The role of acute cortisol and DHEAS in predicting acute and chronic PTSD symptoms

The role of neurosteroids in posttraumatic stress disorder and alcohol use disorder: A review of 10 years of clinical literature and treatment implications

Rates of alcohol use disorder (AUD) are increasing in men and women and there are high rates of concurrent posttraumatic stress disorder (PTSD) and AUD. AUD and PTSD synergistically increase symptomatology and negatively affect treatment outcomes; however, there are very limited pharmacological treatments for PTSD/AUD. Neurosteroids have been implicated in the underlying neurobiological mechanisms of both PTSD and AUD and may be a target for treatment development. This review details the past ten years of research on pregnenolone, progesterone, allopregnanolone, pregnanolone, estradiol, testosterone and dehydroepiandrosterone/dehydroepiandrosterone-sulfate (DHEA/DHEA-S) in the context of PTSD and AUD, including examination of trauma/alcohol-related variables, such as stress-reactivity. Emerging evidence that exogenous pregnenolone, progesterone, and allopregnanolone may be promising, novel interventions is also discussed. Specific emphasis is placed on examining the application of sex as a biological variable in this body of literature, given that women are more susceptible to both PTSD diagnoses and stress-related alcohol consumption.

Endocannabinoids, cortisol, and development of post-traumatic psychopathological trajectories

OBJECTIVE

Our prior published work using the 2-factor model of PTSD identified four subgroups of trauma survivors on average 6 months following trauma: Resilient, Dysphoria, High Comorbid, and Severe Comorbid. Some findings indicate that low and high cortisol responses may increase risk for the development of PTSD and depression respectively, yet ways in which cortisol interacts with other physiological systems to enhance risk is unclear. This study examined the role of circulating eCBs in the development of previously identified psychopathological trajectories that is differentiated by cortisol in traumatically injured adults (N = 169).

METHODS

Circulating concentrations of eCBs, 2-arachidonoylglycerol (2-AG) and N-arachidonoylethanolamine (AEA) were measured during post-injury hospitalization and on average 6 months following trauma. Differences in 2-AG and AEA among the subgroups were tested using multivariate ANCOVA.

RESULTS

Dysphoria (with highest cortisol levels) and High Comorbid subgroups exhibited higher post-injury AEA compared to the Resilient group. Dysphoria subgroup showed a significant decline in AEA by 6 months compared to Resilient and High Comorbid subgroups.

CONCLUSION

Change in AEA over time in individuals with high post-injury cortisol may serve as a buffer against risk for severe psychopathology. Assessing AEA and cortisol levels concurrently across time may serve as indicators of risk.

Mitochondrial dysfunction as a possible trigger of neuroinflammation at post-traumatic stress disorder (PTSD)

Post-traumatic stress disorder (PTSD) is a neuropsychiatric disorder that occurs in approximately 15% of people as a result of some traumatic events. The main symptoms are re-experiencing and avoidance of everything related to this event and hyperarousal. The main component of the pathophysiology of PTSD is an imbalance in the functioning of the hypothalamic-pituitary-adrenal axis (HPA) and development of neuroinflammation. In parallel with this, mitochondrial dysfunction is observed, as in many other diseases. In this review, we focus on the question how mitochondria may be involved in the development of neuroinflammation and its maintaining at PTSD. First, we describe the differences in the operation of the neuro-endocrine system during stress versus PTSD. We then show changes in the activity/expression of mitochondrial proteins in PTSD and how they can affect the levels of hormones involved in PTSD development, as well as how mitochondrial damage/pathogen-associated molecule patterns (DAMPs/PAMPs) trigger development of inflammation. In addition, we examine the possibility of treating PTSD-related inflammation using mitochondria as a target.

Resilience by design: How nature, nurture, environment, and microbiome mitigate stress and allostatic load

Resilience to psychological stress is defined as adaption to challenging life experiences and not the absence of adverse life events. Determinants of resilience include personality traits, genetic/epigenetic modifications of genes involved in the stress response, cognitive and behavioral flexibility, secure attachment with a caregiver, social and community support systems, nutrition and exercise, and alignment of circadian rhythm to the natural light/dark cycle. Therefore, resilience is a dynamic and flexible process that continually evolves by the intersection of different domains in human’s life; biological, social, and psychological. The objective of this minireview is to summarize the existing knowledge about the multitude factors and molecular alterations that result from resilience to stress response. Given the multiple contributing factors in building resilience, we set out a goal to identify which factors were most supportive of a causal role by the current literature. We focused on resilience-related molecular alterations resulting from mind-body homeostasis in connection with psychosocial and environmental factors. We conclude that there is no one causal factor that differentiates a resilient person from a vulnerable one. Instead, building resilience requires an intricate network of positive experiences and a healthy lifestyle that contribute to a balanced mind-body connection. Therefore, a holistic approach must be adopted in future research on stress response to address the multiple elements that promote resilience and prevent illnesses and psychopathology related to stress allostatic load.

Potential peripheral biomarkers associated with the emergence and presence of posttraumatic stress disorder symptomatology: A systematic review

BACKGROUND

Evidence suggests posttraumatic stress disorder (PTSD) involves an interplay between psychological manifestations and biological systems. Biological markers of PTSD could assist in identifying individuals with underlying dysregulation and increased risk; however, accurate and reliable biomarkers are yet to be identified.

METHODS

A systematic review following the PRISMA guidelines was conducted. Databases included EMBASE, MEDLINE, and Cochrane Central. Studies from a comprehensive 2015 review (Schmidt et al., 2015) and English language papers published subsequently (between 2014 and May 2022) were included. Forty-eight studies were eligible.

RESULTS

Alterations in neuroendocrine and immune markers were most commonly associated with PTSD symptoms. Evidence indicates PTSD symptoms are associated with hypothalamic-pituitary-adrenal axis dysfunction as represented by low basal cortisol, a dysregulated immune system, characterized by an elevated pro-inflammatory state, and metabolic dysfunction. However, a considerable number of studies neglected to measure sex or prior trauma, which have the potential to affect the biological outcomes of posttraumatic stress symptoms. Mixed findings are indicative of the complexity and heterogeneity of PTSD and suggest the relationship between allostatic load, biological markers, and PTSD remain largely undefined.

CONCLUSIONS

In addition to prospective research design and long-term follow up, it is imperative future research includes covariates sex, prior trauma, and adverse childhood experiences. Future research should include exploration of biological correlates specific to PTSD symptom domains to determine whether underlying processes differ with symptom expression, in addition to subclinical presentation of posttraumatic stress symptoms, which would allow for greater understanding of biomarkers associated with disorder risk and assist in untangling directionality.

Acute stress reactivity and intrusive memory development: a randomized trial using an adjusted trauma film paradigm

Understanding the neurobiological and cognitive processes underlying the development of posttraumatic stress disorder (PTSD) and its specific symptoms may facilitate preventive intervention development. Severe traumatic stress and resulting biological stress system activations can alter contextual memory processes. This may provide a neurobiological explanation for the occurrence of intrusive memories following trauma. Investigating the associations between temporal aspects and individual variation in peri- and post-traumatic hypothalamic pituitary adrenal (HPA) axis and sympathetic nervous system (SNS) stress reactivity and memory processing may increase our understanding of intrusive symptom development. The experimental trauma film paradigm is commonly used for this purpose but lacks robust SNS and HPA axis activation. Here, we performed an RCT to investigate the effect of an adjusted trauma film paradigm containing an added brief psychosocial stressor on HPA and SNS stress reactivity throughout the experiment and intrusive memory frequency in the following week in healthy males (N = 63, mean age = 22.3). Secondary, we investigated effects on film-related declarative memory accuracy and intrusion-related characteristics, and associations between acute HPA and SNS stress reactivity, film-related memory, glucocorticoid receptor functioning and intrusion frequency and characteristics. Participants were randomized to the socially-evaluated cold pressor test (seCPT n = 29) or control condition (warm water n = 34) immediately prior to a trauma film. Linear Mixed Models revealed increased acute SNS and cortisol reactivity, lower recognition memory accuracy and more intrusions that were more vivid and distressing during the following week in the seCPT compared to control condition. Linear regression models revealed initial associations between cortisol and alpha amylase reactivity during the experimental assessment and subsequent intrusions, but these effects did not survive multiple comparison corrections. Thus, with this adjustment, we increased the translational value of the trauma film paradigm as it appears to elicit a stronger stress response that is likely more comparable to real-life trauma. The adapted paradigm may be useful to investigate individual variation in biological and cognitive processes underlying early post-trauma PTSD symptoms and could advance potential preventive interventions.

