Children suffering from separation anxiety disorder (SAD) show increased HPA axis activity compared to healthy controls

Stress and the CRH System, Norepinephrine, Depression, and Type 2 Diabetes

Major depressive disorder (MDD) increases the risk of type 2 diabetes (T2D) by 60% in untreated patients, and hypercortisolism is common in MDD as well as in some patients with T2D. Patients with MDD, despite hypercortisolism, show inappropriately normal levels of corticotropin-releasing hormone (CRH) and plasma adrenocorticotropin (ACTH) in the cerebrospinal fluid, which might implicate impaired negative feedback. Also, a positive feedback loop of the CRH-norepinephrine (NE)-CRH system may be involved in the hypercortisolism of MDD and T2D. Dysfunctional CRH receptor 1 (CRHR1) and CRH receptor 2 (CRHR2), both of which are involved in glucose regulation, may explain hypercortisolism in MDD and T2D, at least in a subgroup of patients. CRHR1 increases glucose-stimulated insulin secretion. Dysfunctional CRHR1 variants can cause hypercortisolism, leading to serotonin dysfunction and depression, which can contribute to hyperglycemia, insulin resistance, and increased visceral fat, all of which are characteristics of T2D. CRHR2 is implicated in glucose homeostasis through the regulation of insulin secretion and gastrointestinal functions, and it stimulates insulin sensitivity at the muscular level. A few studies show a correlation of the CRHR2 gene with depressive disorders. Based on our own research, we have found a linkage and association (i.e., linkage disequilibrium [LD]) of the genes CRHR1 and CRHR2 with MDD and T2D in families with T2D. The correlation of CRHR1 and CRHR2 with MDD appears stronger than that with T2D, and per our hypothesis, MDD may precede the onset of T2D. According to the findings of our analysis, CRHR1 and CRHR2 variants could modify the response to prolonged chronic stress and contribute to high levels of cortisol, increasing the risk of developing MDD, T2D, and the comorbidity MDD-T2D. We report here the potential links of the CRH system, NE, and their roles in MDD and T2D.

Research Review: Pediatric anxiety disorders - what have we learnt in the last 10 years?

BACKGROUND

Anxiety disorders first emerge during the critical developmental periods of childhood and adolescence. This review synthesizes recent findings on the prevalence, risk factors, and course of the anxiety disorders; and their neurobiology and treatment.

METHODS

For this review, searches were conducted using PubMed, PsycINFO, and clinicaltrials.gov. Findings related to the epidemiology, neurobiology, risk factors, and treatment of pediatric anxiety disorders were then summarized.

FINDINGS

Anxiety disorders are high prevalence, and early-onset conditions associated with multiple risk factors including early inhibited temperament, environment stress, and structural and functional abnormalities in the prefrontal-amygdala circuitry as well as the default mode and salience networks. The anxiety disorders are effectively treated with cognitive behavioral therapy (CBT), selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors (SNRIs).

CONCLUSIONS

Anxiety disorders are high prevalence, early-onset conditions associated with a distinct neurobiological fingerprint, and are consistently responsive to treatment. Questions remain regarding who is at risk of developing anxiety disorders as well as the way in which neurobiology predicts treatment response.

Development of a Computerized Adaptive Test for Separation Anxiety Disorder Among Adolescents

BACKGROUND

Separation anxiety disorder (SAD) is one of the most common mental disorders among children and adolescents, and it may seriously affect their growth, daily life, and learning. Self-report scales have been used for diagnosis, which require lengthy testing and personnel.

METHODS

A total of 1,241 adolescents were recruited from 16 junior- and senior-high schools in China. The initial item bank was selected from classical SAD scales according to the DSM-5. First, the optimal model was selected using item response theory (IRT) according to data fit. Then, per the IRT analysis, items that did not meet the psychometric requirements were deleted (e.g., discriminating values < 0.2). Consequently, a computerized adaptive test (CAT) for SAD was formed (CAT-SAD).

