Increased 24-hour urinary cortisol excretion in patients with post-traumatic stress disorder and patients with major depression, but not in patients with fibromyalgia

Effects of dim-evening lighting optimised for geographical orientation versus standard lighting on mental health: protocol paper for a quasiexperimental study in a psychiatric hospital

INTRODUCTION

Research has provided novel insights into how light stimulates circadian rhythms through specialised retinal ganglion cells to the suprachiasmatic nucleus. In addition, there has been a revolution in light-emitting diode (LED) technology, leading to tunable LED light sources and lighting systems, enabling 24-hour dynamic light scenarios with bright blue-enriched short wavelength light during the day and dim evening light, stimulating the circadian system. These dynamic LED lighting systems are now being implemented at hospitals without adequate understanding of how it may affect the health and well-being of patients and staff.

METHODS AND ANALYSIS

An optimised dynamic LED lighting scenario is investigated at a newly built psychiatric hospital in Copenhagen. In the 12 months baseline period, a standard lighting scenario with dynamic colour temperature and fixed light intensity is investigated. In the following 12-month intervention period, a new DEL scenario is investigated, having dynamic colour temperature as well as dynamic light intensity with a higher daytime and lower evening-time melanopic daylight equivalent illuminance. This setting is furthermore adjusted for geographical orientation to compensate for differences in sunlight access in wintertime. The study uses a quasiexperimental design comparing patients admitted in the two study periods. Prior to each of the study periods, daylight and the contribution from the LED-lighting scenarios was measured. Patient sociodemographic and mental health data will be retrieved retrospectively from electronic medical records and by questionnaires administered in the two periods, evaluating lighting, noise, sleep quality and quality of life. Primary outcome is the proportion of patients receiving pro re nata medications. Secondary outcomes are the length of stay, sleep onset latency, sleep quality and quality of life.

ETHICS AND DISSEMINATION

No ethical issues are expected. The results will be disseminated through peer-reviewed international journal, lectures, posters and interviews.

TRIAL REGISTRATION NUMBER

NCT05868291.

Perceived social support mitigates the associations among household chaos and health and well-being in rural early adolescents

PURPOSE

Previous studies have demonstrated that early adolescents residing in chaotic households experience adverse health and well-being outcomes. However, the potential protective factors that mitigate the relationship between household chaos and early adolescents' health and well-being remain unknown. Accordingly, this study aims to investigate whether perceived social support moderates the link between household chaos and the health and well-being among Chinese rural early adolescents.

METHODS

Physical health difficulties were assessed using two measures: general health and allostatic load (AL). Mental health difficulties were measured by depression. Well-being was reflected by life satisfaction. Specifically, this study included early adolescents (N = 337; Mage  = 10.88 ± 1.36 years) from rural counties in China who reported their household chaos, perceived social support, general health, depression, and life satisfaction. AL scores were determined based on six physiological indices.

RESULTS

Household chaos exhibited a negative relationship with the general health and life satisfaction while a positive correlation with depression. Moreover, perceived social support was found to moderate the association between household chaos and these health and well-being indicators of early adolescents. Specifically, early adolescents who reported higher levels of perceived social support exhibited weaker negative connections among household chaos and their general health, depression, and life satisfaction. Furthermore, no significant relationships were observed between the adolescents' AL and household chaos, perceived social support, or their interactions.

CONCLUSIONS

Household chaos poses a significant risk to health and well-being. Furthermore, the findings indicate that perceived social support can mitigate these negative effects.

Glucocorticoid-based pharmacotherapies preventing PTSD

Posttraumatic stress disorder (PTSD) is a highly disabling psychiatric condition that may arise after exposure to acute and severe trauma. It is a highly prevalent mental disorder worldwide, and the current treatment options for these patients remain limited due to low effectiveness. The time window right after traumatic events provides clinicians with a unique opportunity for preventive interventions against potential deleterious alterations in brain function that lead to PTSD. Some studies pointed out that PTSD patients present an abnormal function of the hypothalamic-pituitary-adrenal axis that may contribute to a vulnerability toward PTSD. Moreover, glucocorticoids have arisen as a promising option for preventing the disorder's development when administered in the aftermath of trauma. The present work compiles the recent findings of glucocorticoid administration for the prevention of a PTSD phenotype, from human studies to animal models of PTSD. Overall, glucocorticoid-based therapies for preventing PTSD demonstrated moderate evidence in terms of efficacy in both clinical and preclinical studies. Although clinical studies point out that glucocorticoids may not be effective for all patients' subpopulations, those with adequate traits might greatly benefit from them. Preclinical studies provide precise insight into the mechanisms mediating this preventive effect, showing glucocorticoid-based prevention to reduce long-lasting behavioral and neurobiological abnormalities caused by traumatic stress. However, further research is needed to delineate the precise mechanisms and the extent to which these interventions can translate into lower PTSD rates and morbidity. This article is part of the Special Issue on 'Fear, Anxiety and PTSD'.

Systemic exertion intolerance disease associated to neuroendocrine dysfunction and cortical atrophy: a case report

BACKGROUND

Scarce evidence about the organic and functional abnormalities of systemic exertion intolerance disease (SEID) is found in literature and the pathophysiology is still unclear.

METHODS

Following the CARE Guidelines, this case report describes a patient with a 5-year history of nonspecific symptoms, lately recognized as SEID.

RESULTS

Low serum thyroid- and adrenocorticotropic stimulating hormone levels, and 24-h urinary cortisol excretion almost twice the upper limit were detected. Computed tomography scan found significant cortical atrophy. Low-dose modafinil improved the clinical outcome, added to nonpharmacologic approach.

CONCLUSION

To ascertain an accurate SEID diagnosis and treatment are a challenge in daily clinical practice, that must be engaged based in clear methods and good practice recommendations. Thus, family practitioners should be aware of this diagnosis.

