Low urinary cortisol excretion in Holocaust survivors with posttraumatic stress disorder

The association between PTSD symptoms and salivary cortisol in youth: the role of time since the trauma

This study examined the direction of association between symptoms of posttraumatic stress disorder (PTSD) and cortisol levels among youth with recent and distal traumas (N = 50; mean age = 10.7 years). Each had a clinical interview for PTSD symptoms, a cortisol assessment, and the time since the child's most recent trauma was assessed. Results indicated that the time since the most recent trauma moderated the association between cortisol and PTSD symptoms and comparisons indicated that there were significant differences in the size of the correlations across the recent and distal trauma groups. The results point to a potentially important role of the time since trauma in understanding the relationship between PTSD symptoms and cortisol.

Elevated morning serum interleukin (IL)-6 or evening salivary cortisol concentrations predict posttraumatic stress disorder in children and adolescents six months after a motor vehicle accident

BACKGROUND

This study examined prospectively the activity of the hypothalamic-pituitary-adrenal axis, the sympathetic nervous system and inflammatory factors in children shortly after a motor vehicle accident (MVA) in relation to later posttraumatic stress disorder (PTSD) development.

PATIENTS AND METHODS

Fifty six children, aged 7-18, were studied after an MVA and 1 and 6 months later; 40 subjects served as controls. Morning serum cortisol and interleukin (IL)-6 and plasma catecholamine concentrations were measured within 24h after the event. Salivary cortisol was measured 5 times at defined time points during the same day. PTSD diagnoses 1 and 6 months later were based on K-SADS interview.

RESULTS

Morning serum IL-6 concentrations, measured within the first 24h after the accident, were higher in children that developed PTSD 6 months later than those who did not and those of the control group. Longitudinal IL-6 measurements revealed normalization of IL-6 in the PTSD group, while no differences between the three groups were detected 1 and 6 months later. Evening salivary cortisol and morning serum IL-6 after the accident were positively inter-related (r=0.54, p<0.001) and in separate regression analyses both predicted PTSD development 6 months later. In contrast, morning serum IL-6 did nor correlate with morning serum or salivary cortisol concentrations.

CONCLUSIONS

Immediate posttraumatic alterations in neuroendocrine or inflammatory factors-increased evening salivary cortisol and/or increased morning serum IL-6 concentrations-are involved in subsequent PTSD development in children and adolescents.

Delayed recall of childhood sexual abuse memories and the awakening rise and diurnal pattern of cortisol

Traumatic stress associated with childhood sexual abuse (CSA) may result in chronic alterations of stress-sensitive neurochemical systems (e.g., the hypothalamic-pituitary-adrenal axis and sympathetic-adrenal medullary activity). Some authors have suggested that these alterations might help explain why some individuals, after a period of inability to remember, demonstrate delayed recall of CSA memories (i.e., "recovered" memories). The present study is the first study that explored morning cortisol responses and circadian cortisol profiles among women with recovered (n=7), repressed (n=8), or continuous (n=6) memories of CSA and women without a history of CSA (n=9). Although there were group differences in current depression and post-traumatic stress symptoms, we found no differences in cortisol awakening response or daytime profile between women reporting recovered, repressed, or continuous memories of CSA as compared to women without a history of CSA. Implications for neurobiological models intended to explain the delayed recall of CSA are discussed.

Hippocampal volume in aging combat veterans with and without post-traumatic stress disorder: relation to risk and resilience factors

OBJECTIVE

To examine whether there are post-traumatic stress disorder (PTSD) related differences in hippocampal volume in middle-aged and elderly veterans and to examine the relationship of neuroendocrine activity, memory performance, and measures of risk and resilience for PTSD to hippocampal volume in this cohort.

METHODS

Seventeen veterans with chronic PTSD and 16 veterans without chronic PTSD received an MRI scan followed by neuroendocrine assessment (24-h urinary cortisol excretion and the lysozyme IC(50-DEX), a measure of glucocorticoid receptor (GR) responsiveness), and cognitive testing.

RESULTS

Veterans with PTSD did not differ from those without PTSD in hippocampal volume, but they did show significantly lower urinary cortisol levels, and poorer memory performance on the Wechsler Logical Memory test and Digit Span test. Smaller left hippocampal volumes were observed in veterans who developed PTSD in response to their first reported traumatic exposure, compared to veterans who had first experienced a traumatic event to which they did not develop PTSD, prior to experiencing a subsequent event that led to PTSD. In contrast, the two neuroendocrine measures were associated with risk factors related to early trauma exposure.

CONCLUSION

Although hippocampal volume was not found to differ between subjects with and without PTSD, smaller hippocampal volumes in PTSD may be associated with specific risk and resilience factors. These may be distinct from vulnerability markers associated with increased responsiveness to glucocorticoids and/or other neuroendocrine measures that have been observed in combat-related PTSD.

Changes in cortisol and DHEA plasma levels after psychotherapy for PTSD

Post-traumatic stress disorder (PTSD) has been associated with dysregulation of the neuroendocrine system. In this study we examine the effects of psychotherapy in 21 PTSD patients, with and without coexisting depression, on the levels of six stress-related hormones: cortisol, dehydroepiandrosterone (DHEA), and dehydroepiandrosterone-sulfate (DHEA-S), prolactin, thyrotropin (TSH) and free thyroxin (fT4). The results show that after brief eclectic psychotherapy (BEP) significant changes occurred in levels of cortisol and DHEA. Responders showed an increase in cortisol and DHEA levels, while in non-responders both hormone levels decreased. Differences were only found after controlling for depressive symptoms. In conclusion, effective psychotherapy for PTSD may alter dysregulations in the Hypothalamus-pituitary-adrenal (HPA)-axis, but comorbid depressive symptoms should be taken into account.

Resilience: research evidence and conceptual considerations for posttraumatic stress disorder

The growing recognition and occurrence of traumatic exposure in the general population has given increased salience to the need to understand the concept of resilience. More than just the "flip side" of a risk factor, the notion of resilience encompasses psychological and biological characteristics, intrinsic to an individual, that might be modifiable and that confer protection against the development of psychopathology in the face of stress. In this review, we provide some perspective on the concept of "resilience" by examining early use of the term in research on "children at risk" and discuss the relationship between risk and resilience factors. We then review psychological and biological factors that may confer resilience to the development of posttraumatic stress disorder (PTSD) following trauma, examine how resilience has been assessed and measured, and discuss issues to be addressed in furthering our understanding of this critical concept going forward.

Disaster-related posttraumatic stress disorder and physical health

OBJECTIVE

To examine the relationship between posttraumatic stress disorder (PTSD) and self-reported as well as physician-recorded physical health in a sample of survivors (n = 896) of a man-made disaster, using a longitudinal design that included predisaster health data. Most studies on the relationship between PTSD and physical health are cross-sectional and use self-reported physical health outcomes.

METHODS

A surveillance using the electronic medical records of survivors' family practitioners (FPs), 1 year predisaster until 4 years postdisaster, was combined with a survey, 3 weeks and 18 months postdisaster. Self-reported PTSD and self-reported physical health were assessed at 18 months postdisaster. FP-recorded physical health problems in the subsequent 2 years were classified according to the International Classification of Primary Care. Multiple regression analyses were used to describe the relationships between PTSD and physical health.

RESULTS

After adjusting for demographics, smoking behavior, and predisaster physical health, PTSD was significantly associated with FP-recorded vascular, musculoskeletal, and dermatological problems, and with all self-reported physical health aspects. Prospectively, PTSD signaled an increased risk of new vascular problems (odds ratio = 1.92; 1.04-3.55).

