Current status on behavioral and biological markers of PTSD: a search for clarity in a conflicting literature

Post traumatic stress disorder associated hypothalamic-pituitary-adrenal axis dysregulation and physical illness

Conventional human stress responses are mediated by the sympathetic adrenal medullar (SAM) axis and the hypothalamic pituitary adrenal (HPA) axis. The SAM axis mediates the immediate response to stress through norepinephrine and epinephrine while the HPA axis mediates the slow response through corticosteroids, primarily cortisol, to effect systemic changes. Post Traumatic Stress Disorder (PTSD), a psychiatric disorder that develops in a small subset of people exposed to a traumatic event, may dysregulate these systems and result in increased risk of various clinical conditions. These conditions include but are not limited to cardiovascular disease, metabolic conditions, autoimmune diseases, neurocognitive disorders, and women's health complications such as preterm birth, polycystic ovarian syndrome, and endometriosis to name a few. This review focuses on how PTSD dysregulates the HPA axis, and further, how these alterations affect the immune system and physical health outcomes.

Longitudinal associations between early post-injury serum BDNF levels and the development of post-traumatic stress disorder over two years

BACKGROUND

This study investigated the longitudinal associations between serum BDNF (sBDNF) levels measured early after injury and the onset of post-traumatic stress disorder (PTSD) across two years.

METHODS

Patients with moderate to severe physical injuries were enrolled from a trauma center. At baseline, sBDNF levels were measured and a comprehensive socio-demographic and clinical data were collected. The range of time from physical injuries to blood collection was 1-28 days, with a median (IQR) of 8.0 (6.0) days. PTSD diagnoses were determined at 3, 6, 12, and 24 months post-injury using the CAPS-5. Linear regression analyses assessed the relationship between sBDNF levels and PTSD diagnoses.

RESULTS

Out of 923 patients, 112 (12.1 %) developed PTSD during the study. Prevalence rates were 8.8 % at 3 months, 7.6 % at 6 months, 4.8 % at 12 months, and 3.7 % at 24 months. Significantly, lower sBDNF levels were associated with PTSD at 12 and 24 months, after adjusting for covariates and applying Bonferroni corrections, but not at earlier assessments.

LIMITATIONS

Focusing on patients with moderate to severe injuries from a single center may limit the findings' generalizability.

CONCLUSION

Early post-injury sBDNF levels are predictive biomarkers for PTSD, especially significant at 12 and 24 months post-injury.

Association between hair cortisol concentration and acute stress symptoms in family members of critically ill patients: a cross-sectional study

OBJECTIVE

The aim of this study was to investigate whether there is an association between hair cortisol concentrations and acute stress symptoms in family members of critically ill patients.

METHODS

A cross-sectional study was conducted in an adult intensive care unit of a tertiary hospital in Porto Alegre, Brazil, from August 2021 to February 2022. Family members of intensive care unit patients admitted for more than 10 days were approached for enrollment. We collected sociodemographic data and assessed resilience, religiosity, and symptoms of acute stress among family members. Samples of family members' hair were collected shortly after the interview to measure the hair cortisol concentration.

RESULTS

A total of 110 family members were included in this study. Eighty-eight (80.0%) family members presented with symptoms of acute stress. The median hair cortisol concentration was 2.37pg/mg (1.16 - 5.06pg/mg). There was no significant difference in hair cortisol concentration between family members with and without acute stress symptoms (p = 0.419). According to the multivariate analysis, only the fact that the patient was alert at the time of the family member's interview was significantly associated with the prevalence of acute stress symptoms in the family member.

CONCLUSION

We did not find an association between the hair cortisol concentration of family members in hair segments in the months prior to admission to the intensive care unit and the occurrence of acute stress symptoms.

Subjective sleep parameters: A marker to PTSD symptoms evolution? A 4-year longitudinal study

Disturbed sleep is a common feature after exposure to a traumatic event, especially when PTSD develops. However, although there is evidence suggesting a potential role of sleep disturbance in the progression of PTSD symptoms, the interrelationship between sleep and PTSD symptoms has yet to be determined. In order to address this knowledge gap, we have investigated the influence of initial sleep characteristics on the evolution of post-traumatic stress disorder (PTSD) symptoms over 4 years of follow-up among individuals exposed to the Brazilian Kiss nightclub fire. Participants were individuals exposed to the 2013 Kiss nightclub fire in Brazil. Sleep characteristics and PTSD symptoms were measured within the 4 years following the fire by self-report questionnaires, such as The Pittsburgh Sleep Quality Index (PSQI), and PTSD Checklist - Civilian version (PCL-C). Generalized estimating equations (GEE) models were used to examine the longitudinal associations (by estimating the relative effects of initial sleep problems on PTSD symptoms after adjusting for covariates). Comprehensive information concerning socio-demographic factors, health status, and sleep complaints were obtained. A total of 232 individuals were included. In GEE models, no significant interactions were observed between sociodemographic variables and PTSD symptoms in the follow-up period, however, associations were found between PTSD at baseline and the following factors: the female gender, the victim individuals and the existence of prior psychiatric disease. Initial subjective sleep parameters were strongly associated with PTSD symptoms over 4 years, mainly the presence of disturbed dreams (p = 0.012), increased sleep latency (p = 0.029), and reduced sleep duration (p = 0.012). Sleep complaints and PTSD symptoms were common among individuals after the disaster. The current study has found that the presence of sleep complaints, especially increased sleep latency, presence of disturbed dreams and short sleep duration, in the initial presentation after the fire was consistently associated with the perpetration of PTSD symptoms in the next 4 years of follow-up. These findings suggest that interventions addressing these sleep complaints have the potential to reduce the persistence and/or severity of PTSD symptoms.

The Role of the Orbitofrontal Cortex in the Regulation of Fear Coping Strategies

ABSTRACT

Under threats, individuals exhibit freezing behavior and prepare for active coping. The ability to flexibly shift between freezing and active coping increases survival chances in animals and decreases susceptibility to mental disorders among human beings. For example, patients with psychiatric disorders, such as obsessive-compulsive disorder and posttraumatic stress disorder, often show maladaptive coping behaviors. The orbitofrontal cortex (OFC) is a critical hub to process higher cognitive functions, sensory inputs, reward learning, and decision-making. It also regulates negative emotions and its aberrant activation level often correlates with numerous mental disorders. The rodent OFC comprises different subdivisions with varying connections to cortical and subcortical regions. Among these subdivisions, the medial orbital area (MO) and the lateral orbital area (LO) have distinct functions in the regulation of fear. Here, we updated the existing rodent literature studying the function of the OFC, with a particular focus on the MO and the LO in different coping strategies of animals. By examining the role of the OFC in the mediation of defensive coping strategies, we aim to deepen the understanding of its functional importance on mental health.

Holocaust centrality, anxiety, and other risk factors associated with terror threat salience among descendants of Holocaust survivors

The study examined risk factors for sensitivity to terror threats among descendants of Holocaust survivors (Holocaust G1) during a significant rise in terrorist attacks in Israel. We examined the association of the number of familial Holocaust G1, trauma exposure, probable posttraumatic stress disorder (PTSD), anxiety symptoms, and Holocaust centrality with terror threat salience (TTS) in children and grandchildren of Holocaust G1 (Holocaust G2; G3). A web-based national sample included 297 Holocaust G2 (Mage=62.95, SD=10.25), 224 comparison G2 (Mage=61.79, SD=10.13), 379 Holocaust G3 (Mage=34.02, SD=8.65) and 171 comparison G3 (Mage=33.55, SD=8.26). Participants completed questionnaires on background characteristics, Holocaust background, trauma exposure, probable PTSD, anxiety symptoms, Holocaust centrality, and TTS. Findings showed that Holocaust G2 and G3 reported higher Holocaust centrality and TTS relative to comparisons, and Holocaust G3 reported higher levels of anxiety than comparison G3. The number of Holocaust G1, background characteristics, Holocaust centrality, and anxiety symptoms were associated with TTS in G2 and G3. Probable PTSD and trauma exposure were also associated with TTS in G2 and G3, respectively. Results highlight Holocaust centrality and anxiety among the factors associated with an increased preoccupation with terror threats in Holocaust descendants. Practitioners should implement interventions focusing on these factors, particularly at times of increased terrorism.

