Low cortisol, high DHEA, and high levels of stimulated TNF-alpha, and IL-6 in women with PTSD

Common pathways and communication between the brain and heart: connecting post-traumatic stress disorder and heart failure

Psychiatric illnesses and cardiovascular disease (CVD) contribute to significant overall morbidity, mortality, and health care costs, and are predicted to reach epidemic proportions with the aging population. Within the Veterans Administration (VA) health care system, psychiatric illnesses such as post-traumatic stress disorder (PTSD) and CVD such as heart failure (HF), are leading causes of hospital admissions, prolonged hospital stays, and resource utilization. Numerous studies have demonstrated associations between PTSD symptoms and CVD endpoints, particularly in the Veteran population. Not only does PTSD increase the risk of HF, but this relationship is bi-directional. Accordingly, a VA-sponsored conference entitled "Cardiovascular Comorbidities in PTSD: The Brain-Heart Consortium" was convened to explore potential relationships and common biological pathways between PTSD and HF. The conference was framed around the hypothesis that specific common systems are dysregulated in both PTSD and HF, resulting in a synergistic acceleration and amplification of both disease processes. The conference was not intended to identify all independent pathways that give rise to PTSD and HF, but rather identify shared systems, pathways, and biological mediators that would be modifiable in both disease processes. The results from this conference identified specific endocrine, autonomic, immune, structural, genetic, and physiological changes that may contribute to shared PTSD-CVD pathophysiology and could represent unique opportunities to develop therapies for both PTSD and HF. Some recommendations from the group for future research opportunities are provided.

Impact of Repetitive Mild Traumatic Brain Injury on Behavioral and Hippocampal Deficits in a Mouse Model of Chronic Stress

Clinical studies examining the interaction between traumatic brain injury (TBI) and stress-related disorders (e.g., post-traumatic stress disorder) are often complicated by methodological constraints, such as heterogeneity in injury type and severity, time post-trauma, and predisposing risk factors. Developing relevant animal models whereby many variables can be efficiently controlled is thus essential to understanding this elusive relationship. Here, we use our repeated unpredictable stress (RUS) paradigm, in combination with our established mouse model of repetitive mild TBI (r-mTBI), to assess the impact of repeated exposures to these paradigms on behavioral and neurobiological measures. C57BL/6J male mice were exposed to RUS and r-mTBI at 3 and 6 months of age followed by batteries of behavioral testing. Mice were euthanized 10 days and 3 months post-exposure, with brain and plasma samples collected for molecular profiling. The RUS paradigm involved exposure to a predator odor (trimethylthiazoline; TMT) while under restraint, daily unstable social housing, five inescapable footshocks on separate days, and chronic social isolation. Animals receiving r-mTBI ( × 5) and stress were exposed to a single closed-head injury 1 h after each footshock. Stress-alone mice showed significant weight loss, recall of traumatic memories, and anxiety-like and passive stress-coping behavior when compared with control mice. However, in stress+r-mTBI animals, the changes in cued fear memory, anxiety, and stress-coping tests were diminished, possibly due to TBI-induced hyperactivity. We also report complex brain molecular and neuropathological findings. Stress and r-mTBI, either individually or comorbidly, were associated with a chronic reduction in dendritic spine GluN2A/GluN2B ratio in the hippocampus. While stress augmented the r-mTBI-dependent astrogliosis in the corpus callosum, it mitigated r-mTBI-induced increases in hippocampal pro-brain-derived neurotrophic factor. We anticipate that our model will be a good platform to untangle the complex comorbid pathophysiology in stress disorders and r-mTBI.

Social isolation as a promising animal model of PTSD comorbid suicide: neurosteroids and cannabinoids as possible treatment options

Post-traumatic stress disorder (PTSD) is a psychiatric condition characterized by drastic alterations in mood, emotions, social abilities and cognition. Notably, one aspect of PTSD, particularly in veterans, is its comorbidity with suicide. Elevated aggressiveness predicts high-risk to suicide in humans and despite the difficulty in reproducing a complex human suicidal behavior in rodents, aggressive behavior is a well reproducible behavioral trait of suicide. PTSD animal models are based on a peculiar phenotype, including exaggerated fear memory and impaired fear extinction associated with neurochemical dysregulations in the brain circuitry regulating emotion. The endocannabinoid and the neurosteroid systems regulate emotions and stress responses, and recent evidence shows these two systems are interrelated and critically compromised in neuropsychiatric disorders. For instance, levels of the neurosteroid, allopregnanolone, as well as those of the endocannabinoids, anandamide and its congener, palmitoylethanolamide are decreased in PTSD. Similarly, the endocannabinoid system and neurosteroid biosynthesis are altered in suicidal individuals. Selective serotonin reuptake inhibitors (SSRIs), the only FDA-approved treatments for PTSD, fail to help half of the treatment-seeking patients. This highlights the need for developing biomarker-based efficient therapies. One promising alternative to SSRIs points to stimulation of allopregnanolone biosynthesis as a treatment and a valid end-point to predict treatment response in PTSD patients. This review highlights running findings on the role of the endocannabinoid and neurosteroid systems in PTSD and suicidal behavior both in a preclinical and clinical perspective. A specific focus is given to predictive PTSD/suicide animal models. Ultimately, we discuss the idea that disruption of neurosteroid and endocannabinoid biosynthesis may offer a novel promising biomarker axis to develop new treatments for PTSD and, perhaps, suicidal behavior.

Chronic predator stress in female mice reduces primordial follicle numbers: implications for the role of ghrelin

Chronic stress is a known suppressor of female reproductive function. However, attempts to isolate single causal links between stress and reproductive dysfunction have not yet been successful due to their multi-faceted aetiologies. The gut-derived hormone ghrelin regulates stress and reproductive function and may therefore be pivotal in the neuroendocrine integration of the hypothalamic-pituitary-adrenal (HPA) and -gonadal (HPG) axes. Here, we hypothesised that chronic stress disrupts ovarian follicle maturation and that this effect is mediated by a stress-induced increase in acyl ghrelin and activation of the growth hormone secretatogue receptor (GHSR). We gave C57BL/6J female mice 30 min daily chronic predator stress for 4 weeks, or no stress, and gave them daily GHSR antagonist (d-Lys3-GHRP-6) or saline. Exposure to chronic predator stress reduced circulating corticosterone, elevated acyl ghrelin levels and led to significantly depleted primordial follicle numbers. GHSR antagonism stress-dependently altered the expression of genes regulating ovarian responsiveness to gonadotropins and was able to attenuate the stress-induced depletion of primordial follicles. These findings suggest that chronic stress-induced elevations of acyl ghrelin may be detrimental for ovarian follicle maturation.

Inflammation and post-traumatic stress disorder

While post-traumatic stress disorder (PTSD) is currently diagnosed based solely on classic psychological and behavioral symptoms, a growing body of evidence has highlighted a link between this disorder and alterations in the immune and inflammatory systems. Epidemiological studies have demonstrated that PTSD is associated with significantly increased rates of physical comorbidities in which immune dysregulation is involved, such as metabolic syndrome, atherosclerotic cardiovascular disease, and autoimmune diseases. In line with this, a number of blood biomarker studies have reported that compared to healthy controls, individuals with PTSD exhibit significantly elevated levels of proinflammatory markers, such as interleukin-1β, interleukin-6, tumor necrosis factor-α, and C-reactive protein. Moreover, various lines of animal and human research have suggested that inflammation is not only associated with PTSD but also can play an important role in its pathogenesis and pathophysiology. In this review, we first summarize evidence suggestive of increased inflammation in PTSD. We then examine findings that suggest possible mechanisms of inflammation in this disorder in terms of two different but interrelated perspectives: putative causes of increased proinflammatory activities and potential consequences that inflammation generates. Given that there is currently a dearth of treatment options for PTSD, possibilities of new therapeutic approaches using pharmacological and non-pharmacological treatments/interventions that have anti-inflammatory effects are also discussed. Despite the increasing attention given to the inflammatory pathology of PTSD, there remains much to be elucidated, including more detailed mechanisms of inflammation, potential usefulness of inflammatory biomarkers as diagnostic and prognostic markers, and efficacy of novel treatment strategies targeting inflammation.

Altered overnight levels of pro-inflammatory cytokines in men and women with posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with disturbed sleep and elevated levels of pro-inflammatory cytokines, including interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α). Studies in animals and healthy humans have also shown that disrupted sleep elevates pro-inflammatory cytokines, including IL-6 and TNF-α. A better understanding of overnight cytokine levels and sleep might shed light on possible mechanisms for elevated inflammation in PTSD. Thus, we investigated overnight levels of IL-6 and TNF-α in individuals with and without PTSD while recording sleep polysomnography (PSG).

