Hypothalamic-pituitary-adrenal activity among Armenian adolescents with PTSD symptoms

The Molecular Biology of Susceptibility to Post-Traumatic Stress Disorder: Highlights of Epigenetics and Epigenomics

Exposure to trauma is one of the most important and prevalent risk factors for mental and physical ill-health. Excessive or prolonged stress exposure increases the risk of a wide variety of mental and physical symptoms. However, people differ strikingly in their susceptibility to develop signs and symptoms of mental illness after traumatic stress. Post-traumatic stress disorder (PTSD) is a debilitating disorder affecting approximately 8% of the world’s population during their lifetime, and typically develops after exposure to a traumatic event. Despite that exposure to potentially traumatizing events occurs in a large proportion of the general population, about 80–90% of trauma-exposed individuals do not develop PTSD, suggesting an inter-individual difference in vulnerability to PTSD. While the biological mechanisms underlying this differential susceptibility are unknown, epigenetic changes have been proposed to underlie the relationship between exposure to traumatic stress and the susceptibility to develop PTSD. Epigenetic mechanisms refer to environmentally sensitive modifications to DNA and RNA molecules that regulate gene transcription without altering the genetic sequence itself. In this review, we provide an overview of various molecular biological, biochemical and physiological alterations in PTSD, focusing on changes at the genomic and epigenomic level. Finally, we will discuss how current knowledge may aid us in early detection and improved management of PTSD patients.

Chronic early trauma impairs emotion recognition and executive functions in youth; specifying biobehavioral precursors of risk and resilience

Exposure to chronic early trauma carries lasting effects on children's well-being and adaptation. Guided by models on resilience, we assessed the interplay of biological, emotional, cognitive, and relational factors in shaping two regulatory outcomes in trauma-exposed youth: emotion recognition (ER) and executive functions (EF). A unique war-exposed cohort was followed from early childhood to early adolescence. At preadolescence (11-13 years), ER and EF were assessed and respiratory sinus arrhythmia (RSA), biomarker of parasympathetic regulation, was quantified. Mother-child dyadic reciprocity, child's avoidance symptoms, and cortisol (CT) were measured in early childhood. Trauma-exposed youth displayed impaired ER and EF abilities. Conditional process analysis described two differential indirect paths leading from early trauma to regulatory outcomes. ER was mediated by avoidance symptoms in early childhood and modulated by cortisol, such that this path was evident only for preadolescents with high, but not low, CT. In comparison, EF was mediated by the degree of dyadic reciprocity experienced in early childhood and modulated by RSA, observed only among youth with lower RSA. Findings pinpoint trauma-related disruptions to key regulatory support systems in preadolescence as mediated by early-childhood relational, clinical, and physiological factors and highlight the need to specify biobehavioral precursors of resilience toward targeted early interventions.

The Two Faces of Janus: Why Thyrotropin as a Cardiovascular Risk Factor May Be an Ambiguous Target

Elevated concentrations of free thyroid hormones are established cardiovascular risk factors, but the association of thyrotropin (TSH) levels to hard endpoints is less clear. This may, at least in part, ensue from the fact that TSH secretion depends not only on the supply with thyroid hormones but on multiple confounders including genetic traits, medication and allostatic load. Especially psychosocial stress is a still underappreciated factor that is able to adjust the set point of thyroid function. In order to improve our understanding of thyroid allostasis, we undertook a systematic meta-analysis of published studies on thyroid function in post-traumatic stress disorder (PTSD). Studies were identified via MEDLINE/PubMed search and available references, and eligible were reports that included TSH or free thyroid hormone measurements in subjects with and without PTSD. Additionally, we re-analyzed data from the NHANES 2007/2008 cohort for a potential correlation of allostatic load and thyroid homeostasis. The available evidence from 13 included studies and 3386 euthyroid subjects supports a strong association of both PTSD and allostatic load to markers of thyroid function. Therefore, psychosocial stress may contribute to cardiovascular risk via an increased set point of thyroid homeostasis, so that TSH concentrations may be increased for reasons other than subclinical hypothyroidism. This provides a strong perspective for a previously understudied psychoendocrine axis, and future studies should address this connection by incorporating indices of allostatic load, peripheral thyroid hormones and calculated parameters of thyroid homeostasis.