CONCLUSIONS

This study suggests an effect of PTSD in the development of vascular problems. The results imply that clinicians should be alert that disaster survivors with PTSD can suffer from comorbid medical problems as well.

Biomarkers of intermediate endpoints in environmental and occupational health

The use of biomarkers in environmental and occupational health is increasing due to increasing demands on information about health risks from unfavourable exposures. Biomarkers provide information about individual loads. Biomarkers of intermediate endpoints benefit in comparison with biomarkers of exposure from the fact that they are closer to the adverse outcome in the pathway from exposure to health effects and may provide powerful information for intervention. Some biomarkers are specific, e.g., DNA and protein adducts, while others are unspecific like the cytogenetic biomarkers of chromosomal aberrations (CA), sister chromatid exchanges and micronuclei (MN). The validation of biomarkers includes measurements of sensitivity and specificity of biomarkers and round robin tests to ensure reproducible protocols within different laboratories. The predictive value of biomarkers with respect to adverse health effect from the result of the measurement has been performed for the cytogenetic biomarkers showing a predictive value of high levels of CA and increased risk of cancer. The use of CA in future studies is, however, limited by the laborious and sensitive procedure of the test and lack of trained cytogeneticists. Less time consuming, but robust biomarkers, sensitive to environmental exposures are suggested. From the selection of developed biomarkers, the comet assay is highly sensitive to lifestyle exposures, often confounding the output, while MN in lymphocytes seem promising with respect to laboratory and health effect (cancer) validity. Also, new biomarkers exploiting the new 'omics' technologies are being developed. A number of ethical issues arise from the use of biomarkers with a predictive value aiming at respecting the autonomy of the study person in participation (only upon written informed consent and with obligations of withdrawal at any time), access to personal information (right to know and right not to know the study result) and securing proper data management (data protection to avoid misuse in employment, insurance, loaning and learning opportunities).

The stress system in depression and neurodegeneration: focus on the human hypothalamus

The stress response is mediated by the hypothalamo-pituitary-adrenal (HPA) system. Activity of the corticotropin-releasing hormone (CRH) neurons in the hypothalamic paraventricular nucleus (PVN) forms the basis of the activity of the HPA-axis. The CRH neurons induce adrenocorticotropin (ACTH) release from the pituitary, which subsequently causes cortisol release from the adrenal cortex. The CRH neurons co-express vasopressin (AVP) which potentiates the CRH effects. CRH neurons project not only to the median eminence but also into brain areas where they, e.g., regulate the adrenal innervation of the autonomic system and affect mood. The hypothalamo-neurohypophysial system is also involved in stress response. It releases AVP from the PVN and the supraoptic nucleus (SON) and oxytocin (OXT) from the PVN via the neurohypophysis into the bloodstream. The suprachiasmatic nucleus (SCN), the hypothalamic clock, is responsible for the rhythmic changes of the stress system. Both centrally released CRH and increased levels of cortisol contribute to the signs and symptoms of depression. Symptoms of depression can be induced in experimental animals by intracerebroventricular injection of CRH. Depression is also a frequent side effect of glucocorticoid treatment and of the symptoms of Cushing's syndrome. The AVP neurons in the hypothalamic PVN and SON are also activated in depression, which contributes to the increased release of ACTH from the pituitary. Increased levels of circulating AVP are also associated with the risk for suicide. The prevalence, incidence and morbidity risk for depression are higher in females than in males and fluctuations in sex hormone levels are considered to be involved in the etiology. About 40% of the activated CRH neurons in mood disorders co-express nuclear estrogen receptor (ER)-alpha in the PVN, while estrogen-responsive elements have been found in the CRH gene promoter region, and estrogens stimulate CRH production. An androgen-responsive element in the CRH gene promoter region initiates a suppressing effect on CRH expression. The decreased activity of the SCN is the basis for the disturbances of circadian and circannual fluctuations in mood, sleep and hormonal rhythms found in depression. Neuronal loss was also reported in the hippocampus of stressed or corticosteroid-treated rodents and primates. Because of the inhibitory control of the hippocampus on the HPA-axis, damage to this structure was expected to disinhibit the HPA-axis, and to cause a positive feedforward cascade of increasing glucocorticoid levels over time. This 'glucocorticoid cascade hypothesis' of stress and hippocampal damage was proposed to be causally involved in age-related accumulation of hippocampal damage in disorders like Alzheimer's disease and depression. However, in postmortem studies we could not find the presumed hippocampal damage of steroid overexposure in either depressed patients or in patients treated with synthetic steroids.

Physical and mental comorbidity, disability, and suicidal behavior associated with posttraumatic stress disorder in a large community sample

OBJECTIVE

To assess if posttraumatic stress disorder (PTSD), recognized as a common mental disorder in the general population and veteran samples, has a unique impact on comorbidity, disability, and suicidal behavior (after adjusting for other mental disorders, especially depression).

METHODS

Data came from the Canadian Community Health Survey Cycle 1.2 (n = 36,984; age > or = 15 years; response rate 77%). All respondents were asked if they had been given a diagnosis of PTSD by a healthcare professional. A select number of mental disorders were assessed by the Composite International Diagnostic Interview. Chronic physical health conditions, measures of quality of life, disability, and suicidal behavior were also assessed.

RESULTS

The prevalence of PTSD as diagnosed by health professionals was 1.0% (95% CI = 0.90-1.15). After adjusting for sociodemographic factors and other mental disorders, PTSD remained significantly associated with several physical health problems including cardiovascular diseases, respiratory diseases, chronic pain conditions, gastrointestinal illnesses, and cancer. After adjusting for sociodemographic factors, mental disorders, and severity of physical disorders, PTSD was associated with suicide attempts, poor quality of life, and short- and long-term disability.

CONCLUSIONS

PTSD was uniquely associated with several physical disorders, disability, and suicidal behavior. Increased early recognition and treatment of PTSD are warranted.

Traumatic stress: effects on the brain

Brain areas implicated in the stress response include the amygdala, hippocampus, and prefrontal cortex. Traumatic stress can be associated with lasting changes in these brain areas. Traumatic stress is associated with increased cortisol and norepinephrine responses to subsequent stressors. Antidepressants have effets on the hippocampus that counteract the effects of stress. Findings from animal studies have been extended to patients with post-traumatic stress disorder (PTSD) showing smaller hippocampal and anterior cingulate volumes, increased amygdala function, and decreased medial prefrontal/anterior cingulate function. In addition, patients with PTSD show increased cortisol and norepinephrine responses to stress. Treatments that are efficacious for PTSD show a promotion of neurogenesis in animal studies, as well as promotion of memory and increased hippocampal volume in PTSD.

Endocrine and inflammatory alterations in post-traumatic stress disorder

Post-traumatic stress disorder has frequently been found associated with alterations in endogenous stress hormone systems, for example the hypothalamus-pituitary-adrenal axis and sympatho-adrenal-medullary system. Hormonal alterations are observed at the central and peripheral level of the central nervous system, and in the periphery for inflammatory disinhibition. Both consequences bear significant hazards for the individual, the former by sustaining or exacerbating the psychiatric condition, the latter by its detrimental effects on somatic health. However, the role of hormonal modifications in the development and maintenance of post-traumatic stress disorder symptoms and in the accompanying cognitive and emotional impairments still remains quite unclear.