METHOD

Serum samples were collected from otherwise healthy, medication-free participants with chronic PTSD (n = 44; 50% female; M age = 30.34 ± 8.11) and matched controls (n = 49; 53% female; M age = 30.53 ± 6.57) during laboratory PSG. Levels of IL-6 and TNF-α were measured at hours 0, 2, 4, 6, and 8 after typical sleep onset time using serial serum samples. Plasma IL-6 and TNF-α levels were quantified using enzyme-linked immunosorbent assays.

RESULTS

Growth model analysis indicated a significantgroup by time interaction for IL-6 (t[247] = -2.92, p = .005) and a significant group by sex by time interaction for TNF-α (t[275] = 2.02, p = .04). PTSD positive men and women initially had higher IL-6 and TNF-α at sleep onset, but not at the end of their sleep cycle. Men with PTSD showed a peak of TNF-α at the end of the sleep cycle, whereas male control subjects demonstrated an inverted U-shaped profile. There were no significant differences in TNF-α levels overnight between women with and without PTSD.

CONCLUSION

To our knowledge, this is the largest study to examine IL-6 overnight in a PTSD sample and the first study to examine overnight TNF-α in PTSD. Overnight IL-6 and TNF-α levels may be altered in individuals with PTSD compared to those without PTSD, and TNF-α trajectories also differed by sex. The current findings highlight the need to consider sex, sleep, time of day, and circadian variation when examining inflammation in PTSD. Additional research in broader study samples will be necessary to clarify associations between disrupted sleep, cytokines, and increased risk for disease in PTSD.

Neuroendocrinological treatment targets for posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is prevalent, disabling, and frequently becomes chronic. Despite this, only two selective serotonergic reuptake inhibitors have been approved to date for its treatment by the United States Food and Drug Administration, and treatment results are often disappointing, with a remission rate of <30%. Certain neuroendocrinological systems are currently gaining attention with respect to their use for PTSD prevention and treatment as standalone options or medication-enhanced psychotherapy due to their involvement in physiological stress reactions, memory consolidation and extinction, cognitive appraisal to stress, and attachment and resilient coping strategies, which are important in the pathogenesis of PTSD. The hypothalamic-pituitary-adrenal axis system takes the most important role in stress reactions. Hydrocortisone has been studied for the prevention of PTSD, and some meta-analyses have suggested its possible efficacy; furthermore, it has been considered both as monotherapy and as an augmentation to psychotherapy in PTSD patients, with some positive results. Glucocorticoid receptor antagonists and corticotropin-releasing factor type 1 antagonists have also been considered for clinical use in PTSD treatment. Additionally, other neuroendocrinological systems have been studied in PTSD including the use of oxytocin for PTSD prevention and augmentation to psychotherapy, allopregnanolone, and neuropeptide Y (NPY) for PTSD treatment. For now, however, these studies offer only limited evidence of efficacy, thus it is prudent to study this issue more vigorously.

Neighborhood Environment and DNA Methylation: Implications for Cardiovascular Disease Risk

Exposure to chronic stress such as living in disadvantaged neighborhoods has been related to cardiovascular disease (CVD). Chronic stress may increase the risk for CVD by increasing levels of systemic inflammation (e.g., higher levels of pro-inflammatory cytokines). Differential DNA methylation of inflammation-related candidate genes is also related to higher risk for CVD. Thus, the purpose of this review was to examine the association of neighborhood disadvantage with DNA methylation. A search of literature was conducted using Scopus, CINAHL, PubMed, Medline, and Embase databases. The keywords neighborhood, neighborhood disorder, neighborhood crime, neighborhood violence, neighborhood safety, built environment, and housing vacancy were combined with the keywords DNA methylation and epigenetics. Five studies were included in this review (n = 3 adult blood samples and n = 2 fetal blood samples). Four of the five studies reported an association of neighborhood socioeconomic status, social environment, and crime with either global or gene-specific DNA methylation. Only two studies examined the association of neighborhood disadvantage with inflammation-related candidate genes. One of these studies found a significant association of neighborhood socioeconomic disadvantage and social environment with DNA methylation in inflammation-related candidate genes. Thus, data are limited on the association between neighborhood disadvantage and DNA methylation of inflammation-related candidate genes, as well as genes in other potential mechanistic pathways including psychosocial stress, toxin response, and adiposity. Future studies should examine these associations and the potential epigenetic mechanisms by which neighborhood disadvantage increases the risk for CVD.

Relations of combat stress and posttraumatic stress disorder to 24-h plasma and cerebrospinal fluid interleukin-6 levels and circadian rhythmicity

BACKGROUND

Acute and chronic stress can lead to a dysregulation of the immune response. Growing evidence suggests peripheral immune dysregulation and low-grade systemic inflammation in posttraumatic stress disorder (PTSD), with numerous reports of elevated plasma interleukin-6 (IL-6) levels. However, only a few studies have assessed IL-6 levels in the cerebrospinal fluid (CSF). Most of those have used single time-point measurements, and thus cannot take circadian level variability and CSF-plasma IL-6 correlations into account.

METHODS

This study used time-matched, sequential 24-h plasma and CSF measurements to investigate the effects of combat stress and PTSD on physiologic levels and biorhythmicity of IL-6 in 35 male study volunteers, divided in 3 groups: (PTSD = 12, combat controls, CC = 12, and non-deployed healthy controls, HC = 11).

RESULTS

Our findings show no differences in diurnal mean concentrations of plasma and CSF IL-6 across the three comparison groups. However, a significantly blunted circadian rhythm of plasma IL-6 across 24 h was observed in all combat-zone deployed participants, with or without PTSD, in comparison to HC. CSF IL-6 rhythmicity was unaffected by combat deployment or PTSD.

CONCLUSIONS

Although no significant group differences in mean IL-6 concentration in either CSF or plasma over a 24-h timeframe was observed, we provide first evidence for a disrupted peripheral IL-6 circadian rhythm as a sequel of combat deployment, with this disruption occurring in both PTSD and CC groups. The plasma IL-6 circadian blunting remains to be replicated and its cause elucidated in future research.

Greater Lifetime Stress Exposure Predicts Blunted Cortisol but Heightened DHEA Responses to Acute Stress

Although prior research has examined how early adversity and chronic stress exposure relate to hypothalamic-pituitary-adrenal (HPA) axis responses to acute stress, to date, no studies have examined how stressors occurring over the entire lifespan predict such responses. To address this issue, we recruited 61 healthy young adults and measured their exposure to 55 different types of acute life events and chronic difficulties occurring over the lifespan. In addition, we characterized differences in participants' HPA axis responses to acute stress by measuring their salivary cortisol and DHEA responses to the Trier Social Stress Test for Groups. Greater cumulative stress exposure was associated with a blunted cortisol response, but a heightened DHEA response, to the acute stressor. Moreover, it was participants' exposure to these stressors (i.e., lifetime count), not their perceived severity, which predicted their cortisol and DHEA responses to acute stress. Furthermore, differential effects were observed by stress exposure domain. Notably, only adulthood and marital/partner stressors significantly predicted cortisol responses to acute stress, whereas stress was more uniformly associated with DHEA responses to the acute stressor. These results thus reveal how cumulative stress exposure is associated with HPA axis responsivity to acute stress, while highlighting the fact that different stressors may have substantially different associations with these biological outcomes.

Stress, sensitive periods, and substance abuse

Research on the inter-relationship between drug abuse and social stress has primarily focused on the role of stress exposure during adulthood and more recently, adolescence. Adolescence is a time of heightened reward sensitivity, but it is also a time when earlier life experiences are expressed. Exposure to stress early in postnatal life is associated with an accelerated age of onset for drug use. Lifelong addiction is significantly greater if drug use is initiated during early adolescence. Understanding how developmental changes following stress exposure interact with sensitive periods to unfold over the course of maturation is integral to reducing their later impact on substance use. Arousal levels, gender/sex, inflammation, and the timing of stress exposure play a role in the vulnerability of these circuits. The current review focuses on how early postnatal stress impacts brain development during a sensitive period to increase externalizing and internalizing behaviors in adolescence that include social interactions (aggression; sexual activity), working memory impairment, and depression. How stress effects the developmental trajectories of brain circuits that are associated with addiction are discussed for both clinical and preclinical studies.

