Chromosomes to Social Contexts: Sex and Gender Differences in PTSD

Testing Quantitative and Qualitative Sex Effects in a National Swedish Twin-Sibling Study of Posttraumatic Stress Disorder

OBJECTIVE

Twin studies have demonstrated that posttraumatic stress disorder (PTSD) is moderately heritable, and the pattern of findings across studies suggests higher heritability in females compared with males. Formal testing of sex differences has yet to be done in twin studies of PTSD. The authors sought to estimate the genetic and environmental contributions to PTSD, and to formally test for sex differences, in the largest sample to date of both sexes, among twins and siblings.

METHODS

Using the Swedish National Registries, the authors performed structural equation modeling to decompose genetic and environmental variance for PTSD and to formally test for quantitative and qualitative sex differences in twins (16,242 pairs) and in full siblings within 2 years of age of each other (376,093 pairs), using diagnostic codes from medical registries.

RESULTS

The best-fit model suggested that additive genetic and unique environmental effects contributed to PTSD. Evidence for a quantitative sex effect was found, such that heritability was significantly greater in females (35.4%) than males (28.6%). Evidence of a qualitative sex effect was found, such that the genetic correlation was high but less than complete (rg=0.81, 95% CI=0.73-0.89). No evidence of shared environment or special twin environment was found.

CONCLUSIONS

This is the first demonstration of quantitative and qualitative sex effects for PTSD. The results suggest that unique environmental effects, but not the shared environment, contributed to PTSD and that genetic influences for the disorder are stronger in females compared with males. Although the heritability is highly correlated, it is not at unity between the sexes.

Post-traumatic stress in older, community-dwelling adults with hypertension during the COVID-19 pandemic: An investigation of pre-pandemic sociodemographic, health, and vascular and inflammatory biomarker predictors

COVID-19 pandemic-related traumatic stress (PRTS) symptoms are reported in various populations, but risk factors in older adults with chronic medical conditions, remain understudied. We therefore examined correlates and pre-pandemic predictors of PRTS in older adults with hypertension during COVID-19. Participants in California, aged 61-92 years (n = 95), participated in a pre-pandemic healthy aging trial and later completed a COVID-19 assessment (May to September 2020). Those experiencing ⩾1 PRTS symptom (n = 40), and those without PRTS symptoms (n = 55), were compared. The PRTS+ group had poorer mental and general health and greater impairment in instrumental activities of daily living. Pre-pandemic biomarkers of vascular inflammation did not predict increased odds of PRTS; however, greater pre-pandemic anxiety and female gender did predict PRTS during COVID-19. Our findings highlight PRTS as a threat to healthy aging in older adults with hypertension; targeted approaches are needed to mitigate this burden, particularly for females and those with pre-existing anxiety.

Shame and Emotion Dysregulation as Pathways to Posttraumatic Stress Symptoms Among Women With a History of Interpersonal Trauma

Women who have survived interpersonal trauma are at elevated risk of developing posttraumatic stress disorder (PTSD), and potentially modifiable factors that may be targeted in treatment warrant further investigation. This study examined a pathway from interpersonal trauma to PTSD symptoms via emotion dysregulation and shame in a large non-clinical sample of women. The sample comprised 380 women, aged 18 to 59 years (M = 31.70, standard deviation = 10.06), all of whom had a history of interpersonal trauma. Participants completed the Experience of Shame Scale, the Difficulties in Emotion Regulation Scale-Short Form, and the Life Events Checklist for DSM-5. A serial and parallel process model with interpersonal trauma as a predictor of PTSD symptoms, emotional dysregulation and facets of shame as intermediary variables, was analyzed using Statistical Package for Social Sciences Statistics PROCESS Model 81with bias-corrected bootstrap tests of indirect effects. Non-interpersonal trauma was included as a covariate. Interpersonal trauma, emotion dysregulation, and characterological and bodily shame were significantly and directly associated with PTSD symptoms, together explaining 59% of the variation in PTSD symptoms. While emotion dysregulation was associated with behavioral shame, interpersonal trauma was not associated with behavioral shame, nor was behavioral shame associated with PTSD symptoms. Tests of indirect effects supported a pathway from interpersonal trauma to PTSD symptoms via emotion dysregulation and characterological and bodily shame. These findings suggest interventions that are particularly effective at reducing emotion dysregulation and characterological and bodily shame, such as compassion and acceptance-based approaches, may complement evidence-based PTSD interventions when working with women who have survived interpersonal trauma.

Gender, sex and complex PTSD clinical presentation: a systematic review

Background: Post-traumatic stress disorder (PTSD) prevalence and clinical presentation reportedly vary with gender and/or sex. Equivalent complex PTSD (CPTSD) research is in its relative infancy and to date no systematic review has been conducted on this topic.Objective: To systematically review the literature and provide a narrative addressing the question of whether gender and/or sex differences exist in CPTSD prevalence and clinical presentation.Method: Embase, PsycINFO, PTSDpubs, PubMed, Web of Science, EThOS and Google Scholar were searched. Twelve papers were eligible for inclusion. Data were extracted and synthesised narratively.Results: Four themes were identified: (i) the reporting of gender and/or sex; (ii) index trauma; (iii) CPTSD prevalence rates; and (iv) CPTSD clinical presentation. Findings were mixed. Nine papers reported prevalence rates: eight found no gender and/or sex differences; one found higher diagnostic rates among women and/or females. Four papers reported clinical presentation: one reported higher cluster-level scores among women and/or females; two used single gender and/or sex samples; and one found higher scores in two clusters in men and/or males. Most papers failed to report in gender- and/or sex-sensitive ways.Conclusions: Gender- and sex-sensitive research and clinical practice is needed. Awareness in research and clinical practice is recommended regarding the intersect between identity and the experience and expression of complex trauma.