RESULTS

An average of 17 items per participant was required to achieve and maintain a 0.3 standard error of measurement in the SAD severity estimate. The estimated correlation of the CAT-SAD with the total 68-item test score was 0.955. CAT-SAD scores were strongly related to the probability of a SAD diagnosis with the Separation Anxiety Assessment Scale-Child and Adolescent Version. Therefore, SAD could be accurately predicted by the CAT-SAD.

CONCLUSIONS

Exploratory factor analyses revealed that SAD was unidimensional. The CAT-SAD, which has good reliability and validity and high sensitivity and specificity, provides an efficient test for adolescents with SAD as compared to standard paper-and-pencil tests. It can be used to diagnose varying degrees of SAD quickly and reliably and ease the burden on adolescents. Potential applications for inexpensive, efficient, and accurate screening of SAD are discussed.

The Role of Children's Neurophysiological Functioning in the Links Between Emotion-Parenting Behaviors and Child Anxiety Symptoms: A Biological Sensitivity to Context Framework

A plethora of data supports links between parenting behaviors and child anxiety, but few studies have examined factors that can contribute to variability in these relations. Adopting a biological sensitivity to context framework, this study explored the role of children's physiological stress reactivity in the links between emotion-parenting and child anxiety symptoms in a group of Chinese families. Sixty-one parent-child dyads (child M_age  = 8.21 years, SD = 1.40, range = 6-12 years) participated in an acute stress protocol, from which children's physiological (cortisol and respiratory sinus arrhythmia) responses to a social speech task were recorded. Participants then completed questionnaires assessing parents' emotion-parenting behaviors and children's anxiety symptoms. Results showed that the relation between supportive emotion-parenting and child anxiety was stronger in the context of greater child RSA suppression to acute stress, such that children higher in RSA suppression exhibited lower anxiety symptoms when supportive emotion-parenting was higher than when it was lower. Thus, these findings supported the biological sensitivity to context model. No significant moderation effect was detected for cortisol reactivity or recovery. Instead, exploratory mediation analyses showed that supportive emotion-parenting was negatively related to child anxiety via greater cortisol recovery. There was also a significant indirect path where unsupportive emotion-parenting was related to blunted cortisol recovery, which in turn was associated with higher child anxiety. The results highlight the importance of coaching parents to respond in supportive ways to children's emotional expressions, particularly in the context of greater child reactivity, to help buffer against childhood anxiety symptoms.

Hair Cortisol Concentration and Mental Disorder in Children With Chronic Physical Illness

Background

To examine changes in hair cortisol concentrations (HCC) in children with chronic physical illness and identify patterns of association between HCC and mental comorbidity.

Methods

A sample of 50 children aged 6 to 16 years were recruited within six months of being diagnosed with a chronic physical illness. Data were collected via hair samples, structured interviews, and behavioral checklists.

Results

There was no change in HCC over six months. Baseline HCC was associated with internalizing—odds ratio (OR) = 1.29 (90% confidence interval (CI): 1.01–1.66)—and externalizing disorders—OR = 1.32 (90% CI: 1.07–1.64). Externalizing disorder at six months was associated with elevated baseline—OR = 1.25 (90% CI: 1.02–1.53)—and six-month HCC—OR = 1.25 (90% CI: 1.02–1.54). Associations between HCC and mental disorder weakened over time, and for internalizing disorders, changed direction (i.e., inverse association), albeit not significantly.

Conclusion

Results provide preliminary evidence that physiological stress, measured using HCC, may be implicated in the relationship between physical and mental illness, and these associations align with attenuated stress responses over time.