Victims of War: Dehydroepiandrosterone Concentrations in Hair and Their Associations with Trauma Sequelae in Palestinian Adolescents Living in the West Bank

Due to its anti-glucocorticoid properties, the steroid hormone dehydroepiandrosterone (DHEA) might play a role for coping with traumatic stress and posttraumatic stress disorder (PTSD). The majority of studies report elevated DHEA secretion and decreased cortisol/DHEA ratio associated with traumatic stress, however, contrasting results have also been published. One reason for this heterogeneity might be that in past studies, DHEA has been measured in plasma or saliva samples reflecting acute hormone levels. In comparison, the current study assessed the hair levels of DHEA and cortisol as long-term markers along with self-reported data on psychopathology and coping in 92 female adolescents aged 11–16 from the West Bank affected by the Israeli–Palestinian conflict. Results showed that trauma-exposed individuals had significantly higher DHEA levels (p = 0.013) and lower cortisol/DHEA ratios (p = 0.036) than participants from the non-trauma group. Furthermore, DHEA and cortisol/DHEA ratio emerged as associated with trauma load and timing, but not with coping. By applying the novel method of DHEA analysis from hair samples, this study adds to the growing literature on the interplay of DHEA, cortisol, traumatic stress and coping, and provides valuable starting points for further research.

Developmental influences on stress response systems: Implications for psychopathology vulnerability in adolescence

The adolescent transition is marked by increases in stress exposure and significant maturation of neural and hormonal stress processing systems. Variability in the development of these systems during adolescence may influence the risk for stress-related psychopathology. This paper aims to review the developmental maturation of the HPA axis and related stress regulation systems, and demonstrate how interference in this adaptive developmental process may increase the risk for negative outcomes. We argue that the developmental maturation of the HPA axis aims to improve the regulatory capacity of the axis in order to more adaptively respond to these increases in stress reactivity. Additionally, we review evidence that sex differences in the development of the HPA and related axes may contribute to sex differences in the risk for stress-related psychopathology. Finally, we discuss how contextual factors, such as early trauma and obesity may alter the development of HPA axis during the adolescence transition and how alterations of normative development increase the risk for stress-related disorders.

Inflaming sex differences in mood disorders

Men and women often experience different symptoms or rates of occurrence for a variety of mood disorders. Many of the symptoms of mood disorders overlap with autoimmune disorders, which also have a higher prevalence in women. There is a growing interest in exploring the immune system to provide biomarkers for diagnosis of mood disorders, along with new targets for developing treatments. This review examines known sex differences in the immune system and their relationship to mood disorders. We focus on immune alterations associated with unipolar depression, bipolar depression, and anxiety disorders. We describe work from both basic and clinical research examining potential immune mechanisms thought to contribute to stress susceptibility and associated mood disorders. We propose that sex and age are important, intertwined factors that need to be included in future experimental designs if we are going to harness the power of the immune system to develop a new wave of treatments for mood disorders.

Could a blood test for PTSD and depression be on the horizon?

INTRODUCTION

Depression and posttraumatic stress disorder (PTSD) are two complex and debilitating psychiatric disorders that result in poor life and destructive behaviors against self and others. Currently, diagnosis is based on subjective rather than objective determinations leading to misdiagnose and ineffective treatments. Advances in novel neurobiological methods have allowed assessment of promising biomarkers to diagnose depression and PTSD, which offers a new means of appropriately treating patients. Areas covered: Biomarkers discovery in blood represents a fundamental tool to predict, diagnose, and monitor treatment efficacy in depression and PTSD. The potential role of altered HPA axis, epigenetics, NPY, BDNF, neurosteroid biosynthesis, the endocannabinoid system, and their function as biomarkers for mood disorders is discussed. Insofar, we propose the identification of a biomarker axis to univocally identify and discriminate disorders with large comorbidity and symptoms overlap, so as to provide a base of support for development of targeted treatments. We also weigh in on the feasibility of a future blood test for early diagnosis. Expert commentary: Potential biomarkers have already been assessed in patients' blood and need to be further validated through multisite large clinical trial stratification. Another challenge is to assess the relation among several interdependent biomarkers to form an axis that identifies a specific disorder and secures the best-individualized treatment. The future of blood-based tests for PTSD and depression is not only on the horizon but, possibly, already around the corner.

The association between anxiety, traumatic stress, and obsessive-compulsive disorders and chronic inflammation: A systematic review and meta-analysis

BACKGROUND

Anxiety is characterized by prolonged preparation for real or perceived threat. This may manifest both as psychological and physiological activation, ultimately leading to greater risk for poor health. Chronic inflammation may play an integral role in this relationship, given the influential role that it has in chronic illness. The aim of this meta-analysis is to examine levels of chronic inflammation, measured by inflammatory cytokines and C-reactive protein, in people with anxiety disorders, PTSD (posttraumatic stress disorder), or obsessive-compulsive disorder compared to healthy controls. Several moderating variables, including specific diagnosis and depression comorbidity, were also assessed.

METHODS

Seventy six full-text articles were screened for eligibility with 41 studies ultimately included in analysis.

RESULTS

Results demonstrated a significant overall difference between healthy controls (HCs) and people with anxiety disorders in pro-inflammatory cytokines (P = 0.013, Hedge's g = -0.39), which appears to be largely driven by interleukin-1β (IL-1β; P = 0.009, Hedge's g = -0.50), IL-6 (P < 0.001, Hedge's g = -0.93), and tumor necrosis factor-α (P = 0.030, Hedge's g = -0.56). Moderation analyses revealed a moderating effect of diagnosis (P = 0.050), as only individuals with PTSD demonstrated differences in inflammation between HCs (P = 0.004, Hedge's g = -0.68).

CONCLUSIONS

These data demonstrate the association between inflammatory dysregulation and diagnoses associated with chronic, impactful, and severe anxiety and provides insight into the way that anxiety, and in particular PTSD, is related to certain inflammatory markers. In doing so, these findings may provide an initial step in disentangling the relationship between anxiety and basic health processes.

Elevated salivary alpha-amylase levels at awakening in patients with depression

BACKGROUND

Specific Major Depressive Disorder (MDD) biomarkers could help improve our understanding of MDD pathophysiology and aid in the refinement of current MDD criteria. While salivary cortisol (SC) can differentiate between healthy controls and patients with psychiatric disorders, salivary alpha amylase (sAA), may be a putative candidate biomarker for MDD specifically.

METHODS

In a naturalistic cohort of consecutive out-patients and healthy controls, sAA and SC were determined in 833 participants (97 MDD patients, 142 patients with other mood, anxiety, and/or somatoform (MAS-) disorders, and 594 healthy controls). Samples were collected at 7 different time points (at awakening, after 30, 45, and 60 min, at 10:00 p.m., at 11:00 p.m., and at awakening on day 2).

RESULTS

The mean age of the sample was 43.8 years (SD = 12.9; 63.9% female). Concerning sAA, MDD patients had higher sAA levels upon awakening on two consecutive days (p = 0.04, p = 0.01 respectively), as well as a higher area under the curve with respect to the increase (AUCi; p = 0.04) in comparison to both controls and the other MAS-disorders group. Regarding SC, mean levels of evening SC were elevated in MDD patients (p = 0.049) in comparison to both controls and the other MAS-disorders group. SC values on day 2 after ingestion of dexamethasone were elevated in both MDD patients and the other MAS-disorders group (p = 0.04, p = 0.047 respectively).

CONCLUSIONS

sAA at awakening and not cortisol differentiates MDD from other psychiatric disorders in outpatients. This suggests that sAA may be a valuable candidate biomarker specifically for MDD.

PTSD and Physical Health

PURPOSE OF REVIEW

We review evidence linking PTSD to physical health symptoms and specific disorders, highlighting areas with multiple studies and objective measures of disease states when available. We also examine evidence for biological, behavioral, and psychosocial mechanisms underlying these associations and discuss the clinical implications of recent research.

RECENT FINDINGS

Recent meta-analyses have found that evidence is particularly strong for increased risk of cardiovascular, metabolic, and musculoskeletal disorders among patients with PTSD. Numerous studies have found alterations in the hypothalamic-pituitary-adrenal axis, sympathetic nervous system, inflammation, and health behaviors that could increase risk of illness, but few studies have simultaneously incorporated measures of mechanisms and disease outcomes. Future research should focus on expanding the diversity of populations studied, particularly with respect to underrepresented racial and ethnic groups. Longitudinal studies that incorporate repeated measures of PTSD, pathogenic mechanisms of disease, and physical health outcomes and the addition of physical health outcomes to PTSD treatment trials will be most informative for the field.

Central intracrine DHEA synthesis in ageing-related neuroinflammation and neurodegeneration: therapeutic potential?