Exogenous glucocorticoids to improve extinction learning for post-traumatic stress disorder patients with hypothalamic-pituitary-adrenal-axis dysregulation: a study protocol description

Background: Trauma-focused treatments for post-traumatic stress disorder (PTSD) are effective for many patients. However, relapse may occur when acquired extinction memories fail to generalize beyond treatment contexts. A subgroup of PTSD patients - potentially with substantial exposure to early-life adversity (ELA) - show dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which results in lower cortisol levels. Glucocorticoids, including cortisol, appear to facilitate strength and generalization of emotional memories.Objective: We describe the protocol of an integrated PTSD study. We investigate (A) associations between HPA-axis dysregulation, ELA, epigenetic markers, and PTSD treatment outcome (observational study); and (B) effects of exogenous glucocorticoids on strength and generalization of extinction memories and associated neural mechanisms [pharmacological intervention study with functional magnetic resonance imaging (fMRI)]. The objective is to provide proof of concept that PTSD patients with HPA-axis dysregulation often experienced ELA and may show improved strength and generalization of extinction learning after glucocorticoid administration.Method: The observational study (n = 160 PTSD group, n = 30 control group) assesses ELA, follow-up PTSD symptoms, epigenetic markers, and HPA-axis characteristics (salivary cortisol levels during low-dose dexamethasone suppression test and socially evaluated cold-pressor test). The pharmacological intervention study (n = 80 PTSD group, with and without HPA-axis dysregulation) is a placebo-controlled fMRI study with a crossover design. To investigate strength and generalization of extinction memories, we use a differential fear acquisition, extinction, and extinction recall task with spatial contexts within a virtual environment. Prior to extinction learning, 20 mg hydrocortisone or placebo is administered. During next-day recall, strength of the extinction memory is determined by recovery of skin conductance and pupil dilation differential responding, whereas generalization is assessed by comparing responses between different spatial contexts.Conclusion: The integrated study described in the current protocol paper could inform a personalized treatment approach in which these PTSD patients may receive glucocorticoids as a treatment enhancer in trauma-focused therapies.Trial registration: The research project is registered in the European Union Drug Regulating Authorities Clinical Trials (EudraCT) database, https://eudract.ema.europa.eu/, EudraCT number 2020-000712-30.

Memory Under Stress: From Adaptation to Disorder

Stressful events are ubiquitous in everyday life. Exposure to these stressors initiates the temporally orchestrated release of a multitude of hormones, peptides, and neurotransmitters that target brain areas that have been critically implicated in learning and memory. This review summarizes recent insights on the profound impact of stress on 4 fundamental processes of memory: memory formation, memory contextualization, memory retrieval, and memory flexibility. Stress mediators instigate dynamic alterations in these processes, thereby facilitating efficient responding under stress and the creation of a decontextualized memory representation that can effectively aid coping with novel future threats. While they are generally adaptive, the same stress-related changes may contribute to the rigid behaviors, uncontrollable intrusions, and generalized fear responding seen in anxiety disorders and posttraumatic stress disorder. Drawing on recent discoveries in cognitive neuroscience and psychiatry, this review discusses how stress-induced alterations in memory processes can simultaneously foster adaptation to stressors and fuel psychopathology. The transition from adaptive to maladaptive changes in the impact of stress on memory hinges on the nuanced interplay of stressor characteristics and individual predispositions. Thus, taking individual differences in the cognitive response to stressors into account is essential for any successful treatment of stress-related mental disorders.

The association between looming cognitive style and posttraumatic stress symptoms: The case of older Holocaust survivors

The looming cognitive style (LCS) refers to a tendency to produce mental illustrations and images of adverse events and potentially threatening situations with perceived accumulating threat and danger. LCS is a well-known cognitive vulnerability for anxiety, nevertheless few studies examined the relationship between LCS and posttraumatic reactions. Among the existing studies, a higher LCS was reported in Holocaust survivors relative to matched comparisons, and directly associated with posttraumatic stress symptoms (PTSS) in older Holocaust survivors. The current study aimed to expand the understanding of the relationship between LCS with PTSS in general, and among older Holocaust survivors in particular. Moreover, whether the number of Holocaust experiences encountered by Holocaust survivors moderated this relationship. The sample consisted of 153 older Holocaust survivors (Mage = 82.42, SD = 5.75). Participants were interviewed regarding their background characteristics, PTSS, LCS, and number of Holocaust experiences. Participants reporting higher LCS showed higher PTSS. There was an interaction between LCS and number of Holocaust experiences for predicting PTSS, suggesting that LCS was associated with higher PTSS to a stronger degree among Holocaust survivors who experienced a smaller number of Holocaust experiences. The findings indicate that Holocaust trauma may have influenced the LCS of Holocaust survivors throughout their lives and into old age. The results provide insight for mental health practitioners treating older Holocaust survivors in focusing on reducing schematic processing biases for threat information and anxiety to enhance better mental health for those suffering from posttraumatic stress symptoms.

Targeting Human Glucocorticoid Receptors in Fear Learning: A Multiscale Integrated Approach to Study Functional Connectivity

Fear extinction is a phenomenon that involves a gradual reduction in conditioned fear responses through repeated exposure to fear-inducing cues. Functional brain connectivity assessments, such as functional magnetic resonance imaging (fMRI), provide valuable insights into how brain regions communicate during these processes. Stress, a ubiquitous aspect of life, influences fear learning and extinction by changing the activity of the amygdala, prefrontal cortex, and hippocampus, leading to enhanced fear responses and/or impaired extinction. Glucocorticoid receptors (GRs) are key to the stress response and show a dual function in fear regulation: while they enhance the consolidation of fear memories, they also facilitate extinction. Accordingly, GR dysregulation is associated with anxiety and mood disorders. Recent advancements in cognitive neuroscience underscore the need for a comprehensive understanding that integrates perspectives from the molecular, cellular, and systems levels. In particular, neuropharmacology provides valuable insights into neurotransmitter and receptor systems, aiding the investigation of mechanisms underlying fear regulation and potential therapeutic targets. A notable player in this context is cortisol, a key stress hormone, which significantly influences both fear memory reconsolidation and extinction processes. Gaining a thorough understanding of these intricate interactions has implications in terms of addressing psychiatric disorders related to stress. This review sheds light on the complex interactions between cognitive processes, emotions, and their neural bases. In this endeavor, our aim is to reshape the comprehension of fear, stress, and their implications for emotional well-being, ultimately aiding in the development of therapeutic interventions.

Psychophysiological reactions during the trauma-film paradigm and their predictive value for intrusions

Background: Adequate adaptation of the autonomic nervous system (ANS) is crucial in potentially life-threatening situations. The defence cascade provides a descriptive model of progressing dominant physiological reactions in such situations, including cardiovascular parameters and body mobility. The empirical evidence for this model is scarce, and the influence of physiological reactions in this model for predicting trauma-induced intrusions is unresolved.Objectives: Using a trauma-film paradigm, we aimed to test physiological reactions to a highly stressful film as an analogue to a traumatic event along the defence cascade model. We also aimed to examine the predictive power of physiological activity for subsequent intrusive symptoms.Method: Forty-seven healthy female participants watched a stressful and a neutral film in randomized order. Heart rate (HR), heart rate variability (HRV), and body sway were measured. Participants tracked frequency, distress, and quality of subsequent intrusions in a diary for 7 consecutive days.Results: For the stressful film, we observed an initial decrease in HR, followed by an increase, before the HR stabilized at a high level, which was not found during the neutral film. No differences in HRV were observed between the two films. Body sway and trembling frequency were heightened during the stressful film. Neither HR nor HRV predicted subsequent intrusions, whereas perceived distress during the stressful film did.Conclusions: Our results suggest that the physiological trauma-analogue response is characterized by an orientation response and subsequent hyperarousal, reaching a high physiological plateau. In contrast to the assumptions of the defence cascade model, the hyperarousal was not followed by downregulation. Potential explanations are discussed. For trauma-associated intrusions in the subsequent week, psychological distress during the film seems to be more important than physiological distress. Understanding the interaction between physiological and psychological responses during threat informs the study of ANS imbalances in mental disorders such as post-traumatic stress disorder.

Hypothalamus and Post-Traumatic Stress Disorder: A Review

Humans have lived in a dynamic environment fraught with potential dangers for thousands of years. While fear and stress were crucial for the survival of our ancestors, today, they are mostly considered harmful factors, threatening both our physical and mental health. Trauma is a highly stressful, often life-threatening event or a series of events, such as sexual assault, war, natural disasters, burns, and car accidents. Trauma can cause pathological metaplasticity, leading to long-lasting behavioral changes and impairing an individual's ability to cope with future challenges. If an individual is vulnerable, a tremendously traumatic event may result in post-traumatic stress disorder (PTSD). The hypothalamus is critical in initiating hormonal responses to stressful stimuli via the hypothalamic-pituitary-adrenal (HPA) axis. Linked to the prefrontal cortex and limbic structures, especially the amygdala and hippocampus, the hypothalamus acts as a central hub, integrating physiological aspects of the stress response. Consequently, the hypothalamic functions have been attributed to the pathophysiology of PTSD. However, apart from the well-known role of the HPA axis, the hypothalamus may also play different roles in the development of PTSD through other pathways, including the hypothalamic-pituitary-thyroid (HPT) and hypothalamic-pituitary-gonadal (HPG) axes, as well as by secreting growth hormone, prolactin, dopamine, and oxytocin. This review aims to summarize the current evidence regarding the neuroendocrine functions of the hypothalamus, which are correlated with the development of PTSD. A better understanding of the role of the hypothalamus in PTSD could help develop better treatments for this debilitating condition.

