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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 4  |  Issue : 1  |  Page : 24-27

Effect of stress and anxiety on 1st year medical students


1 Department of Physiology, Karpaga Vinayaga Institute of Medical Sciences and Research Centre, Kanchipuram, Tamil Nadu, India
2 Department of Physiology, Sri Devaraj Urs Medical College, Kolar, Karnataka, India
3 Department of Integrative Medicine, Sri Devaraj Urs University, Kolar, Karnataka, India

Date of Web Publication17-Aug-2017

Correspondence Address:
Sumitra Sudharkodhy
Department of Physiology, Karpaga Vinayaga Institute of Medical Sciences and Research Centre, Chinna Kolambakkam, Kanchipuram - 603 308, Tamil Nadu,
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijny.ijoyppp_2_16

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  Abstract 


Context: Medical students are exposed to various stresses such as demanding medical education and different teaching protocols.[4],[5] Heart rate variability (HRV) is a simple and noninvasive indicator for the detection of cardiac autonomic dysfunction. This study was done to assess the effect of stress and anxiety on HRV. Aims: This study aims to assess the perceived stress, anxiety, and HRV in 1st year medical students and to correlate stress and anxiety to HRV. Subjects and Methods: The study included 110, 1st year MBBS students, excluding students with any infections, metabolic diseases, cardiorespiratory diseases, and medications which alter the autonomic functions. Anxiety and stress were measured using Spielberger State-Trait Anxiety Inventory (STAI) and Perceived Stress Scale (PSS) questionnaires, respectively. Based on the scores, students were assigned to stress and nonstress group and anxious and nonanxious group. The electrocardiogram (ECG) was recorded using a house built analog ECG amplifier, which was further analyzed using HRV analysis software. Results: STAI and PSS were analyzed; those who have STAI score of above 40 come under anxious group and those with PSS score of 13 and above comes under stress group. Sixty-two percent students are both anxious as well as stressed. The parameters, namely, mean heart rate, standard deviation of normal to normal, root mean square successive difference (RMSSD), low-frequency (LF) normalized unit, and high-frequency (HF) normalized unit were correlated with stress and anxiety scores. During state-anxiety, there is a significant increase in heart rate, RMSDD, LF domain, and LF/HF and during trait-anxiety, there is significant increase in RMSDD and LF/HF ratio. In this study, perceived stress is not significant with HRV. Conclusions: This study shows that during anxiety there is increased activity toward sympathetic, but no difference in parasympathetic activity and during perceived stress, there is no significance with HRV.

Keywords: Anxiety, heart rate variability, Perceived Stress Scale, Spielberger State-Trait Anxiety Inventory, stress


How to cite this article:
Sudharkodhy S, Kutty K, Vinutha Shankar M S, Patil N J. Effect of stress and anxiety on 1st year medical students. Int J Yoga - Philosop Psychol Parapsychol 2016;4:24-7

How to cite this URL:
Sudharkodhy S, Kutty K, Vinutha Shankar M S, Patil N J. Effect of stress and anxiety on 1st year medical students. Int J Yoga - Philosop Psychol Parapsychol [serial online] 2016 [cited 2017 Sep 26];4:24-7. Available from: http://www.ijoyppp.org/text.asp?2016/4/1/24/213077


  Introduction Top


Stress is defined as a mismatch between perceived demands and perceived capacities to meet those demands. It is a huge problem in the present scenario, which may lead to work-related illness directly or indirectly.[1] It affects many physiological parameters in human body and causes imbalance in homeostasis mechanism.[2]

Medical training is highly stressful particularly for those who are beginning their medical education.[3] Medical students are exposed to various stresses in medical college such as demanding medical education and different teaching protocols.[4],[5]

Stress and anxiety are often associated with increased risk for cardiovascular disorders, including ventricular arrhythmias, myocardial infarction, heart failure, and sudden death.[6]

Heart rate variability (HRV) is a noninvasive electrocardiographic (ECG) index of the autonomic control of the heart, which has been extensively studied in anxiety and affective disorders. HRV reflects oscillations in the interval between consecutive heart beats. The analysis in the time domain of ECGs involves the identification of each cardiac cycle and the determination of mean intervals between successive R (R-R) or QT waves.

The aim of the present study is to test the impact of real-life stressors among 1st year medical students on indices of resting cardiac autonomic regulation using spectral analysis of HRV and conventional autonomic tests.

Objective

  • To assess the perceived stress and anxiety levels and HRV in 1st year medical students
  • To correlate stress and anxiety to HRV.



  Subjects and Methods Top


One hundred and ten healthy 1st year medical students of either gender from our tertiary care teaching hospital were included in this study. Informed oral consent was obtained from the study population that was approved by the Institutional Ethical Committee.

Inclusion criteria

First-year medical students of age group 18–20 years.