It is a well-known fact that DHEA declines on ageing and that it is linked to ageing-related neurodegeneration, which is characterised by gradual cognitive decline. Although DHEA is also associated with inflammation in the periphery, the link between DHEA and neuroinflammation in this context is less clear. This review drew from different bodies of literature to provide a more comprehensive picture of peripheral vs central endocrine shifts with advanced age—specifically in terms of DHEA. From this, we have formulated the hypothesis that DHEA decline is also linked to neuroinflammation and that increased localised availability of DHEA may have both therapeutic and preventative benefit to limit neurodegeneration. We provide a comprehensive discussion of literature on the potential for extragonadal DHEA synthesis by neuroglial cells and reflect on the feasibility of therapeutic manipulation of localised, central DHEA synthesis.

Salivary cortisol in post-traumatic stress disorder: a systematic review and meta-analysis

BACKGROUND

Studies investigating salivary cortisol level as susceptibility marker for post-traumatic stress disorder (PTSD) produced inconsistent results. The aim of this study was to compare salivary cortisol concentration levels in PTSD patients with those in controls by synthesizing published data.

METHODS

We did a systematic review, meta-analysis and meta-regression of studies comparing concentrations of salivary cortisol between patients with PTSD and controls. The electronic databases of PubMed, Embase, Web of Science and Psyc-ARTICLES were searched for relevant articles. A random-effects model with restricted maximum-likelihood estimator is used to synthesize the effect size (assessed by standardized mean difference).

RESULTS

A total of 784 articles were identified of which 22 were included in the final analysis. A trend of lower salivary cortisol levels was found in PTSD patients when compared with the controls (SMD = - 0.28, 95% CI-0.53;-0.04, p = 0.022). Subgroup analysis showed that the salivary cortisol levels were lower in patients with PTSD than in controls in studies conducted after 2007 or in studies using saliva samples collected in the morning.

CONCLUSIONS

The evidence from this meta-analysis supports that salivary samples collected in the morning consistently showed a lower salivary cortisol level in patients with PTSD than in controls, although whether salivary cortisol could be used as a diagnostic tool requires further research.

Behavioral immune system activity predicts downregulation of chronic basal inflammation

Here, we present a mechanistically grounded theory detailing a novel function of the behavioral immune system (BIS), the psychological system that prompts pathogen avoidance behaviors. We propose that BIS activity allows the body to downregulate basal inflammation, preventing resultant oxidative damage to DNA and promoting longevity. Study 1 investigated the relationship between a trait measure of pathogen avoidance motivation and in vitro and in vivo proinflammatory cytokine production. Study 2 examined the relationship between this same predictor and DNA damage often associated with prolonged inflammation. Results revealed that greater trait pathogen avoidance motivation predicts a) lower levels of spontaneous (but not stimulated) proinflammatory cytokine release by peripheral blood mononuclear cells (PBMCs), b) lower plasma levels of the proinflammatory cytokine interleukin-6 (IL-6), and c) lower levels of oxidative DNA damage. Thus, the BIS may promote health by protecting the body from the deleterious effects of inflammation and oxidative stress.

Resolution of inflammation and mood disorders

Relationship between mood disorders and inflammation is now well-documented, although molecular mechanisms are not understood. Previously mostly pro-inflammatory cytokines of immune system (IL-6, TNF, etc.) were taken into account. However, recent understanding of resolution of inflammation as an active process drew attention to mediators of resolution, which include both proteins and ω-3 and ω-6 polyunsaturated fatty acids derivatives (resolvins, cyclopentenone prostaglandins, etc.). This review takes into account new data on resolution of inflammation and action of mediators of resolution in models of depression. New facts and ideas about mechanisms of chronic inflammation onset are considered in relation to mood disorders. Basic control mechanisms of inflammation at the cellular level and the role of resolution substances in regulation of depression and other mood disorders are discussed. Signaling systems of innate immunity located in non-immune cells and their ability to generate substances that affect an onset of depression are reviewed. A novel hypothesis of depression as a type of abnormal resolution is proposed.

Food for Mood: Relevance of Nutritional Omega-3 Fatty Acids for Depression and Anxiety

The central nervous system (CNS) has the highest concentration of lipids in the organism after adipose tissue. Among these lipids, the brain is particularly enriched with polyunsaturated fatty acids (PUFAs) represented by the omega-6 (ω6) and omega-3 (ω3) series. These PUFAs include arachidonic acid (AA) and docosahexaenoic acid (DHA), respectively. PUFAs have received substantial attention as being relevant to many brain diseases, including anxiety and depression. This review addresses an important question in the area of nutritional neuroscience regarding the importance of ω3 PUFAs in the prevention and/or treatment of neuropsychiatric diseases, mainly depression and anxiety. In particular, it focuses on clinical and experimental data linking dietary intake of ω3 PUFAs and depression or anxiety. In particular, we will discuss recent experimental data highlighting how ω3 PUFAs can modulate neurobiological processes involved in the pathophysiology of anxiety and depression. Potential mechanisms involved in the neuroprotective and corrective activity of ω3 PUFAs in the brain are discussed, in particular the sensing activity of free fatty acid receptors and the activity of the PUFAs-derived endocannabinoid system and the hypothalamic-pituitary-adrenal axis.

A meta-analysis of cytokine concentrations in eating disorders

Cytokines are signalling molecules, which play an important role in both immune system function and brain development and function, and subsequently mental states and behaviour. Cytokines have been implicated in eating disorders (EDs) due to their role in psychological health, body weight and appetite regulation. This meta-analysis examined cross-sectional and longitudinal studies measuring concentrations of cytokines in individuals with EDs. Using PRISMA guidelines, we systematically reviewed relevant articles in PubMed, Web of Science, and MEDLINE. Random-effects meta-analyses were conducted for interleukin (IL)-1β, IL-6, transforming growth factor (TGF)-β, and tumor necrosis factor (TNF)-α, independently, firstly with all EDs combined and then stratified by ED diagnosis. Twenty-five studies were included: serum/plasma cytokine concentrations were measured in people with anorexia nervosa (AN) in 23 studies and bulimia nervosa (BN) in 4 studies. TNF-α and IL-6 were elevated in ED participants compared to healthy controls (HCs). Specifically, this pattern was seen only when comparing AN participants to HCs. Concentrations of these cytokines did not differ between people with BN and HCs. IL-1β and TGF-β did not differ between HCs and any ED group. Therefore, AN seems to be associated with elevated concentrations of TNF-α and IL-6. Considering the role of cytokines in appetite, mood regulation, and anxiety, these pro-inflammatory cytokines could be a potential future drug target to help people with AN, not only with weight gain, but also with various coexisting psychological problems. Future studies should consider confounding factors that affect cytokine concentrations and report ED-relevant clinical characteristics.

PTSD in women is associated with a block in conversion of progesterone to the GABAergic neurosteroids allopregnanolone and pregnanolone measured in plasma

There is a need to identify new and more effective treatments for posttraumatic stress disorder (PTSD). Allopregnanolone and its stereoisomer pregnanolone (together termed ALLO) are metabolites of progesterone that positively and allosterically modulate GABA effects at GABA_A receptors, thereby reducing anxiety and depression. Previous research revealed that women with PTSD had low cerebrospinal fluid (CSF) ALLO levels and a low ratio of ALLO to the allopregnanolone precursor 5α-DHP, consistent with deficient activity of the ALLO synthetic enzyme 3α-hydroxysteroid dehydrogenase (3α-HSD). The current study examined ALLO and the ratio of ALLO to 5α-DHP in plasma at rest and in response to psychophysiological stressors in trauma-exposed, medication-free women with and without PTSD. Participants were examined twice in random order during the early follicular phase (eFP) and mid-luteal phase (mLP) of the menstrual cycle. Plasma neurosteroids were measured using gas chromatography-mass spectrometry. Results indicate that the ALLO to 5α-DHP ratio in plasma increases between the eFP and mLP. In addition, women with PTSD have a lower ratio of ALLO to 5α-DHP than trauma-exposed healthy women, as well as blunted increases in this ratio in response to a moderately stressful laboratory procedure, i.e., differential fear conditioning, across the menstrual cycle. Clinically feasible testing for 3α-HSD dysfunction is critical to translating this line of research into clinical care. Measurement of this ratio in plasma could facilitate patient stratification in clinical treatment trials, as well as precision medicine targeting of treatments that address ALLO synthesis deficits in women with PTSD.

Life stress as a risk factor for sustained anxiety and cortisol dysregulation during the first year of survivorship in ovarian cancer

BACKGROUND

Patients with ovarian cancer often report elevated anxiety at diagnosis that decreases posttreatment. However, a minority of patients experience sustained anxiety. Few studies have examined risk factors for persistent anxiety or its physiologic sequelae in ovarian cancer. Therefore, the authors investigated associations between prior life events, anxiety, inflammation (plasma levels of interleukin-6), and diurnal cortisol profiles in patients with ovarian cancer during the first year postdiagnosis.