A neurobiological framework of separation anxiety and related phenotypes

In the DSM-5, separation anxiety disorder (SAD) is newly classified in the chapter on anxiety, renewing research efforts into its etiology. In this narrative review, we summarize the current literature on the genetic, endocrine, physiological, neural and neuropsychological underpinnings of SAD per se, SAD in the context of panic disorder, separation anxiety symptoms, and related intermediate phenotypes. SAD aggregates in families and has a heritability of ~43%. Variants in the oxytocin receptor, serotonin transporter, opioid receptor µ1, dopamine D4 receptor and translocator protein genes have all been associated with SAD. Dysregulation of the hypothalamus-pituitary-adrenal axis, dysfunctional cortico-limbic interaction and biased cognitive processing seem to constitute further neurobiological markers of separation anxiety. Hypersensitivity to carbon dioxide appears to be an endophenotype shared by SAD, panic disorder and anxiety sensitivity. The identification of biological risk markers and its multi-level integration hold great promise regarding the prediction of SAD risk, maintenance and course, and in the future may allow for the selection of indicated preventive and innovative, personalized therapeutic interventions.

Cortisol Impacted on Explicit Learning Encoding, but Not on Storage and Retrieval, and Was Not Associated With Sleep Patterns-Results From the Trier Social Stress Test for Children (TSST-C) Among 9-Years Old Children

Background: Learning is the relatively permanent change of behavior as a result of experience and tightly related to memory and cognition. Learning is particularly important for children. Further, restoring sleep is associated both with improved learning performance and lower cortisol levels as a proxy of the so-called hypothalamus-pituitary-adrenocortical axis activity (HPA-AA). With the present study, we investigated, if and to what extent explicit learning performance was associated with cortisol levels at baseline and under challenge conditions and with objective sleep dimensions among 9-years old children.

Methods: A total of 39 children (mean age = 9.5 years; 39% females) took part in the study. Verbal and figural working and long-term memory were tested before and after the Trier Social Stress Test for Children (TSST-C). Further, children underwent sleep-EEG assessment, and cortisol awakening response (CAR) was assessed.

Results: Higher cortisol levels were associated with lower explicit learning encoding (verbal, but not figural learning). Higher verbal and figural working and long-term memory performance predicted lower cortisol secretion under the TSST-C, along with higher verbal and figural working and long-term memory performance after the TSST-C. Cognitive test performances were not mediated by cortisol secretion under the TSST-C. Cognitive performance, cortisol secretion under challenge (TSST-C) and basal conditions (morning) and sleep patterns were unrelated.

Conclusions: The pattern of results suggests that among a sample of 9-years old children cortisol secretion and stages of memory processes (encoding, storage, retrieval) are associated in a complex and bi-directional way. Further, it appears that cognitive-emotional processes underlying cognitive performance and its evaluation might impact on subsequent cortisol secretion as a proxy of neuroendocrinological response to cognitive-emotional processes. Last, cognitive performance and cortisol secretion under challenge conditions were not related to objective sleep patterns and baseline cortisol secretion.

Coupling corticotropin-releasing-hormone and angiotensin converting enzyme 2 dampens stress responsiveness in male mice

This study used mice to evaluate whether coupling expression of corticotropin-releasing hormone (CRH) and angiotensin converting enzyme 2 (ACE2) creates central interactions that blunt endocrine and behavioral responses to psychogenic stress. Central administration of diminazene aceturate, an ACE2 activator, had no effect on restraint-induced activation of the hypothalamic-pituitary-adrenal (HPA) axis; however, mice that ubiquitously overexpress ACE2 had reduced plasma corticosterone (CORT) and pituitary expression of POMC mRNA. The Cre-LoxP system was used to restrict ACE2 overexpression to CRH synthesizing cells and probe whether HPA axis suppression was the result of central ACE2 and CRH interactions. Within the paraventricular nucleus of the hypothalamus (PVN), mice with ACE2 overexpression directed to CRH had a ≈2.5 fold increase in ACE2 mRNA, which co-localized with CRH mRNA. Relative to controls, mice overexpressing ACE2 in CRH cells had a decreased CORT response to restraint as well as decreased CRH mRNA in the PVN and CEA and POMC mRNA in the pituitary. Administration of ACTH similarly increased plasma CORT, indicating that the blunted HPA axis activation that accompanies ACE2 overexpression in CRH cells is centrally mediated. Anxiety-like behavior was assessed to determine whether the decreased HPA axis activation was predictive of anxiolysis. Mice with ACE2 overexpression directed to CRH cells displayed decreased anxiety-like behavior in the elevated plus maze and open field when compared to that of controls. Collectively, these results suggest that exogenous ACE2 suppresses CRH synthesis, which alters the central processing of psychogenic stress, thereby blunting HPA axis activation and attenuating anxiety-like behavior.