Exclusion criteria

Students those were,

  • Practicing any known stress relieving or relaxation technique
  • Not having any drugs or beverages in quantity which affect the autonomic nervous system such as anticholinergic drugs
  • Not having any major illness which is known to affect the autonomic nervous system.


Anxiety and stress were measured using Spielberger State-Trait Anxiety Inventory (STAI) and Perceived Stress Scale (PSS) questionnaires, respectively. Based on the scores, students were assigned to stress group/nonstress group and anxious group/nonanxious group. The ECG was recorded using a house built analog ECG Amplifier.

Recording was done in the morning hours between 9:00 am and 11:00 am.

The participants were given the following instructions:

  • To avoid food 2 h before testing
  • To avoid coffee or alcohol 24 h before testing
  • To wear loose and comfortable clothing during the test.


Recording

The ECG was recorded using in ECG amplifier, with audacity 1.3.13 license free software in the supine position for 5 min after 10 min of supine rest. Participants were instructed to close the eyes and to avoid talking, moving of hands, legs and body, coughing, and sleeping during the test.

ECG was recorded in dot waveform with 8000 samples/s (minimum required is 1000 samples/s), the recorded wave was subjected to digital filtering to filter the noise and amplification to increase the size of ECG wave. Using beat finder every “R” wave was recorded as beat, and the real time was noted. The data were exported as labels to notepad and from there to Microsoft Excel to find out “rhythm-to-rhythm (R-R)” interval; this was saved in notepad. Every participant's raw data, filtered data, and R-R interval in millisecond in notepad are saved. The notepad file is opened in HRV analysis software V1.1 license free software, and the report sheet was saved in the Joint Photographic Experts Group format.

The ECG was analyzed using HRV analysis software. The analysis from the HRV software provides information about time domain (standard deviation of normal to normal [SDNN], root mean square successive difference [RMSSD]) and frequency domain parameters (low frequency [LF], high-frequency [HF], LF/HF ratio).


  Results Top


STAI and PSS were analyzed, those who have STAI score of above 40 comes under anxious group, and those with PSS score of 13 and above comes under stress group. Sixty-two percent of students are both anxious as well as stressed [Figure 1].
Figure 1: Stress and anxiety in 1st year medical students

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The parameters, namely, mean heart rate, SDNN, the root mean square of differences between successive R-R intervals (RMSSD), LF normalized unit (LFnu), and HF normalized unit were correlated with stress and anxiety scores [Table 1],[Table 2],[Table 3].
Table 1: Comparison of State-Trait Anxiety Inventory-State and heart rate variability with nonanxious and anxious group

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Table 2: Comparison of State-Trait Anxiety Inventory-Trait and heart rate variability with nonanxious and anxious group

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Table 3: Comparison of Perceived Stress Scale and heart rate variability with nonstress and stress group

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During state-anxiety, there is significant increase in heart rate, LF domain, LF/HF and decrease in RMSSD [Table 1], and during trait-anxiety, there are significant decrease in RMSDD and increase in LF/HF ratio [Table 2]. In this study, perceived stress is not significant with HRV [Table 3].


  Discussion Top


Anxiety results in psychological problems resulting in deterioration of academic performance. This further affects autonomic balance resulting in cardiac dysfunction. In the present study, heart rate (HR), SDNN, LF, and LF/HF ratio increased and RMSSD, HF decreased were compared to a study done by Miu et al. in 2009 shows that high trait-anxiety is associated with sympathetic dominance. In comparison to mental stress, autogenic training has parasympathetic dominance. No significant effects of Trait anxiety (TA) or the psychophysiological conditions on LF power, or LF/HF ratio.[7] Some other studies have also revealed high prevalence of depression and anxiety among medical students, with levels of overall psychological distress consistently higher than in the general population.[8],[9],[10],[11],[12]

Later on, one Indian study by Srinivasan et al. shows that LFnu and LF/HF ratio of HRV in supine posture was significantly higher in the “stress” group compared to the “no stress” group.[13] In this study, self-rated scale was used instead of STAI and PSS.

One international study by Orsila et al. showed that HRV parameters describing mental stress, i.e., RMSSD, TINN, and HF were lowest in the morning. These low morning values suggest the subjects' perceived stress was high in the morning. On the other hand, these values were highest at night, which suggests the subjects' relaxation and low mental stress. The values of LF and LF/HF, which were the highest in the morning and the lowest at night, are also indicative of high mental stress in the morning and low at night.[14]

Another study done by Melillo et al. showed that almost all HRV features measuring heart rate complexity were significantly decreased in the stress session. The features SD2, D2, En(0.2), En (rchon), a1, and lmax were significantly reduced during university examination as compared with rest session, while lmean, REC, and ShEn increased significantly during stress.[15]

According to the study done by Sato showed that heart rate and LF/HR ratio declined during the massage, but these affects almost subsided after massage.[16]

PSS is an index of an individual's perception to events in one's life that is perceived as stressful. In our study, there was no significant decrease in PSS in contrary to an Indian study that showed significant decreased in health-care students.[17]

Limitations

  • There are some limitations to the present study. We did not measure respiration because in many HRV studies respiratory sinus arrhythmia was ignored.[18] However, the effect of breathing pattern on HRV is a debated question. Some studies showed that different breathing conditions may have an impact on the reproducibility of HRV
  • The results should be interpreted with caution due to the small sample size and the recording of only a single day
  • Variation of resting HR was not considered while interpreting the HRV results.