METHODS

Participants (n = 337) completed surveys and had blood and salivary sampling prediagnosis, postchemotherapy (6 months), and 12 months after diagnosis. The Life Events and Difficulties Schedule was administered to a patient subset (n = 127) within 1 month of diagnosis. Linear mixed-effects models were used to analyze relations between anxiety and biologic variables over time. Linear regression models assessed whether anxiety trajectories mediated associations between prior stress exposure and biologic variables. Age, chemotherapy at 1 year, and cancer stage were covariates.

RESULTS

Decreased anxiety was associated with a more normalized cortisol slope over time (β = 0.092; P = .047). Early life adversity was related to flatter cortisol slopes over time (β = -0.763; P = .002); this relation was partially mediated by anxiety trajectory (P = .046). More danger-related events prediagnosis were associated with sustained anxiety (β = 0.537; P = .019) and flatter cortisol slopes over time (β = -0.243; P = .047); anxiety partially mediated the relation between danger and cortisol slope (P = .037). Neither anxiety nor prior stress exposure was related to levels of interleukin-6.

CONCLUSIONS

Because dysregulated cortisol has been related to fatigue, poorer quality of life, and shorter survival in patients with ovarian cancer, those who have prior life events and chronic anxiety during the first year postdiagnosis may be at risk for more negative outcomes. Cancer 2018. © 2018 American Cancer Society.

Protein-Protein Interaction Network Analysis Revealed a New Prospective of Posttraumatic Stress Disorder

Background

Posttraumatic stress disorder (PTSD) is known by a number of mental disorders, including recurring memories of trauma, mental appalling, and escaping of sign that make them recall the trauma in question. Clinical interviews serve as the main diagnostic tool for PTSD. With respect to treatment, either pharmacotherapy or psychotherapy or a combination of both is used as a therapeutic method for PTSD. In this study, a number of crucial genes related to PTSD, which can be considered as biomarker candidates, were represented.

Materials and Methods

The genes related to PTSD were extracted from the STRING database and organized in a protein-protein interaction network with the help of Cytoscape software version 3.6.0. The network was analyzed, and the important genes were introduced based on central indices. The biological processes related to the crucial genes were enriched via gene ontology using ClueGO.

Results

From a total of 100 genes, 63 genes were extracted that formed the main connected component, and of these, 12 crucial genes-POMC, BDNF, FOS, NR3C1, CRH, IL6, NPS, HTR1A, NPY, CREB1, CRHR1, and TAC1-were introduced. Biological processes were classified into the regulation of corticosterone, regulation of behavior, response to fungus, multicellular organism response to stress, and associative learning.

Conclusion

The introduced 12 crucial genes can be used as a biomarker panel related to PTSD and can be considered as a diagnostic reagent or drug target; however, more investigations are needed to use these genes as biomarkers.

Evaluating Stress during Pregnancy: Do We Have the Right Conceptions and the Correct Tools to Assess It?

Gestational stress is believed to increase the risk of pregnancy failure and perinatal and adult morbidity and mortality in both the mother and her child or children. However, some contradictions might arise from methodological issues or even from differences in the philosophical grounds that guide the studies on gestational stress. Biased perspectives could lead us to use and/or design inadequate/incomplete panels of biochemical determinations and/or psychological instruments to diagnose it accurately during pregnancy, a psychoneuroimmune-endocrine state in which allostatic loads may be significant. Here, we review these notions and propose a model to evaluate and diagnose stress during pregnancy.

Evaluation of the psychological and biological changes of patients diagnosed with benign and malignant breast tumors

Purpose

Posttraumatic stress disorder (PTSD) is a severe anxiety disorder developed by exposure to any incident or circumstance that results in psychological trauma. In this study we compared the psychological and physiological changes between patients with malignant and benign breast tumors.

Methods

We selected 150 Chinese women with a breast mass, aged 20 to 45 years, from the Sichuan Academy of Medical Sciences & Sichuan Provincial People's Hospital between 2009 and 2011 for this study; 30 healthy participants were enrolled into the control group. All subjects were examined and had their tumor mass aspirated for diagnosis. Equal numbers of patients with benign and malignant tumors were recruited. Patients with malignant tumors presented with low grade, minimal tumor invasion and non-involved lymph nodes. Questionnaires regarding anxiety, depression and PTSD were conducted 2 hours before getting the diagnostic result and 1 month after the diagnosis. Serum levels of IL-6, TNF-, cortisol and high-sensitivity C-reactive protein before and after diagnosis were investigated and compared. The number of occurrences of oral ulcerative mucositis was also recorded.

Results

All patients experienced a certain degree of anxiety and their biomarkers were elevated compared with the normal reference range before the pathological report was disclosed. However, 1 month after the operation, the benign tumor group showed significantly lower levels of biomarkers and anxiety scores than patients with a malignant breast tumor. The results were consistent throughout 12 months of study.

Conclusion

Study subjects with a benign tumor returned to their normal condition after being diagnosed, while patients with a malignant tumor suffered from a certain degree of PTSD or depression.

PTSD patients show increasing cytokine levels during treatment despite reduced psychological distress

BACKGROUND

A reciprocal relationship between activated innate immune system and changes in mood and behavior has been established. There is still a paucity of knowledge on how the immune system responds during psychiatric treatment. We aimed to explore circulating cytokines and assess psychiatric symptom severity scores during 12 weeks of inpatient psychiatric treatment.

METHODS

The study was a longitudinal assessment of 124 patients (88 women and 36 men) in treatment at Modum Psychiatric Center, Norway. The patient sample comprised a mixed psychiatric population of whom 39 were diagnosed with posttraumatic stress disorder (PTSD). Serum blood samples for cytokine analysis and measures of mental distress using Global Severity Index were collected at admission (T₀), halfway (T₁), and before discharge (T₂). Other factors assessed were age, gender, and the use of antidepressants and anti-inflammatory drugs. Multilevel modeling was used for longitudinal analyses to assess the repeated cytokine samples within each patient.

RESULTS

Overall level of IL-1RA was higher in PTSD patients when compared to those without PTSD (P=0.021). The level of IL-1β, MCP-1, and TNF-α increased over time in PTSD compared to non-PTSD patients (P=0.025, P=0.011 and P=0.008, respectively). All patients experienced reduced mental distress as measured by self-reported Global Severity Index scores. Stratified analysis showed that PTSD patients who used anti-inflammatory drugs had higher levels of IL-1β (P=0.007) and TNF-α (P=0.049) than PTSD patients who did not use such drugs.

CONCLUSION

The study indicates that traumatized patients may have a distinct neuroimmune development during recovery. Their activated immune system shows even further activation during their rehabilitation despite symptom reduction.

Neuroimmune Impacts of Early-Life Stress on Development and Psychopathology

Maltreatment and trauma in childhood, termed early-life stress (ELS), has long-term effects on the immune system. ELS impacts immune signaling at the time of exposure but also disrupts the developmental trajectory of certain immunological processes, both in the periphery and in the brain. One consequence of these early alterations is a heightened immune response to stressors later in life. However, chronic and sustained inflammatory response can also lead to excitotoxicity and prevent typical brain development. In this chapter, we discuss current progress toward understanding the contribution of neuroimmune signaling to ELS-attributable dysfunction or maladaptation with a focus on postnatal experiences. To do so we first present an operational definition of ELS. Then, we offer a brief overview of the immune system and neuroimmune development, followed by a section discussing the interaction between immunity, childhood trauma, and mental disorders in humans. We present evidence from animal models about immune alterations after ELS and discuss the ways in which ELS-induced immune changes ultimately affect brain and behavior, as well as the importance of individual differences and future directions in this field. Taken together, we submit that when encountered with ELS, some core brain circuits could develop differently via various mechanisms involving dysfunctional immune reprograming. However, given the remarkable plasticity of both the brain and the immune system, many of the deleterious effects of ELS may be mitigated with interventions that account for sex and target neuroimmune interactions over the lifespan.

Association of Trauma and Posttraumatic Stress Disorder With Incident Systemic Lupus Erythematosus in a Longitudinal Cohort of Women

OBJECTIVE

To conduct the first longitudinal study examining whether trauma exposure and posttraumatic stress disorder (PTSD) are associated with increased risk of incident systemic lupus erythematosus (SLE) in a civilian cohort.