HPA- and HPT-axis alterations in chronic posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) has been associated with dysregulation of the hypothalamus-pituitary-adrenal (HPA) axis as well as of the hypothalamus-pituitary-thyroid (HPT) axis. Findings have not been consistent and may depend on methodological issues like controlling for relevant variables. This study examines the levels of six HPA and HPT-axis related hormones in civilian PTSD patients without psychotropic medication. In a cross sectional study, 39 chronic PTSD patients and 44 healthy volunteers were included. Psychometric instruments included SCID, SI-PTSD, IES-R and BDI. The plasma hormones levels assessed were cortisol, dehydroepiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DHEA-S), prolactin, thyrotropin (TSH), and free thyroxin (fT4). Results showed that patients had significantly lower plasma cortisol, prolactin and TSH levels compared to the comparison group. The difference between TSH levels in patients and comparison subjects only emerged after controlling for relevant background variables. Furthermore, the severity of PTSD symptoms was negatively related to cortisol levels. Secondary analyses revealed no statistically significant effect of comorbid depression (26% of patients) on any of the hormone levels. Complex feedback mechanisms are likely to result in altered levels of stress related hormones in PTSD, and results depend on controlling for relevant variables. Further research with longitudinal designs is needed to find out whether these lower hormone levels are preexisting risk factors or consequence of trauma and whether these alterations are deleterious or adaptive.

Alterations in stress reactivity after long-term treatment with paroxetine in women with posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is typically accompanied by both acute and chronic alterations in the stress response. These alterations have mostly been described in individuals under baseline conditions, but studies have also used a challenge model to assess the role of the hypothalamic-pituitary-adrenal (HPA) axis in the stress response. The purpose of this article was to assess the effect of long-term treatment with the selective reuptake inhibitor (SSRI), paroxetine, on stress reactivity in patients with PTSD. We assessed diurnal salivary cortisol and urinary cortisol as well as cortisol, heart rate, and behavioral responses to a standardized cognitive stress challenge, in 13 female patients with chronic PTSD before and after 12 months of paroxetine treatment. Treatment resulted in a significant decrease in PTSD symptoms. Twenty-four-hour urinary cortisol was lower compared to base line after successful treatment. Treatment resulted in a decrease of salivary cortisol levels on all time points on a diurnal curve. Despite similar stress perception, cortisol response to the cognitive stress challenge resulted in a 26.5% relative decrease in stress-induced salivary cortisol with treatment. These results suggest that successful treatment with SSRI in chronic PTSD is associated with a trend for a decrease in baseline diurnal cortisol and with reduced cortisol reactivity to stress.

Predicting PTSD prospectively based on prior trauma history and immediate biological responses

Studies examining the biopsychology of posttraumatic stress disorder (PTSD) have suggested that PTSD is characterized by alterations of the primary stress pathways: the hypothalamic-pituitary-adrenal (HPA) axis and the sympathetic nervous system (SNS). More recent investigations point to the presence of these alterations soon after a traumatic event, leading researchers to suggest that acute biological responses may serve as risk or resilience factors for the development of PTSD. The present article reviews the evidence for early biological predictors of PTSD, with a focus on the role of prior trauma as a contributor to both hormonal abnormalities and increased risk for the development of PTSD following a subsequent trauma.

Cognitive effects of intravenous hydrocortisone in subjects with PTSD and healthy control subjects

On the basis of peripheral (nonbrain) neuroendocrine findings in subjects with posttraumatic stress disorder (PTSD), it has been hypothesized that these individuals also have a greater central (brain) sensitivity to glucocorticoids. In nonpsychiatric subjects, it has been found that working and declarative memory performance is selectively impaired by acute glucocorticoid administration. We hypothesized that subjects with PTSD, as compared to nonpsychiatric controls, would show greater impairments in verbal declarative memory and working memory, but not attention, following exogenous glucocorticoid administration. These data are part of a larger study using functional neuroimaging and peripheral HPA axis measures in these same subjects. Subjects underwent a 0.5-mg dexamethasone suppression test and measurement of basal cortisol, basal plasma lymphocyte glucocorticoid receptor number, and postdexamethasone cortisol on a separate day. Under double-blind randomized crossover conditions, 17-mg hydrocortisone or placebo was administered by intravenous (i.v.) bolus to 15 medication-free PTSD subjects (4 female) and 12 nonpsychiatric control subjects (4 female) matched by age, sex, and education level. Participants then underwent positron emission tomography (PET) scanning and 90 min after the initial drug/placebo administration, cognitive testing was then performed. By repeated measures ANCOVA (covaried for baseline performance on that neuropsychological test), neither attention tasks of digit span forward nor backward showed significant change. However, there were significant drug (F = 17.644, df = 1,25 P < 0.001), group (F = 4.383, df = 1,25 P = 0.048), and drug by group interactions (F = 4.756, df = 1,25 P = 0.040) for verbal declarative memory. By t-test, there was not a difference in baseline performance on this measure between subject groups. The subject group with PTSD experienced a greater decline in verbal declarative memory performance following hydrocortisone administration. For working memory, there were significant group (F = 6.048, df = 1,25 P = 0.022) and drug by group interactions (F = 6.048, df = 1,25 P = 0.022) for verbal declarative memory. By t-test, there was not a difference in baseline performance on this measure between subject groups. The hydrocortisone administration led to impairment in working memory in the group of subjects with PTSD, but not in the control subject group. Exploratory correlations between percent cortisol suppression following dexamethasone and baseline plasma lymphocyte glucocorticoid receptor number with declarative and working memory measures among subject groups separately and in a combined way revealed a negative correlation between lymphocyte glucocorticoid receptor density and working memory (r = -0.54, df = 25, P = 0.008). Brain sensitivity to glucocorticoids appears to be greater in subjects with PTSD. Heightened vulnerability of declarative memory in subjects with PTSD may indicate hippocampal involvement, whereas working memory vulnerability suggests additional brain regions (prefrontal, cingulate, temporal, and parietal cortices) and neurotransmitter systems (dopamine and serotonin) particularly sensitive to glucocorticoids in persons with PTSD.

Assessment of HPA-axis function in posttraumatic stress disorder: pharmacological and non-pharmacological challenge tests, a review

Posttraumatic stress disorder (PTSD) is typically accompanied by acute and chronic alterations in the stress response. These alterations have mostly been described in individuals under baseline conditions, but several studies have also used a challenge model to further assess the role of the hypothalamic-pituitary-adrenal (HPA) axis in the stress response. This paper reviews common methodology and research findings on HPA function in PTSD, and discusses the pathophysiological mechanisms underlying these findings. We reviewed the literature and selected all English-language, human subject, data driven, pharmacological and non-pharmacological challenge studies pertaining to the HPA axis, and in vitro leukocyte glucocorticoid receptor studies in adult PTSD subjects. Studies using a non-pharmacological stress paradigm (cognitive stress, trauma reminders) to stimulate the HPA axis showed an exaggerated cortisol response in PTSD. The most widely used pharmacological challenge with consistent results was the low dose dexamethasone-suppression test (DST). These DST studies showed enhanced cortisol suppression in subjects with PTSD. Different hypotheses have been purported to explain the alterations in HPA axis functioning in PTSD. The results of the reviewed challenge tests, however, did not exclusively support one of the hypothesized mechanisms. Further research assessing hormones at all levels of the HPA axis at both baseline and at challenge conditions with a proper stratification of study population, will be necessary for a better understanding of stress-responsivity on the level of the HPA axis in PTSD.

Increased cortisol in women with intimate partner violence-related posttraumatic stress disorder

BACKGROUND

Alterations of hypothalamic-pituitary-adrenal (HPA) axis function and sympathetic-adrenal activity have been proposed as key factors in biological models of posttraumatic stress disorder (PTSD).