Despite some limitations, there are considerable strengths in this study. The data for this study were gathered using multiple measurements in combination with new variables to quantify HR.


  Conclusions Top


This study shows that during anxiety there is increased activity toward sympathetic, but no difference in parasympathetic activity, and during perceived stress, there is no significance with heart rate.

There are no conflicts of interest.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Lundberg U, Frankenhaeuser M. Stress and workload of men and women in high-ranking positions. J Occup Health Psychol 1999;4:142-51.  Back to cited text no. 1
    
2.
Chandola T, Britton A, Brunner E, Hemingway H, Malik M, Kumari M, et al. Work stress and coronary heart disease: What are the mechanisms? Eur Heart J 2008;29:640-8.  Back to cited text no. 2
    
3.
Stewart SM, Betson C, Marshall I, Wong CM, Lee PW, Lam TH. Stress and vulnerability in medical students. Med Educ 1995;29:119-27.  Back to cited text no. 3
    
4.
Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med 2006;81:354-73.  Back to cited text no. 4
    
5.
Firth J. Levels and sources of stress in medical students. Br Med J (Clin Res Ed) 1986;292:1177-80.  Back to cited text no. 5
    
6.
Elkin AJ, Rosch PJ. Promoting mental health at the workplace: The prevention side of stress management. Occup Med 1990;5:739-54.  Back to cited text no. 6
    
7.
Miu AC, Heilman RM, Miclea M. Reduced heart rate variability and vagal tone in anxiety: Trait versus state, and the effects of autogenic training. Auton Neurosci 2009;145:99-103.  Back to cited text no. 7
    
8.
Park J, Chung S, An H, Park S, Lee C, Kim SY, et al. A structural model of stress, motivation, and academic performance in medical students. Psychiatry Investig 2012;9:143-9.  Back to cited text no. 8
    
9.
Jurkat HB, Richter L, Cramer M, Vetter A, Bedau S, Leweke F, et al. Depression and stress management in medical students. A comparative study between freshman and advanced medical students. Nervenarzt 2011;82:646-52.  Back to cited text no. 9
    
10.
Haight SJ, Chibnall JT, Schindler DL, Slavin SJ. Associations of medical student personality and health/wellness characteristics with their medical school performance across the curriculum. Acad Med 2012;87:476-85.  Back to cited text no. 10
    
11.
Prinz P, Hertrich K, Hirschfelder U, de Zwaan M. Burnout, depression and depersonalisation – Psychological factors and coping strategies in dental and medical students. GMS Z Med Ausbild 2012;29.  Back to cited text no. 11
    
12.
Fan AP, Kosik RO, Su TP, Lee FY, Hou MC, Chen YA, et al. Factors associated with suicidal ideation in Taiwanese medical students. Med Teach 2011;33:256-7.  Back to cited text no. 12
    
13.
Srinivasan K, Vaz M, Sucharita S. A study of stress and autonomic nervous function in first year undergraduate medical students. Indian J Physiol Pharmacol 2006;50:257-64.  Back to cited text no. 13
    
14.
Orsila R, Virtanen M, Luukkaala T, Tarvainen M, Karjalainen P, Viik J, et al. Perceived mental stress and reactions in heart rate variability – A pilot study among employees of an electronics company. Int J Occup Saf Ergon 2008;14:275-83.  Back to cited text no. 14
    
15.
Melillo P, Bracale M, Pecchia L. Nonlinear heart rate variability features for real-life stress detection. Case study: Students under stress due to university examination. Biomed Eng Online 2011;10:96.  Back to cited text no. 15
    
16.
Sato T. Effects of hand massage on the human autonomic system and mood in healthy women. Yamanashi Nurs J 2006;4:25-32.  Back to cited text no. 16
    
17.
Simard AA, Henry M. Impact of a short yoga intervention on medical students' health: A pilot study. Med Teach 2009;31:950-2.  Back to cited text no. 17
    
18.
Ritz T, Dahme B. Implementation and interpretation of respiratory sinus arrhythmia measures in psychosomatic medicine: Practice against better evidence? Psychosom Med 2006;68:617-27.  Back to cited text no. 18
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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