Efficacy of equine-assisted psychotherapy in veterans with posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder (PTSD) is a common and debilitating disorder among war veterans. Although complementary and alternative therapies are gaining acceptance in the treatment of PTSD, the efficacy of animal-based therapies in this disorder is unknown. The goal of equine-assisted psychotherapy (EAP) is to improve the social, emotional, and/or cognitive functions of individuals with PTSD.

OBJECTIVE

This study aims to explore the effects of EAP on PTSD symptoms. We hypothesized that veterans with PTSD who participate in a standardized EAP program for 1 h per week for 6 weeks would experience decreased PTSD symptoms and would demonstrate increased resilience as compared with individuals who do not receive EAP intervention.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTIONS

We conducted a sequentially assigned, two-arm parallel group trial comparing 6 weeks of EAP with standard, previously established, ongoing PTSD therapy. Therapy was conducted at a community EAP facility in conjunction with an academic University Hospital. Twenty adult veterans with symptomatic PTSD completed the study. Ten adult veterans with previously diagnosed PTSD were assigned to EAP and received directed interaction with trained horses for one hour a week in groups of 3 or 4 individuals, while also continuing their previously established therapies. A certified therapist supervised the sessions, and a professional horse handler was also present. Results were compared with those from 10 adult veterans who only received their standard previously established PTSD care as prescribed by their provider.

MAIN OUTCOME MEASURES

Changes in salivary cortisol, scores for the PTSD Check List-Military Version (PCL-M) and the Connor-Davidson Resilience Scale (CD-RISC) after 6 weeks of study were measured.

RESULTS

Of the 20 enrolled patients, 10 served in Afghanistan, 5 served in Iraq, and 3 served in Vietnam. Subjects were (47 ± 14) years old, were predominantly male, and had a body mass index of (29 ± 7) kg/m². They had (9.2 ± 6.1) years of military service and carried 66% ± 37% service-connected disability. PCL-M scores declined significantly in both groups and CD-RISC scores increased significantly in the EAP group. There was no difference between the groups with respect to the magnitude of change.

CONCLUSION

As compared to the control group, a 6-week EAP program did not produce a statistically significant difference with respect to PCL-M and CD-RISC scores, or salivary cortisol. However, our results suggest that EAP may work as well as standard therapy with respect to these parameters. This study supports further inquiry into EAP as a potentially efficacious alternative for veterans suffering from PTSD.

TRIAL REGISTRATION

ClinicalTrials.gov NCT #03039361.

Pre-treatment cortisol awakening response predicts symptom reduction in posttraumatic stress disorder after treatment

Dysfunction of the HPA-axis has frequently been found in the aftermath of trauma exposure with or without PTSD. Decreasing HPA-axis reactivity to different stress cues has been reported during PTSD treatment. The cortisol awakening response (CAR_i) is a well-validated, standardized measure of HPA-axis reactivity which can be easily acquired in the clinical setting. Whether CAR_i changes over time in traumatized individuals are specific to PTSD treatment is unknown. Furthermore, a possible role for the baseline CAR_i in predicting symptom reduction after treatment in PTSD has not been examined before. To answer these questions, a cohort study was conducted in which the awakening cortisol was measured in both PTSD (N=41) and non-PTSD (N=25) combat-exposed male subjects. Measurements took place at inclusion and 6-8 months after inclusion for both the PTSD and the non-PTSD group. During the 6-8 months interval, PTSD patients received trauma-focused focused psychotherapy, whereas non-PTSD patients received no treatment. We found a decrease in the CAR_i over time in both groups, suggesting it was not specific to PTSD or the effect of treatment. Therefore, caution is warranted when attributing diminished HPA-axis reactivity over time to effects of PTSD treatment. Second, CAR_i prior to treatment predicted PTSD symptom reduction (CAPS score change) after treatment, and accounted for 10% of the variance, even when adjusted for changes in depressive symptoms and medication use during the study period. A putative role emerges for CAR_i as a predictive biomarker of symptom reduction in male individuals with combat-related PTSD.