Separation Anxiety Disorder in School-Age Children: What Health Care Providers Should Know

Separation anxiety disorder (SAD) is the most common childhood anxiety disorder, and it has many consequences, particularly for school-age children. These consequences include excessive worry, sleep problems, distress in social and academic settings, and a variety of physical symptoms that, left untreated, can cause social and academic decline. Pediatric providers routinely see children in the primary care office and have the unique opportunity to diagnose, treat, and manage children with SAD. Despite this, SAD continues to be underdiagnosed and undertreated because of a gap in the literature regarding evidence-based practice guidelines for pediatric providers. The purpose of this article is to discuss the diagnosis and management of SAD in school-age children and highlight the role of pediatric providers in managing separation anxiety.

FKBP5 interacts with maltreatment in children with extreme, pervasive, and persistent aggression

Genetic variation in stress response protein FKBP5 is associated with adult psychopathology, but little is known about its role in children's mental health. 5 polymorphisms were genotyped in 170 high aggression cases and 170 age- and sex-matched controls. The rs9470080 polymorphism was associated with physiological anxiety, while rs4713916 polymorphism interacted with maltreatment to influence externalizing traits. These results suggest that genetic variation in FKBP5 has a role in children's vulnerability to stress-related behaviours.

Preschool anxiety disorders predict different patterns of amygdala-prefrontal connectivity at school-age

Objective

In this prospective, longitudinal study of young children, we examined whether a history of preschool generalized anxiety, separation anxiety, and/or social phobia is associated with amygdala-prefrontal dysregulation at school-age. As an exploratory analysis, we investigated whether distinct anxiety disorders differ in the patterns of this amygdala-prefrontal dysregulation.

Methods

Participants were children taking part in a 5-year study of early childhood brain development and anxiety disorders. Preschool symptoms of generalized anxiety, separation anxiety, and social phobia were assessed with the Preschool Age Psychiatric Assessment (PAPA) in the first wave of the study when the children were between 2 and 5 years old. The PAPA was repeated at age 6. We conducted functional MRIs when the children were 5.5 to 9.5 year old to assess neural responses to viewing of angry and fearful faces.

Results

A history of preschool social phobia predicted less school-age functional connectivity between the amygdala and the ventral prefrontal cortices to angry faces. Preschool generalized anxiety predicted less functional connectivity between the amygdala and dorsal prefrontal cortices in response to fearful faces. Finally, a history of preschool separation anxiety predicted less school-age functional connectivity between the amygdala and the ventral prefrontal cortices to angry faces and greater school-age functional connectivity between the amygdala and dorsal prefrontal cortices to angry faces.

Conclusions

Our results suggest that there are enduring neurobiological effects associated with a history of preschool anxiety, which occur over-and-above the effect of subsequent emotional symptoms. Our results also provide preliminary evidence for the neurobiological differentiation of specific preschool anxiety disorders.

Five-year follow-up of effects of neonatal intensive care and morphine infusion during mechanical ventilation on diurnal cortisol rhythm

OBJECTIVE

To test the hypothesis that the diurnal cortisol secretion rhythm of children who as neonates had been hospitalized differs from that of children without a history of neonatal hospital admission and that this rhythm differs between these hospitalized children treated with either continuous morphine infusion or placebo.

STUDY DESIGN

A follow-up cohort study was performed with 5-year-old children who as neonates participated in a randomized controlled trial of continuous morphine infusion (born 24-42 weeks' gestation), and a control group of healthy term born (≥ 37 weeks' gestation) children. Five saliva samples over a school day were assayed for cortisol concentrations. The diurnal cortisol rhythm was analyzed with random regression analysis for repeated measurements.

