The Use of Psychoendocrine Strategies in Post-Traumatic Stress Disorder1

Biochemical Measurements in the Study of Emotion

The study of emotions is complicated by a number of factors, including the biological bases of emotional experience and expression. Although biochemical changes have long been thought to be part of the evocation of emotions, research has not consistently included this level of measurement, and theories of emotion have not systematically specified the role of these biochemical bases. In this paper, we briefly review relevant biochemical principles and measures that can be integrated into research and theory on emotions. Applications of these principles in extant studies of emotion are also discussed.

Psychosomatic pain in children: A psychomuscular tension reaction?

Although recurrent psychosomatic pain is a common paediatric condition, our understanding of it is still limited. In this article, the clinical picture is presented and the concept of psychosomatic pain is discussed. Some recent scientific data are presented including a controlled blind study of pain pressure thresholds showing significantly reduced mean values over common pain areas in a group of children with psychosomatic pain. According to another study, these children also have significantly reduced concentrations of the hypothalamic hormone oxytocin and cortisol. With these data as a point of departure, a model for psychosomatic pain reaction is outlined in which stress is assumed to induce muscular tension, in turn triggering the nociceptive process. In this psychosomatic reaction, the hypothalamus is believed to have a central regulatory function.

Dysregulation of the right brain: a fundamental mechanism of traumatic attachment and the psychopathogenesis of posttraumatic stress disorder

OBJECTIVE

This review integrates recent advances in attachment theory, affective neuroscience, developmental stress research, and infant psychiatry in order to delineate the developmental precursors of posttraumatic stress disorder.

METHOD

Existing attachment, stress physiology, trauma, and neuroscience literatures were collected using Index Medicus/Medline and Psychological Abstracts. This converging interdisciplinary data was used as a theoretical base for modelling the effects of early relational trauma on the developing central and autonomic nervous system activities that drive attachment functions.

RESULTS

Current trends that integrate neuropsychiatry, infant psychiatry, and clinical psychiatry are generating more powerful models of the early genesis of a predisposition to psychiatric disorders, including PTSD. Data are presented which suggest that traumatic attachments, expressed in episodes of hyperarousal and dissociation, are imprinted into the developing limbic and autonomic nervous systems of the early maturing right brain. These enduring structural changes lead to the inefficient stress coping mechanisms that lie at the core of infant, child, and adult posttraumatic stress disorders.

CONCLUSIONS

Disorganised-disoriented insecure attachment, a pattern common in infants abused in the first 2 years of life, is psychologically manifest as an inability to generate a coherent strategy for coping with relational stress. Early abuse negatively impacts the developmental trajectory of the right brain, dominant for attachment, affect regulation, and stress modulation, thereby setting a template for the coping deficits of both mind and body that characterise PTSD symptomatology. These data suggest that early intervention programs can significantly alter the intergenerational transmission of posttraumatic stress disorders.

Psychogenic lowering of urinary cortisol levels linked to increased emotional numbing and a shame-depressive syndrome in combat-related posttraumatic stress disorder

OBJECTIVE

The purpose of the study was to search for the intrapsychic correlates of individual differences in cortisol levels in male Vietnam combat veterans with posttraumatic stress disorder.

METHODS

The study involved measurement of urinary cortisol levels and clinical assessment with a broad profile of psychometric tests during a single 48-hour period in 30 inpatients.

RESULTS

The main finding by both correlation and t test analyses was a significant inverse relationship between urinary cortisol levels and a symptom complex composed of two closely interrelated clinical subgroupings, "disengagement" (principally involving emotional numbing) and "shame-laden depression."

CONCLUSIONS

The findings support the concept that cortisol levels reflect the ongoing balance between the undifferentiated emotional arousal state of engagement (associated with higher cortisol levels) and opposing antiarousal disengagement defense mechanisms (associated with lower cortisol levels). It appears that the low cortisol levels often seen in patients with posttraumatic stress disorder are psychogenic and reflect a dominating effect of disengagement coping strategies, which represent secondary compensatory adaptations during the chronic course of this disorder to counteract primary arousal symptoms, especially those related to an intractable shame-laden depressive syndrome. The psychoendocrine findings suggest that the relatively inconspicuous clinical feature of shame resulting from both the primary and secondary traumatizations is a particularly powerful, preoccupying, and overwhelming source of emotional engagement. Shame may represent a "sleeper" that is worthy of greater attention in both research and clinical efforts to understand the pathogenesis and psychopathology of this devastating stress-related disorder.