Impact of Insomnia Symptoms on the Clinical Presentation of Depressive Symptoms: A Cross-Sectional Population Study

Objective: Insomnia and depression are prevalent disorders that often co-occur. This study aimed to investigate the impact of clinically significant insomnia symptoms on the prevalence and clinical presentation of clinically significant depressive symptoms and vice versa. Methods: This study used data from the Korean Headache-Sleep Study (KHSS), a nationwide cross-sectional population-based survey regarding headache and sleep. Clinically significant insomnia symptoms were defined as Insomnia Severity Index (ISI) scores ≥ 10 and clinically significant depressive symptoms were defined as Patient Health Questionnaire-9 (PHQ-9) scores ≥ 10, respectively. We referred clinically significant insomnia symptoms and clinically significant depressive symptoms as insomnia symptoms and depressive symptoms, respectively. Results: Of 2,695 participants, 290 (10.8%) and 116 (4.3%) were classified as having insomnia and depressive symptoms, respectively. The prevalence of depressive symptoms was higher among participants with insomnia symptoms than in those without insomnia symptoms (25.9 vs. 1.7%, respectively, P < 0.001). Among participants with depressive symptoms, the PHQ-9 scores were not significantly different between participants with and without insomnia symptoms (P = 0.124). The prevalence of insomnia symptoms was significantly higher among participants with depressive symptoms than in those without depressive symptoms (64.7 vs. 8.3%, respectively, P < 0.001). The ISI scores were significantly higher among participants with insomnia and depressive symptoms than in participants with insomnia symptoms alone (P < 0.001). Conclusions: Participants with depressive symptoms had a higher risk of insomnia symptoms than did those without depressive symptoms. The severity of depressive symptoms did not significantly differ based on insomnia symptoms among participants with depressive symptoms; however, the severity of insomnia symptoms was significantly higher in participants with depressive symptoms than in those without depressive symptoms.

A critical review of mechanisms of adaptation to trauma: Implications for early interventions for posttraumatic stress disorder

Although many attempts have been made to limit development of posttraumatic stress disorder (PTSD) by early intervention after trauma exposure, these attempts have achieved only modest success. This review critiques the biological and cognitive strategies used for early intervention and outlines the extent to which they have prevented PTSD. The major predictors of PTSD are reviewed, with an emphasis on potential mechanisms that may underpin the transition from acute stress reaction to development of PTSD. This review highlights that there is a wide range of biological and cognitive factors that have been shown to predict PTSD. Despite this, the major attempts at early intervention have focused on strategies that attempt to augment extinction processes or alter appraisals in the acute period. The documented predictors of PTSD indicate that a broader range of potential strategies could be explored to limit PTSD. The evidence that people follow different trajectories of stress response following trauma and there is a wide array of acute predictors of PTSD indicates that a flexible and tailored approach needs to be investigated to evaluate more effective early intervention strategies.

Anxiety and depressive symptoms effects on cortisol trajectories from pregnancy to postpartum: Differences and similarities between women and men

Anxiety and depressive symptoms may influence cortisol trajectories in women and men during pregnancy and the postpartum period. Using a multilevel approach, anxiety and depressive symptoms effects on 24-hour urinary free cortisol trajectories from the 2nd trimester to 3-months postpartum were examined in a sample of 66 women and 65 men with no known psychosocial or medical risk (N = 131; 33 (50%) of them were couples that participated in the same assessment waves). Results showed that both anxiety and depressive symptoms influence women's and men's cortisol trajectories from mid-pregnancy to 3-months postpartum. Women with high depressive symptoms and men with high anxiety or high depressive symptoms exhibited less accentuated variations in the 24-hour urinary free cortisol trajectories compared with women with low depressive symptoms and men with low anxiety or depressive symptoms, respectively. These effects were significant for women's cortisol trajectories from the 2nd to the 3rd pregnancy trimester and for men's cortisol trajectories throughout the entire period. The effect of anxiety and depressive symptoms on HPA axis functioning and cortisol production during pregnancy and postpartum, seems to be sex-specific. Reproductive-related alterations (associated with gestation, parturition and lactation) in women's HPA axis functioning may explain these sex-specific effects.

A theoretical framework to improve the construct for chronic pain disorders using fibromyalgia as an example

Fibromyalgia (FM) is a frequent, complex condition of chronic musculoskeletal pain with no evidence for biological correlates. For this reason, despite many efforts from the medical community, its construct still appears ill defined. Promising candidate biomarkers are critically reviewed. A research agenda is proposed for developing a clearer construct of FM. The ideal theoretical framework is one of overcoming the illness–disease dichotomy and considering reciprocal interactions between biology and behaviour. This approach may foster research in other fields of pain medicine and of medicine in general.

Early Life Stress and Pediatric Posttraumatic Stress Disorder

Traumatic stress exposure during critical periods of development may have essential and long-lasting effects on the physical and mental health of individuals. Two thirds of youth are exposed to potentially traumatic experiences by the age of 17, and approximately 5% of adolescents meet lifetime criteria for posttraumatic stress disorder (PTSD). The role of the stress system is the maintenance of homeostasis in the presence of real/perceived and acute/chronic stressors. Early-life stress (ELS) has an impact on neuronal brain networks involved in stress reactions, and could exert a programming effect on glucocorticoid signaling. Studies on pediatric PTSD reveal diverse neuroendocrine responses to adverse events and related long-term neuroendocrine and epigenetic alterations. Neuroendocrine, neuroimaging, and genetic studies in children with PTSD and ELS experiences are crucial in understanding risk and resilience factors, and also the natural history of PTSD.

Amygdala, Medial Prefrontal Cortex and Glucocorticoid Interactions Produce Stress-Like Effects on Memory

Adverse stress effects on the hippocampal memory system are generally thought to be due to the high level of circulating glucocorticoids directly modifying the properties of hippocampal neurons and, accordingly, the results should be reproducible with exogenous administration of cortisol in humans and corticosterone in rodents. However, glucocorticoid levels increased to other events, such as exercise and environment enrichment, do not impair but instead enhance hippocampal memory, indicating that cortisol/corticosterone are not invariant causal factors of stress. To better model the complex psychophysiological attributes of stress (i.e., aversiveness, lack of controllability, and glucose metabolism), we examined the functions of the amygdala, medial prefrontal cortex (mPFC), and corticosterone on a hippocampal-based one-trial novel object recognition (OR) memory task in rats. Specifically, animals were subjected to amygdala stimulation, mPFC inactivation, and corticosterone treatments separately or in combination during behavioral testing. Collective amygdala, mPFC, and corticosterone manipulations significantly impaired OR memory comparable to behavioral stress. By contrast, single and dual treatments failed to reliably decrease memory functioning. These results suggest that negative mnemonic impacts of uncontrollable stress involve the amalgamation of heightened amygdala and diminished mPFC activities, and elevated circulating corticosterone level.