METHODS

We examined neuroendocrine function in female survivors of intimate partner violence (IPV) with lifetime (current or remitted) PTSD (n=29) and in women who were exposed to IPV but never developed PTSD (n=20). Salivary cortisol was collected as a marker of HPA axis function at 1, 4, 9, and 11 h after awakening. Platelet epinephrine and norepinephrine were assayed as markers of sympathetic-adrenal activation.

RESULTS

Women with lifetime PTSD had significantly higher cortisol levels across the day compared to abuse-exposed participants without PTSD, after controlling for age, depression, severity, and latency of abuse. There were no significant group differences in levels of platelet catecholamines.

CONCLUSIONS

Elevated cortisol levels may be a biomarker of IPV-related lifetime PTSD, reflecting long-lasting changes associated with trauma-exposure or possibly a reflection of risk for PTSD in women.

Stress reactivity: biological and subjective responses to the cold pressor and Trier Social stressors

The cold pressor test (CPT) and Trier Social Stress Test (TSST) have been shown to reliably increase HPA activity; however, little research has compared responses to these stressors. In this study, biological (plasma cortisol and ACTH levels) and subjective (e.g., stress and mood) responses were compared in 31 subjects administered both the CPT and TSST. Subjects were diagnosed with alcohol dependence and post-traumatic stress disorder (PTSD) (n = 11), alcohol dependence without PTSD (n = 10), PTSD without alcohol use disorder (n = 4), and neither PTSD nor alcohol use disorder (n = 6). All subjects completed both the CPT and TSST. In all groups, the TSST elicited higher levels of ACTH and cortisol than the CPT, and the response time course differed between tasks. The TSST also produced lower mood ratings than the CPT. A comparison of all diagnosed groups with normal controls revealed group differences in ACTH responding for the CPT but not the TSST. The results suggest that the TSST results in a greater HPA response than the CPT; however, the CPT may have utility in diagnostically heterogeneous patients.

Developing an Agenda for Translational Studies of Resilience and Vulnerability Following Trauma Exposure

Here we outline a translational research agenda for studies of resilience, defined as the process of adapting well in the face of adversity or trauma. We argue that an individual differences approach to the study of resilience, in which the full range of behavioral and biological responses to stress exposure is examined can be applied across human samples (e.g., people who have developed psychopathology versus those who have not; people who have been exposed to trauma versus those who have not) and even, in some cases, across species. We delineate important psychological resilience-related factors including positive affectivity and optimism, cognitive flexibility, coping, social support, emotion regulation, and mastery. Key brain regions associated with stress-related psychopathology have been identified with animal models of fear (e.g., extinction and fear conditioning; memory reconsolidation) and we describe how these regions can be studied in humans using neuroimaging technology. Finally, we cite recent research identifying neuroendocrine markers of resilience and recovery in humans (e.g., neuropeptide Y [NPY], dehydroepiandrosterone [DHEA]) that can also be measured, in some cases, in other species. That exposure to adversity or trauma does not necessarily lead to impairment and the development of psychopathology in all people is an important observation. Understanding why this is so will provide clues for the development of therapeutic interventions for those people who do develop stress-related psychopathology, or even for the prevention of adverse outcomes.

Advances in Understanding Neuroendocrine Alterations in PTSD and Their Therapeutic Implications

The findings from investigations of the neuroendocrinology of posttraumatic stress disorder (PTSD) have highlighted alterations that have not historically been associated with pathologic processes, and have, accordingly, raised several questions about the nature of the findings and their relationship to PTSD. The most infamous of these observations--low cortisol levels--has been the subject of much discussion and scrutiny because the finding has been both counterintuitive, and not uniformly reproducible. This fact notwithstanding, novel therapeutic approaches to the treatment of PTSD are in large part predicated on the assumption that glucocorticoid levels may be lower in PTSD. This article summarizes important neuroendocrine observations in cortisol and provides strategies for understanding what has emerged over the past two decades, to be a complex and sometimes contradictory literature.

The ACTH Response to Dexamethasone in Persian Gulf War Veterans

The basis of postdeployment health symptoms in Gulf War veterans remains poorly understood. Alterations in the feedback regulation of the hypothalamic-pituitary-adrenal (HPA) axis have been demonstrated in posttraumatic stress disorder (PTSD) and other bodily disorders related to stress. The objective of this article was to examine whether similar HPA axis alterations are related to Gulf War deployment, postdeployment health symptoms, or PTSD. Plasma adrenocorticotropic hormone (ACTH) was measured on consecutive mornings at 08:00 h before and after a low dose of oral dexamethasone (DEX) at 23:00 h in Gulf War veterans with PTSD (n = 14), Gulf War veterans without PTSD (n = 11), and healthy veterans never deployed to a war zone (n = 12). Both Gulf War veterans with PTSD and Gulf War veterans without PTSD had significantly lower post-DEX ACTH levels than the nonexposed veterans, in the absence of group differences in basal ACTH or DEX levels. Among Gulf War veterans, post-DEX ACTH levels were significantly associated with musculoskeletal symptoms. Gulf War deployment and postdeployment health symptoms appear to be associated with alterations in feedback regulation of the pituitary gland that suggests a possible common link between postdeployment health symptoms and other chronic stress-related conditions.

Glucocorticoid-Induced Inhibition of Memory Retrieval: Implications for Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is characterized by traumatic memories that can manifest as daytime recollections, traumatic nightmares, or flashbacks in which components of the event are relieved. These symptoms reflect excessive retrieval of traumatic memories that often retain their vividness and power to evoke distress for decades or even a lifetime. We have reported previously that elevated glucocorticoid levels inhibit memory retrieval in animals and healthy human subjects. We therefore hypothesized that the administration of cortisol might also inhibit the retrieval of traumatic memories in patients with PTSD. In a recent pilot study, we found the first evidence to support this hypothesis. During a 3-month observation period, low-dose cortisol (10 mg/day) was administered orally for 1 month to three patients with chronic PTSD using a double-blind, placebo-controlled, crossover design. In each patient investigated, there was a significant treatment effect with cortisol-related reductions in one of the daily rated symptoms of traumatic memories without causing adverse side effects. Future studies with more patients and longer treatment periods are required to evaluate the efficacy of cortisol treatment for PTSD.

Tobacco usage interacts with postdisaster psychopathology on circadian salivary cortisol

Posttraumatic stress disorder (PTSD) and major depressive disorder (MDD) have been associated with increased rates of tobacco usage as well as with dysregulations of the hypothalamus-pituitary-adrenal (HPA) axis. At the same time tobacco also affects the HPA axis. This paper examines the relationships between PTSD, posttraumatic MDD, smoking and levels of circadian cortisol 2-3 years postdisaster. Subjects were survivors of the Enschede fireworks disaster. The sample consisted of 38 healthy survivors, 40 subjects with PTSD, and 17 subjects with posttraumatic MDD. The Composite International Diagnostic Interview was used to determine mental disorders in accordance with DSM-IV criteria. Salivary cortisol samples were collected at home immediately upon awakening, 30 min after awakening, at noon, and at 10 p.m. Quantity of smoking was measured through self-report. The results of the study show that salivary cortisol concentrations were higher in smoking subjects. Survivors with MDD following the disaster had a flatter diurnal cortisol curve than subjects with PTSD or healthy survivors. In survivors with PTSD and healthy individuals the usual dynamic pattern of increase in cortisol past awakening was present, while we did not observe this in posttraumatic MDD. These survivors with MDD tended to use more tobacco per day, and the cortisol group differences could only be revealed when we adjusted for quantity of smoking. Smoking, which may be an important palliative coping style in dealing with posttraumatic arousal symptoms, seems to mediate the relationship between traumatic stress and the HPA-axis.

