Journal of Psychosomatic Research 60 (2006) 439 – 444

Effect of autogenic training on cardiac autonomic nervous activity in

high-risk fire service workers for posttraumatic stress disorder
Satoko Mitania,T, Masatoshi Fujitab, Satoko Sakamotob, Taro Shirakawa
a
Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Public Health,
Yoshida-Konoe cho, Sakyo-ku, Kyoto 606-8501, Japan
b
School of Health Sciences, Faculty of Medicine, Kyoto University, Yosida-Konoe cho, Sakyo-ku, Kyoto 606-8501, Japan

Received 18 November 2004

Abstract
Objective: We investigated the effect of autogenic training
(AT) on cardiac autonomic nervous activity in fire services
workers with the use of the questionnaire of the Japanese-
language version of Impact of Event Scale-Revised (IES-R-J) and
indexes of heart rate variability. Methods: We studied 22 male
fire services workers who were divided into posttraumatic stress
disorder (PTSD)-related stress group (n=10) and control group
(n=12). They underwent AT twice or three times a week for
2 months. Results: Posttraumatic stress disorder-related stress
group showed a significantly higher cardiac sympathetic nervous
activity and a significantly lower cardiac parasympathetic ner-
vous activity than control group at baseline. Autogenic training
significantly decreased cardiac sympathetic nervous activity
and significantly increased cardiac parasympathetic nervous
activity in both groups. These changes were accompanied by a
significant decrease in the total points of IES-R-J. Conclusion:
Autogenic training is effective for ameliorating the disturbance
of cardiac autonomic nervous activity and psychological issues
secondary to PTSD.
D 2006 Elsevier Inc. All rights reserved.

Keywords: Autogenic training; Autonomic nervous activity; Heart rate variability; PTSD; Fire services workers

Introduction headache [5,6], anxiety [7], chronic asthmatic disorder [8],

Paramedics, emergency medical technicians, rescue
workers, and firefighters are often exposed to traumatic
events associated with their occupation and have a higher
prevalence of posttraumatic stress disorder (PTSD) than
the general population. Between 10% and 30% of these
fire services workers have been reported to suffer from
PTSD-related symptoms, as assessed and diagnosed by the
bImpact of Event Scale (IES)Q administered through a stan-
dard questionnaire [1 –3].
Autogenic training (AT) is a basic therapeutic technique,
one of several psychophysiologically oriented approaches to
the treatment of a variety of disorders. The theory of AT was
established by Shultz and Luthe [4]. It involves the
simultaneous modulation of mental and somatic functions.
This technique is now widely used for the treatment of
T Corresponding author. Tel.: +81 75 753 4451; fax: +81 75 753 4452.
and other stress-related disorders.
In the present study, AT was applied to fire services
workers to alleviate PTSD-related symptoms. Investiga-
tions of cardiovascular disorders have traditionally utilized
heart rate and blood pressure to track responses. Some
psychiatric PTSD literature has focused on autonomic
nervous system measures, especially resting heart rate
variability (HRV) patterns of low parasympathetic and
elevated sympathetic activity [9 –11]. Power spectral
analysis of HRV has successfully provided reliable and
sensitive indices of cardiac autonomic nervous activity
[12]. Using these indices, the effects of posture [13,14],
drugs [15 –16], cognitive behavioral therapy [17], and
exercise training [18] on HRV have been widely inves-
tigated. However, no studies have been conducted in
which HRV analysis was applied for evaluating the
beneficial effects of AT.
Thus, the purpose of this study was to assess the effects
of AT on PTSD-related symptoms of fire services workers

0022-3999/06/$ – see front matter D 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.jpsychores.2005.09.005
440 S. Mitani et al. / Journal of Psychosomatic Research 60 (2006) 439 – 444