Altered whole-brain resting-state functional connectivity and brain network topology in typhoon-related post-traumatic stress disorder

Background

Altered resting-state functional connectivity has been found in patients with post-traumatic stress disorder (PTSD). However, the alteration of resting-state functional connectivity at whole-brain level in typhoon-traumatized individuals with PTSD remains largely unknown.

Objectives

To investigate changes in whole-brain resting-state functional connectivity and brain network topology in typhoon-traumatized subjects with and without PTSD.

Design

Cross-sectional study.

Methods

Twenty-seven patients with typhoon-related PTSD, 33 trauma-exposed controls (TEC), and 30 healthy controls (HC) underwent resting-state functional MRI scanning. The whole brain resting-state functional connectivity network was constructed based on the automated anatomical labeling atlas. The graph theory method was used to analyze the topological properties of the large-scale resting-state functional connectivity network. Whole-brain resting-state functional connectivity and the topological network property were compared by analyzing the variance.

Results

There was no significant difference in the area under the curve of γ, λ, σ, global efficiency, and local efficiency among the three groups. The PTSD group showed increased dorsal cingulate cortex (dACC) resting-state functional connectivity with the postcentral gyrus (PoCG) and paracentral lobe and increased nodal betweenness centrality in the precuneus relative to both control groups. Compared with the PTSD and HC groups, the TEC group showed increased resting-state functional connectivity between the hippocampus and PoCG and increased connectivity strength in the putamen. In addition, compared with the HC group, both the PTSD and TEC groups showed increased connectivity strength and nodal efficiency in the insula.

Conclusion

Aberrant resting-state functional connectivity and topology were found in all trauma-exposed individuals. These findings broaden our knowledge of the neuropathological mechanisms of PTSD.

Exploration driven by a medial preoptic circuit facilitates fear extinction in mice

Repetitive exposure to fear-associated targets is a typical treatment for patients with panic or post-traumatic stress disorder (PTSD). The success of exposure therapy depends on the active exploration of a fear-eliciting target despite an innate drive to avoid it. Here, we found that a circuit running from CaMKIIα-positive neurons of the medial preoptic area to the ventral periaqueductal gray (MPA-vPAG) facilitates the exploration of a fear-conditioned zone and subsequent fear extinction in mice. Activation or inhibition of this circuit did not induce preference/avoidance of a specific zone. Repeated entries into the fear-conditioned zone, induced by the motivation to chase a head-mounted object due to MPA-vPAG circuit photostimulation, facilitated fear extinction. Our results show how the brain forms extinction memory against avoidance of a fearful target and suggest a circuit-based mechanism of exposure therapy.

11β-Hydroxysteroid dehydrogenase 1 deficiency prevents PTSD-like memory in young adult mice

Post-traumatic stress disorder (PTSD) is characterized by the co-existence of a persistent strong memory of the traumatic experience and amnesia for the peritraumatic context. Most animal models, however, fail to account for the contextual amnesia which is considered to play a critical role in the etiology of PTSD intrusive memories. It is also unclear how aging affects PTSD-like memory. Glucocorticoids alter the formation and retention of fear-associated memory. Here, we investigated whether a deficiency of 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) (an intracellular glucocorticoid generating enzyme) and aging modulates fear conditioning and PTSD-like memory in mice. We first measured memory in 6 months and 24 months old 11β-HSD1 deficient (HSD1 KO) and wildtype (WT) mice following paired tone-shock fear conditioning. Then, separate groups of mice were exposed to restraint stress immediately after unpaired tone-shock contextual fear conditioning. Compared with young controls, aged WT mice exhibited enhanced auditory cued fear memory, but contextual fear memory was not different. Contextual fear memory retention was attenuated in both young and aged HSD1 KO mice. In contrast, auditory cued fear memory was reduced 24 h after training only in aged HSD1 KO mice. When fear conditioned with stress, WT mice displayed PTSD-like memory (i.e., increased fear to tone not predictive of shock and reduced fear to 'aversive' conditioning context); this was unchanged with aging. In contrast, young HSD1 KO mice fear conditioned with stress showed normal fear memory (i.e., increased fear response to conditioning context), as observed in WT mice fear conditioned alone. While aged HSD1 KO mice fear conditioned with stress also displayed normal contextual fear memory, the fear response to the 'safe' tone remained. Thus, a deficiency of 11β-HSD1 protects against both amnesia for the conditioning context and hypermnesia for a salient tone in young adult mice but only contextual amnesia is prevented in aged mice. These results suggest that brain 11β-HSD1 generated glucocorticoids make a significant contribution to fear conditioning and PTSD-like memory. 11β-HSD1 inhibition may be useful in prevention and/or treatment of PTSD.

Biological Psychiatry in Displaced Populations: What We Know, and What We Need to Begin to Learn

Conflict and climate change continue to displace millions of people, who experience unique trauma and stressors as they resettle in host countries. Both children and adults who are forcibly displaced, or choose to migrate, experience posttraumatic stress disorder, anxiety, depression, and other mental health conditions at higher rates than the general population. This may be attributed to severe, cumulative stress and trauma (largely interpersonal traumas); discrimination and harassment in host countries; and structural barriers to accessing and addressing mental health concerns, including clinician availability, language barriers, cultural differences, geographic accessibility, health care access, and stigma. Despite high exposure to and clinical impact of such experiences, and despite representing 1% of the world population, forcibly displaced people are underrepresented in neuroscientific research. The availability of such literature and research findings is significant in understanding the unique genetic and cultural aspects of trauma- and stress-related mental health, advocacy, reducing stigma, informing prevention, and treatment. The present work aimed to explore how the field of neuroscience can address mental health equity for individuals who have been uprooted in relation to land, with a focus on refugee populations. We offer practical suggestions on how to improve research in this area and narrow the gap in knowledge.

Identifying child protection workers at risk for secondary traumatization: A latent class analysis of the Professional Quality of Life Scale-5

Secondary traumatization (ST) is a topical area among trauma-exposed employees, where many are at risk of occupational mental health problems due to their work with trauma survivors. Challenges related to the accurate operationalization of ST symptoms persist, and there is no valid method for identifying employees at risk of clinically significant symptom levels. This study aimed to test the applicability of latent class analysis (LCA) to identify employees at risk for clinically relevant ST symptoms. LCA was used to identify patterns of ST symptom endorsement using the Professional Quality of Life Scale-5 (ProQoL) in a national sample of Danish child protection workers (CPW; N = 545). Predictors and associated levels of distress and functional impairment across the symptom presentations were tested using regression analysis, and three classes were identified. A total of 3.8% (n = 21) of participants were at high risk of endorsing symptoms of ST that were associated with significant levels of distress and increased functional impairment. The LCA approach outperformed existing scoring procedures in differentiating between employees with varying levels of distress, impairment, and well-being. A minority of Danish CPWs are at risk for levels of ST that may be considered clinically significant for their associations with anxiety and social and cognitive impairment. Although the ProQoL is not a diagnostic tool, per se, a revised scoring procedure may render the measure useful when screening for employees who are at risk for levels of distress and impairment that require intervention.

Increased immuno-inflammatory mediators in women with post-traumatic stress disorder after sexual assault: 1-Year follow-up

BACKGROUND

Sexual violence is a traumatic event that can trigger post-traumatic stress disorder (PTSD) and generate biological responses to stress characterized by inhibiting the hypothalamic-pituitary axis (HPA), altering immune activity, and changing the structure and function of the brain. PTSD is associated with increased levels of inflammatory markers. This study aimed to measure differences in inflammatory markers and HPA hormone levels between women with PTSD due to sexual violence and controls at baseline and after 1-year follow-up.

METHODS

Fifty-eight women with PTSD resulting from sexual assault occurring up to 6 months prior were compared to 41 female controls. The patients were followed for 1 year. At baseline (T1), we measured inflammatory biomarkers. We also applied the Mini International Neuropsychiatric Interview (MINI), the Clinician-Administered Post-Traumatic Stress Disorder Scale-5, the Beck Depression Inventory, the Beck Anxiety Inventory, and the Childhood Trauma Questionnaire. The patients were randomized to receive treatment with sertraline or interpersonal psychotherapy for 14 weeks (T2) and then continued the usual treatment if deemed necessary for 1 year. The same interviews and examinations were repeated after 1 year (T3).