Posttraumatic stress disorder: a state-of-the-science review

This article reviews the state-of-the-art research in posttraumatic stress disorder (PTSD) from several perspectives: (1) Sex differences: PTSD is more frequent among women, who tend to have different types of precipitating traumas and higher rates of comorbid panic disorder and agoraphobia than do men. (2) Risk and resilience: The presence of Group C symptoms after exposure to a disaster or act of terrorism may predict the development of PTSD as well as comorbid diagnoses. (3) Impact of trauma in early life: Persistent increases in CRF concentration are associated with early life trauma and PTSD, and may be reversed with paroxetine treatment. (4) Imaging studies: Intriguing findings in treated and untreated depressed patients may serve as a paradigm of failed brain adaptation to chronic emotional stress and anxiety disorders. (5) Neural circuits and memory: Hippocampal volume appears to be selectively decreased and hippocampal function impaired among PTSD patients. (6) Cognitive behavioral approaches: Prolonged exposure therapy, a readily disseminated treatment modality, is effective in modifying the negative cognitions that are frequent among PTSD patients. In the future, it would be useful to assess the validity of the PTSD construct, elucidate genetic and experiential contributing factors (and their complex interrelationships), clarify the mechanisms of action for different treatments used in PTSD, discover ways to predict which treatments (or treatment combinations) will be successful for a given individual, develop an operational definition of remission in PTSD, and explore ways to disseminate effective evidence-based treatments for this condition.

Bullying at work, health outcomes, and physiological stress response

The relationships among bullying or witnessing bullying at work, self-reported health symptoms, and physiological stress reactivity were analysed in a sample of 437 employees (294 women and 143 men). Physiological stress reactivity was measured as cortisol in the saliva. Of the respondents, 5% of the women (n=15) and 5% of the men (n=7) reported bullying, whereas 9% of the women (n=25) and 11% of the men (n=15) had witnessed bullying at work. The results indicated that the bullied respondents had lower social support from coworkers and supervisors, and they reported more symptoms of somatisation, depression, anxiety, and negative affectivity (NA) than did the nonbullied respondents. Witnesses reported more symptoms of anxiety and lower support from supervisor than did the nonbullied employees. Concentrations of cortisol in the saliva were lower at awakening in bullied respondents compared with nonbullied respondents. Previous studies have reported lower diurnal concentration of cortisol for people with posttraumatic stress disorder (PTSD) and chronic fatigue. To our knowledge, this is the first full study on the associations among being subjected to bullying, health outcomes, and physiological stress response.

A primary care perspective of posttraumatic stress disorder for the Department of Veterans Affairs

Posttraumatic stress disorder (PTSD) is a major mental disorder associated with significant morbidity, psychosocial impairment, and disability. The diagnosis of PTSD can be missed in a primary care setting, as patients frequently present with somatic complaints or depression and are often reluctant to discuss their traumatic experiences. As recent studies of veterans returning from the Gulf War and the Iraqi War suggest high rates of PTSD, the U.S. Department of Veterans Affairs (VA) Hospitals are gearing up to face this challenge. It is important to screen these veterans for symptoms of PTSD and make an appropriate referral if required. In this article, we attempt to review PTSD with a special focus on the VA population. In addition to discussing the epidemiology, diagnosis, and treatment options for PTSD, we also suggest screening questions for both combat-related and military sexual trauma-related PTSD.

Relationship between cortisol and age-related memory impairments in Holocaust survivors with PTSD

RATIONALE

Holocaust survivors with PTSD appear to show an accelerated aging effect as evidenced by their performance on tests of explicit memory, and also show more exaggerated patterns on age-related alterations in cortisol release over the diurnal cycle than Holocaust survivors without PTSD and nonexposed subjects. To investigate the implications of age-related HPA axis alterations on cognition, we examined correlations between parameters reflecting circadian cortisol release and implicit and explicit memory performance.

METHODS

Nineteen Holocaust survivors with PTSD (7 men, 12 women), 16 Holocaust survivors without PTSD (7 men, 9 women), and 28 non-exposed healthy comparison subjects (13 men, 15 women) collected salivary samples at six times over the diurnal cycle, and were tested with Paired Associates and Word Stem Completion Tests.

RESULTS

Negative correlations were observed between several measures of salivary cortisol concentrations and explicit memory in Holocaust survivors with PTSD after adjusting for IQ, years of education and current age reflecting poorer performance in association with higher cortisol levels. This relationship was absent in Holocaust survivors without PTSD and in demographically-comparable subjects who were not exposed to the Holocaust or other extremely traumatic events.

CONCLUSION

The significantly different relationship between cortisol and memory performance in these groups suggests that the neuropsychological impairments observed in Holocaust survivors with PTSD may reflect an interaction of PTSD and aging effects.

The morning salivary cortisol response in burnout

OBJECTIVES

The aim of the present study was to examine the free salivary cortisol response to awakening in men and women reporting low, moderate, and high levels of burnout.

METHODS

Twenty-two patients on sick leave due to burnout were compared with 22 working participants with low and 20 working participants with intermediate scores on the Shirom-Melamed Burnout Questionnaire (SMBQ), with regard to the free salivary cortisol response to awakening. Saliva samples were collected upon awakening and at +15, +30, and +60 min thereafter.

RESULTS

Female burnout patients had higher cortisol levels than did the females with low burnout at awakening and at +15, +30, and +60 min after awakening. They also had a greater area under the curve (AUC) for salivary cortisol than did the female participants with low burnout. Male participants with moderate levels of burnout had higher cortisol levels at +60 min after awakening compared with males with low burnout.

CONCLUSIONS

The results of the present study indicate a dysregulation in hypothalamic-pituitary-adrenocortical axis (HPA axis) activity, characterised by elevated morning salivary cortisol levels, among female burnout patients. Among males, increased cortisol levels were observed among participants with moderate levels of burnout, but not among patients or healthy controls.

Hypothalamic-pituitary-adrenal axis activity and sleep in posttraumatic stress disorder

Alterations of the hypothalamic-pituitary-adrenal (HPA) axis and sleep disturbances have been described separately in post-traumatic stress disorder (PTSD). It is not known if HPA alterations and sleep disturbances are associated in PTSD. This study examined sleep and HPA activity in 20 male medication-free subjects with PTSD and 16 matched healthy controls. Two nights of polysomnography were obtained and 24-h urinary cortisol was collected during day 2. Subjects self-administered a low-dose (0.5 mg) salivary dexamethasone test at home. Compared with controls, PTSD subjects had higher 24-h urinary microg cortisol/g creatinine (mean+/-SD 40+/-17 vs 28+/-12, p=0.03) but not significantly higher 24-h urinary cortisol (mean+/-SD 52+/-15 microg/day vs 43+/-23, p=0.19). PTSD subjects showed a trend towards less cortisol suppression after dexamethasone (73%+/-18 vs 83%+/-10, p=0.06). In the combined sample, delta sleep was significantly and negatively correlated with 24-h urinary cortisol (r=-0.36, p=0.04), and with 24-h urinary cortisol/g creatinine on a trend level (r=-0.34, p=0.06). Our results suggest that increased cortisol is negatively associated with delta sleep. This may contribute to sleep abnormalities in conditions associated with elevated cortisol, possibly including PTSD. Future studies should explore the temporal relationship between HPA activity, sleep disturbances, and psychopathology after a traumatic event.