Salivary Cortisol and Alpha-Amylase in Posttraumatic Stress Disorder and Their Potential Role in the Evaluation of Cognitive Behavioral Treatment Outcomes

Alterations in HPA-axis and autonomic nervous system activity have been associated with posttraumatic stress disorder (PTSD) development and maintenance and are potentially associated with trauma-focused cognitive behavioral therapy (TF-CBT) outcomes. We examined the role of salivary cortisol (sCort) and alpha-amylase (sAA) in PTSD and TF-CBT outcomes in German Armed Forces service members (N = 100). Participants categorized as PTSD patients (n = 39), previously deployed healthy controls (n = 33), and nondeployed healthy controls (n = 28) provided diurnal profiles of sCort and sAA; PTSD patients provided samples before, immediately after, and 3 months after an internet-based TF-CBT intervention. No group differences emerged regarding total daily sCort and sAA output or daily slopes, ps = .224-.897, fs = 0.05-0.24. Participants with PTSD demonstrated a significantly attenuated sCort awakening response compared to deployed, p = .021, d = 0.59, but not nondeployed controls, p = .918, d = 0.08. Moreover, a significantly steeper sAA awakening response emerged in PTSD patients, p = .034, d = 0.67, and deployed controls, p = .014, d = 0.80, compared to nondeployed controls. From pretreatment to posttreatment (n = 21) and posttreatment to follow-up (n = 14), stable sCort, ps = .282-.628, fs = 0.34-0.49, and sAA concentrations, ps = .068-.758, fs = 0.24-1.13 paralleled a nonsignificant treatment effect. Both PTSD and trauma exposure were associated with alterations in awakening responses, but further investigation is needed to determine whether the observed correspondence remains when PTSD symptoms significantly decline.

Circulating endocannabinoids and genetic polymorphisms as predictors of posttraumatic stress disorder symptom severity: heterogeneity in a community-based cohort

The endocannabinoid signaling system (ECSS) regulates fear and anxiety. While ECSS hypoactivity can contribute to symptoms of established post-traumatic stress disorder (PTSD), the role of the ECSS in PTSD development following trauma is unknown. A prospective, longitudinal cohort study of 170 individuals (47% non-Hispanic Caucasian and 70% male) treated at a level 1 trauma center for traumatic injury was carried out. PTSD symptom assessments and blood were obtained during hospitalization and at follow-up (6-8 months post injury). Serum concentrations of the endocannabinoids N-arachidonoylethanolamine (AEA) and 2-arachidonoylglycerol (2-AG) were determined at both time points and selected genetic polymorphisms in endocannabinoid genes, including rs324420 in fatty acid amide hydrolase, were assessed. For the entire sample, serum concentrations of AEA at hospitalization were significantly higher in those diagnosed with PTSD at follow-up (p = 0.030). Serum concentrations of 2-AG were significantly, positively correlated with PTSD symptom severity at follow-up only in minorities (p = 0.014). Minority participants (mostly Black/African American) also demonstrated significant, negative correlations between serum AEA concentrations and PTSD symptom severity both measured at hospitalization (p = 0.015). The A/A genotype at rs324420 was associated with significantly higher PTSD symptom severity (p = 0.025) and occurred exclusively in the Black participants. Collectively, these results are contrary to our hypothesis and find positive associations between circulating endocannabinoids and risk for PTSD. Minority status is an important modulator of the association between endocannabinoids and risk for PTSD, suggesting that the ECSS contributes to risk most significantly in these individuals and the contextual factors related to these findings should be further explored.

A cluster analytic approach to examining the role of cortisol in the development of post-traumatic stress and dysphoria in adult traumatic injury survivors

Identification of specific risk factors for posttraumatic stress disorder (PTSD) versus depression after trauma has been challenging, in part due to the high comorbidity of these disorders. As exposure to trauma triggers activation of the hypothalamic-pituitary-adrenal (HPA)-axis, examining atypical stress responses via HPA-axis hormones, namely cortisol, may help in the delineation of these disorders. Indeed, extant research demonstrates that, following stress, individuals with chronic PTSD exhibit hypocortisolism (e.g., lower cortisol response than controls), while those with chronic depression exhibit hypercortisolism (e.g., higher response than controls). Less is known about the role of cortisol and these seemingly disparate profiles immediately following traumatic injury as well as whether cortisol can be used as a predictor of future development of PTSD versus depression symptoms. In this study cortisol was measured blood from 172 traumatic injury survivors during hospitalization (on average 2.5 days post-injury). PTSD and depression severity were assessed from Clinician Assessed PTSD Scale (CAPS-5) six-eight months later using a two-factor dimensional approach that measures trauma-specific symptoms of PTSD versus dysphoria (akin to depression). Cluster analysis was used to group individuals based on post-injury cortisol, PTSD, and dysphoria. Results demonstrated that trauma survivors who only developed symptoms of dysphoria at six months (with minimal symptoms of PTSD) were differentiated by high post-injury cortisol compared to other groups. By contrast, individuals who developed symptoms of both PTSD and dysphoria were differentiated by low post-injury cortisol and most severe symptoms of PTSD. Findings provide support for the presence of subgroups of trauma survivors defined, in part, by post-trauma cortisol.

A Scoping Review and Proposed Framework for Coping in Youth With a History of Psychological Trauma and Chronic Pain

OBJECTIVE

Psychological trauma (e.g., abuse, neglect) and posttraumatic stress symptoms (PTSS) commonly occur in pediatric pain populations and may be related to various maladaptive coping strategies, which may in turn affect short- and long-term pain-related outcomes in youth. Accordingly, the current scoping review and conceptual framework seeks to identify important gaps in the field's current understanding of how coping impacts outcomes in youth who have experienced trauma/PTSS and pediatric chronic pain and explores avenues for future investigation.

METHODS

A scoping review of the literature was performed in Medline, Embase, Cochrane Library, PsycInfo, and Sociological Abstracts. Eligibility criteria included pediatric populations experiencing chronic pain, trauma, adverse childhood events, and/or PTSS and associated coping mechanisms. Nine research papers were selected and used to support the conceptual framework. The framework builds upon the work of Compas et al.'s' model of control-based coping (Compas et al., 2006; Compas & Harding Thomsen, 1999) and outlines the potential effects of trauma and/or PTSS and pain on coping and pain-related outcomes (e.g., pain chronicity, functional outcomes) in pediatric chronic pain populations.

RESULTS

A history of chronic pain and psychological trauma and/or PTSS in youth may contribute to increased risk for maladaptive coping and in turn, poorer pain-related and psychosocial outcomes long-term.

CONCLUSIONS

Findings from the current scoping review and proposed conceptual framework will guide future research and treatment efforts for youths experiencing pain and trauma and/or PTSS and thereby enhance long-term outcomes.

Neuro-consequences of the spaceflight environment

As human space exploration advances to establish a permanent presence beyond the Low Earth Orbit (LEO) with NASA's Artemis mission, researchers are striving to understand and address the health challenges of living and working in the spaceflight environment. Exposure to ionizing radiation, microgravity, isolation and other spaceflight hazards pose significant risks to astronauts. Determining neurobiological and neurobehavioral responses, understanding physiological responses under Central Nervous System (CNS) control, and identifying putative mechanisms to inform countermeasure development are critically important to ensuring brain and behavioral health of crew on long duration missions. Here we provide a detailed and comprehensive review of the effects of spaceflight and of ground-based spaceflight analogs, including simulated weightlessness, social isolation, and ionizing radiation on humans and animals. Further, we discuss dietary and non-dietary countermeasures including artificial gravity and antioxidants, among others. Significant future work is needed to ensure that neural, sensorimotor, cognitive and other physiological functions are maintained during extended deep space missions to avoid potentially catastrophic health and safety outcomes.