RESULTS

Compared with the healthy controls, the trial participants had greater cortisol levels (P = .002) after adjustment for sex and socioeconomic status. The administration of morphine did not affect the cortisol concentrations (P = .66) after adjustment for sex, socioeconomic status, and gestational age at birth.

CONCLUSIONS

The finding that former trial participants had greater cortisol levels at 5 years of age supports the concept of long-lasting programming of the hypothalamic-pituitary-adrenal axis. Morphine infusion in the neonatal period did not alter cortisol secretion at 5 years of age.

Hypothesis of the neuroendocrine cortisol pathway gene role in the comorbidity of depression, type 2 diabetes, and metabolic syndrome

Depression, type 2 diabetes (T2D), and metabolic syndrome (MetS) are often comorbid. Depression per se increases the risk for T2D by 60%. This risk is not accounted for by the use of antidepressant therapy. Stress causes hyperactivation of the hypothalamic–pituitary–adrenal (HPA) axis, by triggering the hypothalamic corticotropin-releasing hormone (CRH) secretion, which stimulates the anterior pituitary to release the adrenocorticotropin hormone (ACTH), which causes the adrenal secretion of cortisol. Depression is associated with an increased level of cortisol, and CRH and ACTH at inappropriately “normal” levels, that is too high compared to their expected lower levels due to cortisol negative feedback. T2D and MetS are also associated with hypercortisolism. High levels of cortisol can impair mood as well as cause hyperglycemia and insulin resistance and other traits typical of T2D and MetS. We hypothesize that HPA axis hyperactivation may be due to variants in the genes of the CRH receptors (CRHR1, CRHR2), corticotropin receptors (or melanocortin receptors, MC1R-MC5R), glucocorticoid receptor (NR3C1), mineralocorticoid receptor (NR3C2), and of the FK506 binding protein 51 (FKBP5), and that these variants may be partially responsible for the clinical association of depression, T2D and MetS. In this review, we will focus on the correlation of stress, HPA axis hyperactivation, and the possible genetic role of the CRHR1, CRHR2, MCR1–5, NR3C1, and NR3C2 receptors and FKBP5 in the susceptibility to the comorbidity of depression, T2D, and MetS. New studies are needed to confirm the hypothesized role of these genes in the clinical association of depression, T2D, and MetS.

Salivary cortisol: a possible biomarker in evaluating stress and effects of interventions in young foster children?

Young foster children undergo an early separation from their caregiver(s) and often experience severe stress before placement. However, a considerable part of the children do not show apparent signs of distress, making it difficult for the foster carer to be aware of the amount of stress in their foster child. Potential evidence for using salivary cortisol levels as a dimension to evaluate the amount of stress in young foster children is reviewed. Moreover, the applicability of salivary cortisol in the evaluation of stress-reducing interventions for young foster children is discussed. A systematic review was performed using the databases Medline, Psychinfo, Embase, Ebscohost, and Academic Search Premier. Nine studies were traced in which salivary cortisol was used to measure stress in children placed in family foster care or in adoptive families. Stress in general but also neglect, early loss of a caregiver, a younger age at first placement, and a higher number of placements were associated with an altered hypothalamic-pituitary-adrenal (HPA) axis function in foster children. Moreover, four studies on the effect of stress-reducing interventions on HPA-axis functioning of young foster children were found. These studies suggest that caregiver-based interventions can actually help to normalize the HPA-axis function in foster children, and that such changes co-occur with improved behavioral functioning. Although the results from the papers discussed in this review suggest that diurnal cortisol with a wake up and a bedtime measurement may be a relevant tool to evaluate stress in young foster children, this cannot yet be concluded from the present studies, because statistical data from the studies on foster care and adoption in this review were not robust and researchers used different methods to collect the salivary cortisol. Still, it is noteworthy that all studies did find the same pattern of reduced levels in relation to chronic stress (caused by maltreatment and neglect of the child).