RESULTS

At baseline, the patients had significantly higher adrenocorticotropic hormone levels, compared to controls; however, there was no baseline difference in inflammatory markers or cortisol. After 1 year, there were significantly higher levels of interleukin-1β (p < 0.0001), monocyte chemoattractant protein-1 (p < 0.0001), tumor necrosis factor-α (p < 0.0001), c-reactive protein (p < 0.0001), and cortisol (p = 0.046) in the patient group. In addition to PTSD, 56 patients presented with a major depressive episode at T1 (according to the MINI). At the end of 1 year, there was a significant improvement in depressive (p < 0.001), anxiety (p = 0.03), and PTSD symptoms (p < 0.001) regardless of the treatment received.

DISCUSSION

The increase of the inflammatory markers after 1 year, even with symptomatic improvement, may indicate that PTSD following sexual violence is associated with high depressive symptoms. This association may have a different pattern of immunoendocrine alterations than PTSD only. Furthermore, these alterations may persist in the long term, even with the improvement of the symptoms, probably generating an immunological imprint that can lead to future clinical consequences. This study adds to the current knowledge of PTSD neurobiology and contributes to broadening approaches to this disorder.

Propranolol versus Other Selected Drugs in the Treatment of Various Types of Anxiety or Stress, with Particular Reference to Stage Fright and Post-Traumatic Stress Disorder

Propranolol, a non-cardioselective β1,2 blocker, is most commonly recognised for its application in the therapy of various cardiovascular conditions, such as hypertension, coronary artery disease, and tachyarrhythmias. However, due to its ability to cross the blood-brain barrier and affinity towards multiple macromolecules, not only adrenoreceptors, it has also found application in other fields. For example, it is one of the very few medications successfully applied in the treatment of stage fright. This review focuses on the application of propranolol in the treatment of various types of anxiety and stress, with particular reference to stage fright and post-traumatic stress disorder (PTSD). Both mechanisms of action as well as comparison with other therapies are presented. As those indications for propranolol are, in most countries, considered off-label, this review aims to gather information that can be useful while making a decision about the choice of propranolol as a drug in the treatment of those mental conditions.

Role of noradrenergic arousal for fear extinction processes in rodents and humans

Fear extinction is a learning mechanism that is pivotal for the inhibition of fear responses towards cues or contexts that no longer predict the occurrence of a threat. Failure of fear extinction leads to fear expression under safe conditions and is regarded to be a cardinal characteristic of many anxiety-related disorders and posttraumatic stress disorder. Importantly, the neurotransmitter noradrenaline was shown to be a potent modulator of fear extinction. Rodent studies demonstrated that excessive noradrenaline transmission after acute stress opens a time window of vulnerability, in which fear extinction learning results in attenuated long-term extinction success. In contrast, when excessive noradrenergic transmission subsides, well-coordinated noradrenaline transmission is necessary for the formation of a long-lasting extinction memory. In addition, emerging evidence suggests that the neuropeptide corticotropin releasing hormone (CRF), which strongly regulates noradrenaline transmission under conditions of acute stress, also impedes long-term extinction success. Recent rodent work - using sophisticated methods - provides evidence for a hypothetical mechanistic framework of how noradrenaline and CRF dynamically orchestrate the neural fear and extinction circuitry to attenuate or to improve fear extinction and extinction recall. Accordingly, we review the evidence from rodent studies linking noradrenaline and CRF to fear extinction learning and recall and derive the hypothetical mechanistic framework of how different levels of noradrenaline and CRF may create a time window of vulnerability which impedes successful long-term fear extinction. We also address evidence from human studies linking noradrenaline and fear extinction success. Moreover, we accumulate emerging approaches to non-invasively measure and manipulate the noradrenergic system in healthy humans. Finally, we emphasize the importance of future studies to account for sex (hormone) differences when examining the interaction between fear extinction, noradrenaline, and CRF. To conclude, NA's effects on fear extinction recall strongly depend on the arousal levels at the onset of fear extinction learning. Our review aimed at compiling the available (mainly rodent) data in a neurobiological framework, suited to derive testable hypotheses for future work in humans.

Predicting Posttraumatic Stress Disorder Among Survivors of Recent Interpersonal Violence

A substantial minority of women who experience interpersonal violence will develop posttraumatic stress disorder (PTSD). One critical challenge for preventing PTSD is predicting whose acute posttraumatic stress symptoms will worsen to a clinically significant degree. This 6-month longitudinal study adopted multilevel modeling and exploratory machine learning (ML) methods to predict PTSD onset in 58 young women, ages 18 to 30, who experienced an incident of physical and/or sexual assault in the three months prior to baseline assessment. Women completed baseline assessments of theory-driven cognitive and neurobiological predictors and interview-based measures of PTSD diagnostic status and symptom severity at 1-, 3-, and 6-month follow-ups. Higher levels of self-blame, generalized anxiety disorder severity, childhood trauma exposure, and impairment across multiple domains were associated with a pattern of high and stable posttraumatic stress symptom severity over time. Predictive performance for PTSD onset was similarly strong for a gradient boosting machine learning model including all predictors and a logistic regression model including only baseline posttraumatic stress symptom severity. The present findings provide directions for future work on PTSD prediction among interpersonal violence survivors that could enhance early risk detection and potentially inform targeted prevention programs.

Post-traumatic stress disorder prevalence and sleep quality in fire victims and rescue workers in southern Brazil: a cross-sectional study

OBJECTIVES

This survey was conducted to evaluate the prevalence of post-traumatic stress disorder (PTSD) and the sleep quality in victims and rescue team of the third deadliest nightclub fire in the world.

STUDY DESIGN

A cross-sectional study.

METHODS

Participants were victims and rescue workers exposed to a fire at a nightclub, which occurred in January 2013 in Southern Brazil. The Pittsburgh Sleep Quality Index (PSQI), composed of seven subjective sleep variables (including daytime dysfunction), and PTSD Checklist - Civilian version (PCL-C) were applied to all people who sought medical attention at the local reference center in the first year after the event. Comprehensive information was obtained concerning sociodemographic factors, health status, and sleep complaints.

RESULTS

A total of 370 individuals, 190 victims and 180 rescue workers, were included. Participants were 70% male, with an average age of 29 years. The prevalence of PTSD was 31.9%, ranging from 24.4% for rescue workers to 38.9% for victims. The prevalence of poor sleep quality was 65.9%, ranging from 56.1% for rescue workers to 75.3% for victims. Most of the participants with PTSD (91.5%) had PSQI scores >5 (poor sleepers), against 54.0% of the non-PTSD individuals. All seven PSQI subscores showed significant differences between PTSD and non-PTSD individuals, especially daytime dysfunction. Sex, shift work, previous psychiatric disease, and sleep quality remained associated with PTSD in adjusted models, with a prevalence ratio (95% CI) of 1.76 (1.28-2.43) in females, 1.73 (1.17-2.55) in shift workers, 1.36 (1.03-1.80) in individuals with psychiatric disease history, and 5.42 (2.55-11.52) in poor sleepers.

CONCLUSIONS

The presence of daytime dysfunction increased by at least tenfold the prevalence of PTSD in this sample. Considering that daytime dysfunction was shown to be strongly associated with PTSD, sleep-related issues should be addressed in the assessment of individuals exposed to traumatic events, both victims and rescuers. Factors like shift work and female sex were also associated with PTSD, especially among victims.

Posttraumatic stress disorder hyperarousal event detection using smartwatch physiological and activity data

Posttraumatic Stress Disorder (PTSD) is a psychiatric condition affecting nearly a quarter of the United States war veterans who return from war zones. Treatment for PTSD typically consists of a combination of in-session therapy and medication. However; patients often experience their most severe PTSD symptoms outside of therapy sessions. Mobile health applications may address this gap, but their effectiveness is limited by the current gap in continuous monitoring and detection capabilities enabling timely intervention. The goal of this article is to develop a novel method to detect hyperarousal events using physiological and activity-based machine learning algorithms. Physiological data including heart rate and body acceleration as well as self-reported hyperarousal events were collected using a tool developed for commercial off-the-shelf wearable devices from 99 United States veterans diagnosed with PTSD over several days. The data were used to develop four machine learning algorithms: Random Forest, Support Vector Machine, Logistic Regression and XGBoost. The XGBoost model had the best performance in detecting onset of PTSD symptoms with over 83% accuracy and an AUC of 0.70. Post-hoc SHapley Additive exPlanations (SHAP) additive explanation analysis showed that algorithm predictions were correlated with average heart rate, minimum heart rate and average body acceleration. Findings show promise in detecting onset of PTSD symptoms which could be the basis for developing remote and continuous monitoring systems for PTSD. Such systems may address a vital gap in just-in-time interventions for PTSD self-management outside of scheduled clinical appointments.