Testosterone, estradiol, DHEA and cortisol in relation to anxiety and depression scores in adolescents

Background Adrenal and sex hormone dysregulation have been independently associated with increased depression and anxiety. Cortisol can modify production of sex hormones and hormone-mood associations. This study evaluated associations and interplay of sex and adrenal hormones with depression and anxiety. Methods We assessed 545 Ecuadorian adolescents (11-17y, 50.4% female, ESPINA) for depression and anxiety symptoms using standardized scales. Testosterone, cortisol, dehydroepiandrosterone (DHEA), and estradiol (boys only) were measured in saliva. We performed logistic regression modeling to calculate odds ratios (OR) of elevated depression or anxiety (scores ≥60) comparing participants with low (<10th percentile) and elevated hormones (≥90th percentile) to normal concentrations (10th-90th percentile). Effect modification by cortisol and testosterone was assessed. Models adjusted for demographic, anthropometric, and circadian measures. Results In all participants, elevated testosterone (OR [95%CI:]=1.78 [0.98, 3.23]) and cortisol (OR=1.69 [0.95, 2.99]) were marginally associated with elevated anxiety scores. In boys, elevated estradiol was associated with elevated depression (OR=4.75 [1.95, 11.56]) and anxiety scores (OR=2.43 [1.01, 5.84]). In linear regression, estradiol was positively associated with depression (difference/10% hormone increase (β=0.45 [0.15, 0.75]) and anxiety scores (β=0.42 [0.13, 0.72]). Higher cortisol levels strengthened the depression association with estradiol in boys (β=0.54 [0.12, 0.96]), and with testosterone (β= -0.19 [-0.35, -0.03]) and DHEA (β= -0.12 [-0.22, -0.02]) in girls. Testosterone also modified associations. Limitations This was a cross-sectional analysis. Discussion Elevated testosterone, cortisol, and estradiol (≥90th percentile) were associated with altered mood. Cortisol and testosterone were considerable effect modifiers to the associations of most hormones with depression and anxiety.

Serum cortisol as a predictor for posttraumatic stress disorder symptoms in post-myocardial infarction patients

BACKGROUND

After an acute myocardial infarction (MI²), patients may develop posttraumatic stress disorder (PTSD³). There is evidence for alterations in the hypothalamic-pituitary-adrenal axis in PTSD. An association between patients` cortisol level after experiencing an MI and subsequent PTSD symptoms has not been investigated yet. Therefore, the aim of this study was to examine whether serum cortisol measured in patients admitted to hospital for acute coronary care after MI is predictive of PTSD symptoms at three and 12 months post-MI, respectively.

METHODS

Patients (N=106) with a verified MI and high risk for the development of MI-induced PTSD symptoms were included in the study within 48 hours of hospital admission for acute coronary intervention. Serum cortisol was measured from fasting venous blood samples the next morning. Hierarchical regression analysis was used to test for an independent contribution of cortisol levels from admission to the Clinician-Administered PTSD Scale sum score three and 12 months after discharge from the coronary care unit.

RESULTS

Hierarchical regression analysis showed that lower serum cortisol levels were significantly associated with more severe PTSD symptoms three months (B=-0.002, p=0.042) and 12 months (B=-0.002, p=0.043) post-MI.

LIMITATIONS

The generalizability of the findings is limited to patients with high acute peri-traumatic distress and without an acute severe depressive episode. The study does not provide any information about the diurnal cortisol pattern.

CONCLUSION

Lower serum cortisol measured during MI hospitalization may predict more severe MI-induced PTSD symptoms three and 12 months after hospital discharge.

Posttraumatic stress disorder symptom trajectories within the first year following emergency department admissions: pooled results from the International Consortium to predict PTSD

BACKGROUND

Research exploring the longitudinal course of posttraumatic stress disorder (PTSD) symptoms has documented four modal trajectories (low, remitting, high, and delayed), with proportions varying across studies. Heterogeneity could be due to differences in trauma types and patient demographic characteristics.

METHODS

This analysis pooled data from six longitudinal studies of adult survivors of civilian-related injuries admitted to general hospital emergency departments (EDs) in six countries (pooled N = 3083). Each study included at least three assessments of the clinician-administered PTSD scale in the first post-trauma year. Latent class growth analysis determined the proportion of participants exhibiting various PTSD symptom trajectories within and across the datasets. Multinomial logistic regression analyses examined demographic characteristics, type of event leading to the injury, and trauma history as predictors of trajectories differentiated by their initial severity and course.

RESULTS

Five trajectories were found across the datasets: Low (64.5%), Remitting (16.9%), Moderate (6.7%), High (6.5%), and Delayed (5.5%). Female gender, non-white race, prior interpersonal trauma, and assaultive injuries were associated with increased risk for initial PTSD reactions. Female gender and assaultive injuries were associated with risk for membership in the Delayed (v. Low) trajectory, and lower education, prior interpersonal trauma, and assaultive injuries with risk for membership in the High (v. Remitting) trajectory.

CONCLUSIONS

The results suggest that over 30% of civilian-related injury survivors admitted to EDs experience moderate-to-high levels of PTSD symptoms within the first post-trauma year, with those reporting assaultive violence at increased risk of both immediate and longer-term symptoms.

Hydrocortisone administration for reducing post-traumatic stress symptoms: A systematic review and meta-analysis

BACKGROUND

Post-traumatic stress disorder (PTSD) is a debilitating disorder that is often accompanied by alterations in the hypothalamic-pituitary (HPA) axis. While there is abundant evidence for the efficacy of psychological therapies in reducing post-traumatic stress symptoms, barely anything is known about pharmacological interventions. Given the role of the HPA axis in the pathophysiology of PTSD, the aim of this study was to provide the first meta-analysis of Hydrocortisone as a potential treatment for this condition.

METHOD

A systematic review of randomized-controlled trials (RCTs) was conducted to investigate the efficacy of hydrocortisone in the prevention and curative treatment of post-traumatic stress symptoms. This study was pre-registered with the OSF (doi:10.17605/OSF.IO/GJAZF).

FINDINGS

Eight studies (9 effect sizes) covering 362 participants met our inclusion criteria. We found that Hydrocortisone as compared to placebo significantly reduced PTSD symptoms (d = 0.96, 95% Cl 0.22-1.69 p = 0.011) and PTSD incidence (logRR = 0.85, 95% CI 1.12-1.59, p = 0.023). Subgroup analyses revealed a significant effect of Hydrocortisone when it was administered in a preventative context (d = 1.50; 95%CI 0.30-2.69, p = 0.014), but not when it was administered in a curative context (d = 0.28; 95%CI -0.11 to 0.66, p = 0.161).

CONCLUSION

Hydrocortisone appears to be a promising and efficient low-cost medication for the prevention of PTSD. However, the small number of included studies and their limited methodological quality emphasize the need for further rigorous studies in this field.

Forecasting individual risk for long-term Posttraumatic Stress Disorder in emergency medical settings using biomedical data: A machine learning multicenter cohort study

The necessary requirement of a traumatic event preceding the development of Posttraumatic Stress Disorder, theoretically allows for administering preventive and early interventions in the early aftermath of such events. Machine learning models including biomedical data to forecast PTSD outcome after trauma are highly promising for detection of individuals most in need of such interventions. In the current study, machine learning was applied on biomedical data collected within 48 h post-trauma to forecast individual risk for long-term PTSD, using a multinominal approach including the full spectrum of common PTSD symptom courses within one prognostic model for the first time. N = 417 patients (37.2% females; mean age 46.09 ± 15.88) admitted with (suspected) serious injury to two urban Academic Level-1 Trauma Centers were included. Routinely collected biomedical information (endocrine measures, vital signs, pharmacotherapy, demographics, injury and trauma characteristics) upon ED admission and subsequent 48 h was used. Cross-validated multi-nominal classification of longitudinal self-reported symptom severity (IES-R) over 12 months and bimodal classification of clinician-rated PTSD diagnosis (CAPS-IV) at 12 months post-trauma was performed using extreme Gradient Boosting and evaluated on hold-out sets. SHapley Additive exPlanations (SHAP) values were used to explain the derived models in human-interpretable form. Good prediction of longitudinal PTSD symptom trajectories (multiclass AUC = 0.89) and clinician-rated PTSD at 12 months (AUC = 0.89) was achieved. Most relevant prognostic variables to forecast both multinominal and dichotomous PTSD outcomes included acute endocrine and psychophysiological measures and hospital-prescribed pharmacotherapy. Thus, individual risk for long-term PTSD was accurately forecasted from biomedical information routinely collected within 48 h post-trauma. These results facilitate future targeted preventive interventions by enabling future early risk detection and provide further insights into the complex etiology of PTSD.