The gut microbiome modulates the susceptibility to traumatic stress in a sex-dependent manner

Post-traumatic stress disorder (PTSD), a psychological condition triggered by exposure to extreme or chronic stressful events, exhibits a sex bias in incidence and clinical manifestations. Emerging research implicates the gut microbiome in the pathogenesis of PTSD and its roles in stress susceptibility. However, it is unclear whether differential gut microbiota contribute to PTSD susceptibility in male and female rats. Here, we utilized the single prolonged stress animal model and employed unsupervised machine learning to classify stressed animals into stress-susceptible subgroups and stress-resilient subgroups. Subsequently, using 16S V3-V4 rDNA sequencing, we investigated the differential gut microbiota alterations between susceptible and resilient individuals in male and female rats. Our findings revealed distinct changes in gut microbiota composition between the sexes at different taxonomic levels. Furthermore, the abundance of Parabacteroides was lower in rats that underwent SPS modeling compared to the control group. In addition, the abundance of Tenericutes in the stress-susceptible subgroup was higher than that in the control group and stress-resilient subgroup, suggesting that Tenericutes may be able to characterize stress susceptibility. What is particularly interesting here is that Cyanobacteria may be particularly associated with anti-anxiety effects in male rats. This study underscores sex-specific variations in gut microbiota composition in response to stress and sex differences should be taken into account when using macrobiotics for neuropsychiatric treatment, highlighting potential targets for PTSD therapeutic interventions.

Epidemical trends and risk factors of PTSD in parents of critically ill children: Evidence from both meta-analysis and subgroup analysis

BACKGROUND

Post-Traumatic Stress Disorder (PTSD) in parents traumatized by a child's critical illness, while differences in prevalence and risk factors for parental PTSD in previous studies. This study aimed to assess trends in the prevalence and risk factors for PTSD in parents of critically ill children.

METHODS

Nine main databases were searched to extract the prevalence, sample size and risk factors from the published literature. Random effects model analysis, I2 statistic, quality assessment, subgroup analysis and sensitivity analysis were performed.

RESULTS

Twenty-five studies met the inclusion criteria, with pooled prevalence rates of 13.8 % (95 % CI: [confidence interval, CI] 10.0 %-17.7 %) in fathers and 20.2 % (95 % CI:16.1 %-24.3 %) in mothers. Mothers had a significantly higher prevalence of PTSD compared to fathers. The prevalence of PTSD generally increased after discharge, with the highest prevalence at 6 months, but then decreased (fathers: 18.0 %, CI: 6.1 %-29.9 %; mothers: 20.2 %, CI: 12.8 %-27.6 %), respectively. The results showed five risks, positive acute stress disorder (ASD) screening (OR [odds ratio, OR] =2.45), disease severity (OR = 3.78), perceived stress (OR = 1.44), unemployed status (OR = 2.52) and length of hospital stay (OR = 1.01).

LIMITATIONS

Due to the limitations of the original study, we could not explore trends in the prevalence of PTSD in this particular population over a more extended period after hospital discharge.

CONCLUSION

The prevalence of PTSD among parents of critically ill children is high and significantly different. Therefore, it is crucial to focus on this vulnerable group, providing them with essential psychological counseling and comprehensive social support to reduce the occurrence of PTSD.

Sex-dependent effects of angiotensin type 2 receptor expressing medial prefrontal cortex (mPFC) interneurons in fear extinction learning

Background

The renin-angiotensin system (RAS) has been identified as a potential therapeutic target for PTSD, though its mechanisms are not well understood. Brain angiotensin type 2 receptors (AT2Rs) are a subtype of angiotensin II receptors located in stress and anxiety-related regions, including the medial prefrontal cortex (mPFC), but their function and mechanism in the mPFC remain unexplored. We therefore used a combination of imaging, cre/lox, and behavioral methods to investigate mPFC-AT2R-expressing neuron involvement in fear learning.

Methods

To characterize mPFC-AT2R-expressing neurons in the mPFC, AT2R-Cre/td-Tomato male and female mice were used for immunohistochemistry (IHC). mPFC brain sections were stained with glutamatergic or interneuron markers, and density of AT2R+ cells and colocalization with each marker was quantified. To assess fear-related behaviors in AT2R-flox mice, we selectively deleted AT2R from mPFC neurons using an AAV-Cre virus. Mice then underwent Pavlovian auditory fear conditioning, approach/avoidance, and locomotion testing.

Results

IHC results revealed that AT2R is densely expressed in the mPFC. Furthermore, AT2R is primarily expressed in somatostatin interneurons in females but not males. Following fear conditioning, mPFC-AT2R deletion impaired extinction in female but not male mice. Locomotion was unaltered by mPFC-AT2R deletion in males or females, while AT2R-deleted females had increased exploratory behavior.

Conclusion

These results lend support for mPFC-AT2R+ neurons as a novel subgroup of somatostatin interneurons that influence fear extinction in a sex-dependent manner. This furthers underscores the role of mPFC in top-down regulation and a unique role for peptidergic (ie., angiotensin) mPFC regulation of fear and sex differences.

Trauma Matters: Integrating Genetic and Environmental Components of PTSD

Trauma is ubiquitous, but only a subset of those who experience trauma will develop posttraumatic stress disorder (PTSD). In this review, it is argued that to determine who is at risk of developing PTSD, it is critical to examine the genetic etiology of the disorder and individual trauma profiles of those who are susceptible. First, the state of current PTSD genetic research is described, with a particular focus on studies that present evidence for trauma type specificity, or for differential genetic etiology according to gender or race. Next, approaches that leverage non-traditional phenotyping approaches are reviewed to identify PTSD-associated variants and biology, and the relative advantages and limitations inherent in these studies are reflected on. Finally, it is discussed how trauma might influence the heritability of PTSD, through type, risk factors, genetics, and associations with PTSD symptomology.