Sensitivity and Resilience to Predator Stress-Enhanced Ethanol Drinking Is Associated With Sex-Dependent Differences in Stress-Regulating Systems

Stress can increase ethanol drinking, and evidence confirms an association between post-traumatic stress disorder (PTSD) and the development of alcohol use disorder (AUD). Exposure to predator odor is considered a traumatic stressor, and predator stress (PS) has been used extensively as an animal model of PTSD. Our prior work determined that repeated exposure to intermittent PS significantly increased anxiety-related behavior, corticosterone levels, and neuronal activation in the hippocampus and prefrontal cortex in naïve male and female C57BL/6J mice. Intermittent PS exposure also increased subsequent ethanol drinking in a subgroup of animals, with heterogeneity of responses as seen with comorbid PTSD and AUD. The present studies built upon this prior work and began to characterize “sensitivity” and “resilience” to PS-enhanced drinking. Ethanol drinking was measured during baseline, intermittent PS exposure, and post-stress; mice were euthanized after 24-h abstinence. Calculation of median and interquartile ranges identified “sensitive” (>20% increase in drinking over baseline) and “resilient” (no change or decrease in drinking from baseline) subgroups. Intermittent PS significantly increased subsequent ethanol intake in 24% of male (↑60%) and in 20% of female (↑71%) C57BL/6J mice in the “sensitive” subgroup. Plasma corticosterone levels were increased significantly after PS in both sexes, but levels were lower in the “sensitive” vs. “resilient” subgroups. In representative mice from “sensitive” and “resilient” subgroups, prefrontal cortex and hippocampus were analyzed by Western Blotting for levels of corticotropin releasing factor (CRF) receptor 1, CRF receptor 2, CRF binding protein, and glucocorticoid receptor, vs. separate naïve age-matched mice. In prefrontal cortex, CRF receptor 1, CRF receptor 2, CRF binding protein, and glucocorticoid receptor levels were significantly higher in “sensitive” vs. naïve and “resilient” mice only in females. In hippocampus, CRF receptor 1, CRF receptor 2 and glucocorticoid receptor levels were significantly lower in “resilient” vs. naïve and “sensitive” mice across both sexes. These results indicate that sex strongly influences the effects of ethanol drinking and stress on proteins regulating stress and anxiety responses. They further suggest that targeting the CRF system and glucocorticoid receptors in AUD needs to consider the comorbidity of PTSD with AUD and sex of treated individuals.

Posttraumatic Stress Disorder, Myocardial Perfusion, and Myocardial Blood Flow: A Longitudinal Twin Study

BACKGROUND

The link between posttraumatic stress disorder (PTSD) and ischemic heart disease remains elusive owing to a shortage of longitudinal studies with a clinical diagnosis of PTSD and objective measures of cardiac compromise.

METHODS

We performed positron emission tomography in 275 twins who participated in two examinations approximately 12 years apart. At both visits, we obtained a clinical diagnosis of PTSD, which was classified as long-standing (both visit 1 and visit 2), late onset (only visit 2), and no PTSD (no PTSD at both visits). With positron emission tomography, we assessed myocardial flow reserve (MFR), which, in absence of significant coronary stenoses, indexes coronary microvascular function. We compared positron emission tomography data at visit 2 across the three categories of longitudinally assessed PTSD and examined changes between the two visits.

RESULTS

Overall, 80% of the twins had no or minimal obstructive coronary disease. Yet, MFR was depressed in twins with PTSD and was progressively lower across groups with no PTSD (2.13), late-onset PTSD (1.97), and long-standing PTSD (1.93) (p = .01). A low MFR (a ratio <2.0) was present in 40% of the twins without PTSD, in 56% of those with late-onset PTSD, and in 72% of those with long-standing PTSD (p < .001). Associations persisted in multivariable analysis, when examining changes in MFR between visit 1 and visit 2, and within twin pairs. Results were similar by zygosity.

CONCLUSIONS

Longitudinally, PTSD is associated with reduced coronary microcirculatory function and greater deterioration over time. The association is especially noted among twins with chronic, long-standing PTSD and is not confounded by shared environmental or genetic factors.

Autonomic nervous system correlates of posttraumatic stress symptoms in youth: Meta-analysis and qualitative review

Physiological dysregulation is a key diagnostic criterion for posttraumatic stress disorder (PTSD). While PTSD is defined by trauma exposure, symptom presentations are varied. Similarly, findings of autonomic nervous system (ANS), including parasympathetic (PNS) and sympathetic nervous system (SNS), function in youth exposed to trauma are mixed (e.g., hyporeactivity and hyperreactivity). The present meta-analysis quantitatively assesses the relation between ANS measures broadly, and PNS- and SNS-specific measures, and posttraumatic stress symptoms (PTSS) in youth (ages 4.98 to 19.55 years) across 38 cross-sectional and longitudinal studies (N = 3488). Findings demonstrate that heightened ANS activity is related to increased PTSS during stress tasks (r = 0.07), while decreased SNS activity at rest corresponded to increased PTSS (r = -0.09). The correlation between PNS measures and PTSS was non-significant. The moderation effect of age on the relation between PNS activity measured during stress tasks and PTSS approached significance, such that younger children showed a stronger negative relation between symptoms and PNS activity compared to older youth. Qualitative review of included studies revealed significant variability across sample and stressor characteristics and study methodology. Findings indicate the importance of autonomic dysregulation in youth with PTSS. Additional considerations for future research are discussed.

Classification of posttraumatic stress disorder and related outcomes in women veterans using magnetoencephalography

Women veterans represent a unique population whose experiences and neurobiology differ from that of their male counterparts. Thus, while previous research has demonstrated the utility of synchronous neural interactions (SNI) as a biomarker of posttraumatic stress disorder (PTSD) in male veterans, the utility of SNI as a biomarker of PTSD in women veterans is unclear. Here we extend that line of research to evaluate classification of women veterans with and without PTSD and other trauma-related outcomes based on functional connectivity using magnetoencephalography (MEG). A total of 121 U.S. women veterans completed diagnostic interviews and underwent a task-free MEG scan from which SNI was computed. Linear discriminant analysis was used to classify PTSD and control groups according to SNI. That discriminant function was then used to classify each individual in the partial recovery and full recovery diagnostic groups as PTSD or control. All individuals were classified correctly (100% accuracy) according to their SNI in their PTSD and control groups. Seventy-seven percent of the full recovery group and 69% of the partial recovery group were classified as control. Individual staging in PTSD recovery was captured by the Mahalanobis D² distances from the center of the control and PTSD centroid clusters. These findings provide compelling evidence supporting the utility of task-free SNI as a biomarker of PTSD and related outcomes in women veterans.

Understanding Heart Rate Reactions to Post-Traumatic Stress Disorder (PTSD) Among Veterans: A Naturalistic Study

OBJECTIVE

We collected naturalistic heart rate data from veterans diagnosed with post-traumatic stress disorder (PTSD) to investigate the effects of various factors on heart rate.

BACKGROUND

PTSD is prevalent among combat veterans in the United States. While a positive correlation between PTSD and heart rate has been documented, specific heart rate profiles during the onset of PTSD symptoms remain unknown.

METHOD

Veterans were recruited during five cycling events in 2017 and 2018 to record resting and activity-related heart rate data using a wrist-worn device. The device also logged self-reported PTSD hyperarousal events. Regression analyses were performed on demographic and behavioral covariates including gender, exercise, antidepressants, smoking habits, sleep habits, average heart rate during reported hyperarousal events, age, glucocorticoids consumption, and alcohol consumption. Heart rate patterns during self-reported PTSD hyperarousal events were analyzed using Auto Regressive Integrated Moving Average (ARIMA). Heart rate data were also compared to an open-access non-PTSD representative case.

RESULTS

Of 99 veterans with PTSD, 91 participants reported at least one hyperarousal event, with a total of 1023 events; demographic information was complete for 38 participants who formed the subset for regression analyses. The results show that factors including smoking, sleeping, gender, and medication significantly affect resting heart rate. Moreover, unique heart rate patterns associated with PTSD symptoms in terms of stationarity, autocorrelation, and fluctuation characteristics were identified.

CONCLUSION

Our findings show distinguishable heart rate patterns and characteristics during PTSD hyperarousal events.

APPLICATION

These findings show promise for future work to detect the onset of PTSD symptoms.

Neuronal Circuits Associated with Fear Memory: Potential Therapeutic Targets for Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a psychiatric disorder that is associated with long-lasting memories of traumatic experiences. Extinction and discrimination of fear memory have become therapeutic targets for PTSD. Newly developed optogenetics and advanced in vivo imaging techniques have provided unprecedented spatiotemporal tools to characterize the activity, connectivity, and functionality of specific cell types in complicated neuronal circuits. The use of such tools has offered mechanistic insights into the exquisite organization of the circuitry underlying the extinction and discrimination of fear memory. This review focuses on the acquisition of more detailed, comprehensive, and integrated neural circuits to understand how the brain regulates the extinction and discrimination of fear memory. A future challenge is to translate these researches into effective therapeutic treatment for PTSD from the perspective of precise regulation of the neural circuits associated with the extinction and discrimination of fear memories.