The Impact of Caring and Killing on Physiological and Psychometric Measures of Stress in Animal Shelter Employees: A Pilot Study

Animal shelter employees are in a unique position where they care for, and later kill, the same animals. The aim of our exploratory study was to assess whether "caring" and/or "killing" evokes physiological and psychometric indicators of stress in employees. Experiment 1 compared three careers that kill regularly, but involve varying degrees of husbandry (n = 28). Blood pressure (BP), salivary cortisol, heart rate (HR), and heart rate variability (HRV) were collected; data showed higher HR and lower HRV during the process of killing. Psychometric scales showed that burnout and Impact Event Scale-Revised (IES-R) scores were higher in careers with higher contact with animals. Experiment 2 compared three careers that involve husbandry, but varying exposure to killing (n = 41). BP, cortisol awakening response, HR, and HRV were measured as well as Professional Quality of Life Scale, IES-R, and Moral Injury Event Scale were administered. There were no significant differences across careers in any measures. The data suggest that the process of killing may be physiologically stressful to the person, and higher levels of animal contact in a euthanasia context may be associated with burnout and traumatic stress, but that the act of euthanasia is not a unique predictor of overall occupational distress.

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.

Early posttraumatic autonomic and endocrine markers to predict posttraumatic stress symptoms after a preventive intervention with oxytocin

BACKGROUND

Efficient prevention of posttraumatic stress disorder (PTSD) needs to target individuals with an increased risk for adverse outcome after trauma. Prognostic or prescriptive biological markers assessed early posttrauma may inform personalized treatment recommendations.

OBJECTIVE

To test prognostic and prescriptive effects of early (posttraumatic) autonomic and endocrine markers on PTSD symptom development.

METHOD

Autonomic and endocrine markers were assessed within 12 days posttrauma and before treatment initiation within a randomized placebo-controlled trial investigating repeated oxytocin administration as preventive intervention for PTSD. Linear mixed effects models were used to test the effects of heart rate (variability), resting cortisol, morning cortisol and cortisol awakening response (CAR), cortisol suppression by dexamethasone and resting oxytocin on PTSD symptoms 1.5, 3 and 6 months posttrauma in men (n = 54), women using hormonal contraception (n = 27) and cycling women (n = 19).

RESULTS

We found significant prognostic effects of resting oxytocin and cortisol suppression. In women using hormonal contraception, higher oxytocin was associated with higher PTSD symptoms across follow-up. Stronger cortisol suppression by dexamethasone, reflecting increased glucocorticoid receptor feedback sensitivity, was associated with lower PTSD symptoms across follow-up in men, but with higher symptoms at 1.5 months in women using hormonal contraception. These effects were independent of treatment condition. No further significant prognostic or prescriptive effects were detected.

CONCLUSION

Our exploratory study indicates that resting oxytocin and glucocorticoid receptor feedback sensitivity early posttrauma are associated with subsequent PTSD symptom severity. Notably, prognostic effects depended on sex and hormonal contraception use, emphasizing the necessity to consider these factors in biomedical PTSD research.

Stressful experiences in youth: "Set-up" for diminished resilience to chronic pain

Chronic pain in youth is common, with prevalence rates in some reports exceeding 50%. Given the plasticity of brain systems in youth and their general level of activity, the underlying processes relating to the evolution of chronic pain may be different from that observed in adults. One aspect that affects brain development is childhood stress. Preliminary research indicates that maladaptive responses to stressful events that induce biological and psychological inability to adapt may be related to pain chronicity in youth. This relationship is particularly notable given the high rates of exposure to stressful events in pediatric pain populations. A review of the literature was performed in the areas of biological, cognitive, psychological and social processes associated with chronic pain and psychological stress and trauma in youth and adult populations. The current review presents a theoretical framework, adapted from McEwen's model (1998) on stress and allostatic load, which aims to outline the potential connection between exposure to stressful events and pediatric chronic pain. Avenues for future investigation are also identified.

The "Managed" or Damaged Heart? Emotional Labor, Gender, and Posttraumatic Stressors Predict Workplace Event-Related Acute Changes in Cortisol, Oxytocin, and Heart Rate Variability

Vital to the everyday operation of police services, police communicators (911 call-takers and dispatchers) are persistently subject to imminent challenges in the workplace; they must always be prepared to engage and deal with a wide variety of circumstances that provoke various intense emotions and physiological stress responses. Acute changes in cortisol, oxytocin, and heart rate variability are central to adaptive responses in stressful complex social interactions, but they might also be indicative of physiological dysregulation due to long-term psychosocial stress exposures. Thus, we examine acute stress-induced release of peripheral oxytocin and cortisol along with changes in heart rate variability, and how each relates to persistent workplace stressors and symptoms of posttraumatic stress. Findings indicate chronic forms of gendered workplace stress such as emotional labor, gender role stress and, posttraumatic stress each have differential associations with, and predict physiological responses to, acutely stressful events in the workplace. These associations suggest potential mechanisms through which communicators become more vulnerable to developing stress-related disorders such as posttraumatic stress injuries, especially after cumulative traumatic exposures in this context. The results also suggest potential pathways for the biological embedding of stressful gendered workplace experiences.

Posttraumatic stress disorder is associated with reduced vitamin D levels and functional polymorphisms of the vitamin D binding-protein in a population-based sample

OBJECTIVE

Low levels of vitamin D were found to be associated with different mental disorders. However, the role of vitamin D in the pathogenesis of PTSD is unclear. In this study, we aimed at investigating whether PTSD is linked to reduced vitamin D levels and vitamin D deficiency. Moreover, we sought to investigate the role of the vitamin D-binding protein (also group-specific component or Gc) by testing if two functional polymorphisms (rs4588 and rs7041) were associated with vitamin D levels and PTSD.

METHODS

Serum levels of total 25(OH)D were measured in a general-population sample of the Study of Health in Pomerania (SHIP-1). The number of traumatic events and status of PTSD were assessed using the PTSD module of the Structured Clinical Interview for the DSM-IV. Study participants were genotyped for rs4588 and rs7041. Associations of 25(OH)D levels and the genotypes with PTSD were tested in subjects with at least one traumatic event (n = 1653).

RESULTS

25(OH)D levels were inversely (OR: 0.96; p = 0.044) and vitamin D deficiency was positively (OR = 2.02; p = 0.028) associated with PTSD. Both polymorphisms of the Gc were associated with 25(OH)D levels and PTSD: Carriers of the CC-genotype of rs4588 showed significantly higher 25(OH)D levels (ß = 0.179, p < 0.001) and lower odds for PTSD (OR = 0.35; p = 0.023) compared to the AA-genotype. Likewise, carriers of the TT-allele of rs7041 showed lower 25(OH)D levels (-0.122; p < 0.001) and increased odds for PTSD (OR = 2.80; p = 0.015) compared to the GG-genotype.

CONCLUSIONS

Our results suggest that an altered vitamin D metabolism may be involved in the pathophysiology of PTSD. Also, genotypes of the Gc and thus Gc serum levels may impact on PTSD development over and above the effects of 25(OH)D. Our findings contribute to explain the associations of PTSD with different mental and physical disorders.

Individual differences in glucocorticoid regulation: Does it relate to disease risk and resilience?

Glucocorticoid (GC) signaling varies among individuals, and this variation may relate to individual differences in health outcomes. To determine if and which aspects of signaling (basal, circadian, integrative, or reactivity) are associated with specific health outcomes, we reviewed recent studies that relate GCs to health outcomes. We identified papers through PubMed and reviewed 100 original research articles related to mental health, cardiovascular health, cancer, diabetes, obesity, pulmonary health, sleep, and fitness. Many studies reported elevated GC secretion associated with worse health, but this was only particularly true for integrative GC measures. On the other hand, accentuated cortisol awakening response and a steeper circadian rhythm were both associated with positive health outcomes. Overall, relationships between GC secretion and health outcomes were relatively weak. This systematic review of relationships between GC metrics and health outcomes highlights the importance of careful consideration when selecting methods to measure GC regulation in health research.