Perceived household financial decline and physical/mental health among adolescents during the COVID-19 crisis: Focusing on gender differences

COVID-19 has worsened adolescents' mental and physical health. Several studies have reported that the effect may be greater in girls; however, relevant socio-ecological factors have not been examined. This study aimed to examine the factors associated with physical and mental health status among adolescents and the moderating role of gender on the relationship between physical and mental health status and perceived household financial decline. We analyzed the cross-sectional 2020 Korea Youth Risk Behavior Web-based Survey (KYRBS) collected between August and November 2020 in South Korea. It included 54,809 adolescents (28,269 males and 26,540 females), on average aged 15.1. We conducted ordinary least squares (OLS) regressions to examine the factors associated with physical and mental health outcomes. Gender differences were observed in associated factors. Then, we tested the moderating effect of gender by including an interaction term between gender and perceived household financial decline due to the COVID-19 pandemic. Perceived household financial decline due to COVID-19 negatively affected both groups. Perceiving moderate and severe financial decline due to COVID-19 is negatively associated with self-rated health among female adolescents than male counterparts. Female adolescents were also more vulnerable to mental health outcomes (i.e., distress, anxiety, and loneliness) when they perceived severe or moderate household financial decline due to COVID-19 compared to their male peers. Our findings suggest that female adolescents are more vulnerable to household financial shocks due to COVID-19, especially in households that have experienced a severe decline. We suggest the need for gender-sensitive policy interventions for adolescent mental health.

Traumatic stress symptoms in family caregivers of patients with acute leukaemia: protocol for a multisite mixed methods, longitudinal, observational study

INTRODUCTION

The diagnosis, progression or recurrence of cancer is often highly traumatic for family caregivers (FCs), but systematic assessments of distress and approaches for its prevention and treatment are lacking. Acute leukaemia (AL) is a life-threatening cancer of the blood, which most often presents acutely, requires intensive treatment and is associated with severe physical symptoms. Consequently, traumatic stress may be common in the FCs of patients with AL. We aim to determine the prevalence, severity, longitudinal course and predictors of traumatic stress symptoms in FCs of patients with AL in the first year after diagnosis, and to understand their lived experience of traumatic stress and perceived support needs.

METHODS AND ANALYSIS

This two-site longitudinal, observational, mixed methods study will recruit 223 adult FCs of paediatric or adult patients newly diagnosed with AL from two tertiary care centres. Quantitative data will be collected from self-report questionnaires at enrolment, and 1, 3, 6, 9 and 12 months after admission to hospital for initial treatment. Quantitative data will be analysed using descriptive and machine learning approaches and a multilevel modelling (MLM) approach will be used to confirm machine learning findings. Semi-structured qualitative interviews will be conducted at 3, 6 and 12 months and analysed using a grounded theory approach.

ETHICS AND DISSEMINATION

This study is funded by the Canadian Institutes of Health Research (CIHR number PJT 173255) and has received ethical approval from the Ontario Cancer Research Ethics Board (CTO Project ID: 2104). The data generated have the potential to inform the development of targeted psychosocial interventions for traumatic stress, which is a public health priority for high-risk populations such as FCs of patients with haematological malignancies. An integrated and end-of-study knowledge translation strategy that involves FCs and other stakeholders will be used to interpret and disseminate study results.

Mental Health Beliefs, Access, and Engagement with Military Sexual Trauma-Related Mental Health Care

BACKGROUND

Military sexual trauma (MST) is associated with negative mental health outcomes. Mental health beliefs, such as stigma or secondary victimization, have been identified as possible barriers to care; however, it is unclear whether such beliefs impact receiving care.

OBJECTIVE

To assess if mental health beliefs impact MST-related mental health care access and engagement.

DESIGN

Veterans completed a survey following detection of MST. Survey data were linked to Veteran's Health Administration administrative data in order to examine associations with outpatient MST-related care in the year following MST detection.

PARTICIPANTS

A national sample of women and men Veterans (N = 1,185) with newly detected MST who reported a perceived need for MST-related mental health treatment.

MAIN MEASURES

Building on prior work that identified four latent classes of mental health beliefs (Hahn et al., J Trauma Stress 34:394-404, 2020; low barrier, stigma-related beliefs, negative perceptions of care, high barrier), we examined associations with outpatient mental health care indicated by a provider as related to MST. Care was examined in total, as well as the specific categories of medication management, individual psychotherapy, and group psychotherapy.

KEY RESULTS

Access to care following MST detection was high: most (71.6%) Veterans had an MST-related mental health visit within 30 days, and nearly all (83.6%) within 180 days, with the median number of days to receiving care being 2. Negative perceptions of care predicted a lower likelihood of treatment engagement (3+ encounters) with MST-related individual psychotherapy (OR = 0.65, 95% CI (0.43-0.96)), whereas the stigma-related beliefs and high barrier classes did not.

CONCLUSIONS

There appears to be excellent access to mental health care among Veterans with a perceived need for MST-related mental health treatment. However, treatment beliefs that represented negative perceptions of care may serve as barriers to engagement. Interventions targeting negative perceptions of care during early encounters could help promote subsequent engagement.

Pharmacological strategies for post-traumatic stress disorder (PTSD): From animal to clinical studies

Post-traumatic stress disorder (PTSD) is a disabling psychiatric condition with a critical familiar, personal, and social impact. Patients diagnosed with PTSD show various symptoms, including anxiety, depression, psychotic episodes, and sleep disturbances, complicating their therapeutic management. Only sertraline and paroxetine, two selective serotonin reuptake inhibitors, are approved by different international agencies to treat PTSD. In addition, these drugs are generally combined with psychotherapy to achieve positive results. However, these pharmacological strategies present limited efficacy. Nearly half of the PTSD patients do not experience remission of symptoms, possibly due to the high prevalence of psychiatric comorbidities. Therefore, in clinical practice, other off-label medications are common, even though the effectiveness of these drugs needs to be further investigated. In this line, antipsychotics, antiepileptics, adrenergic blockers, benzodiazepines, and other emerging pharmacological agents have aroused interest as potential therapeutic tools to improve some specific symptoms of PTSD. Thus, this review is focused on the most widely used drugs for the pharmacological treatment of PTSD with a translational approach, including clinical and preclinical studies, to emphasize the need to develop safer and more effective medications.