METHODS

We examined the association of trauma exposure and PTSD symptoms with SLE incidence over 24 years of follow-up in a US longitudinal cohort of women (n = 54,763). Incident SLE in women meeting ≥4 American College of Rheumatology criteria was ascertained by self-report and confirmed by medical record review. PTSD and trauma exposure were assessed with the Short Screening Scale for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition PTSD and the Brief Trauma Questionnaire, respectively. Women were categorized as having no trauma, trauma and no PTSD symptoms, subclinical PTSD (1-3 symptoms), or probable PTSD (4-7 symptoms). We examined whether longitudinally assessed health risk factors (e.g., smoking, body mass index [BMI], oral contraceptive use) accounted for increased SLE risk among women with trauma exposure and PTSD versus those without.

RESULTS

During follow-up, 73 cases of SLE occurred. Compared to women with no trauma, probable PTSD was associated with increased SLE risk (for 4-7 symptoms, hazard ratio [HR] 2.94 [95% confidence interval {95% CI} 1.19-7.26], P < 0.05). Subclinical PTSD was associated with increased SLE risk, although this did not reach statistical significance (for 1-3 symptoms, HR 1.83 [95% CI 0.74-4.56], P = 0.19). Smoking, BMI, and oral contraceptive use slightly attenuated the associations (e.g., for 4-7 symptoms, adjusted HR 2.62 [95% CI 1.09-6.48], P < 0.05). Trauma exposure, regardless of PTSD symptoms, was strongly associated with incident SLE (HR 2.83 [95% CI 1.29-6.21], P < 0.01).

CONCLUSION

This study contributes to growing evidence that psychosocial trauma and associated stress responses may lead to autoimmune disease.

DHEA and DHEA-S levels in posttraumatic stress disorder: A meta-analytic review

Differences in hypothalamic-pituitary-adrenocortical (HPA) functioning between patients with posttraumatic stress disorder (PTSD) and controls are among the most consistent neurobiological findings in PTSD. HPA-axis activation results in the output of various steroid hormones including dehydroepiandrosterone (DHEA), which is then converted into dehydroepiandrosterone sulfate (DHEA-S), with anti-glucocorticoid actions among its pleiotropic effects. To investigate whether there is evidence for consistent differences in basal DHEA and DHEA-s levels between individuals with and without PTSD, we performed random-effect meta-analyses aggregating findings of previously published studies. Nine studies reporting on DHEA levels (486 participants) and 8 studies reporting on DHEA-S levels (501 participants) were included. No significant differences in DHEA or DHEA-S levels between PTSD and control groups were found. Exploratory subgroup analyses were performed to distinguish between effects of PTSD and trauma exposure. A trend for higher DHEA levels was found in PTSD patients compared to non-trauma-exposed controls (NTC) (k=3, SMD=1.12 95% CI -0.03-2.52, Z=1.91, p=0.06). Significantly higher DHEA-S levels were observed in PTSD patients compared to NTC (k=2, SMD=0.76, 95% CI 0.38-1.13, Z=3.94, p<0.001). Additionally, significantly higher DHEA levels were observed in trauma-exposed controls (TC) compared to NTC (k=3, SMD=0.66, 95% CI 0.33-0.99, Z=3.88, p<0.001, I²=86%) this suggests that trauma exposure, irrespective of further PTSD development, might increase basal DHEA and DHEA-S levels.

Migraine and the risk of post-traumatic stress disorder among a cohort of pregnant women

Background

Individually both migraine and post-traumatic stress disorder (PTSD) prevalence estimates are higher among women. However, there is limited data on the association of migraine and PTSD in women during pregnancy.

Methods

We examined the association between migraine and PTSD among women attending prenatal clinics in Peru. Migraine was characterized using the International Classification of Headache Disorders (ICHD)-III beta criteria. PTSD was assessed using the PTSD Checklist-Civilian Version (PCL-C). Multivariable logistic regression analyses were performed to estimate odds ratios (OR) and 95% confidence intervals (CI) after adjusting for confounders.

Results

Of the 2922 pregnant women included, 33.5% fulfilled criteria for any migraine (migraine 12.5%; probable migraine 21.0%) and 37.4% fulfilled PTSD criteria. Even when controlling for depression, women with any migraine had almost a 2-fold increased odds of PTSD (OR: 1.97; 95% CI: 1.64–2.37) as compared to women without migraine. Specifically, women with migraine alone (i.e. excluding probable migraine) had a 2.85-fold increased odds of PTSD (95% CI: 2.18–3.74), and women with probable migraine alone had a 1.61-fold increased odds of PTSD (95% CI: 1.30–1.99) as compared to those without migraine, even after controlling for depression. In those women with both migraine and comorbid depression, the odds of PTSD in all migraine categories were even further increased as compared to those women without migraine.

Conclusion

In a cohort of pregnant women, irrespective of the presence or absence of depression, the odds of PTSD is increased in those with migraine. Our findings suggest the importance of screening for PTSD, specifically in pregnant women with migraine.

Electronic supplementary material

The online version of this article (doi:10.1186/s10194-017-0775-5) contains supplementary material, which is available to authorized users.

Alterations of hair cortisol and dehydroepiandrosterone in mother-infant-dyads with maternal childhood maltreatment

BACKGROUND

Child maltreatment (CM) has severe effects on psychological and physical health. The hypothalamic-pituitary-adrenal (HPA) axis, the major stress system of the body, is dysregulated after CM. The analysis of cortisol and dehydroepiandrosterone (DHEA) in scalp hair presents a new and promising methodological approach to assess chronic HPA axis activity. This study investigated the effects of CM on HPA axis activity in the last trimester of pregnancy by measuring the two important signaling molecules, cortisol and DHEA in hair, shortly after parturition. In addition, we explored potential effects of maternal CM on her offspring's endocrine milieu during pregnancy by measuring cortisol and DHEA in newborns' hair.

METHODS

CM was assessed with the Childhood Trauma Questionnaire (CTQ). Cortisol and DHEA were measured in hair samples of 94 mothers and 30 newborns, collected within six days after delivery. Associations of maternal CM on her own and her newborn's cortisol as well as DHEA concentrations in hair were analyzed with heteroscedastic regression models.

RESULTS

Higher CM was associated with significantly higher DHEA levels, but not cortisol concentrations in maternal hair. Moreover, maternal CM was positively, but only as a non-significant trend, associated with higher DHEA levels in the newborns' hair.

CONCLUSIONS

Results suggest that the steroid milieu of the mother, at least on the level of DHEA, is altered after CM, possibly leading to non-genomic transgenerational effects on the developing fetus in utero. Indeed, we observed on an explorative level first hints that the endocrine milieu for the developing child might be altered in CM mothers. These results need extension and replication in future studies. The measurement of hair steroids in mothers and their newborns is promising, but more research is needed to better understand the effects of a maternal history of CM on the developing fetus.

Biological markers for anxiety disorders, OCD and PTSD: A consensus statement. Part II: Neurochemistry, neurophysiology and neurocognition

OBJECTIVE

Biomarkers are defined as anatomical, biochemical or physiological traits that are specific to certain disorders or syndromes. The objective of this paper is to summarise the current knowledge of biomarkers for anxiety disorders, obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD).

METHODS

Findings in biomarker research were reviewed by a task force of international experts in the field, consisting of members of the World Federation of Societies for Biological Psychiatry Task Force on Biological Markers and of the European College of Neuropsychopharmacology Anxiety Disorders Research Network.

RESULTS

The present article (Part II) summarises findings on potential biomarkers in neurochemistry (neurotransmitters such as serotonin, norepinephrine, dopamine or GABA, neuropeptides such as cholecystokinin, neurokinins, atrial natriuretic peptide, or oxytocin, the HPA axis, neurotrophic factors such as NGF and BDNF, immunology and CO2 hypersensitivity), neurophysiology (EEG, heart rate variability) and neurocognition. The accompanying paper (Part I) focuses on neuroimaging and genetics.

CONCLUSIONS

Although at present, none of the putative biomarkers is sufficient and specific as a diagnostic tool, an abundance of high quality research has accumulated that should improve our understanding of the neurobiological causes of anxiety disorders, OCD and PTSD.

Cortisol and DHEA in development and psychopathology

Dehydroepiandrosterone (DHEA) and cortisol are the most abundant hormones of the human fetal and adult adrenals released as end products of a tightly coordinated endocrine response to stress. Together, they mediate short- and long-term stress responses and enable physiological and behavioral adjustments necessary for maintaining homeostasis. Detrimental effects of chronic or repeated elevations in cortisol on behavioral and emotional health are well documented. Evidence for actions of DHEA that offset or oppose those of cortisol has stimulated interest in examining their levels as a ratio, as an alternate index of adrenocortical activity and the net effects of cortisol. Such research necessitates a thorough understanding of the co-actions of these hormones on physiological functioning and in association with developmental outcomes. This review addresses the state of the science in understanding the role of DHEA, cortisol, and their ratio in typical development and developmental psychopathology. A rationale for studying DHEA and cortisol in concert is supported by physiological data on the coordinated synthesis and release of these hormones in the adrenal and by their opposing physiological actions. We then present evidence that researching cortisol and DHEA necessitates a developmental perspective. Age-related changes in DHEA and cortisol are described from the perinatal period through adolescence, along with observed associations of these hormones with developmental psychopathology. Along the way, we identify several major knowledge gaps in the role of DHEA in modulating cortisol in typical development and developmental psychopathology with implications for future research.