Violence Victimization Predicts Body Mass Index One Decade Later among an Urban Sample of African American Young Adults: Sex as a Moderator and Dehydroepiandrosterone as a Mediator

Psychological stressors such as violence victimization are known contributors to obesity. However, moderators and mediators of this association have not been studied, although they might offer pathways for intervention or prevention. Using a sample of African American young adults, this study tested: (1) the moderating effect of sex on the effect of violence victimization on trajectories of body mass index (BMI), and (2) the mediating effect of dehydroepiandrosterone (DHEA) on this association. This 13-year longitudinal study followed 73 male and 80 female African American young adults who lived in an urban area from 1999 to 2012 when the youth were 20-32 years old. The independent variable was violence victimization measured in 1999 and 2000. The dependent variable was BMI measured in 2002 and 2012. The mediator was DHEA measured in 2001 and 2002. Multilevel path analysis was used to test if males and females differed in violence victimization predicting change in BMI (Model I) and the mediating effect of DHEA change on the above association (Model II). The results of Model I suggested that the change in violence victimization from 1999 to 2000 predicted change in BMI from 2002 to 2012 for females, but not males. Based on Model II, the DHEA change from 2000 to 2001 for females fully mediated the association between violence victimization from 1999 to 2000 and increases in BMI from 2002 to 2012. Our findings suggest that violence victimization in urban areas contributes to the development of obesity among African American female young adults and change in DHEA mediates this link. Violence prevention may have important implications for obesity prevention of African American young women who live in unsafe urban areas. This study also suggests that DHEA may be involved in the violence victimization-obesity link for African American women.

Acute Physiologic Stress and Subsequent Anxiety Among Family Members of ICU Patients

Supplemental Digital Content is available in the text.

Objectives:

The ICU is a complex and stressful environment and is associated with significant psychologic morbidity for patients and their families. We sought to determine whether salivary cortisol, a physiologic measure of acute stress, was associated with subsequent psychologic distress among family members of ICU patients.

Design:

This is a prospective, observational study of family members of adult ICU patients.

Setting:

Adult medical and surgical ICU in a tertiary care center.

Subjects:

Family members of ICU patients.

Interventions:

Participants provided five salivary cortisol samples over 24 hours at the time of the patient ICU admission. The primary measure of cortisol was the area under the curve from ground; the secondary measure was the cortisol awakening response. Outcomes were obtained during a 3-month follow-up telephone call. The primary outcome was anxiety, measured by the Hospital Anxiety and Depression Scale-Anxiety. Secondary outcomes included depression and posttraumatic stress disorder.

Measurements and Main Results:

Among 100 participants, 92 completed follow-up. Twenty-nine participants (32%) reported symptoms of anxiety at 3 months, 15 participants (16%) reported depression symptoms, and 14 participants (15%) reported posttraumatic stress symptoms. In our primary analysis, cortisol level as measured by area under the curve from ground was not significantly associated with anxiety (odds ratio, 0.94; p = 0.70). In our secondary analysis, however, cortisol awakening response was significantly associated with anxiety (odds ratio, 1.08; p = 0.02).

Conclusions:

Roughly one third of family members experience anxiety after an ICU admission for their loved one, and many family members also experience depression and posttraumatic stress. Cortisol awakening response is associated with anxiety in family members of ICU patients 3 months following the ICU admission. Physiologic measurements of stress among ICU family members may help identify individuals at particular risk of adverse psychologic outcomes.

The hypothalamic-pituitary-adrenal axis in PTSD: Pathophysiology and treatment interventions

Questions of how altered functioning of the hypothalamic pituitary adrenal (HPA) axis contribute to the development and maintenance of posttraumatic stress disorder (PTSD) have been the focus of extensive animal and human research. As a rule, results have been inconsistent across studies, likely due to a variety of confounding variables that have received inadequate attention. Important confounding factors include the effects of early life stress, biological sex, and the glucocorticoid used for interventions. In this manuscript we review: 1) the literature on identified abnormalities of HPA axis function in PTSD, both in terms of basal functioning and as part of challenge paradigms; 2) the role of HPA axis function pre- and immediately post-trauma as a risk factor for PTSD development; 3) the impact of HPA axis genes' allelic variants and epigenetic modifications on PTSD risk; 4) the contributions of HPA axis components to fear learning and extinction; and 5) therapeutic manipulations of the HPA axis to both prevent and treat PTSD, including the role of glucocorticoids as part of medication enhanced psychotherapy.

Neuroendocrinological treatment targets for posttraumatic stress disorder

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

Dehydroepiandrosterone (DHEA) and its ratio to cortisol moderate associations between maltreatment and psychopathology in male juvenile offenders

This study examined whether DHEA and its ratio to cortisol moderated risk for psychopathology among incarcerated youth exposed to childhood maltreatment. Resistance to stress-related psychopathology under adversity was also examined in relation to callous-unemotional (CU) traits, a personality construct characterized by resistance to pathological anxiety and blunted reactivity to threatening stimuli. Participants were 201 ethnically heterogeneous (41.8% White, 35.3% Black, 17.2% Hispanic) adolescent boys (M age = 16.75, SD = 1.15 years) incarcerated in a juvenile detention facility in the South Eastern United States who provided four afternoon saliva samples (later assayed for DHEA and cortisol) and completed self-report questionnaires. Results indicated that childhood maltreatment was associated with greater internalizing problems at lower DHEA concentrations and at higher cortisol-to-DHEA ratios. Conversely, higher DHEA levels and lower cortisol-to-DHEA ratios were associated with greater CU traits, irrespective of maltreatment exposure. CU traits did not attenuate levels of psychopathology in maltreated youth. Findings inform biosocial models of how exposure to parental maltreatment in early life contributes to risk and resilience through mechanisms associated with adaptive environmentally sensitive biological systems and processes.

Estimating the risk of PTSD in recent trauma survivors: results of the International Consortium to Predict PTSD (ICPP)

A timely determination of the risk of post-traumatic stress disorder (PTSD) is a prerequisite for efficient service delivery and prevention. We provide a risk estimate tool allowing a calculation of individuals' PTSD likelihood from early predictors. Members of the International Consortium to Predict PTSD (ICPP) shared individual participants' item-level data from ten longitudinal studies of civilian trauma survivors admitted to acute care centers in six countries. Eligible participants (N=2,473) completed an initial clinical assessment within 60 days of trauma exposure, and at least one follow-up assessment 4-15 months later. The Clinician-Administered PTSD Scale for DSM-IV (CAPS) evaluated PTSD symptom severity and diagnostic status at each assessment. Participants' education, prior lifetime trauma exposure, marital status and socio-economic status were assessed and harmonized across studies. The study's main outcome was the likelihood of a follow-up PTSD given early predictors. The prevalence of follow-up PTSD was 11.8% (9.2% for male participants and 16.4% for females). A logistic model using early PTSD symptom severity (initial CAPS total score) as a predictor produced remarkably accurate estimates of follow-up PTSD (predicted vs. raw probabilities: r=0.976). Adding respondents' female gender, lower education, and exposure to prior interpersonal trauma to the model yielded higher PTSD likelihood estimates, with similar model accuracy (predicted vs. raw probabilities: r=0.941). The current model could be adjusted for other traumatic circumstances and accommodate risk factors not captured by the ICPP (e.g., biological, social). In line with their use in general medicine, risk estimate models can inform clinical choices in psychiatry. It is hoped that quantifying individuals' PTSD risk will be a first step towards systematic prevention of the disorder.

