up assessments.

RESULTS
Measures
Peritraumatic reactions. The Peritraumatic Distress Inventory (PDI; Brunet et al., 2001) is a 13-item self-report
questionnaire measuring distress experienced during and
immediately after trauma. The State Dissociation Questionnaire (SDQ; Murray, Ehlers, & Mayou, 2002) is a
9-item self-report measure assessing peritraumatic dissociation. The rst HR recorded upon admission to the ED
was obtained from participants medical charts.
Acute stress disorder and posttraumatic stress disorder.
Acute stress disorder was assessed with the ASD Interview
(Bryant, Harvey, Dang, & Sackville, 1998) and the 19item, self-report ASD Scale (Bryant, Moulds, & Guthrie,
2000). Posttraumatic stress disorder was assessed with the
Clinician-Administered PTSD Scale for DSM-IV (CAPS;
Blake et al., 1998) and the 17-item self-report Posttraumatic Checklist (PCL; Weathers, Litz, Herman, Huska, &
Keane, 1993).

Procedure
The appropriate institutional review boards approved study
procedures. All participants provided written informed
consent. Recruitment of all available, eligible ED patients
was conducted in the spring of 2003 for approximately
6 days a week for several hours per day. Inclusion criteria required that patients had no impairment in consciousness at
the time of consent; spoke English, and were 18 to 70 years
of age. Participants completed assessments at 2 weeks, 1, 3,
and 6 months post-MVA. The 2-week assessment included
the PDI, SDQ, ASD Scale, and the ASD Interview. The
three subsequent assessments included the PCL and the
CAPS. Questionnaires were mailed with a stamped return

At the 2-week assessment, 5 participants were diagnosed

with ASD, and 14 had sub-ASD (all criteria met except
dissociative symptoms). At 1, 3, and 6 months, 7, 4, and
4 participants were diagnosed with PTSD, respectively.
To evaluate the hypothesis that elevated ED heart rate
would predict ASD and PTSD symptom severity, correlations were conducted. Because of signicant positive skew
in CAPS and PCL scores, Spearman correlations were computed throughout (see Table 1). Participants ED heart rate
was signicantly correlated with the ASD Scale but not the
ASD Interview. Participants ED heart rate was also significantly correlated with 6-month CAPS but not the PCL
at that time nor was it signicantly correlated with either
measure at the earlier assessments. Table 1 also presents
the correlations between participants ED heart rate and
the peritraumatic psychological variables. Participants ED
heart rate was signicantly correlated with peritraumatic
dissociation and its correlation with peritraumatic distress
approached statistical signicance ( p = .08). There were
no signicant mean differences found for any of the variables listed in Table 1 based on gender or injury severity
(as reected in whether the participant was hospitalized or
not) except for the ASD Interview, where the hospitalized
group had a lower mean number of symptoms than the
nonhospitalized group.

DISCUSSION
In accord with our hypothesis, participants ED heart rate
predicted ASD symptom severity and partial support was
found for ED heart rate predicting PTSD symptom severity. Participants ED heart rate was signicantly correlated with peritraumatic dissociation and its correlation
with peritraumatic distress approached signicance. These

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

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Kuhn et al.

Table 1. Spearman Correlation Coefcients Between Heart Rate Taken in the Emergency Department and Measures
of ASD and PTSD Symptom Severity
Correlation Coefcients

HR taken in ED (N = 50)
SDQ (N = 44)
PDI (N = 44)
ASD Interview (N = 50)
ASD Scale (N = 44)
1-Month CAPS (N = 42)
1-Month PCL (N = 40)
3-Month CAPS (N = 37)
3-Month PCL (N = 35)
6-Month CAPS (N = 37)
6-Month PCL (N = 34)