Cortisol awakening response is blunted and pain perception is increased during menses in cyclic women

BACKGROUND AND AIMS

The incidence of menstrual symptoms is reported to be as high as 90% in cyclic women. These symptoms, including anxiety and pain, might be associated with cortisol, as its receptors are widely distributed in the brain areas associated with behavior. Therefore, the current study aimed to assess the cortisol awakening response (CAR) throughout the menstrual cycle and correlate it with pain perception and trait anxiety.

MATERIALS AND METHODS

CAR was assessed by measuring salivary cortisol at 0, 15, 30, and 60min following awakening in the same women (n=59, age 22.2±0.37years) at various stages of the menstrual cycle (menses, midcycle, luteal and premenstrual phases). Progesterone and estradiol concentrations were also determined in saliva samples to assess cyclic changes. Self-reported pain, trait anxiety, and menstrual symptoms were assessed by visual analog scale (VAS), state-trait anxiety inventory (STAI-T), and the Daily Record of Severity of Problems (DRSP), respectively.

RESULTS

Estradiol was significantly elevated during the midcycle period and remained high during the early luteal phase (p<0.05). Progesterone was increased during the luteal phase (p<0.05). Post-awakening cortisol values increased during midcycle, luteal phase, and premenstrual phase (p<0.05, classical CAR), but not during the menses (p>0.05, blunted or flat CAR). Positive and significant correlations were found between cortisol and estradiol (R²=0.322; p=0.000), cortisol and progesterone (R²=0.156; p=0.000), and estradiol and progesterone (R²=0.349; p=0.001). Premenstrual symptom scores were higher in the menses and premenstrual phases than in the midcycle and luteal phases (p<0.001). Pain perception was the highest during the menses followed by the premenstrual phase (p<0.01).

CONCLUSIONS

CAR was blunted during the menses, suggesting that cortisol might play a phase-specific role in the regulation of the cycle. Additionally, premenstrual symptoms, including pain, were more severe when ovarian steroid levels reduced (i.e., menses and the premenstrual phase).

Effects of the cortisol stress response on the psychotherapy outcome of panic disorder patients

BACKGROUND

A proportion of patients with panic disorder (PD) fail to show a remission after psychotherapy. Biological correlates of psychotherapy non-response have rarely been described in the literature. The aim of the present study was to research the relationship between the cortisol stress response and the psychotherapy outcome in PD patients.

METHODS

Twenty-eight PD patients (20 females, mean age±SD: 35.71±13.18) seeking psychological treatment for PD and n=32 age- and sex-matched healthy control participants (21 females, aged 34.66±12.07) participated in this study. The patients underwent five weeks of cognitive behavioural therapy (CBT). Within the first two weeks of the CBT, both study groups were confronted with the Trier Social Stress Test (TSST). Blood sampling for cortisol and adrenocorticotropic hormone (ACTH) evaluation as well as fear-rating (Visual Analogue Scale; Primary Appraisal and Secondary Appraisal Questionnaire, PASA) accompanied the TSST. The global severity of PD (Panic & Agoraphobia Scale; PAS), agoraphobic cognitions (Agoraphobic Cognitions Questionnaire; ACQ), fear of bodily sensations (Bodily Sensations Questionnaire; BSQ), agoraphobic avoidance (Mobility Inventory; MI), and depressiveness (Beck Depression Inventory; BDI) were assessed before and after the CBT (except the BDI).

RESULTS

The statistical analysis revealed significant main effects of time for cortisol and the ACTH concentration in response to the TSST, independently of the study group. 42.9% of the PD patients and 65.6% of the healthy control participants showed a cortisol stress response to the TSST≥55.2nmol/l (descriptive finding). The data showed a significant inverse association of the TSST cortisol stress response with the MI total score when accompanied. Further, a significant association of the PASA subjective level of fear and the BSQ as well as a trend for an association of the PASA with the ACQ were observed.

CONCLUSION

Consistent with prior research, we could replicate findings of decreased cortisol concentrations in the PD patients in comparison to the healthy control participants. Furthermore, our findings agree with previous data showing an association of the attenuated cortisol stress response with the psychotherapy non-response. In the present sample, those patients with the lowest cortisol concentrations showed the least improvement in agoraphobic avoidance after psychotherapy. The patients with the highest level of fear showed the most improvement in fear of bodily sensations. Study limitations as well as implications for future studies will be discussed.

Primer in Genetics and Genomics, Article 2-Advancing Nursing Research With Genomic Approaches

PURPOSE

Nurses investigate reasons for variable patient symptoms and responses to treatments to inform how best to improve outcomes. Genomics has the potential to guide nursing research exploring contributions to individual variability. This article is meant to serve as an introduction to the novel methods available through genomics for addressing this critical issue and includes a review of methodological considerations for selected genomic approaches.

APPROACH

This review presents essential concepts in genetics and genomics that will allow readers to identify upcoming trends in genomics nursing research and improve research practice. It introduces general principles of genomic research and provides an overview of the research process. It also highlights selected nursing studies that serve as clinical examples of the use of genomic technologies. Finally, the authors provide suggestions about how to apply genomic technology in nursing research along with directions for future research.

CONCLUSIONS

Using genomic approaches in nursing research can advance the understanding of the complex pathophysiology of disease susceptibility and different patient responses to interventions. Nurses should be incorporating genomics into education, clinical practice, and research as the influence of genomics in health-care research and practice continues to grow. Nurses are also well placed to translate genomic discoveries into improved methods for patient assessment and intervention.

Meta-analysis of Plasma Interleukine-6 Levels in Patients with Depressive Disorder

Growing body of evidence suggests that inflammatory processes play an important role in the pathophysiology and the clinical course of depressive disorder, as well as several others major psychiatric and somatic conditions. Interleukin (IL-6), one of the proinflammatory cytokines, has been extensively examined in a number of studies among depressed patients. To assess quantitatively the relationship between depression and IL-6, a systematic review of relevant literature published to October 2009 was performed and relevant data were meta-analysed using random-effects model. A positive association was found (standardized difference in means=1.055, p>0,001), although a significant heterogeneity among studies (Q(15)=141, p<0,001) points to relevance of further subgroup analyses.

DNA damage in lymphocytes of patients suffering from complex traumatization

It has been shown that complex childhood traumatization (CCT) increases the risk for severe somatic and mental disorders. However, the somatic pathways linking maladaptive affect regulation and disease are not understood. Here we tested the hypothesis that traumatic stress is linked to the induction of DNA damage. We isolated peripheral lymphocytes (PBLCs) from blood of healthy donors and patients suffering from CCT. Cells were immobilised on slides and stained with anti-phosphohistone 2AX (γH2AX). The number of γH2AX foci, which are an accepted surrogate marker of DNA double-strand breaks (DSBs), was determined and set in relation to the patient characteristics. We show that CCT patients (HS) have higher levels of DSBs in PBLCs than healthy volunteers (CG) and psychiatric patients without CCT (LS) (HS: 0.88±0.46 foci/cell; LS: 0.31±0.23 foci/cell; CG: 0.15±0.10 foci/cell). The difference between HS and control group was highly significant (p<0.001). Insecure-dismissing attachment as a psychological marker was related to an increase in the γH2AX foci in all groups, but especially in the CCT patients. There was no significant correlation in the γH2AX level to potential external genotoxic influences such as smoking and alcohol consumption. In PBLCs, spontaneous occurring γH2AX foci partially colocalized with 53BP1 and pATM, supporting the notion they represent DSBs. Overall, our data indicate that complex traumatization is a source of genotoxic stress that can cause systemic DNA damage, pointing to the importance of emotional early life experiences for the genetically determined health status in later life periods. The finding of CCT to be interrelated to genomic instability opens new opportunities for a deeper understanding of the link between emotional stress, DNA damage and somatic disorders.

The role of glucocorticoids and corticotropin-releasing hormone regulation on anxiety symptoms and response to treatment

The stress response has been linked to the expression of anxiety and depression, but the mechanisms for these connections are under continued consideration. The activation and expression of glucocorticoids and CRH are variable and may hold important clues to individual experiences of mood disorders. This paper explores the interactions of glucocorticoids and CRH in the presentation of anxiety and depressive disorders in an effort to better describe their differing roles in each of these clinical presentations. In addition, it focuses on ways in which extra-hypothalamic glucocorticoids and CRH, often overlooked, may play important roles in the presentation of clinical disorders.