The stress system in the human brain in depression and neurodegeneration

Corticotropin-releasing hormone (CRH) plays a central role in the regulation of the hypothalamic-pituitary-adrenal (HPA)-axis, i.e., the final common pathway in the stress response. The action of CRH on ACTH release is strongly potentiated by vasopressin, that is co-produced in increasing amounts when the hypothalamic paraventricular neurons are chronically activated. Whereas vasopressin stimulates ACTH release in humans, oxytocin inhibits it. ACTH release results in the release of corticosteroids from the adrenal that, subsequently, through mineralocorticoid and glucocorticoid receptors, exert negative feedback on, among other things, the hippocampus, the pituitary and the hypothalamus. The most important glucocorticoid in humans is cortisol, present in higher levels in women than in men. During aging, the activation of the CRH neurons is modest compared to the extra activation observed in Alzheimer's disease (AD) and the even stronger increase in major depression. The HPA-axis is hyperactive in depression, due to genetic factors or due to aversive stimuli that may occur during early development or adult life. At least five interacting hypothalamic peptidergic systems are involved in the symptoms of major depression. Increased production of vasopressin in depression does not only occur in neurons that colocalize CRH, but also in neurons of the supraoptic nucleus (SON), which may lead to increased plasma levels of vasopressin, that have been related to an enhanced suicide risk. The increased activity of oxytocin neurons in the paraventricular nucleus (PVN) may be related to the eating disorders in depression. The suprachiasmatic nucleus (SCN), i.e., the biological clock of the brain, shows lower vasopressin production and a smaller circadian amplitude in depression, which may explain the sleeping problems in this disorder and may contribute to the strong CRH activation. The hypothalamo-pituitary thyroid (HPT)-axis is inhibited in depression. These hypothalamic peptidergic systems, i.e., the HPA-axis, the SCN, the SON and the HPT-axis, have many interactions with aminergic systems that are also implicated in depression. CRH neurons are strongly activated in depressed patients, and so is their HPA-axis, at all levels, but the individual variability is large. It is hypothesized that particularly a subgroup of CRH neurons that projects into the brain is activated in depression and induces the symptoms of this disorder. On the other hand, there is also a lot of evidence for a direct involvement of glucocorticoids in the etiology and symptoms of depression. Although there is a close association between cerebrospinal fluid (CSF) levels of CRH and alterations in the HPA-axis in depression, much of the CRH in CSF is likely to be derived from sources other than the PVN. Furthermore, a close interaction between the HPA-axis and the hypothalamic-pituitary-gonadal (HPG)-axis exists. Organizing effects during fetal life as well as activating effects of sex hormones on the HPA-axis have been reported. Such mechanisms may be a basis for the higher prevalence of mood disorders in women as compared to men. In addition, the stress system is affected by changing levels of sex hormones, as found, e.g., in the premenstrual period, ante- and postpartum, during the transition phase to the menopause and during the use of oral contraceptives. In depressed women, plasma levels of estrogen are usually lower and plasma levels of androgens are increased, while testosterone levels are decreased in depressed men. This is explained by the fact that both in depressed males and females the HPA-axis is increased in activity, parallel to a diminished HPG-axis, while the major source of androgens in women is the adrenal, whereas in men it is the testes. It is speculated, however, that in the etiology of depression the relative levels of sex hormones play a more important role than their absolute levels. Sex hormone replacement therapy indeed seems to improve mood in elderly people and AD patients. Studies of rats have shown that high levels of cumulative corticosteroid exposure and rather extreme chronic stress induce neuronal damage that selectively affects hippocampal structure. Studies performed under less extreme circumstances have so far provided conflicting data. The corticosteroid neurotoxicity hypothesis that evolved as a result of these initial observations is, however, not supported by clinical and experimental observations. In a few recent postmortem studies in patients treated with corticosteroids and patients who had been seriously and chronically depressed no indications for AD neuropathology, massive cell loss, or loss of plasticity could be found, while the incidence of apoptosis was extremely rare and only seen outside regions expected to be at risk for steroid overexposure. In addition, various recent experimental studies using good stereological methods failed to find massive cell loss in the hippocampus following exposure to stress or steroids, but rather showed adaptive and reversible changes in structural parameters after stress. Thus, the HPA-axis in AD is only moderately activated, possibly due to the initial (primary) hippocampal degeneration in this condition. There are no convincing arguments to presume a causal, primary role for cortisol in the pathogenesis of AD. Although cortisol and CRH may well be causally involved in the signs and symptoms of depression, there is so far no evidence for any major irreversible damage in the human hippocampus in this disorder.

Intimate partner violence and post-traumatic stress disorder symptoms in women: what we know and need to know

This article presents a review of knowledge regarding post-traumatic stress disorder (PTSD) in women experiencing intimate partner violence. Knowledge related to the prevalence and predictors of PTSD in battered women, the association between PTSD and physical health, and the emerging science regarding PTSD and physiological and immune parameters is addressed. Primary recommendations for future research includes the need for longitudinal and intervention research that incorporates a range of psychosocial and physiologic health outcomes.

Prediction of numbing and effortful avoidance in female rape survivors with chronic PTSD

The purpose of the present study was to investigate the relationships among numbing, arousal, intrusion, and avoidance in a sample of 272 female rape survivors. Multiple regression analyses were conducted to test a theoretical model, which posits that hyperarousal and numbing are functionally related mechanisms and intrusions and avoidance are functionally related. Results supported the hypothesis that arousal explained the majority of the variance in numbing beyond that explained by avoidance and intrusion. In addition, intrusive symptoms explained the majority of the variance in effortful avoidance beyond that explained by numbing and arousal. The findings suggest that numbing and effortful avoidance may be separate mechanisms associated with symptoms of arousal and intrusion, respectively.

Noradrenergic mechanisms in the pathophysiology of post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a serious psychiatric illness that may develop in individuals after exposure to a traumatic event. Recent data suggest that trauma and/or long-term stressors can cause alterations in the functioning of neuroanatomical structures and neural networks throughout the central nervous system. Specifically, dysregulation in central and perhaps, peripheral noradrenergic neural networks has been implicated as the cause of specific symptom clusters in the pathophysiology of PTSD. In this review, both clinical and preclinical data are presented to highlight types of noradrenergic dysfunction observed in individuals with PTSD. Additionally, the role of noradrenaline dysregulation in the acquisition/initiation, and maintenance of hyperarousal and reexperiencing symptom clusters in PTSD will be addressed.

Child maltreatment and HPA axis dysregulation: relationship to major depressive disorder and post traumatic stress disorder in females

A history of child maltreatment increases the vulnerability to the development of Major Depressive Disorder (MDD) and/or Posttraumatic Stress Disorder (PTSD), especially in females. Both MDD and PTSD are associated with a dysregulation of the Hypothalamic-Pituitary-Adrenal (HPA) axis. Dysregulation of the HPA axis may be an important etiological link between child maltreatment and subsequent psychiatric disorder, yet little is known about the relationship between exposure and outcome. The aim of this review is to explore the role of HPA axis dysregulation in the link between child maltreatment and MDD/PTSD among women. Studies of females with MDD frequently indicate a hyperactivity of the HPA axis, and contribute to our understanding of the underlying mechanisms involved in mood dysregulation. Evidence for HPA axis dysregulation in PTSD is less convincing and suggests that timing of the stressful experience as well as the type of the trauma may influence the outcome. The strongest evidence to date suggesting that the development of the HPA axis may be affected by early life stressful experiences comes from pre-clinical animal studies. Together these studies add to our understanding of the role of the HPA axis in psychiatric disorders in relation to stress. The literature on HPA axis function in both children and adults following child maltreatment further highlights the potential relevance of early stress to later onset of major psychiatric disorders. Such knowledge may also contribute to the development of early interventions targeted at primary prevention.