Evidence-based posttraumatic stress disorder treatment in a community sample: Military-affiliated versus civilian patient outcomes

Posttraumatic stress disorder (PTSD) is a significant mental health issue among military service members and veterans. Although the U.S. Department of Veterans Affairs (VA) provides crucial resources for behavioral health care, many veterans seek mental health services through community clinics. Previous research illustrates that military and veteran patients benefit less from evidence-based treatments (EBTs) for PTSD than civilians. However, most PTSD treatment outcome research on military and veteran populations is conducted in VA or military settings. Little is known about outcomes among military-affiliated patients in community settings. The primary aim of this study was to directly compare civilian versus military-affiliated patient outcomes on PTSD and depression symptoms using the PTSD Checklist for DSM-5 (PCL-5) and the nine-item Patient Health Questionnaire (PHQ-9) in a community setting. Participants (N = 502) included military-affiliated (veteran, Guard/Reservist, active duty) and civilian patients who engaged in cognitive processing therapy (CPT) or prolonged exposure (PE) for PTSD in community clinics. Both groups demonstrated significant reductions on the PCL-5, military-affiliated: d = -0.91, civilian: d = -1.18; and PHQ-9, military-affiliated: d = -0.65, civilian: d = -0.88, following treatment. However, military-affiliated patients demonstrated smaller posttreatment reductions on the PCL-5, M_diff = 5.75, p = .003, and PHQ-9, M_diff = 1.71, p = .011, compared to civilians. Results demonstrate that military-affiliated patients benefit from EBTs for PTSD, albeit to a lesser degree than civilians, even in community settings. These findings also highlight the importance of future research on improving EBTs for military personnel with PTSD.

Deficient DNA base-excision repair in the forebrain leads to a sex-specific anxiety-like phenotype in mice

Background

Neuropsychiatric disorders, such as schizophrenia (SZ) and autism spectrum disorder (ASD), are common, multi-factorial and multi-symptomatic disorders. Ample evidence implicates oxidative stress, deficient repair of oxidative DNA lesions and DNA damage in the development of these disorders. However, it remains unclear whether insufficient DNA repair and resulting DNA damage are causally connected to their aetiopathology, or if increased levels of DNA damage observed in patient tissues merely accumulate as a consequence of cellular dysfunction. To assess a potential causal role for deficient DNA repair in the development of these disorders, we behaviourally characterized a mouse model in which CaMKIIa-Cre-driven postnatal conditional knockout (KO) of the core base-excision repair (BER) protein XRCC1 leads to accumulation of unrepaired DNA damage in the forebrain.

Results

CaMKIIa-Cre expression caused specific deletion of XRCC1 in the dorsal dentate gyrus (DG), CA1 and CA2 and the amygdala and led to increased DNA damage therein. While motor coordination, cognition and social behaviour remained unchanged, XRCC1 KO in the forebrain caused increased anxiety-like behaviour in males, but not females, as assessed by the light–dark box and open field tests. Conversely, in females but not males, XRCC1 KO caused an increase in learned fear-related behaviour in a cued (Pavlovian) fear conditioning test and a contextual fear extinction test. The relative density of the GABA(A) receptor alpha 5 subunit (GABRA5) was reduced in the amygdala and the dorsal CA1 in XRCC1 KO females, whereas male XRCC1 KO animals exhibited a significant reduction of GABRA5 density in the CA3. Finally, assessment of fast-spiking, parvalbumin-positive (PV) GABAergic interneurons revealed a significant increase in the density of PV+ cells in the DG of male XRCC1 KO mice, while females remained unchanged.

Conclusions

Our results suggest that accumulation of unrepaired DNA damage in the forebrain alters the GABAergic neurotransmitter system and causes behavioural deficits in relation to innate and learned anxiety in a sex-dependent manner. Moreover, the data uncover a previously unappreciated connection between BER deficiency, unrepaired DNA damage in the hippocampus and a sex-specific anxiety-like phenotype with implications for the aetiology and therapy of neuropsychiatric disorders.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12915-022-01377-1.

A Pilot Randomized Clinical Trial of a Novel, Culturally Adapted, Trauma-Focused Cognitive-Behavioral Intervention for War-Related PTSD in Iraqi Women

Trauma-focused cognitive-behavioral therapy (TF-CBT), broadly, is one of the leading evidence-based treatments for youth with posttraumatic stress disorder (PTSD). Generally, few culturally adapted TF-CBT interventions have been examined among war trauma-affected populations in low- and middle-income countries. Using a randomized clinical trial design, a total of 48 war trauma-exposed women in Iraq, M_age (SD) = 32.91 (5.33), with PTSD were randomly assigned to either TF-CBT or wait-list control (WLC) conditions. The intervention group received 12 individual weekly sessions of a culturally adapted TF-CBT intervention. Significant reductions in PTSD symptom severity were reported by women in the TF-CBT condition from pre- to posttreatment. Women in the TF-CBT condition reported significantly greater reductions in PTSD symptoms compared to WLC at 1-month follow-up. Additionally, levels of depression, anxiety, stress, and use of maladaptive emotion regulation strategies were significantly lower in the TF-CBT condition at posttreatment and 1-month follow-up, compared to the WLC condition. Women in the TF-CBT condition also reported significant improvements in various domains of quality of life at posttreatment and 1-month follow-up. This clinical trial provides preliminary cross-cultural support for the feasibility and efficacy of TF-CBT for the treatment of PTSD symptoms among women in non-Western cultures. Future directions and study limitations are discussed.