SD

HR in ED

SDQ

PDI

85.9
22.8
25.1
6.8
52.2
21.8
34.9
15.3
30.9
14.7
28.8

16.4
8.1
12.8
4.1
17.4
21.0
15.8
19.0
15.8
22.1
15.6

.31
.27
.16
.36
.02
.01
.27
.20
.34
.27

.31

.32
.14
.46
.10
.02
.18
.01
.09
.03

.27
.32

.55
.56
.27
.31
.22
.30
.22
.07

Note. ASD = Acute Stress Disorder; HR = Heart Rate; SDQ = State Dissociation Questionnaire; PDI = Peritraumatic Distress Inventory; PTSD = Posttraumatic
Stress Disorder; ED = Emergency Department; CAPS = Clinician-Administered PTSD Scale; PCL = PTSD Checklist.
p < .05. p < .01. p < .10.

ndings, however, are not without qualication. First, participants ED heart rate predicted self-reported ASD symptom severity and not clinician-rated severity. This may be
due to the fact that the ASD Scale has better sensitivity
as it provides a more continuous severity summation than
the ASD Interview, which uses clinician-rated presence or
absence of each symptom resulting in an overall symptom count. Second, for ED heart rate predicting PTSD
symptom severity ndings were also dependent upon the
method of assessment and time post-MVA. At 1 and 3
months, no signicant correlations were found between
participants ED heart rate and PTSD symptom severity.
At 6 months, however, a signicant correlation emerged between participants ED heart rate and clinician-rated but
not self-reported PTSD symptom severity.
The positive nding at 6 months replicates those of both
Shalev et al. (1998) and Bryant et al. (2000) and our correlation (r = .34) is of similar magnitude to those reported
in these other studies (r s = .31 and .28, respectively). The
failure of ED heart rate to predict PTSD symptom severity
at 1 month also replicates Buckley et al.s (2005) ndings.
Taken together, this suggests that the timing of PTSD
assessment is important for the appearance of this relationship. Because early posttraumatic distress is elevated for

many survivors, it may not be until after the nonpathological distress has subsided that a clear relationship emerges.
Emergency department HR predicting self-reported ASD
symptom severity seems to contradict this reasoning; however, ASD might better discriminate between pathological
and normal early posttraumatic distress than does PTSD.
The nding that ED heart rate signicantly correlated
with peritraumatic dissociation contrasts with previous
null ndings (Delahanty et al., 2003; Shalev et al., 1998).
It also contradicts the hypothesis that peritraumatic dissociation dampens physiological arousal; instead lending
support to the counter-hypothesis that heightened physiological arousal is necessary for the occurrence of peritraumatic dissociation (Brewin, 2001). Finally, although
the correlation between ED heart rate and peritraumatic
distress was not signicant, it did approach signicance,
which is consistent with Shalev et al.s nding.
Although the present study has many strengths (e.g.,
longitudinal prospective design, structured clinical interviews), it also has several limitations. Foremost among these
is the small sample size. Consequently, few individuals were
diagnosed with ASD or PTSD precluding statistical testing of ED heart rate differences between diagnostic groups
and estimation of optimal ED heart rate cut scores for

Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.

Victims Heart Rate in the Emergency Department, ASD, and PTSD

739

identifying cases of ASD or PTSD, strategies that were

employed in previous research. The small sample size also
resulted in insufcient power for statistically establishing
even modest correlations (r s = .27.31). In addition, the
study relied on a non-standardized ED heart rate measurement. Although not ideal, routinely collected ED heart rate
was used in all but one of the studies reviewed above (i.e.,
Bryant et al., 2000). The small sample size precluded statistically controlling factors such as gender or injury severity
and others that could have inuenced our ndings. The
study also suffered from substantial attrition and those who
dropped out were younger than those who did not. Lastly,
it is not known how well the current ndings will generalize to other trauma populations, particularly those who
experience chronic or repeated trauma.
Despite these limitations, the current ndings are important as they (a) provide preliminary evidence for the
role of ED heart rate in predicting ASD symptom severity,
(b) provide additional support for ED heart rate predicting
chronic PTSD symptom severity, and (c) suggest that this
predictive relationship depends on how long posttrauma
PTSD is assessed. Our ndings also further question the
hypothesized inverse link between peritraumatic dissociation and physiological arousal, which certainly requires
further explication in future research.

Brunet, A., Weiss, D. S., Metzler, T. J., Best, S. R., Neylan, T. C.,
Rogers, C., et al. (2001). The Peritraumatic Distress Inventory:
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Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.