Comparing anxiety and depression to obesity and smoking as predictors of major medical illnesses and somatic symptoms

OBJECTIVE

Anxiety and depression predict poor physical health longitudinally, but are neglected in primary care settings compared to other risk factors such as obesity and smoking. Further, anxiety has been less commonly studied than depression, and whether anxiety has unique predictive effects for physical health is unknown. We compared anxiety and depression to obesity and smoking as predictors of physical health indices and examined unique predictive effects of anxiety and depression.

METHOD

Using data from the Health and Retirement study, a US population-based cohort study of older adults, we tested longitudinal associations of anxiety and depression symptoms with onset of self-reported physical health indices (N = 15,418; M age = 68). Medical illnesses (heart disease, stroke, arthritis, high blood pressure, diabetes, and cancer) and somatic symptoms (stomach problems, shortness of breath, dizziness, back pain, headache, pain, and eyesight difficulties) were assessed on two occasions over four years. Anxiety and depression were measured at the initial time point and tested as predictors of medical illness and somatic symptom onset.

RESULTS

Anxiety and depression symptoms predicted greater incidence of nearly all medical illnesses and somatic symptoms. Effects were as strong as or stronger than those of obesity and smoking, and anxiety and depression independently increased risk for most physical health indices assessed.

CONCLUSIONS

Findings suggest that anxiety and depression are as strongly predictive of poor future physical health as obesity and smoking and that anxiety is independently linked to poor physical health. Greater attention should be paid towards these conditions in primary care. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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.

A narrative review on the difficulties associated with fibromyalgia diagnosis

Fibromyalgia presents a clinical enigma as its pathophysiology is not well understood and its symptoms are nonspecific and overlap with many disorders, making its diagnosis a challenge for clinicians and researchers. Efforts have been made to develop a set of diagnostic criteria for this disorder. However, these criteria rely heavily on expert clinician opinion and produce a large heterogeneity within the diagnosed population. With no present specific technique reflecting the underlying pathophysiology of fibromyalgia, a definitive diagnosis of fibromyalgia remains elusive. This review discusses some problems and challenges associated with fibromyalgia diagnosis and presents some novel findings on the pathophysiological nature of fibromyalgia.

Shared metabolic and immune-inflammatory, oxidative and nitrosative stress pathways in the metabolic syndrome and mood disorders

This review examines the shared immune-inflammatory, oxidative and nitrosative stress (IO&NS) and metabolic pathways underpinning metabolic syndrome (MetS), bipolar disorder (BD) and major depressive disorder (MDD). Shared pathways in both MetS and mood disorders are low grade inflammation, including increased levels of pro-inflammatory cytokines and acute phase proteins, increased lipid peroxidation with formation of malondialdehyde and oxidized low density lipoprotein cholesterol (LDL-c), hypernitrosylation, lowered levels of antioxidants, most importantly zinc and paraoxonase (PON1), increased bacterial translocation (leaky gut), increased atherogenic index of plasma and Castelli risk indices; and reduced levels of high-density lipoprotein (HDL-c) cholesterol. Insulin resistance is probably not a major factor associated with mood disorders. Given the high levels of IO&NS and metabolic dysregulation in BD and MDD and the high comorbidity with the atherogenic components of the MetS, mood disorders should be viewed as systemic neuro-IO&NS-metabolic disorders. The IO&NS-metabolic biomarkers may have prognostic value and may contribute to the development of novel treatments targeting neuro-immune, neuro-oxidative and neuro-nitrosative pathways.

Hair cortisol in relation to acute and post-traumatic stress symptoms in children and adolescents

BACKGROUND

We report on the preliminary results of two independent studies that (1) compare the hair cortisol concentrations (HCC) of healthy controls with patients displaying post-traumatic stress symptoms (PTSS, study 1+2), (2) investigate whether pre-trauma HCC are predictive for the development of acute stress symptoms (ASS) and PTSS (study 1) and (3) determine whether HCC correlate with PTSS in a clinical sample of children (study 2).

METHODS

In study 1, the clinical symptoms of 35 minors were examined one (T1) and seven weeks (T2) after surgery following an accident. Hair samples were taken after the accident that reflect cortisol secretion over the past three months before the accident (healthy controls). In study 2, HCC and PTSS symptoms were cross-sectionally assessed in 22 minors who had experienced a psychological trauma.

RESULTS

The HCC of patients with PTSS were lower than the HCC of healthy controls (study 1+2). Secondary analyses showed that HCC were significantly lower in male PTSS patients than in male healthy controls, whereas the HCC in females were comparably low in both groups. Pre-trauma HCC did not predict the total ASS and PTSS scores (study 1) and HCC were not directly related to the total PTSS scores (study 2).

Inflammation in Fear- and Anxiety-Based Disorders: PTSD, GAD, and Beyond

The study of inflammation in fear- and anxiety-based disorders has gained interest as growing literature indicates that pro-inflammatory markers can directly modulate affective behavior. Indeed, heightened concentrations of inflammatory signals, including cytokines and C-reactive protein, have been described in posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), panic disorder (PD), and phobias (agoraphobia, social phobia, etc.). However, not all reports indicate a positive association between inflammation and fear- and anxiety-based symptoms, suggesting that other factors are important in future assessments of inflammation's role in the maintenance of these disorders (ie, sex, co-morbid conditions, types of trauma exposure, and behavioral sources of inflammation). The most parsimonious explanation of increased inflammation in PTSD, GAD, PD, and phobias is via the activation of the stress response and central and peripheral immune cells to release cytokines. Dysregulation of the stress axis in the face of increased sympathetic tone and decreased parasympathetic activity characteristic of anxiety disorders could further augment inflammation and contribute to increased symptoms by having direct effects on brain regions critical for the regulation of fear and anxiety (such as the prefrontal cortex, insula, amygdala, and hippocampus). Taken together, the available data suggest that targeting inflammation may serve as a potential therapeutic target for treating these fear- and anxiety-based disorders in the future. However, the field must continue to characterize the specific role pro-inflammatory signaling in the maintenance of these unique psychiatric conditions.