Gender Differences in Diagnostic Remission of Posttraumatic Stress Disorder (PTSD): Proportions and Correlates of Remission in a Nationally Representative U.S. Sample

This study examines differences in a nationally representative sample, in proportions of men and women with lifetime diagnoses of Posttraumatic Stress Disorder (PTSD) who achieved diagnostic remission and gender-specific correlates. Data from the 2012-13 National Epidemiologic Survey on Alcohol and Related Conditions-III included 1,997 adults with a lifetime PTSD diagnosis (70.8% female and 29.2% male). Of these 25.3% of women and 24.3% of men experienced remission (ns). Women who remitted were older than other women, more likely to be retired, and less likely to report disability, past homelessness, suicide attempts, criminal history, violent behavior, or parental histories of drug problems or suicide. Men who remitted were less likely than other men to be separated/divorced, disabled, incarcerated after age 15, and reported fewer violent behaviors. Remission was significantly more strongly associated among women than men with greater age, emergency room visits, trauma and less with schizotypal personality. Although women were twice as likely to be diagnosed with PTSD, there were no significant gender differences in the proportions who experienced remission. Remission was associated with diverse sociodemographic and clinical disadvantages among both men and women but only four were statistically significantly different between genders.

Factors associated with peritraumatic stress symptoms among the frontline healthcare workers during the outbreak of COVID-19 in China

OBJECTIVES

This study aimed to examine the prevalence of peritraumatic stress symptoms (PTSSs), perceived threat, social support and factors contributing to clinically significant PTSS among frontline COVID-19 healthcare workers (HCWs) in China.

DESIGN AND SETTING

An online survey through self-administered questionnaires was conducted from 18 February to 4 March 2020, during the outbreak of COVID-19.

OUTCOMES MEASURES

PTSS was assessed using the post-traumatic stress disorder (PTSD) self-rating scale. Demographic and socioeconomic characteristics, self-reported health, physical/psychological symptoms, perceived threat from frontline work and perceived social support were investigated. Multivariable line regression analysis distinguished factors associated with HCWs' PTSS scores.

RESULTS

A total of 676 (58.1%) HCWs have shown clinically significant high levels of PTSS. Only 441 (37.9%) self-reported good health. Most had physical symptom(s) (915 (78.7%)), psychological symptom(s) (906 (77.9%)), inability to vent emotions (284 (24.4%)), emotional exhaustion (666 (57.3%)) and 1037 (89.2%) needed professional respect. Moreover, social support received was less than expected, and the receipt of psychological services/help scored the lowest (3.11±1.73). Combined psychological and physical symptoms, difficulty in releasing tension and venting emotions timely, fear of infection, emotional exhaustion and depersonalisation are significantly associated with PTSS scores among frontline HCWs. Working ≥8 hours, having the senior professional title, self-reported health, enjoying perfect protection and control measures, economic subsidy and control policy on reducing discriminatory practices are negatively correlated with PTSS scores.

CONCLUSIONS

During the outbreak of COVID-19, frontline HCWs experienced clinically significant high levels of PTSS and heavy workload, and the emergency resulted in their inadequate psychosocial support. If this is left unchecked, HCWs have a higher risk of developing PTSD. Early detection, identification and person-directed, targeted multidisciplinary interventions should be undertaken to address various influencing factors. Comprehensive measures, including setting up emotional release channels, as well as providing psychological and social support intervention for HCWs globally, are highly recommended.

A single case report of using Dummett’s systemic cognitive behavioural formulation to guide treatment of adolescent PTSD

Trauma-focused CBT (TF-CBT) is recommended by NICE for adolescents with post-traumatic stress disorder (PTSD). Whilst caregiver involvement is recommended, no specific guidance on the nature of involvement is provided although it is important that involvement takes account of the nature of the trauma. This case report details how Dummett’s systemic CBT formulation was used to plan an intervention such that systemic sessions were included in TF-CBT treatment of an adolescent female with PTSD which arose following interpersonal trauma. Trauma symptoms, trauma cognitions and depressive symptoms were measured throughout, with trauma symptoms showing clinically significant change over the course of therapy. Clinical implications are considered regarding the applicability of systemic CBT formulation and the inclusion of systemic sessions within TF-CBT for adolescents whose traumas arose interpersonally.

Key learning aims

(1)

An investigation of the incidence of post-traumatic stress disorder, turnover intention and psychological resilience among medical staff in a public hospital in China during the outbreak of the omicron variant in the COVID-19 pandemic in 2022

OBJECTIVE

To investigate the incidence of post-traumatic stress disorder (PTSD), turnover intention and psychological resilience of medical staff during the Outbreak of the Omicron Variant in the COVID-19 pandemic in 2022 and to provide a basis for adopting relevant psychological interventions to reduce medical staff turnover.

METHODS

Using the PTSD Checklist-Civilian Version (PCL-C) and a total score ranging from 17 to 85 points, a total score ≥ 38 indicates significant PTSD symptoms and a diagnosis of PTSD. The Chinese version of the Turnover Intention Scale (TIS) has a total score of 6 to 24 points; the higher the score, the stronger the turnover intention. The Chinese version of the Connor-Davidson Resilience Scale (CD-RISC) has a total score of 0 to 100 points, with higher scores indicating a better level of psychological resilience. A total of 443 front-line medical staff working in Chinese public hospitals and still treating all patients normally during COVID-19 were invited via the internet to complete a survey from 15 May to 30 May 2022 in China.

RESULTS

The incidence of PTSD was 14.4%, the total turnover intention score was 13.38 ± 4.08, and the total psychological resilience score was 87.16 ± 18.42. The prevalence of PTSD was higher among medical staff who were married, had children, and were worried about being infected; in addition, the PTSD group had a higher level of education, higher turnover intention, and lower psychological resilience than the non-PTSD group. The total scores for turnover intention and fear of being infected were risk factors for PTSD, while a high total psychological resilience score and high education level were protective factors for PTSD; the differences were statistically significant (all P < 0.05).