Genetic variability of interleukin-1 beta as prospective factor from developing post-traumatic stress disorder

Individual susceptibility to post-traumatic stress disorder (PTSD) is conditioned by genetic factors, and association between this disorder and polymorphisms of several genes have been shown. The aim of this study was to explore a potential association between single nucleotide polymorphisms (SNP) of the IL-1β gene (IL1B) and PTSD. In genomic DNA samples of PTSD-affected and healthy subjects, the rs16944, rs1143634, rs2853550, rs1143643, and rs1143633 SNPs of IL1B gene have been genotyped. The results obtained demonstrated that IL1B rs1143633*C and rs16944*A minor allele frequency were significantly lower in patients than in controls. Our results confirm that IL1B rs1143633 and rs16944 SNPs are negatively associated with PTSD which allows us to consider them as protective variants for PTSD. IL1B rs1143633*C and rs16944*A minor allele frequencies and carriage rates are significantly lower in the PTSD patients as compared to the controls. These results may provide a base to conclude that above-mentioned alleles can be protective against PTSD, and IL1B gene can be involved in the pathogenesis of this disorder.

Effect of Rivastigmine Augmentation in Treatment of Male Patients With Combat-Related Chronic Posttraumatic Stress Disorder: A Randomized Controlled Trial

BACKGROUND

Posttraumatic stress disorder (PTSD) is one of the chronic and disabling psychiatric disorders, particularly in combat veterans. In a case series, rivastigmine was suggested to be an effective augmentation in treatment of PTSD. The aim of the present study was to evaluate this finding in a randomized controlled trial.

METHOD

A 12-week, double-blind, placebo-controlled clinical trial was performed on 36 male patients (aged 42-60 years) diagnosed with chronic, combat-related PTSD. Subjects were screened for apparent cognitive deficits by means of Mini-Mental State Examination. All patients received selective serotonin reuptake inhibitors plus sodium valproate for 4 weeks and then reevaluated. Subjects who did not show adequate response were randomly assigned into 3 groups receiving rivastigmine (up to 6 mg/d), placebo, or the prior treatment regimen. Efficacy of medication was measured by administering PTSD Check List-Military Version at baseline and weeks 2, 4, 8, and 12. Collected data were analyzed by analysis of variance and repeated measurement. Reported differences were considered significant at the level of 0.05 or less.

RESULTS

The 3 groups showed statistically significant reductions in the total PTSD Check List-Military Version, avoidance subscale, and the reexperience subscale but not in the hyperarousal subscale. No significant differences were found between the 3 groups.

CONCLUSIONS

In contrast to the previous case series, findings of the current study did not support the efficacy of adjunctive rivastigmine in treatment of PTSD. This hypothetically could be due to the fact that all the study's subjects scored higher than 25 on Mini-Mental State Examination.

Endocrine and emotional response to exclusion among women and men; cortisol, salivary alpha amylase, and mood

BACKGROUND AND OBJECTIVES

Social exclusion is ubiquitous and painful. Evolutionary models indicate sex differences in coping with social stress. Recent empirical data suggest different sex patterns in hypothalamic-pituitary-adrenal (HPA) and sympathetic-adrenal-medullary (SAM) reactivity. The present study sought to test this hypothesis.

DESIGN

We examined differences in endocrine and emotional response to exclusion by using a virtual ball tossing paradigm (Cyberball). Saliva samples and mood ratings were collected to reflect levels before, and repeatedly following, exclusion.

METHODS

The sample included 21 women and 23 men. Cortisol and salivary alpha amylase (sAA), biomarkers of the HPA and SAM systems, respectively, were used as indices of two arms of stress response.

RESULTS

Following exclusion, all participants experienced mood worsening followed by mood improvement, with men reporting less distress than women. Women evinced decline in cortisol following the Cyberball task, whereas men's cortisol levels showed a non-significant rise, and then decline, following exclusion.

CONCLUSIONS

Our results concur with previous findings showing SAM reactivity to be gender-neutral and HPA reactivity to be gender-divergent. Additional studies are needed to examine sex-specific response to social exclusion. Implications for individual differences in recovery from stress are discussed.