Social cognitive performance in posttraumatic stress disorder: A meta-analysis

BACKGROUND

Social support represents a key factor in the development of post-traumatic stress disorder (PTSD). Social cognition - the ability to perceive, interpret, and respond to other people - is considered fundamental in making use of social support. Gaining knowledge on the link between PTSD and social cognition is therefore essential. Whilst social cognitive difficulties in patients with PTSD are documented, an understanding of which particular social cognitive processes might be affected more than others, is lacking. The current meta-analysis was therefore aimed to examine social cognitive functioning in four underlying social cognitive domains (mentalization, emotion recognition, social perception, and attributional style) in PTSD diagnosed patients versus controls.

METHODS

Meta-analyzes were conducted on studies examining performance on at least one social cognitive domain in PTSD diagnosed patients compared to controls.

RESULTS

19 studies were included, involving 565 patients and 641 controls. Relative to controls, the PTSD group scored lower on overall social cognitive functioning (SMD = -0.42), specifically on mentalization (SMD = -0.81) and social perception (SMD = -0.30), whilst the latter should be interpreted with caution as only one study was found pertaining to this domain. No emotion recognition and attributional style differences were found.

LIMITATIONS

There was evidence of moderate heterogeneity in the results of the included studies for overall social cognition and attributional style.

CONCLUSIONS

Findings indicate that social cognition represents a potential important clinical factor in PTSD and underscore the importance of differentiating between underlying social cognitive processes in research and treatment of PTSD.

Differential Role of mGluR5 in Cognitive Processes in Posttraumatic Stress Disorder and Major Depression

Background

A robust literature supports the role of the metabotropic glutamate receptor type 5 (mGluR5) in cognitive functioning. mGluR5 is also implicated in the pathophysiology of posttraumatic stress disorder (PTSD) and major depressive disorder (MDD), which are characterized by cognitive alterations. However, the relationship between mGluR5 and cognition in MDD and PTSD has not yet been directly investigated. To address this gap, we examined the relationship between in vivo mGluR5 availability and cognition in PTSD, MDD, and matched healthy adults (HA).

Methods

Individuals with PTSD (N = 28) and MDD (N = 21), and HA (N = 28) were matched for age, gender, and smoking status. Participants completed 18F-FPEB positron emission tomography (PET) scan, psychiatric and cognitive assessments.

Results

Across models examining the relationship between mGluR5 availability and different domains of cognition across diagnostic groups, only the interaction of diagnosis*attention was significant (F 4,64 = 3.011, P = .024). Higher mGluR5 availability was associated with poorer attention in PTSD in 4 frontolimbic regions of interests (ROI's: OFC (r = -.441, P = .016), vmPFC (r = -.408, P = .028), dlPFC (r = -.421, P = .023), hippocampus (r = -.422, P = .025). By contrast, mGluR5 availability in the MDD group was positively related to Attention (ATTN) in the OFC (r = .590, P = .006), vmPFC (r = .653, P = .002), and dlPFC (r = .620, P = .004). Findings in the hippocampus for MDD followed the same pattern but did not survive correction for multiple comparisons (r = .480, P = .036). ATTN and mGluR5 availability were not significantly related in the HA group. Of note, in MANOVA analyses group*ATTN interaction results in the OFC did not survive multiple comparisons (P = .046). All other findings survived correction for multiple comparisons and remained significant when covarying for potential confounds (eg, depressed mood).

Conclusions

We observed a significant relationship between frontolimbic mGluR5 availability and performance on tests of attention in individuals with MDD and PTSD. This finding aligns with animal work showing dysregulation in mGluR5 in cognitive functioning, and differed as a function of diagnosis. Results suggest interventions targeting mGluR5 may help bolster cognitive difficulties, highlighting the importance of employing different mGluR5 directed treatment strategies in MDD and PTSD.

A case report of posttraumatic stress disorder at the end of life

A case of posttraumatic stress disorder (PTSD) in the last days of life is presented. It shows insufficient pharmacological therapy and PTSD that was not recognized early enough. We discuss the dilemma caused by the necessity of a long-term psychotherapy and the challenge of little time being left at the end of life. Additionally, a language barrier can be a main reason for misinterpreting symptoms of PTSD.

The symptom structure of posttraumatic stress disorder and co-morbid depression among college students with childhood abuse experience: A network analysis

BACKGROUND

Posttraumatic stress disorder (PTSD) and depression are highly co-morbid among individuals with childhood abuse history, while the mechanism of the co-morbidity is highly debated. This study sought to extent the work among college students with network analysis, which is a novel method that sees the co-morbidity from a symptom interacting perspective.

METHODS

Data was collected from 476 college students who were assessed to have childhood abuse history, PTSD and depression at the same time, using Childhood Trauma Questionnaire- Short Form, PTSD Checklist for DSM-5 and The Center for Epidemiological Studies Depression. We created a Graphical Gaussian Model (GGM) network to show associations between symptom pairs and a Directed Acyclic Graph (DAG) to estimate potential casual relationships among symptoms.

RESULTS

The GGM network was reliably stable, feeling sad (Depression) and trouble experiencing positive feelings (PTSD) were the most central nodes. Trouble experiencing positive feelings and several negative affect symptoms, sleep problems and difficulty in concentrating were acting as important bridging nodes. The DAG network suggested the key triggering roles of exaggerated startle (PTSD) and several re-experiencing symptoms.

LIMITATIONS

The study used cross-sectional data and self-reported measures. Results from network analysis could be affected by scale factors and contain spurious correlations.

CONCLUSIONS

In the childhood-abuse-related co-morbid structure, several negative affect symptoms both in PTSD and depression have pivotal roles, hyper-arousal symptoms and re-experiencing symptoms could trigger the co-morbid structure. Illustrating the strength and limitations of network analysis, this study help target the potentially influential symptoms for better clinical intervention.

Neural Responsivity to Reward versus Punishment Shortly after Trauma Predicts Long-term Development of Post-Traumatic Stress Symptoms

BACKGROUND

Processing negative and positive valenced stimuli involve multiple brain regions including the amygdala and ventral striatum (VS). Post-Traumatic Stress Disorder (PTSD) is often associated with hyper-responsivity to negatively valenced, yet recent evidence also points to deficient positive valence functioning. It is yet unclear what is the relative contribution of such opposing valence processing shortly after trauma to the development of chronic PTSD.

METHODS

Neurobehavioral indicators of motivational positive vs. negative valence sensitivities were longitudinally assessed in 171 adults (87 females, age=34.19±11.47 years) at 1-, 6-, and 14-months following trauma exposure (TP1, TP2, TP3). Using a gambling fMRI paradigm, amygdala and VS functionality (activity and functional connectivity with the prefrontal cortex) in response to rewards vs. punishments were assessed with relation to PTSD severity at different time-points. The effect of valence processing was depicted behaviorally by the amount of risk taken to maximize reward.

RESULTS

PTSD severity at TP1 was associated with greater neural functionality in the amygdala (but not the VS) towards punishments vs. rewards, and fewer risky choices. PTSD severity at TP3 was associated with decreased neural functionality in both the VS and amygdala towards rewards vs. punishments at TP1 (but not with risky behavior). Explainable machine learning revealed the primacy of VS biased processing, over the amygdala, in predicting PTSD severity at TP3.

CONCLUSIONS

These results highlight the importance of biased neural responsivity to positive relative to negative motivational outcomes in PTSD development. Novel therapeutic strategies early after trauma may thus target both valence fronts.

Cross-Platform Evaluation of Commercially Targeted and Untargeted Metabolomics Approaches to Optimize the Investigation of Psychiatric Disease

Metabolomics methods often encounter trade-offs between quantification accuracy and coverage, with truly comprehensive coverage only attainable through a multitude of complementary assays. Due to the lack of standardization and the variety of metabolomics assays, it is difficult to integrate datasets across studies or assays. To inform metabolomics platform selection, with a focus on posttraumatic stress disorder (PTSD), we review platform use and sample sizes in psychiatric metabolomics studies and then evaluate five prominent metabolomics platforms for coverage and performance, including intra-/inter-assay precision, accuracy, and linearity. We found performance was variable between metabolite classes, but comparable across targeted and untargeted approaches. Within all platforms, precision and accuracy were highly variable across classes, ranging from 0.9-63.2% (coefficient of variation) and 0.6-99.1% for accuracy to reference plasma. Several classes had high inter-assay variance, potentially impeding dissociation of a biological signal, including glycerophospholipids, organooxygen compounds, and fatty acids. Coverage was platform-specific and ranged from 16-70% of PTSD-associated metabolites. Non-overlapping coverage is challenging; however, benefits of applying multiple metabolomics technologies must be weighed against cost, biospecimen availability, platform-specific normative levels, and challenges in merging datasets. Our findings and open-access cross-platform dataset can inform platform selection and dataset integration based on platform-specific coverage breadth/overlap and metabolite-specific performance.