Effects of oxytocin on stress reactivity and craving in veterans with co-occurring PTSD and alcohol use disorder

Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD) are highly prevalent and commonly co-occur. The dual diagnosis of PTSD/AUD is associated with serious negative sequalae, and there are currently no effective pharmacological treatments for this comorbidity. Both PTSD and AUD are characterized by dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, which helps modulate stress reactivity. Oxytocin, a neuropeptide that attenuates HPA axis dysregulation, may be beneficial for individuals with co-occurring PTSD/AUD. Thus, the current study examined the effects of intranasal oxytocin (40 IU) as compared with placebo on stress reactivity (e.g., cortisol) as well as subjective alcohol craving in response to a laboratory stress task (Trier Social Stress Task). Participants were 67 male U.S. military veterans with current PTSD and AUD (oxytocin n = 32, placebo n = 35; overall mean age = 49.06 years). Baseline cortisol levels were examined as a moderator of outcome. The findings revealed that oxytocin marginally attenuated cortisol reactivity in response to the stress task. Furthermore, oxytocin's effect was moderated by baseline cortisol level, such that oxytocin mitigated cortisol reactivity to a greater extent among participants with higher, as compared with lower, baseline cortisol. Oxytocin did not reduce craving. Although preliminary, the findings are the first to examine oxytocin in co-occurring PTSD/AUD. The findings from this study contribute to the growing literature examining the potential utility of oxytocin among individuals with psychiatric disorders, such as PTSD and substance use disorders. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Metabolomic and glycomic findings in posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is a stressor-related disorder that develops in a subset of individuals exposed to a traumatic experience. Factors associated with vulnerability to PTSD are still not fully understood. PTSD is frequently comorbid with various psychiatric and somatic disorders, moderate response to treatment and remission rates. The term "theranostics" combines diagnosis, prognosis, and therapy and offers targeted therapy based on specific analyses. Theranostics, combined with novel techniques and approaches called "omics", which integrate genomics, transcriptomic, proteomics and metabolomics, might improve knowledge about biological underpinning of PTSD, and offer novel therapeutic strategies. The focus of this review is on metabolomic and glycomic data in PTSD. Metabolomics evaluates changes in the metabolome of an organism by exploring the set of small molecules (metabolites), while glycomics studies the glycome, a complete repertoire of glycan structures with their functional roles in biological systems. Both metabolome and glycome reflect the physiological and pathological conditions in individuals. Only a few studies evaluated metabolic and glycomic changes in patients with PTSD. The metabolomics studies in PTSD patients uncovered different metabolites that might be associated with psychopathological alterations in PTSD. The glycomics study in PTSD patients determined nine N-glycan structures and found accelerated and premature aging in traumatized subjects and subjects with PTSD based on a GlycoAge index. Therefore, further larger studies and replications are needed. Better understanding of the biological basis of PTSD, including metabolomic and glycomic data, and their integration with other "omics" approaches, might identify new molecular targets and might provide improved therapeutic approaches.

Inflammation as a predictor of disease course in posttraumatic stress disorder and depression: A prospective analysis from the Mind Your Heart Study

BACKGROUND

Prior research has focused largely on the pro-inflammatory states of PTSD and depression, with few studies evaluating the direction of inflammation's association with these disorders. To clarify whether inflammation plays a role in the development of PTSD or depression, we assessed the predictive value of inflammatory biomarkers on the courses of these conditions in a cohort of Veterans.

METHODS

This research was part of the Mind Your Heart Study, a prospective cohort study designed to examine PTSD-related health outcomes. Between 2008 and 2010, 746 San Francisco area Veterans Administration patients were enrolled. At baseline, inflammatory biomarkers were measured from fasting morning venous blood draws, and cortisol and catecholamine levels were measured from 24-hour urine samples. PTSD was diagnosed using the PTSD Checklist at baseline and annual follow-up. Depression was evaluated using the 9-item Patient Health Questionnaire at baseline and follow-up. Ordinal logistic regression models were used to assess the predictive value of baseline biomarker levels on clinically relevant courses of PTSD and depression categorized and ordered as none, resolved, developed, and chronic.

RESULTS

After adjustment for age and sex, elevated levels of white blood cell count (OR = 1.27(1.10-1.47), p = 0.001), C-reactive protein (OR = 1.20(1.04-1.39), p = 0.02), fibrinogen (OR = 1.19(1.03-1.38), p = 0.02), and ESR (OR = 1.17(1.00-1.36, p = 0.05), and decreased levels of urine cortisol (OR = 0.84(0.71-0.99), p = 0.04) were significant predictors of poorer courses of PTSD. Elevated levels of WBC count (OR = 1.31(1.14-1.50), p < 0.001), CRP (OR = 1.24(1.07-1.43), p = 0.003), fibrinogen (OR = 1.26(1.09-1.46), p = 0.002), and catecholamines (OR = 1.17(1.01-1.36), p = 0.04) were significant predictors of poorer courses of depression. After additionally controlling for physical activity, elevated WBC count (p = 0.002) and decreased levels of urine cortisol (p = 0.05) remained significant predictors of PTSD course, and elevated WBC count (p = 0.001), CRP (p = 0.03), and fibrinogen (p = 0.02) remained significant predictors of depression course. After adjusting for all significant variables, elevated WBC count (p = 0.02) was a significant predictor of a poorer course of PTSD, and elevated WBC count (p = 0.04) and platelet count (p = 0.03) were significant predictors of a poorer course of depression.

CONCLUSIONS

Increased levels of several inflammatory biomarkers were associated with significantly increased odds of clinically worse courses of PTSD and depression. Inflammation may be a target for prevention and treatment of these mental health disorders.

Psychotherapeutic treatment and HPA axis regulation in posttraumatic stress disorder: A systematic review and meta-analysis

Posttraumatic stress disorder (PTSD) has been associated with dysregulation of the hypothalamic-pituitary- adrenal (HPA) axis. Research over the past years has investigated potential changes of these alterations in the context of psychotherapy. Yet, no systematic review has been conducted. To summarize the current state of research on psychotherapy and HPA hormones, namely cortisol, dehydroepiandrosterone and its sulfate form (DHEA(S)), we searched for studies investigating predictions or changes in hormones over treatment course within the databases PubMed, Scopus, Medline, PsychINFO, Pilots/ProQuest, and Web of Science, and in the grey literature up to May 2018. Controlled and uncontrolled trials investigating adult samples with a clinical status of PTSD were eligible for inclusion. Twelve studies (428 participants) were included. Study quality was overall sufficient. Hormone assessment designs differed considerably. Treatment efficacy on PTSD symptom reduction was mostly high, but predictions of pre-treatment hormone concentrations on treatment efficacy were largely non-significant. Changes from pre- to post-test in basal cortisol (g = -0.07, 95% CI = -0.36; 0.21) and in the cortisol awakening response (g = -0.07, 95% CI = -0.48; 0.35) were also non-significant. Future studies require comparable designs and need to be sufficiently powered to be able to detect potential associations with HPA regulation.

The impact of an exercise training intervention on cortisol levels and post-traumatic stress disorder in juveniles from an Ugandan refugee settlement: study protocol for a randomized control trial

Background

Latest research demonstrates a significant improvement in stress-related symptoms in psychological disorders as a result of exercise training (ET). Controlled clinical trials further validate the significance of ET by demonstrating lower salivary cortisol levels in patients with post-traumatic stress disorder (PTSD) after intervention. A significant change in cortisol and dehydroepiandrosterone (DHEA) levels can already be found after an 8–12-week ET program. The proposed study aims to investigate the impact of an 8-week ET on PTSD symptoms and changes in cortisol levels in a juvenile refugee sample from the Democratic Republic of the Congo (DRC) at an Ugandan refugee settlement. It is the first to implement an ET intervention in a resource-poor, post-conflict setting.

Methods/design

In a randomized controlled trial, 198 adolescent participants aged 13–16 years from the DRC who, suffer from PTSD, will be investigated. The participants are based at the Nakivale refugee settlement, an official refugee camp in Uganda, Africa, which is among the largest in the world. The participants will be randomized into an Exercise Training (ET) group with a maximum heart rate (HR_max) of > 60%, an Alternative Intervention (AI) group with low-level exercises, and a Waiting-list Control (WC) group. After the 8-week interventional phase, changes in cortisol awakening response (CAR) and DHEA in the ET group that correspond to an improvement in PTSD symptoms are expected that remain at follow-up after 3 months.

Discussion

To date, there is no controlled and reliable longitudinal study examining the effects of an ET program on symptom severity in individuals with PTSD that can be explained with a harmonization of cortisol secretion. The presented study design introduces an intervention that can be implemented with little expenditure. It aims to provide a promising low-threshold and cost-effective treatment approach for the application in resource-poor settings.

Trial registration

German Trials Register, ID: DRKS00014280. Registered prospectively on 15 March 2018.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2753-x) contains supplementary material, which is available to authorized users.