Fibromyalgia: A Critical and Comprehensive Review

Fibromyalgia is a disorder that is part of a spectrum of syndromes that lack precise classification. It is often considered as part of the global overview of functional somatic syndromes that are otherwise medically unexplained or part of a somatization disorder. Patients with fibromyalgia share symptoms with other functional somatic problems, including issues of myalgias, arthralgias, fatigue and sleep disturbances. Indeed, there is often diagnostic and classification overlap for the case definitions of a variety of somatization disorders. Fibromyalgia, however, is a critically important syndrome for physicians and scientists to be aware of. Patients should be taken very seriously and provided optimal care. Although inflammatory, infectious, and autoimmune disorders have all been ascribed to be etiological events in the development of fibromyalgia, there is very little data to support such a thesis. Many of these disorders are associated with depression and anxiety and may even be part of what has been sometimes called affected spectrum disorders. There is no evidence that physical trauma, i.e., automobile accidents, is associated with the development or exacerbation of fibromyalgia. Treatment should be placed on education, patient support, physical therapy, nutrition, and exercise, including the use of drugs that are approved for the treatment of fibromyalgia. Treatment should not include opiates and patients should not become poly pharmacies in which the treatment itself can lead to significant morbidities. Patients with fibromyalgia are living and not dying of this disorder and positive outlooks and family support are key elements in the management of patients.

Prolonged secretion of cortisol as a possible mechanism underlying stress and depressive behaviour

Stress is associated with the onset of depressive episodes, and cortisol hypersecretion is considered a biological risk factor of depression. However, the possible mechanisms underlying stress, cortisol and depressive behaviours are inconsistent in the literature. This study examined the interrelationships among stress, cortisol and observed depressive behaviours in female rhesus macaques for the first time and explored the possible mechanism underlying stress and depressive behaviour. Female monkeys were video-recorded, and the frequencies of life events and the duration of huddling were analysed to measure stress and depressive behaviour. Hair samples were used to measure chronic cortisol levels, and the interactions between stress and cortisol in the development of depressive behaviour were further evaluated. Significant correlations were found between stress and depressive behaviour measures and between cortisol levels and depressive behaviour. Stress was positively correlated with cortisol levels, and these two factors interacted with each other to predict the monkeys’ depressive behaviours. This finding extends the current understanding of stress/cortisol interactions in depression, especially pertaining to females.

Possible Contribution of PTSD to Altered Cortisol Activity in Young Adult Obese African-American Women

OBJECTIVE

African-Americans have been found to experience increased rates of post-traumatic stress disorder (PTSD), obesity, and flatter diurnal cortisol slopes compared to other demographic groups. Further exploration, however, is needed to understand how PTSD impacts diurnal cortisol activity in obese African-American women. The purpose of the current study is to examine the relationship between salivary cortisol levels and PTSD in a sample of obese young adult African-American women and to examine how depression and insomnia influence the relationship.

METHODS

Thirty-four young adult African-American women (mean age = 24.0 years; mean BMI = 37.4 kg/m(2), 6/34 of the sample had a score of 40 or above on the PTSD Checklist (PCL) representing clinically significant PTSD) filled out questionnaires assessing PTSD, lifetime exposure to traumatic events, insomnia severity, and depression. A home-based assessment of salivary cortisol was provided upon awakening at 30 min and 1, 3, 6, and 12 h.

RESULTS

There was a significant interaction between PTSD status and diurnal cortisol activity (p < 0.04). There were trends for higher cortisol levels at awakening (p < 0.051) and 30 min post-awakening (p < 0.059) with PTSD. The significance of the interaction between PTSD and cortisol was attenuated by co-varying for depression and insomnia (p > 0.05).

CONCLUSION

PTSD, influenced by depression and insomnia symptoms, has an impact on diurnal cortisol activity in obese young adult African-American women.

Induction and Expression of Fear Sensitization Caused by Acute Traumatic Stress

Fear promotes adaptive responses to threats. However, when the level of fear is not proportional to the level of threat, maladaptive fear-related behaviors characteristic of anxiety disorders result. Post-traumatic stress disorder develops in response to a traumatic event, and patients often show sensitized reactions to mild stressors associated with the trauma. Stress-enhanced fear learning (SEFL) is a rodent model of this sensitized responding, in which exposure to a 15-shock stressor nonassociatively enhances subsequent fear conditioning training with only a single trial. We examined the role of corticosterone (CORT) in SEFL. Administration of the CORT synthesis blocker metyrapone prior to the stressor, but not at time points after, attenuated SEFL. Moreover, CORT co-administered with metyrapone rescued SEFL. However, CORT alone without the stressor was not sufficient to produce SEFL. In these same animals, we then looked for correlates of SEFL in terms of changes in excitatory receptor expression. Western blot analysis of the basolateral amygdala (BLA) revealed an increase in the GluA1 AMPA receptor subunit that correlated with SEFL. Thus, CORT is permissive to trauma-induced changes in BLA function.

The relationship between cortisol, stress and psychiatric illness: New insights using hair analysis

BACKGROUND

Stress is an established important contributor to the development of mental illness and stress related disorders. The biology implicated in the homeostasis of pathological stress mechanisms is not fully established. One of the difficulties with current techniques is the limitation in capturing chronic levels of cortisol as an expression of stress levels in humans. Hair samples can be used to evaluate cortisol levels averaged over relatively long periods of time, therefore providing a more valid measure of chronic levels of this hormone. A highly replicable technique to measure long-term cortisol could prove pivotal in improving our understanding of the role of stress in psychiatric disorders.

METHODS

This review synthesises all the published studies relating hair cortisol concentration (HCC) to stress and to psychiatric disorders. It describes and summarises their findings with the aim of providing a summary picture of the current state of this line of research.

RESULTS

The strongest finding to date is the replicable increases in hair cortisol associated with stressful life events. Findings in psychiatric disorders are more sparse and inconsistent. There is some support for the presence of raised HCC in major depressive disorders, and for lowered HCC in posttraumatic stress disorder, suggesting chronic hypercortisolaemia and hypocortisolaemia respectively.