Responses to voluntary hyperventilation in children with separation anxiety disorder: implications for the link to panic disorder

BACKGROUND

Biological theories on respiratory regulation have linked separation anxiety disorder (SAD) to panic disorder (PD). We tested if SAD children show similarly increased anxious and psychophysiological responding to voluntary hyperventilation and compromised recovery thereafter as has been observed in PD patients.

METHODS

Participants were 49 children (5-14 years old) with SAD, 21 clinical controls with other anxiety disorders, and 39 healthy controls. We assessed cardiac sympathetic and parasympathetic, respiratory (including pCO2), electrodermal, electromyographic, and self-report variables during baseline, paced hyperventilation, and recovery.

RESULTS

SAD children did not react with increased anxiety or panic symptoms and did not show signs of slowed recovery. However, during hyperventilation they exhibited elevated reactivity in respiratory variability, heart rate, and musculus corrugator supercilii activity indicating difficulty with respiratory regulation.

CONCLUSIONS

Reactions to hyperventilation are much less pronounced in children with SAD than in PD patients. SAD children showed voluntary breathing regulation deficits.

In pre-school children, cortisol secretion remains stable over 12 months and is related to psychological functioning and gender

OBJECTIVES

Cross-sectional studies provide evidence that cortisol secretion as a marker of hypothalamus-pituitary-adrenocortical axis activity (HPA AA) is related to psychological functioning and behavior. However, there are no studies of the stability of the HPA AA in pre-schoolers over the longer term. The aim of the present study was therefore to investigate cortisol secretion in pre-schoolers longitudinally, and to predict psychological functioning 12 months later.

METHOD

92 pre-schoolers (mean age: 5.4 years; 44% females) took part in a follow-up assessment 12 months after initial assessment. Cortisol secretion was assessed both at baseline (morning cortisol secretion) and under challenge conditions, and a thorough psychological assessment was included.

RESULTS

Increased cortisol secretion at 5.4 years predicted increased cortisol secretion and psychological difficulties at 6.4 years. Compared to boys, girls had higher cortisol secretion at both 5.4 and 6.4 years. Cross-sectionally, at the age of 6.4 years, levels of cortisol secretion impacted differentially on girls' and boys' behavior.

CONCLUSION

In pre-schoolers, HPA axis activity at 5.4 years is stable over the following 12 months and is associated with psychological functioning. Pre-schoolers with higher cortisol levels are at increased risk of developing further psychological difficulties. Gender affects the manner in which HPA axis activity impacts on psychological functioning. Moreover, gender differences in cortisol secretion occur already in prepubertal children and appear to be independent from sex steroids.

Cortisol in the morning and dimensions of anxiety, depression, and aggression in children from a general population and clinic-referred cohort: An integrated analysis. The TRAILS study

Anxiety and depressive problems have often been related to higher hypothalamic-pituitary-adrenal (HPA)-axis activity (basal morning cortisol levels and cortisol awakening response [CAR]) and externalizing problems to lower HPA-axis activity. However, associations appear weaker and more inconsistent than initially assumed. Previous studies from the Tracking Adolescents Individual Lives Study (TRAILS) suggested sex-differences in these relationships and differential associations with specific dimensions of depressive problems in a general population sample of children (10-12 years). Using the TRAILS population sample (n=1604), we tested hypotheses on the association between single day cortisol (basal morning levels and CAR) and specifically constructed dimensions of anxiety (cognitive versus somatic), depressive (cognitive-affective versus somatic), and externalizing problems (reactive versus proactive aggression), and explored the modifying role of sex. Moreover, we repeated analyses in an independent same-aged clinic-referred sample (n=357). Structural Equation Modeling was used to investigate the association between cortisol and higher- and lower-order (thus, broad and specific) problem dimensions based on self-reports in an integrated model. Overall, findings were consistent across the population and clinic-referred samples, as well as with the existing literature. Most support was found for higher cortisol (mainly CAR) in relation to depressive problems. However, in general, associations were weak in both samples. Therefore, the present results shed doubt on the relevance of single day cortisol measurements for problem behaviors in the milder range. Associations may be stronger in more severe or persistent psychopathology.