Glucocorticoid Abnormalities in Female Rats Exposed to a Predator-Based Psychosocial Stress Model of PTSD

People with post-traumatic stress disorder (PTSD) exhibit heightened anxiety and enhanced negative feedback of the hypothalamus-pituitary-adrenal (HPA) axis. We previously reported that male rats exposed to a predator-based psychosocial stress model of PTSD exhibited comparable changes in anxiety-like behavior and HPA axis activity, including lower baseline levels of corticosterone and a greater suppression of corticosterone after dexamethasone administration. Here, we assessed whether we would observe similar effects in female rats exposed to this model. Adult female Sprague-Dawley rats were exposed to a cat on two occasions (separated by 10 days), in combination with chronic social instability. Three weeks after the second cat exposure, we assessed anxiety-like behavior on an elevated plus maze (EPM) and collected blood samples from rats in the absence or presence of dexamethasone to quantify serum corticosterone levels. Although stressed females did not display heightened anxiety on the EPM, they exhibited significantly lower overall corticosterone levels and a greater suppression of corticosterone after dexamethasone administration. The observation of significantly lower overall corticosterone levels in stressed females was replicated in a separate, independent experiment. These findings suggest that the predator-based psychosocial stress model of PTSD may be useful for studying mechanisms that underlie changes in HPA axis function in females exposed to trauma.

Is PTSD-Phenotype Associated with HPA-Axis Sensitivity?: The Endocannabinoid System in Modulating Stress Response in Rats

Endocannabinoids play a role in adaptation to stress and regulate the release of glucocorticoids in stressed and unstressed conditions. We recently found that basal corticosterone pulsatility may significantly impact the vulnerability for developing post-traumatic-stress-disorder (PTSD), suggesting that the endocannabinoid system may contribute to its development. To examine this, we exposed rats to predator scent stress (PSS). Behavioral reactions were recorded seven days post-PSS. Cerebrospinal fluid (CSF) was collected from anesthetized rats shortly after PSS exposure to determine the levels of 2-arachidonoyl glycerol (2-AG) and anandamide (AEA). To correlate between endocannabinoids and corticosterone levels, rats were placed in metabolic cages for urine collection. To assess the levels of endocannabinoids in specific brain regions, rats' brains were harvested one day after behavioral analysis for staining and fluorescence quantification. Moreover, 2-AG was elevated in the CSF of PTSD-phenotype rats as compared with other groups and was inversely correlated with corticosterone urinary secretion. Eight days post-PSS exposure, hippocampal and hypothalamic 2-AG levels and hippocampal AEA levels were significantly more reduced in the PTSD-phenotype group compared to other groups. We posit that maladaptation to stress, which is propagated by an abnormal activation of endocannabinoids, mediates the subsequent stress-induced behavioral disruption, which, later, reduces neuronal the expression of endocannabinoids, contributing to PTSD symptomology.

Dissociation in Borderline Personality Disorder: Recent Experimental, Neurobiological Studies, and Implications for Future Research and Treatment

PURPOSE OF REVIEW

The aim of this review article is to give an overview over recent experimental neurobiological research on dissociation in borderline personality disorder (BPD), in order to inform clinicians and to stimulate further research. First, we introduce basic definitions and models that conceptualize dissociation from a transdiagnostic perspective. Then, we discuss recent findings in BPD.

RECENT FINDINGS

Stress-related dissociation is a key symptom of BPD, closely linked to other core domains of the disorder (emotion dysregulation, identity disturbances, and interpersonal disturbances). The understanding of neurobiological correlates of dissociation across different psychiatric disorders (e.g., dissociative disorders, post-traumatic stress disorder) is steadily increasing. At the same time, studies explicitly focusing on dissociation in BPD are still scarce. There is evidence for adverse effects of dissociation on affective-cognitive functioning (e.g., interference inhibition), body perception, and psychotherapeutic treatment response in BPD. On the neural level, increased activity in frontal regions (e.g., inferior frontal gyrus) and temporal areas (e.g., inferior and superior temporal gyrus) during symptom provocation tasks and during resting state was observed, although findings are still diverse and need to be replicated. Conceptual differences and methodological differences in study designs and sample characteristics (e.g., comorbidities, trauma history) hinder a straightforward interpretation and comparison of studies. Given the potentially detrimental impact of dissociation in BPD, more research on the topic is strongly needed to deepen the understanding of this complex clinical condition.

Advancing a Model of Secondary Trauma: Consequences for Victim Service Providers

A burgeoning body of scholarship is attempting to understand, normalize, and ameliorate the emotional strain of victim service provision. The literature, however, has yet to fully theorize the hazardous process of empathetic engagement with victims. As a result, concepts, mechanisms, and outcomes are often conflated, making it difficult to understand the etiological path of this occupational risk. The goal of this article is to attend to this gap by accomplishing three objectives. The first is to engage with the perspective of symbolic interaction to theoretically ground a conceptual model of secondary trauma. The second objective is to propose a model of secondary trauma that acknowledges its inherently interactional, interpretive, and, thus, vicariously transmissible nature. The third objective is to begin the work of empirically supporting this model with data from a sample of victim service providers (n = 94) collected using in-depth interviews, focus groups, ethnographic participant observation, and community-based participatory research. Our findings suggest that victim service provision, in the form of empathetic engagement, can blur the boundary between self and other, and lead to a sense of damage in the self that manifests in unreliable self-agency, untrustworthy coherence of other, desensitized self-affectivity, and fractured self-history. This work has significant implications. We illustrate an important paradox by showing how victim service provision can be helpful to victims but harmful to providers. We also offer a pathway for reducing this harm. By specifying mechanisms of damage, the model can be used to inform policies and practices supportive of victim service providers' health and well-being.

Posttraumatic stress disorder (PTSD) and depression severity in sexually assaulted women: hypothalamic-pituitary-adrenal (HPA) axis alterations

BACKGROUND

Sexual assault is implicated in several adverse psychological and physical health outcomes, including posttraumatic stress disorder (PTSD) and depression. Neurobiological research has shown variations related to the hypothalamic-pituitary-adrenal (HPA) axis, immune alterations, metabolic function, and brain circuitry. Although these mechanisms have been extensively studied, the results have demonstrated different outcomes in PTSD.

METHODS

We compared the plasma adrenocorticotropin (ACTH) and salivary cortisol levels of fifty-eight women with PTSD developed after sexual assault to those of forty-four female controls with no history of trauma. We also evaluated the psychiatric diagnosis and symptom severity of PTSD and depression. The participants' clinical conditions were associated with their hormonal levels to assess whether symptom severity was related to hormonal imbalance.

RESULTS

A large percentage of sexually assaulted women had PTSD and comorbid depression. The ACTH levels were higher in the PTSD group than the control group and increased as PTSD severity increased, considering depressive symptoms, measured by the Beck Depression Inventory (BDI) (p < 0.0001), as well as PTSD symptoms, measured by subscale D of the Clinician-Administered PTSD Scale (CAPS-5) (p = 0.045) and the CAPS-5 total scale (p = 0.026). Cortisol levels measured at 10 pm were higher for the PTSD group than the control group (p = 0.045, p = 0.037, respectively), and the cortisol awakening response showed elevated cortisol levels for the PTSD group.

CONCLUSIONS

These results show a correlation between symptom severity and HPA axis imbalance in patients with PTSD. Elevated ACTH and an elevated cortisol response in patients with comorbid depressive symptoms were the opposite of the expected response for patients with PTSD only. This association leads to the hypothesis that the neurobiological alterations of PTSD are related to the type of symptoms presented and their severity. These manifestations likely influence the disease course, prognosis and response to treatment. These outcomes highlight the need to discuss particular neurobiological alterations in patients with PTSD developed after sexual assault, mainly those with severe depressive symptoms.

Pupillary Response to Affective Voices: Physiological Responsivity and Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is related to dysfunctional emotional processing, thus motivating the search for physiological indices that can elucidate this process. Toward this aim, we compared pupillary response patterns in response to angry and fearful auditory stimuli among 99 adults, some with PTSD (n = 14), some trauma-exposed without PTSD (TE; n = 53), and some with no history of trauma exposure (CON; n = 32). We hypothesized that individuals with PTSD would show more pupillary response to angry and fearful auditory stimuli compared to those in the TE and CON groups. Among participants who had experienced a traumatic event, we explored the association between PTSD symptoms and pupillary response; contrary to our prediction, individuals with PTSD displayed the least pupillary response to fearful auditory stimuli compared those in the TE, B = -0.022, p = .077, and CON, B = -0.042, p = .002, groups, but they did not differ on angry auditory stimuli, B = 0.019, p = .118 and B = 0.006, p = .634, respectively. It is important to note that within-group analyses revealed that participants with PTSD differed significantly in their response to angry versus fearful stimuli, B = -0.032, p = .015. We also found a positive association between PTSD symptoms and pupillary response to angry stimuli. Our findings suggest that differential pupil response to anger and fear stimuli may be a promising way to understand emotional processing in PTSD.