Cerebrospinal fluid and plasma testosterone levels in post-traumatic stress disorder and tobacco dependence

BACKGROUND

Little is known about the relationship between endogenous central nervous system (CNS) testosterone and any psychiatric syndrome. The goal of this study was to screen for potential abnormalities in CNS testosterone levels in patients with post-traumatic stress disorder (PTSD) and/or tobacco dependence.

METHODS

We sampled cerebrospinal fluid (CSF) via a subarachnoid catheter over six hours and determined hourly basal CSF concentrations of testosterone in 11 combat veterans with PTSD and 12 normal volunteers. Smokers were abstinent for 11-17 h. Testosterone in CSF and matching plasma samples was assayed by radioimmunoassay.

RESULTS

A factor analysis for effects of PTSD status, smoking status and sample time revealed significant effects of PTSD or smoking status, but not time, on CSF testosterone. CSF testosterone levels were lower in individuals with PTSD as compared with normal volunteers. When divided by smoking status, abstinent smokers had mean CSF testosterone levels higher than those of non-smokers. A similar analysis of plasma testosterone revealed no significant effects of any factor on plasma testosterone.

CONCLUSIONS

These results indicate that CSF testosterone is significantly influenced by PTSD and smoking status. The exposure of the brain to altered levels of testosterone in smokers and patients with PTSD may have pathophysiologic significance in these conditions.

Urinary catecholamines and cortisol in recent-onset posttraumatic stress disorder after motor vehicle accidents

OBJECTIVE

This study examined relationships among stress hormone levels, posttraumatic stress disorder (PTSD) diagnosis and symptoms, and gender shortly after a common civilian trauma.

METHODS

Levels of catecholamines and cortisol in 15-hour urine samples were examined in 55 adults who had been in serious motor vehicle accidents and in 22 age-matched control.

RESULTS

Catecholamines were related to PTSD diagnosis and symptoms, but only among men: PTSD-symptomatic men who had been in an accident exhibited elevated levels of epinephrine and norepinephrine 1 month after the accident and had higher epinephrine levels 5 months later. Intrusive thoughts predicted catecholamine levels at 1 month, and avoidance of trauma-relevant stimuli was associated with higher epinephrine levels 5 months later. These effects were not significant among women. Urinary cortisol was also elevated among PTSD-symptomatic men, but not women, and only immediately (1 month) after the accident. For men and women, greater emotional numbing predicted a lower cortisol level 6 months after the accident.

CONCLUSIONS

These findings were interpreted as limited support for the generalizability of findings in men with chronic, combat-related PTSD and indicate the need for additional research on psychoendocrine assessment of traumatized women and specific dimensions of PTSD symptomatology.

Trierer Inventar zur Erfassung von chronischem Streß (TICS): Skalenkonstruktion, teststatistische Überprüfung und Validierung der Skala Arbeitsüberlastung

Zusammenfassung. Angeregt durch Befunde der Streßforschung, wonach chronischer Streß und nicht akute Belastungen mit klinisch relevanten Beeinträchtigungen der Gesundheit in Zusammenhang steht, wurde das Trierer Inventar zur Erfassung von chronischem Streß (TICS) entwickelt. Der Fragebogen erfaßt sechs Aspekte von chronischem Streß: Arbeitsüberlastung, Arbeitsunzufriedenheit, soziale Belastung, Fehlen sozialer Anerkennung, Sorgen/Besorgnis und belastende Erinnerungen. Die Chronizität der Belastung wird durch die Häufigkeit retrospektiv erfragter Streßerfahrungen erhoben. Zur Beantwortung der Items stehen fünfstufige Ratingskalen zur Verfügung. In der hier vorgestellten Untersuchung mit N = 157 Probanden konnten die in Vorstudien ermittelten Skalen des TICS faktorenanalytisch bestätigt werden. Die sechs Skalen zeigen zufriedenstellende Reliabilitätskoeffizienten. Es können erste Ergebnisse zur Validierung des Fragebogens berichtet werden. In zwei Studien ergaben sich signifikante Korrelationen zwischen der Skala Arbeitsüberlastung und (a) verschiedenen Skalen des Gießener Beschwerdebogens (GBB) sowie (b) der Konzentration des Streßhormons Cortisol. Die Skala differenziert zwischen 19 Tinnituspatienten und 16 gesunden Kontrollpersonen.