Hypothalamic-pituitary-adrenal axis dysfunction as a neurobiological correlate of emotion dysregulation in adolescent suicide

BACKGROUND

Biological markers of vulnerability for current or future risk of suicide in adolescents could be important adjuncts to the treatment and prevention of this phenomenon.

DATA SOURCES

We conducted a PubMed search of all English-language articles published between January 1990 and June 2011 using the following search terms: ("hypothalamic-pituitary-adrenal" OR "HPA") AND ("adolescence" OR "adolescent" OR "teenager") AND ("depression" OR "major depressive disorder" OR "suicidal behavior" OR "suicidal ideation" OR "suicidal thoughts" OR "deliberate self-harm" OR "suicidal attempt" OR "suicide").

RESULTS

HPA axis activity can be examined using different methods that do not have the same biological interpretation. An abnormal HPA axis functioning together with an anomalous interaction between HPA mechanisms and other systems such as the serotonergic system may be one of the neurobiological correlates of emotion dysregulation (ED). ED may play an important role in adolescent suicidal behavior. Some psychopathological conditions such as depression or childhood psychological trauma that increase suicidal risk in adolescents are also associated with HPA axis dysregulation. ED, a personality trait, can also be viewed as a predisposing factor that augments the vulnerability to suffer from psychiatric conditions.

CONCLUSIONS

Correlating HPA axis dysfunction with psychological factors such as ED could lead to a better understanding of the role of HPA abnormalities in adolescent suicide and may enhance preventive and treatment strategies.

Pre-schoolers suffering from psychiatric disorders show increased cortisol secretion and poor sleep compared to healthy controls

BACKGROUND

Various studies of child cortisol secretion and sleep show a close association between poor sleep, deterioration of the HPA axis and unfavorable psychological functioning. However, there is little evidence as to whether these associations are clearly present in pre-school children suffering from psychiatric disorders.

METHOD

A total of 30 pre-schoolers suffering from psychiatric disorders (anxiety, adjustment disorders, emotional and attachment disorder; hyperactivity or oppositional disorder) and 35 healthy controls took part in the study. Saliva cortisol secretion was assessed both at baseline and under challenge conditions. Sleep was assessed via activity monitoring for seven consecutive days and nights, using a digital movement-measuring instrument. Parents and teachers completed questionnaires assessing children's cognitive, emotional and social functioning. The Berkeley Puppet Interview provided child-based reports of cognitive-emotional processes.

RESULTS

Compared to healthy controls, children suffering from psychiatric disorders had much higher cortisol secretion both at baseline and under challenge conditions. Sleep was also more disturbed, and parents and teachers rated children suffering from psychiatric disorders as cognitively, emotionally and behaviorally more impaired, relative to healthy controls. Children with psychiatric disorders reported being more bullied and victimized.

CONCLUSIONS

In five-year old children the presence of psychiatric disorders is reflected not only at psychological, social and behavioral, but also at neuroendocrine and sleep-related levels. It is likely that these children remain at increased risk for suffering from psychiatric difficulties later in life.