A Functional Interleukin-18 Haplotype Predicts Depression and Anxiety through Increased Threat-Related Amygdala Reactivity in Women but Not Men

Common functional polymorphisms in the gene encoding interleukin-18 (IL18), a cytokine belonging to the IL-1 superfamily that can induce synthesis of several other cytokines, have been associated with major depressive episodes following the experience of stressful life events. The neural mechanisms underlying these associations remain unexamined. Here we use an imaging genetics strategy to examine the effects of risk-related IL18 haplotypes comprising rs187238 and rs1946518 on threat-related amygdala reactivity and, through an indirect effect, stress-related symptoms of depression and anxiety in 448 non-Hispanic Caucasian university students. Analyses indicated that women but not men possessing an IL18 haplotype comprising both risk-related alleles evidenced increased threat-related left centromedial amygdala reactivity relative to other haplotype groups. Moreover, in women only, increased threat-related left centromedial amygdala reactivity predicted increased symptoms of depression and anxiety in individuals also reporting higher levels of life stress. Path analyses revealed a significant indirect effect of IL18 risk haplotype on symptoms of depression and anxiety through increased threat-related amygdala reactivity. These results suggest that a common functional IL18 haplotype associated with heightened proinflammatory responses confers susceptibility to stress-related depression and anxiety through effects on threat-related amygdala function, a risk pathway specific to women. If replicated, these patterns can inform the search for personalized interventions targeting neurobiological pathways of risk associated with inflammation.

Immune and Neuroendocrine Mechanisms of Stress Vulnerability and Resilience

Diagnostic criteria for mood disorders including major depressive disorder (MDD) largely ignore biological factors in favor of behavioral symptoms. Compounding this paucity of psychiatric biomarkers is a need for therapeutics to adequately treat the 30-50% of MDD patients who are unresponsive to traditional antidepressant medications. Interestingly, MDD is highly prevalent in patients suffering from chronic inflammatory conditions, and MDD patients exhibit higher levels of circulating pro-inflammatory cytokines. Together, these clinical findings suggest a role for the immune system in vulnerability to stress-related psychiatric illness. A growing body of literature also implicates the immune system in stress resilience and coping. In this review, we discuss the mechanisms by which peripheral and central immune cells act on the brain to affect stress-related neurobiological and neuroendocrine responses. We specifically focus on the roles of pro-inflammatory cytokine signaling, peripheral monocyte infiltration, microglial activation, and hypothalamic-pituitary-adrenal axis hyperactivity in stress vulnerability. We also highlight recent evidence suggesting that adaptive immune responses and treatment with immune modulators (exogenous glucocorticoids, humanized antibodies against cytokines) may decrease depressive symptoms and thus represent an attractive alternative to the current antidepressant treatments.

Post-traumatic stress disorder and cardiometabolic disease: improving causal inference to inform practice

Post-traumatic stress disorder (PTSD) has been declared 'a life sentence' based on evidence that the disorder leads to a host of physical health problems. Some of the strongest empirical research - in terms of methodology and findings - has shown that PTSD predicts higher risk of cardiometabolic diseases, specifically cardiovascular disease (CVD) and type 2 diabetes (T2D). Despite mounting evidence, PTSD is not currently acknowledged as a risk factor by cardiovascular or endocrinological medicine. This view is unlikely to change absent compelling evidence that PTSD causally contributes to cardiometabolic disease. This review suggests that with developments in methods for epidemiological research and the rapidly expanding knowledge of the behavioral and biological effects of PTSD the field is poised to provide more definitive answers to questions of causality. First, we discuss methods to improve causal inference using the observational data most often used in studies of PTSD and health, with particular reference to issues of temporality and confounding. Second, we consider recent work linking PTSD with specific behaviors and biological processes, and evaluate whether these may plausibly serve as mechanisms by which PTSD leads to cardiometabolic disease. Third, we evaluate how looking more comprehensively into the PTSD phenotype provides insight into whether specific aspects of PTSD phenomenology are particularly relevant to cardiometabolic disease. Finally, we discuss new areas of research that are feasible and could enhance understanding of the PTSD-cardiometabolic relationship, such as testing whether treatment of PTSD can halt or even reverse the cardiometabolic risk factors causally related to CVD and T2D.

The role of automatic defensive responses in the development of posttraumatic stress symptoms in police recruits: protocol of a prospective study

Background: Control over automatic tendencies is often compromised in challenging situations when people fall back on automatic defensive reactions, such as freeze-fight-flight responses. Stress-induced lack of control over automatic defensive responses constitutes a problem endemic to high-risk professions, such as the police. Difficulties controlling automatic defensive responses may not only impair split-second decisions under threat, but also increase the risk for and persistence of posttraumatic stress disorder (PTSD) symptoms. However, the significance of these automatic defensive responses in the development and maintenance of trauma-related symptoms remains unclear due to a shortage of large-scale prospective studies. Objective: The 'Police-in-Action' study is conducted to investigate the role of automatic defensive responses in the development and maintenance of PTSD symptomatology after trauma exposure. Methods: In this prospective study, 340 police recruits from the Dutch Police Academy are tested before (wave 1; pre-exposure) and after (wave 2; post-exposure) their first emergency aid experiences as police officers. The two waves of data assessment are separated by approximately 15 months. To control for unspecific time effects, a well-matched control group of civilians (n = 85) is also tested twice, approximately 15 months apart, but without being frequently exposed to potentially traumatic events. Main outcomes are associations between (changes in) behavioural, psychophysiological, endocrine and neural markers of automatic defensive responses and development of trauma-related symptoms after trauma exposure in police recruits. Discussion: This prospective study in a large group of primary responders enables us to distinguish predisposing from acquired neurobiological abnormalities in automatic defensive responses, associated with the development of trauma-related symptoms. Identifying neurobiological correlates of (vulnerability for) trauma-related psychopathology may greatly improve screening for individuals at risk for developing PTSD symptomatology and offer valuable targets for (early preventive) interventions for PTSD.

Inflammation in Fear- and Anxiety-Based Disorders: PTSD, GAD, and Beyond

The study of inflammation in fear- and anxiety-based disorders has gained interest as growing literature indicates that pro-inflammatory markers can directly modulate affective behavior. Indeed, heightened concentrations of inflammatory signals, including cytokines and C-reactive protein, have been described in posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), panic disorder (PD), and phobias (agoraphobia, social phobia, etc.). However, not all reports indicate a positive association between inflammation and fear- and anxiety-based symptoms, suggesting that other factors are important in future assessments of inflammation's role in the maintenance of these disorders (ie, sex, co-morbid conditions, types of trauma exposure, and behavioral sources of inflammation). The most parsimonious explanation of increased inflammation in PTSD, GAD, PD, and phobias is via the activation of the stress response and central and peripheral immune cells to release cytokines. Dysregulation of the stress axis in the face of increased sympathetic tone and decreased parasympathetic activity characteristic of anxiety disorders could further augment inflammation and contribute to increased symptoms by having direct effects on brain regions critical for the regulation of fear and anxiety (such as the prefrontal cortex, insula, amygdala, and hippocampus). Taken together, the available data suggest that targeting inflammation may serve as a potential therapeutic target for treating these fear- and anxiety-based disorders in the future. However, the field must continue to characterize the specific role pro-inflammatory signaling in the maintenance of these unique psychiatric conditions.

Microglial production of TNF-alpha is a key element of sustained fear memory

The proinflammatory cytokine productions in the brain are altered in a process of fear memory formation, indicating a possibility that altered microglial function may contribute to fear memory formation. We aimed to investigate whether and how microglial function contributes to fear memory formation. Expression levels of M1- and M2-type microglial marker molecules in microglia isolated from each conditioned mice group were assessed by real-time PCR and immunohistochemistry. Levels of tumor necrosis factor (TNF)-α, but not of other proinflammatory cytokines produced by M1-type microglia, increased in microglia from mice representing retention of fear memory, and returned to basal levels in microglia from mice representing extinction of fear memory. Administration of inhibitors of TNF-α production facilitated extinction of fear memory. On the other hand, expression levels of M2-type microglia-specific cell adhesion molecules, CD206 and CD209, were decreased in microglia from mice representing retention of fear memory, and returned to basal levels in microglia from mice representing extinction of fear memory. Our findings indicate that microglial TNF-α is a key element of sustained fear memory and suggest that TNF-α inhibitors can be candidate molecules for mitigating posttraumatic reactions caused by persistent fear memory.