Effect of pregabalin augmentation in treatment of patients with combat-related chronic posttraumatic stress disorder: a randomized controlled trial

OBJECTIVE

It has been suggested that the anticonvulsant drug pregabalin may be useful in some anxiety disorders. The goal of this study was to evaluate the effectiveness of pregabalin augmentation of standard treatment (selective serotonin reuptake inhibitors and sodium valproate) for patients with chronic posttraumatic stress disorder (PTSD).

METHODS

This doubleblind, placebo-controlled clinical trial was conducted at Ibn-E-Sina Psychiatric Hospital (Mashhad, Iran) in 2013. Thirty-seven male patients diagnosed with combat-related PTSD based on DSM-IV-TR criteria were randomly assigned to two groups: 18 patients, the case group, received pregabalin (300 mg/day) while 19 patients, the control group, received placebo for 6 weeks. Assessments were done at baseline and at 2, 4, and 6 weeks after the onset of treatment, using the PTSD Check List-Military Version (PCL-M), the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, and the Spitzer Quality of Life Index.

RESULTS

Pregabalin was just significantly effective in improving PCL-M scores (p=0.045) in comparison to placebo. Although depression and anxiety scores diminished significantly in both groups (p=0.001 and 0.0001, respectively), comparison of the efficacy of pregabalin and placebo did not show significant differences in depression, anxiety, and quality of life scores (p=0.614, 0.144, and 0.076, respectively).

CONCLUSION

Pregabalin effectively reduced the severity of PTSD symptoms but it was not effective in improving the severity of depression, anxiety, and quality of life. Further investigations are required to confirm or refute these findings.

Inflamed by the flames? The impact of terrorism and war on immunity

The physiological impact on citizens of prolonged exposure to violence and conflict is a crucial, yet underexplored, issue within the political science and biology literature. We examined the effect of high levels of exposure to rocket and terrorist attacks on biological markers of immunity and inflammation in a sample of 92 Israelis. A stratified random sample of individuals was drawn from a pool of subjects in Israel who had previously been interviewed regarding their stress exposure and psychological distress during a period of active rocket and terrorist attacks. These individuals were reinterviewed and blood samples were collected to assess antibodies to cytomegalovirus (CMV antibodies) and C-reactive protein (CRP). Posttraumatic stress disorder (PTSD) was significantly related to CRP, β = .33, p = .034, with body mass index, depression, and exposure to terrorism included in the model. Depression scores were not significantly associated with CRP or CMV antibody levels. In contrast to the established convention that psychological distress is the sole outcome of terrorism exposure, these findings reveal that individuals exposed to terrorism experience higher levels of both PTSD/depression, and inflammation. This study has important ramifications for how policy makers and medical health professionals should formulate public health policies and medically treat individuals living in conflict zones.

Thyrotropin secretion patterns in health and disease

Thyroid hormones are extremely important for metabolism, development, and growth during the lifetime. The hypothalamo-pituitary-thyroid axis is precisely regulated for these purposes. Much of our knowledge of this hormonal axis is derived from experiments in animals and mutations in man. This review examines the hypothalamo-pituitary-thyroid axis particularly in relation to the regulated 24-hour serum TSH concentration profiles in physiological and pathophysiological conditions, including obesity, primary hypothyroidism, pituitary diseases, psychiatric disorders, and selected neurological diseases. Diurnal TSH rhythms can be analyzed with novel and precise techniques, eg, operator-independent deconvolution and approximate entropy. These approaches provide indirect insight in the regulatory components in pathophysiological conditions.

Persistence of anxiety disorders and concomitant changes in cortisol

In a clinical sample of 116 children and adolescents we studied the relation between the course of an anxiety disorder during treatment and the concomitant changes in cortisol levels. Assessments at baseline, after three months, and at one-year follow-up were performed with the Anxiety Disorders Interview Schedule. When we compared cortisol levels at baseline and one-year follow-up, persistence of the anxiety disorder was associated with both increased daytime cortisol production (F=3.2, p=0.04) and a trend towards a decreased cortisol morning rise (F=2.4, p=0.09). At one-year follow-up daytime cortisol production was lowest in the early remitters (109.7±29.2 h mmol/l), higher in the late remitters (121.0±40.0 h mmol/l) and highest in the non-remitters (131.1±48.9 h mmol/l). Early remitters had the highest cortisol morning rise (1.1±1.5 h mmol/l), followed by the late remitters (0.8±1.8 h mmol/l), the non-remitters had the lowest cortisol morning rise (0.07±1.7 h mmol/l). Persistence of an anxiety disorder may thus lead to changes in HPA-axis functioning, underscoring the importance adequate treatment of anxiety disorders.