Effects of early stress on adult affiliative behavior

The recently evolved mammalian species preservative behavior as opposed to the ancient self preservative behavior involves parental care, nursing, social interaction, pair bonding and mutual defense. Gonadal steroids together with oxytocin are critical for this affiliative, attachment behavior. When there is stressful loss of control, gonadotrophins are diminished, and the self preservative, fight-flight catecholamine coping response takes priority. It is suggested that self preservation is associated with left hemispheric brain function and that species preservation is associated with right hemispheric function. Stress during infancy that is severe enough to create insecure attachment has a dissociative effect, disrupting right hemispheric emotional functioning and species preservative behavior, and a permanent bias towards self preservation can become an adult trait. In such a person with impaired affiliation, corticoid responses may be deficient. The coronary type A behavior pattern common in our society exhibits some of this deficiency in species preservative activity.

Psychological correlates of salivary cortisol secretion among unemployed men and women

The aim of the present study was to examine the association between psychological factors and salivary cortisol secretion (baseline level, reactivity to laboratory stressors) in a sample of 59 long-term unemployed men and women (mean age 42+/-10 years). Subjects were divided into four groups according to their basal levels of salivary cortisol as well as their reactivity to experimental stress (stress level minus baseline): (1) low base/ low reactivity; (2) high base/low reactivity; (3) low base/high reactivity; and (4) high base/ high reactivity. The low base/low reactivity group was characterized by significantly higher somatic anxiety, muscular tension, irritability, and depression (Beck's Depression Inventory) and lower perceived control (mastery) than the other groups. The low base/high reactivity group was also characterized by depression and low perceived control. The high base/low reactivity group was higher in terms of monotony avoidance, Type-A behavior (JAS) and mastery, but lower in depression. The results indicate that (1) individuals with personality traits reflecting emotional distress are more vulnerable to exhaustion of the HPA-axis following long-term unemployment and (2) monotony avoidance and Type-A behavior, at least temporarily, seem to exert a beneficial influence on mental well-being among long-term unemployed individuals.

Psychoneuroendocrinology of post-traumatic stress disorder

In 1980, the diagnosis of post-traumatic stress disorder (PTSD) was established to describe the long-lasting symptoms that can occur following exposure to extremely stressful life events. This article reviews the findings of neuroendocrinologic alterations in PTSD and summarizes the finding of hypothalamic-pituitary-adrenal (HPA), catecholamine, hypothalamic-pituitary-thyroid (HPT) and hypothalamic-pituitary-gonadal (HPG) systems. These are the neuroendocrine systems that have been studied in PTSD. Also included is a review of the basic facts about PTSD and biologic data.

Relationships between hormonal profile and novelty seeking in combat-related posttraumatic stress disorder

This study examines relationships between hormonal levels and novelty seeking in a group of 27 Vietnam veterans with combat-related posttraumatic stress disorder (PTSD). Novelty seeking in the veteran sample, measured by the Cloninger Tridimensional Personality Questionnaire (TPQ), was almost twice as high as previously published norms. A distinctive pattern of significant positive correlations was found between novelty seeking scores and serum total triiodothyronine (T3), free T3, the T3/free thyroxine (FT4) ratio, urinary norepinephrine and the norepinephrine/cortisol ratio, while a negative correlation was found between novelty seeking scores and urinary cortisol levels. The findings were confirmed by t test analyses of high vs low novelty seeking subgroups and do not appear to be related simply to the severity of PTSD. These preliminary findings indicate the need to include measures of characterological traits in psychoendocrine studies of PTSD and to investigate their possible usefulness in subtyping this disorder.