Initial urinary epinephrine and cortisol levels predict acute PTSD symptoms in child trauma victims

BACKGROUND

Previous research examining biological correlates of posttraumatic stress disorder (PTSD) in children has suggested that children with chronic PTSD have altered levels of catecholamines and cortisol compared to similarly traumatized children who do not meet diagnostic criteria. The present study extended these findings by examining whether urinary hormone levels collected soon after a trauma were related to subsequent acute PTSD symptoms in child trauma victims.

METHODS

Initial 12-h urine samples were collected from 82 children aged 8-18 admitted to a Level 1 trauma center. Collection was begun immediately upon admission, and samples were assayed for levels of catecholamines and cortisol. PTSD and depressive symptomatology were assessed 6 weeks following the accident.

RESULTS

Initial urinary cortisol levels were significantly correlated with subsequent acute PTSD symptoms (r=0.31). After removing the variance associated with demographic variables and depressive symptoms, urinary cortisol and epinephrine levels continued to predict a significant percentage (7-10%) of the variance in 6-week PTSD symptoms. Examination of boys and girls separately suggested that significance was primarily driven by the strength of the relationships between hormone levels and acute PTSD symptoms in boys.

CONCLUSIONS

The present findings suggest that high initial urinary cortisol and epinephrine levels immediately following a traumatic event may be associated with increased risk for the development of subsequent acute PTSD symptoms, especially in boys.

Holocaust child survivors and child sexual abuse

This study utilized a qualitative analysis of child survivors of the Holocaust who were sexually abused during World War II. The research study aimed to give this specific group of survivors a voice and to explore the impact of multiple extreme traumas, the Holocaust and childhood sexual abuse, on the survivors. Twenty-two child survivors of the Holocaust who were sexually abused during the war completed open-ended interviews. The data was qualitatively analyzed according to Tutty, Rothery, and Grinnell's (1996) guidelines. Three major themes were found: issues relating to the sexual abuse trauma, survivors' perceptions of the abuse, and survivors' general perspectives towards life. The identity of the offenders, Jewish or non-Jewish, determined the survivors' feelings towards themselves, the perpetrators, and about the worth of life.

Neuroendocrine aspects of PTSD

This chapter discussed how neuroendocrine findings in posttraumatic stress disorder (PTSD) potentially inform hypothalamic-pituitary-adrenal (HPA) alterations in PTSD and highlight alterations relevant to the identification of targets for drug development. Most studies demonstrate alterations consistent with an enhanced negative feedback inhibition of cortisol on the pituitary, an overall hyperreactivity of other target tissues (adrenal gland, hypothalamus), or both in PTSD. However, findings of low cortisol and increased reactivity of the pituitary in PTSD are also consistent with reduced adrenal output. The observations in PTSD are part of a growing body of neuroendocrine data providing evidence of insufficient glucocorticoid signaling in stress-related neuropsychiatric disorders.

Posttraumatic Stress Disorder and Physical Illness: Results from Clinical and Epidemiologic Studies

Research indicates that exposure to traumatic stressors and psychological trauma is widespread. The association of such exposures with posttraumatic stress disorder (PTSD) and other mental health conditions is well known. However, epidemiologic research increasingly suggests that exposure to these events is related to increased health care utilization, adverse health outcomes, the onset of specific diseases, and premature death. To date, studies have linked traumatic stress exposures and PTSD to such conditions as cardiovascular disease, diabetes, gastrointestinal disease, fibromyalgia, chronic fatigue syndrome, musculoskeletal disorders, and other diseases. Evidence linking cardiovascular disease and exposure to psychological trauma is particularly strong and has been found consistently across different populations and stressor events. In addition, clinical studies have suggested the biological pathways through which stressor-induced diseases may be pathologically expressed. In particular, recent studies have implicated the hypothalamic-pituitary-adrenal (HPA) and the sympathetic-adrenal-medullary (SAM) stress axes as key in this pathogenic process, although genetic and behavioral/psychological risk factors cannot be ruled out. Recent findings, indicating that victims of PTSD have higher circulating T-cell lymphocytes and lower cortisol levels, are intriguing and suggest that chronic sufferers of PTSD may be at risk for autoimmune diseases. To test this hypothesis, we assessed the association between chronic PTSD in a national sample of 2,490 Vietnam veterans and the prevalence of common autoimmune diseases, including rheumatoid arthritis, psoriasis, insulin-dependent diabetes, and thyroid disease. Our analyses suggest that chronic PTSD, particularly comorbid PTSD or complex PTSD, is associated with all of these conditions. In addition, veterans with comorbid PTSD were more likely to have clinically higher T-cell counts, hyperreactive immune responses on standardized delayed cutaneous hypersensitivity tests, clinically higher immunoglobulin-M levels, and clinically lower dehydroepiandrosterone levels. The latter clinical evidence confirms the presence of biological markers consistent with a broad range of inflammatory disorders, including both cardiovascular and autoimmune diseases.

Effects of dexamethasone on declarative memory function in posttraumatic stress disorder

Alterations in the hypothalamic-pituitary-adrenal (HPA) axis and hippocampal-based memory have been associated with posttraumatic stress disorder (PTSD), and the administration of exogenous glucocorticoids has been shown to result in a transient verbal declarative memory impairment in healthy human subjects. The purpose of this study was to assess the effects of the glucocorticoid dexamethasone on verbal declarative memory function in patients with PTSD. Forty-two men and women with (n=14) and without (n=28) PTSD received placebo or dexamethasone (1 and 2 mg on two successive days) in a double-blind, randomized fashion. Declarative memory was assessed with paragraph recall at baseline (day 1) and day 3. There was a significant interaction between diagnosis and drug (dexamethasone vs. placebo) on paragraph recall related to a relative detrimental effect of dexamethasone on memory function in healthy subjects, but not those with PTSD. These findings are consistent with an altered sensitivity of declarative memory function in PTSD to regulation by glucocorticoids, possibly explainable by alterations in glucocorticoid receptors in the hippocampus or other brain regions mediating declarative memory.

Effects of propranolol on symptom and endocrine responses to pentagastrin

Intravenous injections of CCK-B agonists, such as pentagastrin, produce symptoms of panic and potent activation of the human hypothalamic-pituitary-adrenal (HPA) axis. It is unclear whether these psychological and endocrine effects are mediated by similar or independent processes. Independence is supported by prior evidence that beta-adrenergic receptor blockade attenuates cardiovascular and symptom but not vasopressin responses to CCK-4. To further explore associations between somatic, emotional and endocrine responses to CCK-B agents, and potential beta-adrenergic mediating mechanisms, symptom and endocrine responses to pentagastrin were examined after propranolol pre-treatment. Cardiovascular, symptom, and endocrine (ACTH, cortisol, epinephrine) responses to pentagastrin were measured in 16 healthy adult subjects randomly assigned to receive propranolol or placebo pre-treatment. Propranolol significantly blocked the normal cardiac acceleration produced by pentagastrin, but did not reduce panic symptom or anxiety effects. It delayed and perhaps enhanced the cortisol response. No relationship between HPA and symptom responses following pentagastrin could be detected, though pre-pentagastrin cortisol was inversely related to post-injection panic symptom intensity. Endocrine, cardiovascular and symptom responses to pentagastrin appear to be separately mediated, as they did not change in concert in response to propranolol pre-treatment, nor were they correlated with one another. The results are consistent with the presence of inhibitory beta-adrenergic mediation of the HPA axis in humans. They support the hypothesis that the HPA response to pentagastrin is not secondary to the psychological stress of its side effects.