Validation of the UCLA Child Post traumatic stress disorder-reaction index in Zambia

BACKGROUND

Sexual violence against children is a major global health and human rights problem. In order to address this issue there needs to be a better understanding of the issue and the consequences. One major challenge in accomplishing this goal has been a lack of validated child mental health assessments in low-resource countries where the prevalence of sexual violence is high. This paper presents results from a validation study of a trauma-focused mental health assessment tool - the UCLA Post-traumatic Stress Disorder - Reaction Index (PTSD-RI) in Zambia.

METHODS

The PTSD-RI was adapted through the addition of locally relevant items and validated using local responses to three cross-cultural criterion validity questions. Reliability of the symptoms scale was assessed using Cronbach alpha analyses. Discriminant validity was assessed comparing mean scale scores of cases and non-cases. Concurrent validity was assessed comparing mean scale scores to a traumatic experience index. Sensitivity and specificity analyses were run using receiver operating curves.

RESULTS

Analysis of data from 352 youth attending a clinic specializing in sexual abuse showed that this adapted PTSD-RI demonstrated good reliability, with Cronbach alpha scores greater than .90 on all the evaluated scales. The symptom scales were able to statistically significantly discriminate between locally identified cases and non-cases, and higher symptom scale scores were associated with increased numbers of trauma exposures which is an indication of concurrent validity. Sensitivity and specificity analyses resulted in an adequate area under the curve, indicating that this tool was appropriate for case definition.

CONCLUSIONS

This study has shown that validating mental health assessment tools in a low-resource country is feasible, and that by taking the time to adapt a measure to the local context, a useful and valid Zambian version of the PTSD-RI was developed to detect traumatic stress among youth. This valid tool can now be used to appropriately measure treatment effectiveness, and more effectively and efficiently triage youth to appropriate services.

Psychophysiological characteristics of PTSD in children and adolescents: a review of the literature

This review summarizes studies investigating psychophysiological alterations associated with pediatric posttraumatic stress disorder (PTSD). The authors conducted a computer-based search in the databases PsycINFO, PSYNDEXplus, and Medline. Additional studies were retrieved using a pyramid scheme. The literature search identified 29 articles. Most studies measured alterations shortly after exposure. Differences from controls emerged mainly in the sympathoadrenal system and the hypothalamic-pituitary-adrenal axis. Elevated acute heart rate immediately after traumatization was associated with increased risk for PTSD. The literature on psychophysiological characteristics of pediatric PTSD is relatively small and diverse. Nevertheless, findings indicate exaggerated baseline activation across various measures. Studies examining the course and reversibility of psychophysiological alterations are lacking.

Associations between common arginine vasopressin 1b receptor and glucocorticoid receptor gene variants and HPA axis responses to psychosocial stress in a child psychiatric population

On the one hand, a suitable response to daily stressors is crucial for adequate functioning in any natural environment. On the other hand, depending on the individual's genetic makeup, prolonged stress that is accompanied by an inappropriate level of responsiveness may lead to physiological and psychiatric disorders. Several psychiatric conditions have been linked with stress and alterations in hypothalamic-pituitary-adrenal (HPA) activity. While stress is a general phenomenon, illness is only seen in a proportion of individuals, suggesting that genetic factors may play a role in the ability to cope with stress. In children, relatively little research has been conducted to determine the impact of genetic factors on the variability in HPA axis functioning. In the present exploratory investigation, 106 prepubertal children were studied to estimate the impact of four glucocorticoid receptor gene (NR3C1) polymorphisms (NR3C1-1 [rs10482605], ER22/23EK [rs6190], N363S [rs6195], N766N [rs6196]) and five arginine vasopressin (AVP) receptor 1b gene (AVPR1b) polymorphisms (AVPR1b_s1 [rs28536160], AVPR1b_s2 [rs28373064], AVPR1b_s3 [rs33976516], AVPR1b_s4 [rs33985287], AVPR1b_s5 [rs33933482]) on cortisol responses after a psychosocial stress test (public speaking task). ER22/23EK carriers had significantly lower cortisol responses to psychosocial stress compared with noncarriers. These findings provide evidence for the relevance of the ER22/23EK polymorphism in childhood HPA axis regulation. However, the small number of ER22/23EK subjects does not allow us to draw definitive conclusions about the genotypic effect.