Serum triiodothyronine elevation with posttraumatic stress disorder: a cross-cultural study

This study examines the thyroid hormonal profile in Israeli combat veterans with posttraumatic stress disorder (PTSD) and compares it with the previously reported profile in American Vietnam combat veterans with PTSD. Eleven male combat veterans with PTSD were compared with 11 normal subjects. Thyroid junction was evaluated by the measurement of serum total triiodothyronine (TT3), free triiodothyronine (FT3), total thyroxine (TT4), free thyroxine (FT4), thyroxine-binding globulin (TBG), and thyroid-stimulating hormone (TSH). The mean total T3 level in the Israeli PTSD patients (160.5 ng/dL) was significantly elevated (t = 2.53, p < .02) above that of the comparison group (135.5 ng/dL). Total T3 mean levels were not significantly different between the Israeli PTSD group and two American PTSD groups, but all three PTSD groups had significantly higher total T3 levels than both Israeli and American comparison groups. This preliminary study indicates that T3 elevation in combat-related PTSD may extend across cultures and suggests that further comparison of Israeli and American PTSD and normal groups may be useful in evaluating the significance and implications of the unusual alterations in the thyroid system in PTSD.

Self-reported stressors, symptom complaints and psychobiological functioning-II: Psychoneuroendocrine variables

The present study examined resting endocrinological functioning and endocrine responsivity to new challenges as a function of self-reported stress load and symptomatology. Following a baseline period, four groups of male subjects (low-load/low-symptoms; low-load/high-symptoms; high-load/low-symptoms; high-load/high-symptoms) were exposed to stressful films, followed by a rest period. Blood samples were drawn after each film and after the rest condition, and urinary samples were collected during two nights preceding the experimental session. Neuroendocrine variables measured in plasma included adrenaline, noradrenaline, ACTH, cortisol, growth hormone, prolactin, and testosterone. The urinary samples were assayed for noradrenaline and adrenaline (in relation to creatinin). High-symptom subjects had significantly higher plasma levels of noradrenaline and overnight urinary adrenaline levels, whereas their cortisol levels tended to be lower as compared to the low-symptom group. The plasma noradrenaline/cortisol ratio was higher among the high-symptom subjects. However, upon controlling for neuroticism and life style factors (smoking and alcohol consumption), all but the effects on cortisol failed to meet significance criteria. Higher stress load was associated with higher plasma adrenaline responses during the laboratory session, irrespective of neuroticism or life-style measures. These results therefore suggest that in addition to measuring exposure to real-life stressors, it is also necessary to measure outcomes, such as symptoms, and to be aware of the effects of neuroticism and life-style when attempting to understand which specific psychosocial factors effect psychoendocrinological functioning.

Relationships between thyroid hormones and symptoms in combat-related posttraumatic stress disorder

This study was designed to investigate relationships between serum thyroid hormone levels and the severity of posttraumatic stress disorder (PTSD) symptoms in a group of 65 male Vietnam combat veterans who participated as members of cohorts in an elective inpatient treatment program. Thyroid hormone measures included serum free and total triiodothyronine (T3), free and total thyroxine (T4), and thyroxine-binding globulin. To estimate symptom severity, the Clinician-Administered PTSD Scale (CAPS-2), based on DSM-III-R diagnostic criteria for PTSD, was used. Significant positive correlations were observed between free T3, total T3, total T4, and the "hyperarousal" frequency subscale score and the CAPS-2 frequency sum score. Patients with increased thyroid hormone levels and increased hyperarousal symptoms might constitute a clinically significant subtype among patients with PTSD. Alternatively, increased thyroid activity and hyperarousal symptoms may be associated with phase-related characteristics in PTSD. Research strategies for further evaluation of these preliminary findings are discussed.

Role of psychological stress in cortisol recovery from exhaustive exercise among elite athletes

Life-event stress (LES) was used to classify elite athletes (n = 39) into high- and low-LES groups. A repeated measures analysis of variance revealed higher cortisol concentration after a graded exercise lest among the high-LES group relative to the low-LES group, which was maintained for up to 20 hr. Subsequent prospective analyses further indicated that high-LES athletes were more likely lo he symptomatic than low-LES athletes and that elevated cortisol level was positively correlated with symptomatology. To the extent that cortisol is a marker of exercise recovery in competitive athletes. our results suggest that chronic stress prolongs the recovery process, which may potentially widen a window of susceptibility for illness and injury among competitive athletes.