CONCLUSION

Post-traumatic stress disorder among Chinese medical personnel was associated with the marital status, childbirth, education level, turnover intention, and psychological resilience. Among these factors, psychological resilience might be exploited as a protective factor.

Cannabis in the management of PTSD: a systematic review

Introduction

Existing reviews exploring cannabis effectiveness have numerous limitations including narrow search strategies. We systematically explored cannabis effects on PTSD symptoms, quality of life (QOL), and return to work (RTW). We also investigated harm outcomes such as adverse effects and dropouts due to adverse effects, inefficacy, and all-cause dropout rates.

Methods

Our search in MEDLINE, EMBASE, PsycInfo, CINAHL, Web of Science, CENTRAL, and PubMed databases, yielded 1 eligible RCT and 10 observational studies (n = 4672). Risk of bias (RoB) was assessed with the Cochrane risk of bias tool and ROBINS-I.

Results

Evidence from the included studies was mainly based on non-randomized studies with no comparators. Results from unpooled, high RoB studies showed that cannabis was associated with a reduction in overall PTSD symptoms and improved QOL. Dry mouth, headaches, and psychoactive effects such as agitation and euphoria were the commonly reported adverse effects. In most studies, cannabis was well tolerated, but small proportions of patients experienced a worsening of PTSD symptoms.

Conclusion

Evidence in the current study primarily stems from low quality and high RoB observational studies. Further RCTs investigating cannabis effects on PTSD treatment should be conducted with larger sample sizes and explore a broader range of patient-important outcomes.

Extended amygdala circuits are differentially activated by context fear conditioning in male and female rats

As the incidence of anxiety disorders is more prevalent in females, comparing the neural underpinnings of anxiety in males and females is imperative. The bed nucleus of the stria terminalis (BNST) contributes to long-lasting, anxiety-like states including the expression of context fear conditioning. Currently, there is conflicting evidence as to which nuclei of the BNST contribute to these behaviors. The anterolateral portion of the BNST (BNST-AL) located dorsal to the anterior commissure and lateral to the stria terminalis sends robust projections to the central nucleus of the amygdala (CE). Here we asked whether the BNST-AL is active during the expression of context fear conditioning in both male and female rats. At the cellular level, the expression of context fear produced upregulation of the immediate-early gene ARC in the BNST-AL as well as an upregulation of ARC specifically in neurons projecting to the CE, as labeled by the retrograde tracer Fluorogold infused into the CE. However, this pattern of ARC expression was observed in male rats only. Excitotoxic lesions of the BNST reduced context fear expression in both sexes, suggesting that a different set of BNST subnuclei may be recruited by the expression of fear and anxiety-like behaviors in females. Overall, our data highlight the involvement of the BNST-AL in fear expression in males, and suggest that subnuclei of the BNST may be functionally different in male and female rats.

Early Adolescence Prefrontal Cortex Alterations in Female Rats Lacking Dopamine Transporter

Monoamine dysfunctions in the prefrontal cortex (PFC) can contribute to diverse neuropsychiatric disorders, including ADHD, bipolar disorder, PTSD and depression. Disrupted dopamine (DA) homeostasis, and more specifically dopamine transporter (DAT) alterations, have been reported in a variety of psychiatric and neurodegenerative disorders. Recent studies using female adult rats heterozygous (DAT+/-) and homozygous (DAT-/-) for DAT gene, showed the utility of those rats in the study of PTSD and ADHD. Currently, a gap in the knowledge of these disorders affecting adolescent females still represents a major limit for the development of appropriate treatments. The present work focuses on the characterization of the PFC function under conditions of heterozygous and homozygous ablation of DAT during early adolescence based on the known implication of DAT and PFC DA in psychopathology during adolescence. We report herein that genetic ablation of DAT in the early adolescent PFC of female rats leads to changes in neuronal and glial cell homeostasis. In brief, we observed a concurrent hyperactive phenotype, accompanied by PFC alterations in glutamatergic neurotransmission, signs of neurodegeneration and glial activation in DAT-ablated rats. The present study provides further understanding of underlying neuroinflammatory pathological processes that occur in DAT-ablated female rats, what can provide novel investigational approaches in human diseases.

Sex-specific effects of the histone variant H2A.Z on fear memory, stress-enhanced fear learning and hypersensitivity to pain

Emerging evidence suggests that histone variants are novel epigenetic regulators of memory, whereby histone H2A.Z suppresses fear memory. However, it is not clear if altered fear memory can also modify risk for PTSD, and whether these effects differ in males and females. Using conditional-inducible H2A.Z knockout (cKO) mice, we showed that H2A.Z binding is higher in females and that H2A.Z cKO enhanced fear memory only in males. However, H2A.Z cKO improved memory on the non-aversive object-in-place task in both sexes, suggesting that H2A.Z suppresses non-stressful memory irrespective of sex. Given that risk for fear-related disorders, such as PTSD, is biased toward females, we examined whether H2A.Z cKO also has sex-specific effects on fear sensitization in the stress-enhanced fear learning (SEFL) model of PTSD, as well as associated changes in pain sensitivity. We found that H2A.Z cKO reduced stress-induced sensitization of fear learning and pain responses preferentially in female mice, indicating that the effects of H2A.Z depend on sex and the type of task, and are influenced by history of stress. These data suggest that H2A.Z may be a sex-specific epigenetic risk factor for PTSD susceptibility, with implications for developing sex-specific therapeutic interventions.