by using the results of a self-administered questionnaire and repeated three times on November 2003, January 2004, and
analysis of HRV. March 2004. We analyzed ECG data obtained between
9:00 a.m. and 10:00 a.m. after 30 min of bed rest. The
complete recording was split into 5-min segments. We
Methods selected ECG recordings consisting predominantly of sinus
rhythm. Recordings with frequent supraventricular or
We distributed a questionnaire to each male fire services ventricular ectopic rhythms or atrial fibrillation were
worker in a specific fire station, and each subject was asked excluded from subsequent analysis. Heart rate and HRV
to seal it in an envelope after completing it. We studied parameters were computed for each segment. Spectral
22 fire services workers who were divided into a PTSD- analysis was conducted by computing the following fre-
related stress (PS) group (n = 10) and a control group quency domain variables for HRV by means of fast Fourier
(n = 12), based on the results of the questionnaire. They transformation. The direct current component was excluded
were followed up over a 4 -month period. Subjects were also in the calculation of the power spectrum to remove the
divided into two teams to avoid the time sequence effect. nonharmonic components in the very low-frequency (LF)
The effects of AT were assessed using both the question- region (b 0.04 Hz). The area of spectral peaks within the
naire and the HRV analysis. whole range of 0.04 to 0.40 Hz was defined as total power
(TP), the area of spectral peaks within the range of 0.04 to
The questionnaire: IES-R 0.15 Hz as LF power, and the area of spectral peaks within
the range of 0.15 to 0.40 Hz as high-frequency (HF) power.
In all cases, the following self-administrated question- The normalized HF power (= HF/TP) was used as an index of
naire was conducted before and after the AT application. modulation of vagal activity [24]. The LF/HF power ratio
The Japanese-language version of the Impact of Event was used as the index of sympathovagal balance [25 –27].
Scale-Revised (IES-R-J) [19] was used to determine the
frequency of self-reported posttraumatic symptoms of Autogenic training and procedure
reexperiencing/intrusion, avoidance, and arousal symptoms,
according to the Diagnostic and Statistical Manual of The first (heaviness of limbs) and second (warmth of
Mental Disorders, Fourth Edition (DSM-IV), criteria. This limbs) standard mental exercise of the classical Schultz-type
instrument contains 22 items (8 intrusion, 8 avoidance, and AT was utilized in the present study. The therapist was the
6 hyperarousal items). Each question was scaled ranging same (S.M.) in all cases. The training was applied
from 0 (not at all) to 4 (yes, absolutely). Despite being individually for a 60-min treatment session. Subjects were
developed before the formal introduction of PTSD within instructed to conduct AT by themselves twice or three times
the diagnostic literature, the Horowitz’s IES [20] remains a week for 2 months. To avoid the time effect, we randomly
one of the most widely used self-reported measures of divided the subjects into two teams. The first intervention
PTSD. Although not a PTSD diagnostic measure, the team underwent AT from November 2003 to January 2004,
psychometric properties of the IES are satisfactory, and
the use of IES as a measure of intrusion and avoidance,
which are the core of PTSD symptomatology on DSM-III, Table 1
Population characteristic and HRV baseline data of PS and the control
was warranted [21]. Impact of Event Scale-Revised is the
groups
revised version of Horowitz’s IES, with additional questions
PS Control t test or
on hyperarousal. By using the cutoff point of 24/25 on Total group group v test
IES-R-J, the sensitivity was calculated to be 0.75– 0.89, the
Number 22 10 12
specificity 0.71–0.93, the positive predictive value Age (meanFS.D., 42.2F9.7 43.6F8.9 41.1F10.6 t = 0.606,
0.44 –0.80, and the negative predictive value 0.90–0.96 year) P = .551
with regard to PTSD+partial PTSD vs. Normal [22]. Frequency 2.8F2.0 3.0F2.3 t =0.219,
Scoring high on the IES-R scale does not necessarily mean of AT P = .829
that the patient has PTSD; it may include neurosis, ex- per week
Shift worker 18 8 10 v 2 = 0.04
PTSD, or various adjustment disorder patients as well [23]. Daily worker 4 2 2 P = .63
In this study, our objective was not to determine whether Marriage 20 9 11 v 2 = 0.02