Depressed concentrations of oxytocin and cortisol in children with recurrent abdominal pain of non-organic origin

The purpose of the present study was to measure plasma concentrations of oxytocin, cortisol and prolactin in children with recurrent abdominal pain of non-organic origin (RAP). Forty children with RAP and 34 controls, matched for age and sex, participated in the study. A blood sample was collected after an overnight fast in association with clinical examinations. Oxytocin, cortisol and prolactin levels were determined by radioimmunoassay (RIA). Oxytocin and cortisol concentrations in the children with RAP were found to be significantly reduced compared with those of the controls (approximately 24 versus 63 pmol/l for oxytocin and 160 versus 300 nmol/l for cortisol, respectively). The low oxytocin and cortisol levels persisted at a second examination 3 months later. No significant differences in the prolactin levels were observed between RAP and controls.

Psychological and endocrine abnormalities in refugees from East Germany: Part I. Prolonged stress, psychopathology, and hypothalamic-pituitary-thyroid axis activity

The influence of prolonged psychological stress on hormonal secretion was investigated in 84 East Germany refugees suffering from psychiatric disorders within 6 weeks of their arrival in West Berlin shortly before or after the fall of the Berlin Wall. Before leaving the German Democratic Republic, these patients had already experienced prolonged stress, which continued after migration. In most cases, the diagnosis was anxious-depressive syndrome with vegetative complaints and symptoms of increased arousal. Their formal DSM-III-R diagnoses (American Psychiatric Association, 1987) included adjustment disorders, depressive disorders, and anxiety disorders (the latter including posttraumatic stress disorder). Serum levels of thyroid stimulating hormone (TSH) and thyroid hormones (thyroxine, free thyroxine, triiodothyronine, and reverse triiodothyronine) were measured and compared with those of 20 healthy control subjects. TSH and all thyroid hormone concentrations were significantly reduced in the patient group. Fifty-two of the patients (62%) were in the hypothyroid range but did not show any clinical signs of hypothyroidism. These disturbances in hormonal secretion were not correlated to any psychiatric diagnosis or to the severity of acute or chronic stress. The marked abnormalities in the hypothalamic-pituitary-thyroid axis seen in these refugees differ from those reported in depression and would seem to reflect severe chronic stress rather than specific psychiatric disorders. The underlying neurochemical mechanisms remain to be investigated.

Abnormal stimulus processing in posttraumatic stress disorder

This study investigated event-related potential (ERP) indices of information processing in sufferers of posttraumatic stress disorder (PTSD). ERPs were obtained from 18 PTSD patients and 20 controls while they performed a target discrimination task requiring the detection of infrequent target tones from a background sequence of frequent and infrequent distractor tones. A delayed N2 and an attenuated P3 that failed to differentiate target from distractor tones indicated that patients had abnormal difficulty distinguishing task stimuli of differing relevance. It is proposed that this difficulty is reflected behaviorally in the slowed reaction time by patients to target stimuli and may underlie the disturbed concentration and memory impairments found in PTSD. It may also be related to dysfunction in central noradrenaline function, which has been shown to be both crucial in selective attention and abnormal in PTSD.

Psychoneuroendocrine assessment of posttraumatic stress disorder: current progress and new directions

1. Studies in our laboratory have used the psychoendocrine strategy to explore differences in basal hormone levels between patients with posttraumatic stress disorder (PTSD) and other groups. This approach has allowed us to explore the relationship between hormone levels and specific psychological and biological processes which appear to develop following exposure to extreme trauma. 2. The concurrent assessment of several hormonal systems provides an opportunity to explore differences in hormonal patterns in various psychiatric disorders. PTSD appears to be characterized by a specific profile of hormonal changes that is distinct from that of other diagnostic groups and normal controls. These findings raise the possibility that the psychoendocrine approach may be useful in further exploring the pathophysiology and diagnosis of PTSD. 3. This paper reviews psychoendocrine changes in PTSD and describes updated multivariate methods that further elucidate psychological and neurochemical correlates of hormonal alterations in this disorder.