Childhood stressful events, HPA axis and anxiety disorders

Anxiety disorders are among the most common of all mental disorders and their pathogenesis is a major topic in psychiatry, both for prevention and treatment. Early stressful life events and alterations of hypothalamic pituitary adrenal (HPA) axis function seem to have a significant role in the onset of anxiety. Existing data appear to support the mediating effect of the HPA axis between childhood traumata and posttraumatic stress disorder. Findings on the HPA axis activity at baseline and after stimuli in panic disordered patients are inconclusive, even if stressful life events may have a triggering function in the development of this disorder. Data on the relationship between stress, HPA axis functioning and obsessive-compulsive disorder (OCD) are scarce and discordant, but an increased activity of the HPA axis is reported in OCD patients. Moreover, normal basal cortisol levels and hyper-responsiveness of the adrenal cortex during a psychosocial stressor are observed in social phobics. Finally, abnormal HPA axis activity has also been observed in generalized anxiety disordered patients. While several hypothesis have attempted to explain these findings over time, currently the most widely accepted theory is that early stressful life events may provoke alterations of the stress response and thus of the HPA axis, that can endure during adulthood, predisposing individuals to develop psychopathology. All theories are reviewed and the authors conclude that childhood life events and HPA abnormalities may be specifically and transnosographically related to all anxiety disorders, as well as, more broadly, to all psychiatric disorders.

In healthy young and elderly adults, hypothalamic-pituitary-adrenocortical axis reactivity (HPA AR) varies with increasing pharmacological challenge and with age, but not with gender

BACKGROUND

Hypothalamic-pituitary-adrenocortical axis reactivity (HPA AR) is the key indicator of the psychophysiological response to stress. The HPA AR may vary with age and gender. To investigate these factors concurrently, the aims of the present study were to observe HPA AR (plasma ACTH and plasma cortisol) in response to a pharmacological challenge (dexamethasone/corticotropin releasing hormone test: DEX/CRH-test) and as a function of age and gender.

METHOD

19 young (10 females and 9 males; mean age = 24.05 years) and 23 elderly (11 females and 12 males; mean age = 71.61 years) healthy volunteers took part in the study. To assess HPA AR, participants underwent the combined DEX/CRH test applied with the following DEX doses: 0.75, 1.5, and 3.0 mg, respectively.

RESULTS

A dose-dependent response was observed in young adult participants, but not in elderly participants. With increasing DEX doses, ACTH and cortisol values decreased in young adult participants, while the decrease was blunted among elderly compared to young adult participants. No differences were observed for gender.

CONCLUSIONS

Results point to diminished HPA axis sensitivity as an effect of normal aging, irrespective of gender. Therefore, altered HPA regulation in old age should be taken into account for developing new therapeutic approaches acting on the HPA axis and its receptor mechanisms.

Intensive two-day cognitive-behavioral intervention decreases cortisol secretion in soldiers suffering from specific phobia to wear protective mask

RESEARCH QUESTIONS

Wearing a protective mask is compulsory for those in professions such as fire-fighters, rescue personnel and soldiers. The phobia to wear a protective mask is considered a specific claustrophobia and may become of major concern during military service. To date, no data are available with respect to the hypothalamus-pituitary-adrenocortical system activity (HPA SA) for both the so-called protective mask phobia (PMP) and its treatment. The aim of the present study was three-fold: 1) to assess HPA SA in soldiers suffering from PMP before and after intensive cognitive-behavioral treatment, 2) to compare these data with controls, and 3) to relate these data to subjective sleep.

METHODS

46 Swiss Army recruits suffering from PMP were enrolled in a two-day intensive treatment course. During initial and final assessments, saliva was sampled to analyse HPA SA via salivary cortisol; saliva samples were also gathered in the morning. For comparison, saliva samples were gathered of 39 Emergency Rescue Service (ERS) recruits. All participants also completed a questionnaire related to sleep and to anxiety.

RESULTS

Compared to controls from the ERS, among army recruits suffering from PMP, cortisol secretion was significantly higher during initial and final assessments, and in the morning. Cortisol secretion decreased from initial and final assessment. Subjectively assessed sleep was more impaired in recruits suffering from PMP compared to controls. After cognitive-behavioral treatment, all recruits suffering from PMP were able to wear the protective mask.

CONCLUSIONS

Specific phobia about wearing a protective mask is treatable via a two-day intensive course. Treatment success is reflected in modified HPA SA. Methodology and results may be transferred to treat patients suffering from sleep apnea syndrome and presenting high anxiety about wearing continuous positive airway pressure devices.