Diurnal cortisol levels, psychiatric symptoms and sense of coherence in abused adolescents

BACKGROUND

The role of the hypothalamic-pituitary-adrenal (HPA) axis in psychiatric disorders following trauma is poorly studied and most studies have been done on adults.

AIMS

To investigate the association of mental well-being and diurnal cortisol in abused adolescents.

METHODS

The present cross-sectional study examined diurnal salivary cortisol (measured three times a day during three days) in relation to psychiatric symptoms (Trauma Symptoms Checklist for Children) and the salutogenic construct "sense of coherence", in 15 adolescents exposed to childhood abuse.

RESULTS

Significant correlations were found between symptoms and sense of coherence versus early and late morning cortisol concentrations. The correlations were most consistent for internalizing and externalizing symptoms, and somewhat less for post-traumatic symptoms and sense of coherence. In contrast, evening cortisol did not correlate with any of the psychological measures.

CONCLUSION

These results extend previous research findings by pointing towards a relation between symptoms and higher morning cortisol and accentuated diurnal cortisol variation in abused adolescent as opposed to lower basal cortisol and a flattening of the cortisol rhythm repeatedly observed in traumatized adults.

CLINICAL IMPLICATIONS

The pathophysiology of the impact of trauma on youth, including the impact on biological stress systems, are important for an understanding of the consequences of trauma and may serve as a basis for the development of new treatment options.

Cortisol metabolic predictors of response to psychotherapy for symptoms of PTSD in survivors of the World Trade Center attacks on September 11, 2001

BACKGROUND

A proportion of subjects with symptoms of posttraumatic stress disorder (PTSD) are unresponsive to specialized psychotherapy, but a biological basis for this has not been described. To observe whether differences in cortisol or its metabolites predict or correlate with response to therapy for PTSD symptoms, cortisol and its metabolites were measured from urine samples at pre-treatment, at the conclusion of psychotherapy, and at 3-month follow-up.

METHODS

28 survivors of the World Trade Center attacks on September 11, 2001 seeking psychological treatment for PTSD symptoms received four sessions of either exposure therapy or supportive counseling, followed by up to 10 sessions of prolonged exposure in a specialized PTSD treatment program at a private hospital serving the New York City metropolitan area. 24-h mean integrated cortisol excretion was assessed by radioimmunoassay (RIA); urinary free cortisol and metabolites cortisone, 5alpha-tetrahydrocortisol (5alpha-THF), 5beta-tetrahydrocortisol, and tetrahydrocortisone were assessed by gas chromatography-mass spectrometry (GC-MS); and indices of enzyme activity for 5alpha- and 5beta-reductase and for the 11beta-hydroxysteroid dehydrogenases were derived from the metabolite and glucocorticoid measures.

RESULTS

5alpha-Reductase activity was significantly lower at pre-treatment among non-responders, whereas there were no significant pre-treatment differences between responders and non-responders in any other hormone or metabolite level. In repeated measures analyses across the three time points, 5alpha-reductase activity, as well as 5alpha-THF and total glucocorticoids, significantly differed between responders and non-responders. For urinary cortisol measured by RIA, there was a significant groupxtime interaction indicating that, although not different at pre-treatment, urinary cortisol levels declined over time in the non-responder group, such that by follow-up, lowered cortisol significantly distinguished non-responders from responders. Indices of 5alpha-reductase activity, including 5alpha-THF and total glucocorticoids, were significantly negatively correlated with avoidance symptom severity at pre-treatment. At follow-up, indices of 5alpha-reductase activity were significantly negatively correlated with severity of all three PTSD symptom clusters and with total PTSD severity scores.