CONCLUSIONS

HCC is a promising methodology to study chronic cortisol levels with the potential to help characterise psychiatric and stress related disorders. The combination of chronic and acute cortisol measurements has the potential for more accurately determining different aspects of the stress response, and ultimately for the development of a biological marker to aid diagnosis and response to treatment.

An Overview of Translationally Informed Treatments for Posttraumatic Stress Disorder: Animal Models of Pavlovian Fear Conditioning to Human Clinical Trials

Posttraumatic stress disorder manifests after exposure to a traumatic event and is characterized by avoidance/numbing, intrusive symptoms and flashbacks, mood and cognitive disruptions, and hyperarousal/reactivity symptoms. These symptoms reflect dysregulation of the fear system likely caused by poor fear inhibition/extinction, increased generalization, and/or enhanced consolidation or acquisition of fear. These phenotypes can be modeled in animal subjects using Pavlovian fear conditioning, allowing investigation of the underlying neurobiology of normative and pathological fear. Preclinical studies reveal a number of neurotransmitter systems and circuits critical for aversive learning and memory that have informed the development of therapies used in human clinical trials. In this review, we discuss the evidence for a number of established and emerging pharmacotherapies and device-based treatments for posttraumatic stress disorder that have been developed via a bench to bedside translational model.

Does aerobic exercise affect the hypothalamic-pituitary-adrenal hormonal response in patients with fibromyalgia syndrome?

[Purpose] The hypothalamic-pituitary-adrenal (HPA) axis in the etiopathogenesis of fibromyalgia is not clear. This study aimed to analyze the effects of a 6-week aerobic exercise program on the HPA axis in patients with fibromyalgia and to investigate the effects of this program on the disease symptoms, patients' fitness, disability, and quality of life. [Subjects and Methods] Fifty fibromyalgia patients were randomized to Group 1 (stretching and flexibility exercises at home for 6 weeks) and Group 2 (aerobic exercise three times a week and the same at-home exercises as Group 1 for 6 weeks). Serum levels of cortisol, adrenocorticotropic hormone, insulin-like growth factor-1, and growth hormone were analyzed at baseline and at the end of, and 1 hr after an exercise stress test. [Results] Group 2 showed better improvement in morning stiffness duration and pain. Growth hormone levels significantly increased after intervention and cortisol levels significantly decreased at time-time interaction in both groups. No significant differences in adrenocorticotropic hormone and insulin-like growth factor-1 were found. [Conclusion] The results of this study seem to support the hypothesis that there is a dysregulation of the HPA axis in patients with FM, and that a six-week exercise program can influence symptoms and affect the HPA axis hormones.

Anxiety and depressive symptoms and medical illness among adults with anxiety disorders

OBJECTIVE

Anxiety is linked to a number of medical conditions, yet few studies have examined how symptom severity relates to medical comorbidity.

PURPOSE

The current study assessed associations between severity of anxiety and depression and the presence of medical conditions in adults diagnosed with anxiety disorders.

METHOD

Nine-hundred eighty-nine patients diagnosed with panic, generalized anxiety, social anxiety, and posttraumatic stress disorders reported on the severity of anxiety and depressive symptoms and on diagnoses of 11 medical conditions.

RESULTS

Severity of anxiety and depressive symptoms was strongly associated with having more medical conditions over and above control variables, and the association was as strong as that between BMI and disease. Odds of having asthma, heart disease, back problems, ulcer, migraine headache and eyesight difficulties also increased as anxiety and depressive symptom severity increased. Anxiety symptoms were independently associated with ulcer, whereas depressive symptoms were independently associated with heart disease, migraine, and eyesight difficulties.

CONCLUSIONS

These findings add to a growing body of research linking anxiety disorders with physical health problems and indicate that anxiety and depressive symptoms deserve greater attention in their association with disease.

Early intervention with intranasal NPY prevents single prolonged stress-triggered impairments in hypothalamus and ventral hippocampus in male rats

Intranasal administration of neuropeptide Y (NPY) is a promising treatment strategy to reduce traumatic stress-induced neuropsychiatric symptoms of posttraumatic stress disorder (PTSD). We evaluated the potential of intranasal NPY to prevent dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis, a core neuroendocrine feature of PTSD. Rats were exposed to single prolonged stress (SPS), a PTSD animal model, and infused intranasally with vehicle or NPY immediately after SPS stressors. After 7 days undisturbed, hypothalamus and hippocampus, 2 structures regulating the HPA axis activity, were examined for changes in glucocorticoid receptor (GR) and CRH expression. Plasma ACTH and corticosterone, and hypothalamic CRH mRNA, were significantly higher in the vehicle but not NPY-treated group, compared with unstressed controls. Although total GR levels were not altered in hypothalamus, a significant decrease of GR phosphorylated on Ser232 and increased FK506-binding protein 5 mRNA were observed with the vehicle but not in animals infused with intranasal NPY. In contrast, in the ventral hippocampus, only vehicle-treated animals demonstrated elevated GR protein expression and increased GR phosphorylation on Ser232, specifically in the nuclear fraction. Additionally, SPS-induced increase of CRH mRNA in the ventral hippocampus was accompanied by apparent decrease of CRH peptide particularly in the CA3 subfield, both prevented by NPY. The results show that early intervention with intranasal NPY can prevent traumatic stress-triggered dysregulation of the HPA axis likely by restoring HPA axis proper negative feedback inhibition via GR. Thus, intranasal NPY has a potential as a noninvasive therapy to prevent negative effects of traumatic stress.