Using the tools of genetic epidemiology to understand sex differences in neuropsychiatric disorders

Many neuropsychiatric disorders exhibit differences in prevalence, age of onset, symptoms or course of illness between males and females. For the most part, the origins of these differences are not well understood. In this article, we provide an overview of sex differences in psychiatric disorders including autism spectrum disorder (ASD), attention deficit/hyperactivity disorder (ADHD), anxiety, depression, alcohol and substance abuse, schizophrenia, eating disorders and risk of suicide. We discuss both genetic and nongenetic mechanisms that have been hypothesized to underlie these differences, including ascertainment bias, environmental stressors, X‐ or Y‐linked risk loci, and differential liability thresholds in males and females. We then review the use of twin, family and genome‐wide association approaches to study potential genetic mechanisms of sex differences and the extent to which these designs have been employed in studies of psychiatric disorders. We describe the utility of genetic epidemiologic study designs, including classical twin and family studies, large‐scale studies of population registries, derived recurrence risks, and molecular genetic analyses of genome‐wide variation that may enhance our understanding sex differences in neuropsychiatric disorders.

Heterogeneity and Polygenicity in Psychiatric Disorders: A Genome-Wide Perspective

Genome-wide association studies (GWAS) have been performed for many psychiatric disorders and revealed a complex polygenic architecture linking mental and physical health phenotypes. Psychiatric diagnoses are often heterogeneous, and several layers of trait heterogeneity may contribute to detection of genetic risks per disorder or across multiple disorders. In this review, we discuss these heterogeneities and their consequences on the discovery of risk loci using large-scale genetic data. We primarily highlight the ways in which sex and diagnostic complexity contribute to risk locus discovery in schizophrenia, bipolar disorder, attention deficit hyperactivity disorder, autism spectrum disorder, posttraumatic stress disorder, major depressive disorder, obsessive-compulsive disorder, Tourette’s syndrome and chronic tic disorder, anxiety disorders, suicidality, feeding and eating disorders, and substance use disorders. Genetic data also have facilitated discovery of clinically relevant subphenotypes also described here. Collectively, GWAS of psychiatric disorders revealed that the understanding of heterogeneity, polygenicity, and pleiotropy is critical to translate genetic findings into treatment strategies.

Factors associated with the resilience of Tibetan adolescent survivors five years after the 2010 Yushu earthquake

Resilience contributes to the recovery of disaster victims. The resilience of Tibetan adolescents after the Yushu earthquake has not been properly studied. This study aimed to examine the current resilience and associated factors in Tibetan adolescent survivors in the hardest-hit area 5 years after the Yushu earthquake. This cross-sectional survey was conducted in the area hit the hardest by the Yushu earthquake. Data were collected from 4681 respondents in October and November 2015. Measurements included the participant characteristics, traumatic earthquake experience, the Connor-Davidson resilience scale (CD-RISC), and the social support appraisals (SS-A) scale. The individual datasets were randomized as 80% for the training set and 20% for the validation set. The mean resilience score of the Tibetan adolescent survivors was 55.0±12.3. Thirteen variables were entered into the regression equation. The three dimensions of social support (from family, from friends, from others than family/friends) were positively associated with resilience (all P<0.05), among which support from others than family/friends was the strongest (r = 0.388, P<0.001). Academic performance, activeness of participation in school activities, harmonious relationship with teachers/classmates, health over the last year, and regular physical exercise were positively associated with resilience (all P<0.05). Being female and being extremely worried about their own lives were negatively associated with resilience (both P<0.05). In conclusion, among Tibetan adolescent survivors to the Yushu earthquake of 2010, support from others than family/friends was the strongest positive factor associated with resilience, while being female and extreme worry about their own lives were negative factors. These results expand our knowledge regarding resilience in Tibetan adolescent disaster survivors.

Differential Effects of Nicotine and Nicotine Withdrawal on Fear Conditioning in Male Rats

BACKGROUND

Tobacco use is prevalent in individuals who are routinely exposed to stress. However, little is known about how nicotine affects responses to trauma. We examined in rats how nicotine exposure affects fear conditioning, a procedure often used to study stress-related psychiatric illness.

METHODS

We examined 2 methods of nicotine exposure: self-administration, modeling voluntary use, and experimenter-programmed subcutaneous administration, modeling medicinal administration (nicotine patch). For self-administered nicotine, rats trained to self-administer nicotine i.v. were fear conditioned (via light cue preceding foot-shock) either immediately after a 12-hour self-administration session or 12 hours later during a period with somatic signs of nicotine withdrawal. For experimenter-delivered nicotine, rats were conditioned after 1-21 days of nicotine delivered by programmable (12 hours on) subcutaneous mini-pumps. Tests to evaluate acoustic startle responses to the conditioning environment (context-potentiated startle) and in the presence or absence of the light cue (fear-potentiated startle) occurred after a 10-day period.

RESULTS

Rats fear conditioned immediately after nicotine self-administration showed reduced responses to the shock-associated context, whereas those trained during nicotine withdrawal showed exaggerated responses. Experimenter-programmed nicotine produced effects qualitatively similar to those seen with self-administered nicotine.

CONCLUSIONS

Self-administration or experimenter-programmed delivery of nicotine immediately before exposure to aversive events can reduce conditioned fear responses. In contrast, exposure to aversive events during nicotine withdrawal exacerbates fear responses. These studies raise the possibility of developing safe and effective methods to deliver nicotine or related drugs to mitigate the effects of stress while also highlighting the importance of preventing withdrawal in nicotine-dependent individuals.

Cannabinoids and the endocannabinoid system in anxiety, depression, and dysregulation of emotion in humans

PURPOSE OF REVIEW

This review is to summarize most recent evidence published in the last 18 months on medical and recreational use of cannabis and cannabinoids in relation to anxiety, depression (unipolar and bipolar), and dysregulation of emotions as part of posttraumatic stress disorders (PTSD) and emotionally instable personality disorders. It also covers the investigation of endocannabinoids as potential biomarkers in these conditions. This is important with increasing medicinal use of cannabinoids and growing social tolerance towards recreational cannabis use.