Application of data pooling to longitudinal studies of early post-traumatic stress disorder (PTSD): the International Consortium to Predict PTSD (ICPP) project

Background: Understanding the development of post-traumatic stress disorder (PTSD) is a precondition for efficient risk assessment and prevention planning. Studies to date have been site and sample specific. Towards developing generalizable models of PTSD development and prediction, the International Consortium to Predict PTSD (ICPP) compiled data from 13 longitudinal, acute-care based PTSD studies performed in six different countries. Objective: The objectives of this study were to describe the ICPP's approach to data pooling and harmonization, and present cross-study descriptive results informing the longitudinal course of PTSD after acute trauma. Methods: Item-level data from 13 longitudinal studies of adult civilian trauma survivors were collected. Constructs (e.g. PTSD, depression), measures (questions or scales), and time variables (days from trauma) were identified and harmonized, and those with inconsistent coding (e.g. education, lifetime trauma exposure) were recoded. Administered in 11 studies, the Clinician Administered PTSD Scale (CAPS) emerged as the main measure of PTSD diagnosis and severity. Results: The pooled data set included 6254 subjects (39.9% female). Studies' average retention rate was 87.0% (range 49.1-93.5%). Participants' baseline assessments took place within 2 months of trauma exposure. Follow-up durations ranged from 188 to 1110 days. Reflecting studies' inclusion criteria, the prevalence of baseline PTSD differed significantly between studies (range 3.1-61.6%), and similar differences were observed in subsequent assessments (4.3-38.2% and 3.8-27.0% for second and third assessments, respectively). Conclusion: Pooling data from independently collected studies requires careful curation of individual data sets for extracting and optimizing informative commonalities. However, it is an important step towards developing robust and generalizable prediction models for PTSD and can exceed findings of single studies. The large differences in prevalence of PTSD longitudinally cautions against using any individual study to infer trauma outcome. The multiplicity of instruments used in individual studies emphasizes the need for common data elements in future studies.

PTSD and depressive symptoms are linked to DHEAS via personality

BACKGROUND

Research results on dehydroepiandrosterone sulfate ester (DHEAS) in post-traumatic stress disorder (PTSD) are inconsistent. We hypothesized that personality traits could be the confounders of DHEAS levels and disease symptoms, which could in part explain the discrepancy in findings.

METHOD

This study was a part of a broader project in which simultaneous psychological and biological investigations were carried out in hospital conditions. 380 male subjects were categorized in four groups: A) current PTSD (n = 132), B) lifetime PTSD (n = 66), C) trauma controls (n = 101), and D) healthy controls (n = 81), matched by age.

RESULTS

The level of DHEAS is significantly lower in the current PTSD group than in trauma controls. All groups significantly differ in personality traits Disintegration and Neuroticism (current PTSD group having the highest scores). DHEAS is related to both PTSD and depressive symptoms; however, Structural Equation Model (SEM) shows that the relations are indirect, realized via their confounder - personality trait Disintegration.

CONCLUSIONS

According to our project results, DHEAS is the second putative biomarker for trauma-related disorders that fails to fulfil this expectation. It appears to be more directly related to personality than to the disease symptoms (the first one being basal cortisol). Our data promote personality as a biologically based construct with seemingly important role in understanding the mental health status.

Current Status of Animal Models of Posttraumatic Stress Disorder: Behavioral and Biological Phenotypes, and Future Challenges in Improving Translation

Increasing predictability of animal models of posttraumatic stress disorder (PTSD) has required active collaboration between clinical and preclinical scientists. Modeling PTSD is challenging, as it is a heterogeneous disorder with ≥20 symptoms. Clinical research increasingly utilizes objective biological measures (e.g., imaging, peripheral biomarkers) or nonverbal behaviors and/or physiological responses to complement verbally reported symptoms. This shift toward more-objectively measurable phenotypes enables refinement of current animal models of PTSD, and it supports the incorporation of homologous measures across species. We reviewed >600 articles to examine the ability of current rodent models to probe biological phenotypes of PTSD (e.g., sleep disturbances, hippocampal and fear-circuit dysfunction, inflammation, glucocorticoid receptor hypersensitivity) in addition to behavioral phenotypes. Most models reliably produced enduring generalized anxiety-like or depression-like behaviors, as well as hyperactive fear circuits, glucocorticoid receptor hypersensitivity, and response to long-term selective serotonin reuptake inhibitors. Although a few paradigms probed fear conditioning/extinction or utilized peripheral immune, sleep, and noninvasive imaging measures, we argue that these should be incorporated more to enhance translation. Data on female subjects, on subjects at different ages across the life span, or on temporal trajectories of phenotypes after stress that can inform model validity and treatment study design are needed. Overall, preclinical (and clinical) PTSD researchers are increasingly incorporating homologous biological measures to assess markers of risk, response, and treatment outcome. This shift is exciting, as we and many others hope it not only will support translation of drug efficacy from animal models to clinical trials but also will potentially improve predictability of stage II for stage III clinical trials.

Longitudinal interplays of estrogen receptor alpha gene rs9340799 with social-environmental factors on post-traumatic stress disorder in Chinese Han adolescents after Wenchuan earthquake

Indirect evidences suggested associations of estrogen receptor alpha (ESR1) with post-traumatic stress disorder (PTSD). However, the relationship between rs9340799 on ESR1 gene and PTSD has not been reported yet. The present study was to explore the longitudinal changes of prevalence and severity of PTSD in adolescents with different genotypes of rs9340799 after the 2008 Wenchuan earthquake. Social-environmental factors were collected by questionnaires in 465 high school students. Variants of rs9340799 were determined by polymerase chain reaction-restriction fragment length polymorphism analyses and verified by DNA sequencing. PTSD symptoms were assessed by PTSD Checklist-Civilian Version (PCL-C) at 6, 12, and 18 months after the earthquake. The female AA homozygotes had a trend of higher prevalence of PTSD and significantly higher PCL-C scores than the female G allele carriers at 6 months after the earthquake. The female students had higher prevalence of PTSD and higher PCL-C scores than the male subjects at 6 months in the AA homozygotes, but not in the G allele carriers. Consecutive decreases in PCL-C scores were observed only in the female AA homozygotes. Only in the female, the AA genotype was the risk factor and predictor of PCL-C scores at 6 months. Potential factors of PTSD prevalence and predictors of PCL-C scores were different between the AA homozygotes and G allele carriers at different time during the follow-up. These results suggest gene-environment interactions may occur among rs9340799 and social-environmental factors, and influence the development and natural rehabilitation of PTSD in the course after stressed by the earthquake.

Basal blood DHEA-S/cortisol levels predicts EMDR treatment response in adolescents with PTSD

OBJECTIVE

In literature, recent evidence has shown that the hypothalamic-pituitary-adrenal (HPA) axis can be dysregulated in patients with post-traumatic stress disorder (PTSD) and HPA axis hormones may predict the psychotherapy treatment response in patients with PTSD. In this study, it was aimed to investigate changing cortisol and DHEA-S levels post-eye movement desensitization and reprocessing (EMDR) therapy and the relationship between treatment response and basal cortisol, and DHEA-S levels before treatment.

METHOD

The study group comprised 40 adolescents (age, 12-18 years) with PTSD. The PTSD symptoms were assessed using the Child Depression Inventory (CDI) and Child Post-traumatic Stress Reaction Index (CPSRI) and the blood cortisol and DHEA-S were measured with the chemiluminescence method before and after treatment. A maximum of six sessions of EMDR therapy were conducted by an EMDR level-1 trained child psychiatry resident. Treatment response was measured by the pre- to post-treatment decrease in self-reported and clinical PTSD severity.

RESULTS

Pre- and post-treatment DHEA-S and cortisol levels did not show any statistically significant difference. Pre-treatment CDI scores were negatively correlated with pre-treatment DHEA-S levels (r: -0.39). ROC analysis demonstrated that the DHEA-S/cortisol ratio predicts treatment response at a medium level (AUC: 0.703, p: .030, sensitivity: 0.65, specificity: 0.86).

CONCLUSION

The results of this study suggested that the DHEA-S/cortisol ratio may predict treatment response in adolescents with PTSD receiving EMDR therapy. The biochemical parameter of HPA-axis activity appears to be an important predictor of positive clinical response in adolescent PTSD patients, and could be used in clinical practice to predict PTSD treatment in the future.