Neurobehavioral, neuropathological and biochemical profiles in a novel mouse model of co-morbid post-traumatic stress disorder and mild traumatic brain injury

Co-morbid mild traumatic brain injury (mTBI) and post-traumatic stress disorder (PTSD) has become the signature disorder for returning combat veterans. The clinical heterogeneity and overlapping symptomatology of mTBI and PTSD underscore the need to develop a preclinical model that will enable the characterization of unique and overlapping features and allow discrimination between both disorders. This study details the development and implementation of a novel experimental paradigm for PTSD and combined PTSD-mTBI. The PTSD paradigm involved exposure to a danger-related predator odor under repeated restraint over a 21 day period and a physical trauma (inescapable footshock). We administered this paradigm alone, or in combination with a previously established mTBI model. We report outcomes of behavioral, pathological and biochemical profiles at an acute timepoint. PTSD animals demonstrated recall of traumatic memories, anxiety and an impaired social behavior. In both mTBI and combination groups there was a pattern of disinhibitory like behavior. mTBI abrogated both contextual fear and impairments in social behavior seen in PTSD animals. No major impairment in spatial memory was observed in any group. Examination of neuroendocrine and neuroimmune responses in plasma revealed a trend toward increase in corticosterone in PTSD and combination groups, and an apparent increase in Th1 and Th17 proinflammatory cytokine(s) in the PTSD only and mTBI only groups respectively. In the brain there were no gross neuropathological changes in any groups. We observed that mTBI on a background of repeated trauma exposure resulted in an augmentation of axonal injury and inflammatory markers, neurofilament L and ICAM-1 respectively. Our observations thus far suggest that this novel stress-trauma-related paradigm may be a useful model for investigating further the overlapping and distinct spatio-temporal and behavioral/biochemical relationship between mTBI and PTSD experienced by combat veterans.

Post traumatic stress disorder and the adrenal gland

Low serum and urinary Cortisol has been a consistent finding in post traumatic stress disorder (PTSD). Glucocorticoid receptor numbers are increased. PTSD patients have a significantly lower adrenocorticotropic hormone (ACTH) in response to corticotrophin releasing hormone (CRH) when compared to a control group of normal volunteers. The dexamethasone suppression test exhibits an exaggerated suppression response of Cortisol to dexamethasone, when the dose utilised is lower than that utilised to test patients with depression. Increased urine levels of noradrenaline and dopamine has been noted in patients with PTSD. This is believed to be related to the hyperarousal state of PTSD.

A review on the evidence of transgenerational transmission of posttraumatic stress disorder vulnerability

OBJECTIVE

To understand the risks of posttraumatic stress disorder (PTSD) development in the next generation of PTSD patients, we conducted a review on the biological, but not genetic, evidence of transgenerational transmission of PTSD vulnerability.

METHODS

Pertinent articles published from 1985 to September 2011 were searched using online academic search engines, including MEDLINE, EMBASE, ScienceDirect, OVID, PsycLIT, and SCOPUS, and a non-systematic review was conducted.

RESULTS

There is paradoxical evidence that hypothalamic-pituitary-adrenal axis changes in PTSD patients may also be evident in their offspring. This effect and biological vulnerability to PTSD may be transmitted across generations through maternal epigenetic programming during pregnancy. The samples of most studies, which were not large enough and represented the outcome of few research groups, consisted of a specific type of patients with a particular trauma.

CONCLUSIONS

There is still a need to conduct studies in other geographical areas with different genetic background and larger samples considering different types of trauma other than those specified in the current literature, so as to strengthen the evidence of transgenerational transmission of PTSD vulnerability.

Biomarkers in posttraumatic stress disorder: overview and implications for future research

PTSD can develop in the aftermath of traumatic incidents like combat, sexual abuse, or life threatening accidents. Unfortunately, there are still no biomarkers for this debilitating anxiety disorder in clinical use. Anyhow, there are numerous studies describing potential PTSD biomarkers, some of which might progress to the point of practical use in the future. Here, we outline and comment on some of the most prominent findings on potential imaging, psychological, endocrine, and molecular PTSD biomarkers and classify them into risk, disease, and therapy markers. Since for most of these potential PTSD markers a causal role in PTSD has been demonstrated or at least postulated, this review also gives an overview on the current state of research on PTSD pathobiology.

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

Extensive research has identified stereotypic behavioral and biological abnormalities in post-traumatic stress disorder (PTSD), such as heightened autonomic activity, an exaggerated startle response, reduced basal cortisol levels and cognitive impairments. We have reviewed primary research in this area, noting that factors involved in the susceptibility and expression of PTSD symptoms are more complex and heterogeneous than is commonly stated, with extensive findings which are inconsistent with the stereotypic behavioral and biological profile of the PTSD patient. A thorough assessment of the literature indicates that interactions among myriad susceptibility factors, including social support, early life stress, sex, age, peri- and post-traumatic dissociation, cognitive appraisal of trauma, neuroendocrine abnormalities and gene polymorphisms, in conjunction with the inconsistent expression of the disorder across studies, confounds attempts to characterize PTSD as a monolithic disorder. Overall, our assessment of the literature addresses the great challenge in developing a behavioral and biomarker-based diagnosis of PTSD.

Dysregulated diurnal cortisol pattern is associated with glucocorticoid resistance in women with major depressive disorder

Dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis is believed to play a role in the pathophysiology of depression. To investigate mechanisms that may underlie this effect, we examined several indices of HPA axis function - specifically, diurnal cortisol slope, cortisol awakening response, and suppression of cortisol release following dexamethasone administration - in 26 pre-menopausal depressed women and 23 never depressed women who were matched for age and body mass index. Salivary cortisol samples were collected at waking, 30 min after waking, and at bedtime over three consecutive days. On the third day, immediately after the bedtime sample, participants ingested a 0.5mg dexamethasone tablet; they then collected cortisol samples at waking and 30 min after waking the following morning. As predicted, depressed women exhibited flatter diurnal cortisol rhythms and more impaired suppression of cortisol following dexamethasone administration than non-depressed women over the three sampling days. In addition, flatter diurnal cortisol slopes were associated with reduced cortisol response to dexamethasone treatment, both for all women and for depressed women when considered separately. Finally, greater self-reported depression severity was associated with flatter diurnal cortisol slopes and with less dexamethasone-related cortisol suppression for depressed women. Depression in women thus appears to be characterized by altered HPA axis functioning, as indexed by flatter diurnal cortisol slopes and an associated impaired sensitivity of cortisol to dexamethasone. Given that altered HPA axis functioning has been implicated in several somatic conditions, the present findings may be relevant for understanding the pathophysiology of both depression and depression-related physical disease.