CONCLUSION

Lower 5alpha-reductase activity is associated with avoidance severity and predicts non-responsiveness to psychological treatment for PTSD symptomatology. Relatively diminished 5alpha-reductase activity may mark a state of primary vulnerability, perhaps via attenuated peripheral catabolism of cortisol resulting in the suppression of hypothalamic-pituitary-adrenal axis responsiveness. Lower cortisol levels appear later in the progression to chronic, treatment-resistant PTSD.

Associations between HPA axis functioning and level of anxiety in children and adolescents with an anxiety disorder

The hypothalamus-pituitary-adrenal (HPA) axis becomes active in response to stress. Hence, increased levels of anxiety in children and adolescents may be associated with changes in HPA-axis functioning. The aim of this study was to test if level of anxiety or specific anxiety disorders were associated with basal HPA axis activity in children and adolescents with an anxiety disorder. In 99 8- to 16-year-olds with an anxiety disorder, basal cortisol levels were assessed. It was tested if (1) cortisol levels correlated with the level of self-reported anxiety and (2) if cortisol levels were different for individuals with different anxiety disorders. In girls, low levels of anxiety were associated with a stronger rise in early morning cortisol concentrations. In both boys and girls, harm avoidance predicted low cortisol concentrations after awakening. Separation anxiety and physical anxiety symptoms predicted cortisol concentrations at noon. Differences between individuals with different anxiety disorders were not found. More research is needed regarding mechanisms that explain the associations that were found, and to investigate if treatment may influence HPA axis functioning in children and adolescents with an anxiety disorder.

Higher cortisol awakening response in young adolescents with persistent anxiety problems

OBJECTIVE

The aims of the present study were to test the association between current anxiety problems and basal cortisol levels in a large population sample of young preadolescents, and to test if HPA-axis activity differs between individuals with no, only current, or persistent anxiety problems.

METHOD

Cortisol levels of 10- to 12-year olds (n = 1,768) from the general population were measured on three time points during the day. A self-report questionnaire (RCADS) was used to assess current anxiety, a parent-report questionnaire (TPBQ) to assess anxiety problems at age 4.

RESULTS

Associations between cortisol levels and current anxiety problems were not found. However, individuals with persistent anxiety problems had higher morning cortisol levels and a higher cortisol awakening response.

CONCLUSION

Apparently, only persistent, and not current, anxiety problems are associated with higher HPA-axis activity. Alterations in HPA-axis activity might underlie persistent anxiety problems, or result from the stress accompanied by persistent anxiety problems.

Changes in cortisol and DHEA plasma levels after psychotherapy for PTSD

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

PTSD and stress sensitisation: a tale of brain and body Part 1: human studies

Post-traumatic stress disorder (PTSD) is a chronic, debilitating psychiatric disorder that can follow exposure to extreme stressful experiences. It is characterised by hyperarousal and increased startle responses, re-experiencing of the traumatic event, withdrawal or avoidance behaviour and emotional numbing. The focus of this review is on aspects that have received less attention. PTSD develops only in a substantial minority of people exposed to traumatic stress, and possible individual traits that increase vulnerability are discussed. An overview is given of the wide variety of physiological disturbances that accompany PTSD and may contribute to disability, including neuroendocrine, cardiovascular, gastrointestinal and immune function and pain sensitivity. Brain imaging and pharmacological studies have generated some insight into the circuitry that may be involved in the generation of PTSD symptoms. Major limitations of human studies so far are the issue of causality and our lack of understanding of the underlying molecular substrates in the brain, which are easier to address in relevant animal models and will be discussed in a companion paper.