Clinical perspectives on neurobiological effects of psychological trauma

Physical trauma to the brain has always been known to affect brain functions and subsequent neurobiological development. Research primarily since the early 1990s has shown that psychological trauma can have detrimental effects on brain function that are not only lasting but that may alter patterns of subsequent neurodevelopment, particularly in children although developmental effects may be seen in adults as well. Childhood trauma produces a diverse range of symptoms and defining the brain's response to trauma and the factors that mediate the body's stress response systems is at the forefront of scientific investigation. This paper reviews the current evidence relating psychological trauma to anatomical and functional changes in the brain and discusses the need for accurate diagnosis and treatment to minimize such effects and to recognize their existence in developing treatment programs.

An increased capacity for adrenal DHEA release is associated with decreased avoidance and negative mood symptoms in women with PTSD

We recently found increased adrenal cortisol responses to adrenocorticotropic hormone (ACTH)1-24 and increased pituitary ACTH and adrenal cortisol responses to corticotropin-releasing factor in premenopausal women with chronic post-traumatic stress disorder (PTSD) compared to healthy nontraumatized subjects. This pattern of hypothalamic-pituitary-adrenal axis (HPA) hyper-reactivity has been previously seen in healthy individuals treated with the antiglucocorticoid mifepristone. We therefore investigated whether endogenous plasma levels of antiglucocorticoids such as dehydroepiandrosteroine (DHEA) and progesterone were increased in premenopausal women with PTSD at baseline or in response to adrenal activation by ACTH1-24. The study revealed that DHEA responses to 250 microg ACTH1-24 were increased in 13 PTSD subjects compared to 13 healthy nontraumatized subjects, while DHEA levels were generally increased in the PTSD subjects compared to seven healthy traumatized subjects. Cortisol responses to ACTH1-24 were also higher in the women with PTSD, while progesterone levels and responses were not different among the three groups. In addition, among the PTSD subjects, the peak change in DHEA in response to ACTH1-24 was negatively correlated with the total Clinician Administered PTSD Scale score, while the peak DHEA to cortisol ratio was inversely associated with negative mood symptoms measured by the Profile of Mood States scale. This work suggests that an increased capacity for DHEA release in response to extreme adrenal activation may influence the pattern of HPA axis adaptation to extreme stress, as well as mitigate the severity of PTSD and negative mood symptoms in premenopausal women with PTSD.

Saliva cortisol in posttraumatic stress disorder: a community epidemiologic study

BACKGROUND

Stress activates the hypothalamic-pituitary-adrenal (HPA) axis, so it was expected that posttraumatic stress disorder (PTSD) would be associated with activation of this axis; however, studies have found both increased and decreased cortisol in PTSD. To address this question, we collected saliva cortisol at home in a subsample of a longitudinal epidemiologic sample.

METHODS

Six hundred eighty-four persons randomly selected from the total sample of 913 were requested to collect saliva samples upon awakening and in the early evening. Of these, 538 responded with samples, 516 of whom met inclusion criteria. These were 68 exposed to trauma with lifetime PTSD, 265 exposed to trauma with no PTSD, and 183 never exposed to trauma.

RESULTS

In a comparison of these three groups, lifetime PTSD revealed elevated evening saliva cortisol compared with exposed/no PTSD. When lifetime comorbidity with major depressive disorder (MDD) was included in the analysis, only persons with comorbid PTSD and MDD showed this evening elevation in cortisol. Persons with PTSD alone (never MDD) showed normal saliva cortisol levels, as did subjects with lifetime MDD alone.

CONCLUSIONS

Neither exposure to trauma nor PTSD alone is associated with alterations in saliva cortisol; however, elevated cortisol is found in PTSD comorbid with lifetime MDD.

Enhanced sensitivity to glucocorticoids in peripheral mononuclear leukocytes in posttraumatic stress disorder

BACKGROUND

The aim of this study was to determine whether there is increased responsiveness to corticosteroids in posttraumatic stress disorder (PTSD) by examining the differential effects of dexamethasone (DEX) on the inhibition of lysozyme activity.

METHODS

60 mL of blood was withdrawn at 8:00 am, and mononuclear leukocytes were isolated from the blood of 26 men with, and 18 men without, PTSD. An aliquot of live cells was incubated with a series of concentrations of DEX to determine the rate of inhibition of lysozyme activity; a portion of cells was frozen for the determination of glucocorticoid receptors (GR).

RESULTS

Subjects with PTSD showed evidence of a greater sensitivity to glucocorticoids as reflected by a significantly lower mean concentration (nmol/L) of dexamethasone at which 50% of lysozyme activity is inhibited (IC(50-DEX)) (PTSD+ = 4.9 +/-.53; PTSD- group = 7.2 +/-.64). The lysozyme IC(50-DEX) was significantly correlated with age at exposure to the first traumatic event in subjects with PTSD (r =.44, n = 26, p =.025). The number of cytosolic glucocorticoid receptors was also correlated with age at exposure to the focal traumatic event (r = -.44, n = 25, p =.03) in PTSD.

CONCLUSIONS

This is the first in vitro demonstration of an alteration in target tissue sensitivity to glucocorticoids in PTSD. The lower lysozyme IC(50-DEX) might be related to the risk factor of prior exposure to trauma.

Basal and dexamethasone suppressed salivary cortisol concentrations in a community sample of patients with posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) has been associated with lower concentrations of cortisol and enhanced suppression of cortisol by dexamethasone, although discrepancies exist among reports. The objective of the study was to determine the pattern of cortisol responses in patients seeking treatment for PTSD resulting from a variety of traumatic experiences and to test whether cortisol responses are significantly related to childhood trauma, severity of symptoms, or length of time since trauma.

METHODS

Salivary cortisol was measured at 8 AM, 4 PM, and 10 PM on 2 consecutive days before and after a 10 PM dose of .5 mg dexamethasone in 17 psychotropic medication and substance-free subjects with PTSD and 17 matched control subjects.

RESULTS

Repeated-measures analysis of variance (ANOVA) of the baseline salivary cortisol concentrations demonstrated a significant effect for group with higher concentrations in the PTSD group but no significant differences in responses to dexamethasone. The presence of childhood abuse did not significantly affect salivary cortisol concentrations, and there was no correlation between predexamethasone cortisol and either the severity of PTSD symptoms or the time since the index trauma.

CONCLUSIONS

Neither low basal concentrations nor enhanced suppression of cortisol are consistent markers of a PTSD diagnosis.

Effects of trauma exposure on the cortisol response to dexamethasone administration in PTSD and major depressive disorder

OBJECTIVE

To evaluate cortisol suppression following 0.5 mg of dexamethasone (DEX) in trauma survivors (N=52) with posttraumatic stress disorder (PTSD), major depressive disorder (MDD), both, or neither disorder, and in subjects never exposed to trauma (N=10), in order to examine interactions between diagnosis and trauma history on cortisol negative feedback inhibition.

METHOD

Lifetime trauma exposure and psychiatric diagnoses were assessed and blood samples were obtained at 8:00 a.m. for the determination of baseline cortisol. Participants ingested 0.5 mg of DEX at 11:00 p.m. and blood samples for determination of cortisol and DEX were obtained at 8:00 a.m. the following day.

RESULTS

PTSD was associated with enhanced cortisol suppression in response to DEX. Among trauma survivors, the presence of a traumatic event prior to the "focal" trauma had a substantial impact on cortisol suppression in subjects with MDD. Such subjects were more likely to show cortisol alterations similar to those associated with PTSD, whereas subjects with MDD with no prior trauma were more likely to show alterations in the opposite direction, i.e. relative non-suppression.

CONCLUSIONS

Cortisol hypersuppression in PTSD appears not to be dependent on the presence of traumatic events prior to the focal trauma. However, prior trauma exposure may affect cortisol suppression in MDD. This finding may have implications for understanding why only some depressed patients show non-suppression on the DST.