Psychobiology of PTSD in the acute aftermath of trauma: Integrating research on coping, HPA function and sympathetic nervous system activity

Research on the psychobiological sequelae of trauma has typically focused on long-term alterations in individuals with chronic posttraumatic stress disorder (PTSD). Far less is known about the nature and course of psychobiological risk factors for PTSD during the acute aftermath of trauma. In this review, we summarize data from prospective studies focusing on the relationships among sympathetic nervous system activity, hypothalamic-pituitary-adrenal function, coping strategies and PTSD symptoms during the early recovery (or non-recovery) phase. Findings from pertinent studies are integrated to inform psychobiological profiles of PTSD-risk in children and adults in the context of existing models of PTSD-onset and maintenance. Data regarding bidirectional relations between coping strategies and stress hormones is reviewed. Limitations of existing literature and recommendations for future research are discussed.

Trauma sequelae and cortisol levels in women exposed to intimate partner violence

Intimate partner violence (IPV) is often a chronic form of trauma with deleterious mental health problems. Furthermore, IPV survivors have also often experienced trauma in childhood. Consequently, by examining a sample of IPV survivors, this study sought to assess typical trauma sequelae--Posttraumatic Stress Disorder (PTSD), Major Depressive Disorder (MDD), or dissociative symptoms-and trauma-related characteristics consistent with Herman's Trauma theory (1992; i.e., chronicity of trauma, age of first trauma exposure, and social support), in relation to hypothalamic-pituitary-adrenal axis function. The study compared basal and diurnal cortisol in women (n = 88) based on diagnostic status and symptom severity (PTSD [n = 14], PTSD and comorbid MDD [n = 43], subthreshold symptoms of PTSD and MDD [n = 19]), dissociative symptoms, and the aforementioned trauma-related characteristics to a matched control group (n = 12) without any lifetime history of mental health diagnoses or exposure to interpersonal trauma. Regardless of their diagnostic status and trauma-related characteristics, trauma-exposed women had higher levels of dissociative symptoms relative to women in the control group, and these dissociative symptoms were inversely related to awakening cortisol levels. Findings suggest that low cortisol levels may not be a diagnostic marker, but instead may be associated with a dissociative coping style developed in the context of trauma exposure, consistent with mechanisms posited by Trauma theory.

Exaggerated neurobiological sensitivity to threat as a mechanism linking anxiety with increased risk for diseases of aging

Anxiety disorders increase risk for the early development of several diseases of aging. Elevated inflammation, a common risk factor across diseases of aging, may play a key role in the relationship between anxiety and physical disease. However, the neurobiological mechanisms linking anxiety with elevated inflammation remain unclear. In this review, we present a neurobiological model of the mechanisms by which anxiety promotes inflammation. Specifically we propose that exaggerated neurobiological sensitivity to threat in anxious individuals may lead to sustained threat perception, which is accompanied by prolonged activation of threat-related neural circuitry and threat-responsive biological systems including the hypothalamic-pituitary-adrenal (HPA) axis, autonomic nervous system (ANS), and inflammatory response. Over time, this pattern of responding can promote chronic inflammation through structural and functional brain changes, altered sensitivity of immune cell receptors, dysregulation of the HPA axis and ANS, and accelerated cellular aging. Chronic inflammation, in turn, increases risk for diseases of aging. Exaggerated neurobiological sensitivity to threat may thus be a treatment target for reducing disease risk in anxious individuals.

Relations among posttraumatic stress disorder, comorbid major depression, and HPA function: a systematic review and meta-analysis

Exposure to traumatic stress is associated with increased risk for posttraumatic stress disorder (PTSD) and alterations of hypothalamic-pituitary-adrenocortical (HPA) function. Research linking traumatic stress with HPA function in PTSD has been inconsistent, however, in part due to (a) the inclusion of trauma-exposed individuals without PTSD (TE) in control groups and (b) a failure to consider comorbid major depressive disorder (MDD) and moderating variables. This meta-analysis of 47 studies (123 effect sizes, N=6008 individuals) revealed that daily cortisol output was lower for PTSD (d=-.36, SE=.15, p=.008) and PTSD+MDD (d=-.65, SE=.25, p=.008) groups relative to no trauma controls (NTC); TE and NTC groups did not differ significantly from each other. Afternoon/evening cortisol was lower in TE (d=-.25, SE=.09, p=.007) and PTSD (d=-.27, SE=.12, p=.021) groups and higher in PTSD+MDD groups (d=.49, SE=.24, p=.041) relative to NTC. Post-DST cortisol levels were lower in PTSD (d=-.40, SE=.12, p<.001), PTSD+MDD (d=-.65, SE=.14, p<.001), and TE groups (d=-.53, SE=.14, p<.001) relative to NTC. HPA effect sizes were moderated by age, sex, time since index event, and developmental timing of trauma exposure. These findings suggest that enhanced HPA feedback function may be a marker of trauma-exposure rather than a specific mechanism of vulnerability for PTSD, whereas lower daily cortisol output may be associated with PTSD in particular.

Role of cytokines in atypical depression

BACKGROUND

Atypical depression (AD) is considered a biologically and psychologically distinct subtype of depression. AD, contrary to melancholic depression (MD), may have different alteration in cytokine activity.

AIMS

We aimed to investigate the differences of cytokine activity between AD patients and MD patients. Among psychiatric patients visited to the Psychiatry Department, Korea University Medical Center, 105 patients with major depression who met the Diagnostic and Statistical Manual (DSM-IV) criteria based on clinical interviews using a Structured Clinical Interview for DSM-IV were recruited. Among 105 patients, 35 patients had atypical feature. We measured in vitro cytokines (interleukins) IL-2, IL-4, IL-6 and tumor necrosis factor-α (TNF-α).

RESULTS

Decreased IL-4 and increased IL-2 was observed in AD patients. IL-6 and TNF-α level of AD patients showed no difference from the controls.

CONCLUSIONS

Contrary to MD, AD has reversed vegetative symptoms, i.e. hypersomnia and hyperphagia. It is assumed that the phenotype difference between AD and MD might be related to Th1 cytokines (IL-2) and Th2 cytokines (IL-4) and not related to monocytic cytokines (IL-6, and TNF-α).