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

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

Advances in Understanding Neuroendocrine Alterations in PTSD and Their Therapeutic Implications

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

The poor have become rich, and the rich have become poor: Collective trauma in the Guinean Languette

This paper uses Kai Erikson's (Everything in its path: the disaster at Buffalo Creek. Simon & Schuster, New York, 1978) definition of collective trauma to interrogate the symptom reports and narrative accounts of six Guinean communities attacked by Sierra Leonean and Liberian RUF forces in 2000-2001. These data, collected in 2003, found high rates of fear, physical anxiety, emotional anxiety, depression, physical distress, sadness, and post-traumatic stress disorder-related symptoms across all communities, but found lower rates of distress among communities that had developed collective narratives of resistance to violence, or had concertedly resisted post-conflict social change. Communities with higher rates of distress tended to report community narratives of violence and post-conflict social life, which emphasized abandonment, isolation, disregard of community rituals and social supports, and the dislocation of local moral worlds. This study argues that the physical and emotional symptoms of trauma-related mental illness are articulations of collective trauma and represent the physical and emotional manifestations of the destruction of local moral worlds. It illuminates the processes by which violence inverts social experience, and argues that the social dimensions of trauma have long-term consequences for post-conflict reconstruction.

Localization of glucocorticoid receptors at postsynaptic membranes in the lateral amygdala

Glucocorticoids, released in high concentrations from the adrenal cortex during stressful experiences, bind to glucocorticoid receptors in nuclear and peri-nuclear sites in neuronal somata. Their classically known mode of action is to induce gene promoter receptors to alter gene transcription. Nuclear glucocorticoid receptors are particularly dense in brain regions crucial for memory, including memory of stressful experiences, such as the hippocampus and amygdala. While it has been proposed that glucocorticoids may also act via membrane bound receptors, the existence of the latter remains controversial. Using electron microscopy, we found glucocorticoid receptors localized to non-genomic sites in rat lateral amygdala, glia processes, presynaptic terminals, neuronal dendrites, and dendritic spines including spine organelles and postsynaptic membrane densities. The lateral nucleus of the amygdala is a region specifically implicated in the formation of memories for stressful experiences. These newly observed glucocorticoid receptor immunoreactive sites were in addition to glucocorticoid receptor immunoreactive signals observed using electron and confocal microscopy in lateral amygdala principal neuron and GABA neuron soma and nuclei, cellular domains traditionally associated with glucocorticoid immunoreactivity. In lateral amygdala, glucocorticoid receptors are thus also localized to non-nuclear-membrane translocation sites, particularly dendritic spines, where they show an affinity for postsynaptic membrane densities, and may have a specialized role in modulating synaptic transmission plasticity related to fear and emotional memory.

Current Measures of PTSD for Children and Adolescents

OBJECTIVE

To review measures of posttraumatic stress disorder (PTSD) and posttraumatic stress symptoms (PSS) for children and adolescents.

METHODS

We reviewed broad-based child mental health journals within the disciplines of pediatrics, child psychology, and trauma, from 1995 to 2004, to identify measures of PTSD and PSS for children and adolescents. The review includes a summary of the psychometric properties and associated features of the measures and the clinical domains and types of studies using each measure.

RESULTS

Seven measures of PTSD and PSS were identified, including clinician-administered interviews and self-report questionnaires. Sixty-five articles containing the measures were categorized into eight trauma domains. We found there is little consensus over measures used within each trauma domain.

CONCLUSIONS

Few measures of PTSD and PSS have been designed specifically for young people. Further directions for measurement of PTSD in this age group are discussed to prevent under-diagnosis and under-treatment for youth.

Neuroendocrine aspects of PTSD

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

The University of California at Los Angeles Post-traumatic Stress Disorder Reaction Index

Over the past decade, the University of California at Los Angeles Post-traumatic Stress Disorder Reaction Index has been one of the most widely used instruments for the assessment of traumatized children and adolescents. This paper reviews its development and modifications that have been made as the diagnostic criteria for post-traumatic stress disorder have evolved. The paper also provides a description of standard methods of administration, procedures for scoring, and psychometric properties. The Reaction Index has been extensively used across a variety of trauma types, age ranges, settings, and cultures. It has been broadly used across the US and around the world after major disasters and catastrophic violence as an integral component of public mental health response and recovery programs. The Reaction Index forms part of a battery that can be efficiently used to conduct needs assessment, surveillance, screening, clinical evaluation, and treatment outcome evaluation after mass casualty events.