Biomarkers of Pathological Dissociation: A Systematic Review

Pathological dissociation is a severe, debilitating and transdiagnostic psychiatric symptom. This review identifies biomarkers of pathological dissociation in a transdiagnostic manner to recommend the most promising research and treatment pathways in support of the precision medicine framework. A total of 205 unique studies that met inclusion criteria were included. Studies were divided into four biomarker categories, namely neuroimaging, psychobiological, psychophysiological and genetic biomarkers. The dorsomedial and dorsolateral prefrontal cortex, bilateral superior frontal regions, (anterior) cingulate, posterior association areas and basal ganglia are identified as neurofunctional biomarkers of pathological dissociation and decreased hippocampal, basal ganglia and thalamic volumes as neurostructural biomarkers. Increased oxytocin and prolactin and decreased tumor necrosis factor alpha (TNF-α) are identified as psychobiological markers. Psychophysiological biomarkers, including blood pressure, heart rate and skin conductance, were inconclusive. For the genetic biomarker category studies related to dissociation were limited and no clear directionality of effect was found to warrant identification of a genetic biomarker. Recommendations for future research pathways and possible clinical applicability are provided.

Blunted salivary cortisol response to psychosocial stress in women with posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is characterized by alterations in the hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system (SNS). There is evidence for a blunted HPA axis reactivity to psychosocial stress. Less is known about how the SNS reacts to psychosocial stress. Here, we compared the HPA axis and SNS responses to psychosocial stress and a non-stressful condition in patients with PTSD and in healthy individuals. Twenty-one women with PTSD and 32 healthy women participated in the Trier social stress test (TSST) and placebo TSST (P-TSST). We measured salivary cortisol, alpha amylase activity and blood pressure before and after the tests. Subjective perceived stress response was also assessed. We found a blunted cortisol response to the TSST in patients with PTSD compared with healthy participants 10 min (t (51) = -2.58, p = .01) and 25 min (t (51) = -2.16, p = .04) after TSST. We found no evidence for an increased SNS reactivity after psychosocial stress in patients with PTSD (all p > .05). Patients with PTSD, but not healthy participants, reported more dissociative symptoms (t (20) = -2.31, p = .03) and being more tired (t (20) = 2.90, p = .01) directly after TSST compared with the placebo condition. Our results suggest a blunted HPA stress reactivity and an increased subjective perceived stress response in female patients with PTSD. Longitudinal studies could test if these altered stress responses constitute a predisposition to or a cause of PTSD. Future studies should investigate whether these results are transferable to men.

SNP-SNP interactions in the BDNF, COMT, CBR1 and CCK genes, associated with post-traumatic stress disorder in urban residents of Itagüí, Colombia

Introducción. Los polimorfismos de un solo nucleótido (SNP, por su sigla en inglés) en los genes BDNF, COMT, CBR1 y CCK han sido asociados con el proceso de extinción del miedo en humanos. Dado que la extinción del miedo es clave para la recuperación del trauma psicológico, es posible que estos genes modulen el riesgo de desarrollar trastorno de estrés postraumático (TEPT).Objetivo. Evaluar las asociaciones unilocus y multilocus entre los SNP en los genes BDNF, COMT, CBR1 y CCK y el riesgo de desarrollar TEPT.Materiales y métodos. 129 habitantes del municipio de Itagüí, Colombia, que habían experimentado trauma psicológico al menos una vez, fueron genotipificados para estos polimorfismos (38 casos de TEPT y 91 controles). Se realizaron pruebas de asociación unilocus y multilocus por regresión logística para SNP únicos y las combinaciones genotípicas SNP-SNP existentes.Resultados. No se encontraron asociaciones unilocus, pero se observaron interacciones entre BDNF y CBR1, y CCK y COMT. De estas interacciones, las combinaciones genotípicas que se comportaron como factores de riesgo fueron AG-AA (OR=13.52, p<0.05) de BDNF-CBR1 y TC-AA (OR=13.70, p<0.05) de CCK-COMT.Conclusiones: Los dos pares de polimorfismos en interacción encontrados en el presente estudio podrían actuar de forma aditiva y generar un mayor riesgo de desarrollar TEPT después de sufrir trauma psicológico. Quienes portan un solo alelo tienen un menor riesgo de desarrollar el trastorno que quienes portan dos alelos en genes que interactúan entre sí.

Animal models for the discovery of novel drugs for post-traumatic stress disorder

INTRODUCTION

Existing pharmacological treatments for PTSD are limited and have been used primarily because of their effectiveness in other psychiatric conditions. To generate novel, PTSD specific pharmacotherapy, researchers must utilize animal models to assess the efficacy of experimental drugs.

AREAS COVERED

This review includes a discussion of factors that should be considered when developing an animal model of PTSD, as well as descriptions of the most commonly used models. Researchers have utilized physical stressors, psychological stressors, or a combination of the two to induce PTSD-like physiological and behavioral sequelae in animals. Such models have provided researchers with a valuable tool to examine the neurobiological mechanisms underlying the condition.

EXPERT OPINION

PTSD is a heterogeneous disorder that manifests as different symptom clusters in different individuals. Thus, there cannot be a one-size-fits-all approach to modeling the disorder in animals. Preclinical investigators must adopt a concentrated effort aimed at modeling specific PTSD subtypes and the distinct symptom profiles that result from specific types of human trauma. Moreover, researchers have focused so much on modeling a single PTSD syndrome in animals that studies examining only specific facets of the disorder are largely ignored. Future research employing animal models of PTSD requires greater focus on the nuances of PTSD.

Application of Noninvasive Vagal Nerve Stimulation to Stress-Related Psychiatric Disorders

BACKGROUND

Vagal Nerve Stimulation (VNS) has been shown to be efficacious for the treatment of depression, but to date, VNS devices have required surgical implantation, which has limited widespread implementation.

METHODS

New noninvasive VNS (nVNS) devices have been developed which allow external stimulation of the vagus nerve, and their effects on physiology in patients with stress-related psychiatric disorders can be measured with brain imaging, blood biomarkers, and wearable sensing devices. Advantages in terms of cost and convenience may lead to more widespread implementation in psychiatry, as well as facilitate research of the physiology of the vagus nerve in humans. nVNS has effects on autonomic tone, cardiovascular function, inflammatory responses, and central brain areas involved in modulation of emotion, all of which make it particularly applicable to patients with stress-related psychiatric disorders, including posttraumatic stress disorder (PTSD) and depression, since dysregulation of these circuits and systems underlies the symptomatology of these disorders.

RESULTS

This paper reviewed the physiology of the vagus nerve and its relevance to modulating the stress response in the context of application of nVNS to stress-related psychiatric disorders.

CONCLUSIONS

nVNS has a favorable effect on stress physiology that is measurable using brain imaging, blood biomarkers of inflammation, and wearable sensing devices, and shows promise in the prevention and treatment of stress-related psychiatric disorders.

Hair cortisol predicts avoidance behavior and depressiveness after first-time and single-event trauma exposure in motor vehicle crash victims

The role of cortisol as a premorbid vulnerability factor for trauma sequelae remains unclear. Furthermore, the onset of long-term endocrine changes in response to first-time trauma as a function of later psychopathology is not clarified yet. Thus the predictive value of pre- and post-traumatic hair cortisol concentrations (HCCs) for psychological trauma sequelae was investigated in response to motor vehicle crash (MVC). A total of N= 62 MVC survivors participated in this study (46 females, mean age (SD): 43.94(12.95)). Subsequent trauma sequelae were measured with a structured clinical interview and self-report questionnaires to evaluate psychological symptoms (pre-MVC and three months post-MVC). Hair strands were taken immediately after MVC and three months post-MVC, reflecting cumulative cortisol secretion over the three-month period before and after the MVC. A total of 22.6% of the participants developed a trauma sequela with an affective disorder (14.5%) and/or anxiety disorder (16.1%). We observed a significant main effect of group and diagnosis × time interaction with an increase of HCC in those individuals who presented a subsequent psychiatric disorder. Regression analyses revealed that post-MVC increased HCC were significantly predictive of higher levels of subsequent depressiveness, and that pre-MVC increased HCC were predictive of higher levels of subsequent avoidance behavior. Our findings demonstrate that individual differences in long-term cortisol secretion in response to a first-time traumatic event (MVC) contribute to subsequent psychopathology. Specifically, higher long-term cortisol secretion before and after first-time MVC was a risk factor for subsequent development of avoidance behavior and depressiveness, respectively.Lay summaryHigher cortisol secretion and stress experience before a motor vehicle crash was a risk factor for subsequent development of psychological symptoms.