RECENT FINDINGS

There is some recent evidence suggesting cannabinoids, cannabidiol or cannabidiol-enriched cannabis preparations have anxiolytic properties. In addition, depression may be worsened by cannabis use, however, randomized controlled trials (RCT) are lacking. New evidence also suggests that cannabidiol or cannabidiol-enriched cannabis use for PTSD and emotion regulation can induce hyporesponse to fear and stress. Further, several lines of evidence point to the endocannabinoid system as a key player in some of the reviewed disorders, in particular anxiety and PTSD.

SUMMARY

The most recent evidence for a therapeutic use of cannabinoids in the reviewed conditions is weak and lacking well designed RCTs. However, there is some indication of the role of the endocannabinoid system in these conditions that warrant further studies.

Single housing-induced effects on cognitive impairment and depression-like behavior in male and female mice involve neuroplasticity-related signaling

Single-housed stress elicits a range of social isolation-related behavioral and neurobiological abnormalities. To investigate single housing-induced behavioral changes and sex differences on stress outcomes, we examined single-housed stress-induced learning and memory impairment, depression-like behaviors, neuroplasticity abnormalities and underlying mechanism. The results showed that male and female mice socially isolated for 8 weeks had significantly decreased memory acquisition, as demonstrated in the learning curve of the Morris water maze task. Memory consolidation and retrieval were also decreased in both the single-housed male and female mice. These findings were corroborated further by the two classical animal models, Y-maze and novel object recognition tests, as demonstrated by reduced spontaneous alternation and recognition index in both sexes of single-housed mice. Subsequent studies suggested that single-housed male mice exhibited increased immobility time in both the forced swim and tail suspension tests, while the female mice only exhibited increased immobility time in the tail suspension test. Moreover, single-housed stress significantly decreased the apical and basal branch points, dendritic length, and spine density in the CA1 of hippocampal neurons in both male and female mice. These effects were consistent with decreased neuroplasticity and neuroprotective-related molecules such as synaptophysin, PSD95, PKA, pCREB and BDNF expression. These findings suggest that loss of neuronal remodeling and neuroprotective mechanisms due to single housing are involved in behavioral changes in both male and female mice. The results provide further evidence that neuroplasticity-related signaling plays a crucial role in isolation-induced effects on neuropsychiatric behavioral deficits in both sexes.

Impairment of Quality of Life Associated With Lifetime Diagnosis of Post-traumatic Stress Disorder in Women - A National Survey in Italy

Introduction

The aim of the study was to measure the lifetime prevalence of Post-Traumatic Stress Disorder (PTSD) among women of an Italian community sample, the comorbidity of PTSD with mood and anxiety disorders and the burden attributable to PTSD in worsening the Quality of Life (QoL).

Methods

Community survey on a sample of 1961 adult women randomly selected. Tools: psychiatric clinical interview ANTAS partially derived from the SCID-DSM-IV, administered by psychologists or medical doctors; Short Form Health Survey (SF-12); Mood Disorder Questionnaire (MDQ).

Results

Lifetime prevalence of PTSD in women was 1.3%, (1.4% in<45 years aged, 1.3% in >44 years aged; p=0.8). In order of risk of comorbidity, PTSD was associated with: Bipolar Spectrum Disorders (MDQ+), Panic Disorders (PD) and Major Depressive Disorder (MDD). People with PTSD showed an SF-12 mean score lower than women of the same sample without PTSD (standardized by gender and age), with a mean difference (attributable burden) of 3.9±0.9 similarly to MDD and Eating Disorders and higher than PD. Among the analyzed nonpsychiatric diseases, Multiple Sclerosis and Carotid Atherosclerosis showed a higher burden in impairing QoL than PTSD; Wilson's Disease showed a similar burden and Celiac Disease was found less impairing on QoL than PTSD.

Conclusion

The attributable burden in worsening women' perceived QoL due to a lifetime diagnosis of PTSD was found comparable to those caused by MDD, Eating Disorders or by neurological condition such as Wilson's Disease. The comorbidity of PTSD with Bipolar Spectrum Disorders was remarkable, even further studies are needed to clarify the direction of causality.

Neurosteroid Levels in the Orbital Frontal Cortex of Subjects with PTSD and Controls: A Preliminary Report

Background

Neurosteroids mediate stress signaling and have been implicated in the pathogenesis of post-traumatic stress disorder (PTSD) in both preclinical and clinical studies. Compared to controls, subjects with PTSD exhibit altered neurosteroid levels in peripheral blood and cerebrospinal fluid as well as hypoactivity in the medial orbital frontal cortex (mOFC). Therefore, the aim of this study was to compare neurosteroid levels in the mOFC of subjects with PTSD (n = 18) and controls (n = 35).

Methods

Gray matter was dissected from fresh-frozen mOFC, and levels of the neurosteroids pregnenolone, allopregnanolone, pregnanolone, epiallopregnanolone, epipregnanolone, tetrahydrodeoxycorticosterone, and androsterone were determined by gas chromatography - tandem mass spectrometry (GC/MS/MS).

Results

Analyses of unadjusted levels revealed that males with PTSD had significantly decreased levels of allopregnanolone (p = 0.03) compared to control males and females with PTSD had significantly increased levels of pregnenolone (p = 0.03) relative to control females. After controlling for age, postmortem interval, and smoking status, results showed that males with PTSD had significantly decreased levels of androsterone (t46 = 2.37, p = 0.02) compared to control males and females with PTSD had significantly increased levels of pregnanolone (t46 = -2.25, p = 0.03) relative to control females.

Conclusions

To our knowledge, this is the first report of neurosteroid levels in postmortem brain tissue of subjects with PTSD. Although replication is required in other brain regions and in a larger cohort of subjects, the results suggest a dysregulation of allopregnanolone and androsterone in males with PTSD and pregnanolone in females with PTSD in the mOFC.