subjects are PTSD patients. We defined empirically the sub- No marriage 2 1 1 P = .71
jects having above 18 points on the IES-R-J as the PS group. Smoker 16 6 9 v 2 = 0.57
Nonsmoker 6 4 3 P = .38
LF/HF 4.25F1.85 1.70F0.56 t = 4.56,
Heart rate variability analysis P b.001
HF/TP 0.21F0.07 0.39F0.08 t = 5.36,
The 24 -h Holter ECG recordings were obtained with a P b.001
Spider View (ela Medical, France) and were analyzed with a Values are the meanFS.D.
Syne TEC (ela Medical). In all cases, ECG recordings were HF/TP, normalized HF power.
 S. Mitani et al. / Journal of Psychosomatic Research 60 (2006) 439 – 444
Table 2
Changes of LF/HF and HF/(HF+LF) on each intervention team
Values are the meanFS.D. Arrows indicate the time of the AT.
HF/TP, normalized HF power.
and the second intervention team did AT from January 2004
to March 2004. Subjects were instructed to carry out AT at
least two or three times per week. After the intervention
periods, the number of AT training per week was assessed
by the self-administered questionnaire.
Before the study, all subjects gave written informed
consent. The ethical committee at Kyoto University
Graduate School of Medicine reviewed and approved the
study protocol.
Data analysis
Demographic and physiological data are presented as the
meanFS.D. The differences between the periods and
between the groups and intervention teams were analyzed
using the Student’s t test and the analytic software SPSS for
Windows version 10.0.
Results
Twenty-two adult Japanese fire services workers with a
mean age of 42.2F9.7 years participated in this study.
Among these subjects, 10 persons who scored 18 points
or more on the IES-R-J were designated as the PS group,
and 12 persons with fewer than points served as the
control group. We found that 18 of 22 (82%) worked on a
24 -h shift. Twenty persons were married. Sixteen were
smokers and six were nonsmokers. There were no
significant differences in age (t =0.606, P =.551) and the
frequency of AT (t =0.219, P = .829) between the two
groups. There were no significant differences between the
two groups with respect to work shift, marriage, and
smoking. At baseline (pre-AT), cardiac sympathetic
nervous activity was significantly higher (t = 4.56,
P b.001) in the PS group than the control group. In
contrast, parasympathetic nervous activity was signifi-
cantly lower (t =5.36, P b.001) in the PS group than the
control group (Table 1).
441
Table 2 summarizes data on cardiac autonomic nervous
activity in November, January, and March for each
intervention team. In both the first and the second
intervention teams, there were significant differences in
cardiac nervous activity between pre- and post-AT. In the
first intervention team, AT was applied from November
2003 to January 2004, the sympathetic nervous activity in
January was significantly lower (t =3.86, P =.004), and the
parasympathetic nervous activity in January was signifi-
cantly higher (t = 2.86, P =.019) than those recorded in
November. In the second intervention team, AT was applied
from January 2004 to March 2004, the sympathetic nervous
activity in March was significantly lower (t = 4.34, P = .001),
and the parasympathetic nervous activity in March was
significantly higher (t =4.05, P = .002) than those in January.
Table 3 compares the effects of AT between the first and
the second intervention teams. Low/high frequency
decreased and HF/TP increased in both the first and second
intervention teams, and there were no significant differences
in the effect of AT between the first and the second
intervention teams in terms of the effects of AT on
sympathetic and parasympathetic nervous activities.
Table 4 shows the effects of AT in the PS (n =10) and
control (n = 12) groups. Low/high frequency significantly
decreased in both the PS (t = 6.336, P b.001) and the control
(t = 3.432, P = .006) groups after AT. High frequency/total
power significantly increased in both the PS (t = 3.686,
P =.005) and the control (t =3.269, P = .007) groups. In
addition, in the PS group, the total scores on the IES-R-J
Table 3
Comparison of the effects of AT between the first and the second
intervention teams
The first The second
intervention team intervention team t P
Number 10 12
LF/HF 0.68F0.56 0.84F0.67 0.61 .55
HF/TP + 0.07F0.07 + 0.09F0.08 0.74 .47
HF/TP, normalized HF power.
442 S. Mitani et al. / Journal of Psychosomatic Research 60 (2006) 439 – 444