Depression subtyping based on evolutionary psychiatry: Proximate mechanisms and ultimate functions

Major depressive disorder constitutes one of the leading causes of disability worldwide. However, it is not a unitary disease-it is a heterogeneous syndrome, with patients differing remarkably in symptom profile, pathophysiology and treatment responsiveness. Previous attempts to subtype major depressive disorder have showed limited clinical applicability. We present a classification of major depressive disorder episodes based on the proximate mechanisms that led to the original mood change that caused the depressive episode. We identify discrete depression subtypes that are induced by: 1) infection, 2) long-term stress, 3) loneliness, 4) traumatic experience, 5) hierarchy conflict, 6) grief, 7) romantic rejection, 8) postpartum events, 9) the season, 10) chemicals, 11) somatic diseases and 12) starvation. We further examine the ultimate functions of these subtypes and show that not all types of mood changes that trigger depression are adaptive. Instead, some are clearly maladaptive and some are byproducts of other adaptations. In modern societies, low mood after adverse life events may turn into a pathological depressive state. Modern lifestyle increases susceptibility to inflammatory dysregulation and chronic stress, both of which increase the amount of proinflammatory cytokines in peripheral blood, leading to low mood and sickness behaviour. Proinflammatory cytokines may aggravate the previously adaptive short-term mood changes to a chronic maladaptive depressive state by preventing the normalization of mood after adverse life events. Subtyping depression enables an effective and intelligent long-term treatment of patients in each subtype by treating the underlying causes of depression.

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

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

Trauma and psychiatric disorders: A systematic review

BACKGROUND

Suicide is currently a topic of high priority for policy-makers, researchers and clinicians. The World Health Organization estimated 804,000 suicide deaths worldwide in 2012. Some studies that focused on patients with self-inflicted injury revealed that mortality in this group is higher than for patients who sustain unintentional injury. However little is known about the impact of psychiatric disorders on health care resources including length of hospital stay.

OBJECTIVES

To determine whether trauma patients with a psychiatric disorder or after attempting suicide are at higher risk of a complicated course than patients without a psychiatric disorder or accidental cause. The secondary objective was to provide an overview of the current literature on the same group of trauma patients with psychiatric comorbidity in regard to mortality rate, length of stay, hospital costs and quality of life. Our primary outcome measure, complicated course, was found to be most clinically relevant.

METHODS

We searched PubMed, Embase and PsycInfo electronic databases. All searches were updated to March 2016. The methodological quality was assessed using the QUIPS tool.

RESULTS

Our search identified 9284 articles (PubMed 3660, Embase 2590, PsycInfo 3034). Of these, 18 articles were included. Four studies investigated the association between psychiatric disorders and a complicated course after trauma, three found a significant higher risk of complications. Mortality was reviewed in 14 studies, of which seven showed significant higher risk of in-hospital mortality for trauma patients with psychiatric disorder. Eight of nine studies found significant prolonged length of stay for these patients.

CONCLUSION

Patients who have a psychiatric disorder or who have attempted suicide are at higher risk of increased in-hospital mortality and prolonged length of stay after sustaining injuries. These patients also tend to be at higher risk of complications after severe trauma, however future research is needed to confirm these potentially important implications.

LEVEL OF EVIDENCE

Systematic review, level III.

Neuroendocrine and neuroimmune markers in PTSD: pre-, peri- and post-trauma glucocorticoid and inflammatory dysregulation

We review current knowledge on how posttraumatic stress disorder (PTSD) is associated with dysregulation of the most commonly studied markers of the endocrine and immune systems pre-, peri- and post-trauma. Lower basal cortisol output, enhanced glucocorticoid receptor function, and a proinflammatory state have been most consistently found in PTSD, with considerable variability among studies and participants. Longitudinal research is scarce, but there is converging evidence that biological dysregulation is present before PTSD onset. Biological dysregulation may become more apparent with increasing time since trauma, and may be reversible with and predict effective treatment. However, considering the variability of findings and the complex interplay of these systems with other factors, the current clinical application of these findings remains limited.

Fatty acid concentrations in patients with posttraumatic stress disorder compared to healthy controls

BACKGROUND

Although fatty acid (FA)-supplementation studies are currently being implemented, in fact little is known about FA-profiles in posttraumatic stress disorder (PTSD). Therefore, the present study aimed at comparing FA-concentrations between PTSD-patients and healthy controls.

METHODS

A cross-sectional study comparing a mixed-gender sample of 49 patients with PTSD due to civilian trauma to 46 healthy controls regarding erythrocyte FAs including docosahexaenoic acid (DHA), eicosapentaenoic acid (EPA), arachidonic acid (AA), and nervonic acid (NA).

RESULTS

DHA was found to be significantly lower in PTSD-patients compared to controls after adjusting for sociodemographic and dietary factors (p =0.043). Additionally, exploratory analyses showed lower vaccenic acid (p =0.035) and eicosatrienoic acid (p =0.006), but higher erucic acid (p =0.032) in PTSD-patients. The effect of erucic acid remained after adjustment for sociodemographic factors (p =0.047); with the additional adjustment for dietary factors none of these FAs were found to be significant.

LIMITATIONS

Statistical power for differences with small effect sizes was limited, and dietary assessment could be optimized.

CONCLUSIONS

We found little evidence for a considerable role of FA-metabolism in PTSD. Apart from lower DHA after adjusting for confounders, no differences were observed in the hypothesized long-chained polyunsaturated FA-concentrations. Additionally, we found few alterations in the long-chained monounsaturated FAs, which may be explained by dietary factors. Nevertheless, the observed small effect sizes and limited extent of the alterations emphasize the importance of further investigating the assumed role of FA-metabolism and its underlying mechanisms in PTSD, before implementing further FA-supplementation studies.

Cortisol, heart rate, and blood pressure as early markers of PTSD risk: A systematic review and meta-analysis

Individuals with posttraumatic stress disorder (PTSD) typically exhibit altered hypothalamic-pituitary-adrenal (HPA) function and sympathetic nervous system (SNS) activity. The goals of this study were to determine whether HPA and SNS alterations in the immediate aftermath of trauma predict subsequent PTSD symptom development and whether inconsistencies observed between studies can be explained by key demographic and methodological factors. This work informs secondary prevention of PTSD by identifying subgroups of trauma survivors at risk for PTSD. This meta-analysis (26 studies, N=5186 individuals) revealed that higher heart rate measured soon after trauma exposure was associated with higher PTSD symptoms subsequently (r=0.13). Neither cortisol (r=-0.07) nor blood pressure (diastolic: r=-0.01; systolic: r=0.02) were associated with PTSD symptoms which may be influenced by methodological limitations. Associations between risk markers (heart rate, cortisol, systolic blood pressure) and PTSD symptoms were in the positive direction for younger samples and negative direction for older samples. These findings extend developmental traumatology models of PTSD by revealing an age-related shift in the presentation of early risk markers. More work will be needed to identify risk markers and pathways to PTSD while addressing methodological limitations in order to shape and target preventive interventions.

Role of neuroinflammation and sex hormones in war-related PTSD

The susceptibility to develop posttraumatic stress disorder (PTSD) is greatly influenced by both innate and environmental risk factors. One of these factors is gender, with women showing higher incidence of trauma-related mental health disorders than their male counterparts. The evidence so far links these differences in susceptibility or resilience to trauma to the neuroprotective actions of sex hormones in reducing neuroinflammation after severe stress exposure. In this review, we discuss the impact of war-related trauma on the incidence of PTSD in civilian and military populations as well as differences associated to gender in the incidence and recovery from PTSD. In addition, the mutually influencing role of inflammation, genetic, and sex hormones in modulating the consequences derived from exposure to traumatic events are discussed in light of current evidence.

Zebrafish: A Versatile Animal Model for Fertility Research

The utilization of zebrafish in biomedical research is very common in the research world nowadays. Today, it has emerged as a favored vertebrate organism for the research in science of reproduction. There is a significant growth in amount numbers of scientific literature pertaining to research discoveries in reproductive sciences in zebrafish. It has implied the importance of zebrafish in this particular field of research. In essence, the current available literature has covered from the very specific brain region or neurons of zebrafish, which are responsible for reproductive regulation, until the gonadal level of the animal. The discoveries and findings have proven that this small animal is sharing a very close/similar reproductive system with mammals. More interestingly, the behavioral characteristics and along with the establishment of animal courtship behavior categorization in zebrafish have laid an even stronger foundation and firmer reason on the suitability of zebrafish utilization in research of reproductive sciences. In view of the immense importance of this small animal for the development of reproductive sciences, this review aimed at compiling and describing the proximate close similarity of reproductive regulation on zebrafish and human along with factors contributing to the infertility, showing its versatility and its potential usage for fertility research.