Table 4 a traumatic event. Thus, the results of this subscale reflected

Comparison of the effects of AT in both PS group and the control groups
the efficacy of AT. The other two subscales (hyperarousal
P Control P and avoidance) tended to decrease compared with pre-AT
PS group group
(paired (paired levels; however, they did not reach statistical significance,
N 10 t test) 12 t test) presumably due to the small sample size.
LF/HF Pre-AT 4.25F1.85
Š b.001 1.70F0.56
Š .006
Earlier studies of PTSD revealed a lower resting HRV in
Post-AT 3.11F2.12 1.25F0.41 patients compared with controls, suggesting increased
HF/TP Pre-AT 0.21F0.07 0.39F0.08
Post-AT 0.30F0.13
Š .005 0.46F0.08
Š .007 sympathetic and decreased parasympathetic tone [29 –31].
Total points Pre-AT 26.30F16.47 5.42F7.37 Our results are in agreement with earlier reports, implying
of IES-R Post-AT 10.30F10.49
Š .037 5.75F6.40
Š .887 that the PTSD-related symptoms are associated with
Intrusion Pre-AT 8.30F5.98
Š .038 2.17F3.13
Š 1.000
disturbed cardiac autonomic nervous activity.
Post-AT 2.50F2.72 2.17F3.16 Special treatment programs for PTSD, including psy-
Hyperarousal Pre-AT 7.30F5.12 1.33F1.92
Post-AT 3.50F3.60
Š .065 1.41F2.27
Š .920 chodynamic reprocessing, behavioral therapy, cognitive
Avoidance Pre-AT 10.0F6.82 1.92F3.00 psychotherapy, rapid eye-movement desensitization, phar-
Post-AT 4.30F5.08
Š .075 2.17F3.30
Š .768 macotherapeutic approaches, preventative intervention,
Values are the meanFS.D. behavioral treatment, and medicinal treatments, have been
proposed [32,33]; however, there have been few
approaches that involve persons who were not yet
markedly decreased (t = 2.453, P =.037). Among the three diagnosed with psychiatric disorders, rather than those
subscales of the IES-R-J, intrusion decreased significantly in who were not yet diagnosed but at an elevated risk of
the PS group (t = 2.437, P = .038); however, hyperarousal PTSD. Although AT has been applied in the treatment of
and avoidance did not change significantly (Table 4). vehicle accident survivors [34], Japanese postwar high
school students [35], and U.S. military prisoners in North
Vietnam [36], the effects on autonomic nervous activity
Discussion were not fully assessed. We have demonstrated, for the
first time, the effect of AT on PS from the viewpoint of
There were no significant differences in the effects of AT cardiac autonomic nervous activity.
between the first and the second intervention teams,
indicating that there was no time effect in the present study.
Therefore, we can compare the AT effect accurately in the Limitations to the study
two groups with and without PS symptoms. Subjects with a
higher score on the IES-R-J — that is, the PS group — Several limitations to this study deserve comment. First,
revealed numerous symptoms of PTSD (intrusion, avoid- there is still a question as to whether IES-R-J is an
ance, and hyperarousal). This high scoring PS group appropriate means of assessing PTSD. In this study, it was
showed a predominance of cardiac sympathetic nervous used to measure PTSD symptoms, not establish a diagnosis
activity at baseline. By applying AT, the sympathetic of PTSD. Thus, the subjects of this study were not patients
nervous activity decreased, and the parasympathetic nervous with a psychiatric diagnosis of PTSD. However, it is
activity increased in both the PS and the control groups. generally recognized that the psychometric properties of
Autonomic nervous activity in the PS group changed to a IES-R-J are satisfactory and available for epidemiological
greater extent than the control group; however, it did not use [21].
reach the level observed in the control group. Moreover, AT Second, it remains controversial whether spectral analy-
reduced self-reported psychological dysfunction. The IES- sis of HRV is really an appropriate index for autonomic
R-J score decreased significantly in the PS group. Among nervous activity. Spectral analysis of HRV has recently
the three subscales of the IES-R-J, b intrusionQ decreased gained recognition as a reliable noninvasive test for quan-
significantly, including bemotional flashback,Q bawakening titative assessment of cardiovascular autonomic regulatory
from sleep,Q and bemotional welling up.Q These results response. This technique also provides a dynamic map of
reveal that psychological strain, which was caused by sympathetic and parasympathetic tone and can thus be used
intrusion experiences, gave tense to autonomic nervous to indicate the nature of sympathetic–parasympathetic
tone. The sympathetic branch is activated by any stimulus interactions [37,38].
above an organismal threshold, and it functions to increase Third, it is necessary to confirm whether participants
arousal, trigger an immediate anticipatory state, and rapidly conducted AT properly. We recommended that they perform
mobilize in response to an appraised stressor [28]. People AT several times per week, as most of them were shift
tend to present an oscillating pattern wherein intrusive workers and were on duty two or three times a week, and
symptoms are followed by avoidance. Intrusive experiences carried out AT before taking a nap during their on-duty day.
cannot, however, be warded off with avoidance behavior. At the end of this study, the number of AT exercises was
Intrusion is the most characteristic symptom of PTSD from calculated based on the self-reported questionnaire.
 S. Mitani et al. / Journal of Psychosomatic Research 60 (2006) 439 – 444
Finally, this study was limited by a small sample size.
Therefore, future studies are necessary to elucidate the effect
of AT in a large cohort of subjects.
In conclusion, the findings reported here suggest that AT
is effective for ameliorating the disturbance of cardiac
autonomic nervous activity and psychological issues secon-
dary to PTSD.
These data also show that AT alleviates PS and
psychological symptoms secondary to PTSD; however, we
do not claim that AT is an effective treatment for PTSD.
Acknowledgments
The authors thank Dr. J Sugimoto for his invaluable
knowledge and guidance on AT.
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