Altered salivary alpha-amylase awakening response in Bosnian War refugees with posttraumatic stress disorder

In posttraumatic stress disorder (PTSD), chronic activation of the sympathetic nervous system (SNS) has been suggested. No study so far has investigated diurnal secretion patterns of salivary alpha-amylase (sAA) in PTSD, a promising candidate for non-invasive assessment of SNS activity. We compared sAA diurnal profiles between a group of Bosnian War refugees with PTSD and a healthy control group, and further analyzed for associations with psychiatric symptoms and glucocorticoid (GC) sensitivity of inflammatory regulation. PTSD patients showed a sAA awakening response profile that was opposite to those seen in healthy controls, i.e. an increase instead of a sharp decrease. Patterns of sAA secretion were further positively associated with psychiatric symptoms of PTSD. Finally, higher sAA awakening responses were associated with higher GC sensitivity of inflammatory cytokine production. These findings are in line with altered SNS function in PTSD, and lend further support for employing assessment of diurnal sAA profiles as non-invasive biomarkers in stress-related disease.

Modeling cortisol dynamics in the neuro-endocrine axis distinguishes normal, depression, and post-traumatic stress disorder (PTSD) in humans

Cortisol, secreted in the adrenal cortex in response to stress, is an informative biomarker that distinguishes anxiety disorders such as major depression and post-traumatic stress disorder (PTSD) from normal subjects. Yehuda et al. proposed a hypothesis that, in humans, the hypersensitive hypothalamus-pituitary-adrenal (HPA) axis is responsible for the occurrence of differing levels of cortisol in anxiety disorders. Specifically, PTSD subjects have lower cortisol levels during the late subjective night in comparison to normal subjects, and this was assumed to occur due to strong negative feedback loops in the HPA axis. In the present work, to address this hypothesis, we modeled the cortisol dynamics using nonlinear ordinary differential equations and estimated the kinetic parameters of the model to fit the experimental data of three categories, namely, normal, depressed, and PTSD human subjects. We concatenated the subjects (n = 3) in each category and created a model subject (n = 1) without considering the patient-to-patient variability in each case. The parameters of the model for the three categories were simultaneously obtained through global optimization. Bifurcation analysis carried out with the optimized parameters exhibited two supercritical Hopf points and, for the choice of parameters, the oscillations were found to be circadian in nature. The fitted kinetic parameters indicate that PTSD subjects have a strong negative feedback loop and, as a result, the predicted oscillating cortisol levels are extremely low at the nadir in contrast to normal subjects, albeit within the endocrinologic range. We also simulated the phenotypes for each of the categories and, as observed in the clinical data of PTSD patients, the simulated cortisol levels are consistently low at the nadir, and correspondingly the negative feedback was found to be extremely strong. These results from the model support the hypothesis that high stress intensity and strong negative feedback loop may cause hypersensitive neuro-endocrine axis that results in hypocortisolemia in PTSD.

PTSD is an anxiety disorder that occurs among persons exposed to a traumatic event involving life threat and injury. This is a co-morbid psychiatric disorder that occurs along with depression. Cortisol is an informative endocrine biomarker that can distinguish PTSD from other co-morbid disorders. In comparison to normal subjects, hypocortisolemia was observed during the night in PTSD, while hypercortisolemia was observed in depressed subjects. From analyzing the clinical data, Yehuda et al. hypothesized that hypocortisolemia in PTSD was due to the strong negative feedback loop operating in the neuroendocrine axis under severe stress. We complemented this hypothesis by constructing a mathematical model for cortisol dynamics in HPA axis and estimated the kinetic parameters that fitted the cortisol time series obtained from the clinical data of normal, depressed and PTSD patients. The parameters obtained from the simulated phenotypes also strongly support the hypothesis that, due to disruptive negative feedback loops, cortisol levels are different in normal, PTSD and depressed subjects during the night. Importantly, the model predicted the transitions from normal to various diseased states, and these transitions were shown to occur due to changes in the strength of the negative feedback loop and the stress intensity in the neuro-endocrine axis.

Delineating psychological and biomedical profiles in a heterogeneous fibromyalgia population using cluster analysis

The heterogeneity of patients meeting American College of Rheumatology (ACR) criteria for a diagnosis of fibromyalgia (FM) challenges our ability to understand the underlying pathogenesis and to optimize treatment of this enigmatic disorder. Our goal was to discern clinically relevant subgroups across multiple psychological and biomedical domains to better characterize the phenomenology of FM. Women meeting 1990 ACR criteria for FM (N = 107) underwent psychological (childhood trauma, mood, anxiety, and stress) and biomedical (neuroendocrine, immune, and metabolic) testing. Cluster analysis identified four distinct subgroups. Subgroups I, II, and III exhibited profiles that included high psychological distress. Subgroup I was further distinguished by a history of childhood maltreatment and hypocortisolism, and these women reported the most pain and disability. Subgroup II evinced more physiological dysregulation and also reported high levels of pain, fatigue, and disability. Subgroup III was characterized by normal biomarkers and reported intermediate pain severity with higher global functioning. Subgroup IV was distinguished by their psychological well-being, reporting less disability and pain. Our findings underscore the heterogeneity of both psychological and physiological features among FM patients presenting with nearly identical tender point counts. This subgroup categorization is compatible with hypothesized pathogenetic mechanisms of early trauma, stress system dysregulation, and pro-inflammatory bias, each prominent in some but not all FM patients. Appreciation of distinct FM subgroup features is invaluable for selecting the most appropriate treatment modalities.

Increased cortisol concentrations in hair of severely traumatized Ugandan individuals with PTSD

Previous research has mostly suggested general hypocortisolism in posttraumatic stress disorder (PTSD). However, PTSD is a complex disorder and opposite neuroendocrinological changes have also been reported. Amongst other things, heterogeneous results might be related to differences in sample characteristics as well as methodological factors associated with the assessment of cortisol. The current study used the novel method of hair cortisol analysis to examine cumulative long-term cortisol secretion in a severely traumatized PTSD sample. Hair samples of 10 traumatized individuals with PTSD and 17 traumatized controls without PTSD from a civil war area of Northern Uganda were analyzed. Results revealed that hair samples of PTSD participants contained higher cortisol levels than those of traumatized controls (p<.05). Furthermore, a positive association between hair cortisol levels and the number of lifetime traumatic events was found (p<.05). The current hair cortisol findings suggest that PTSD in severely traumatized individuals who continue to live under stressful conditions might be associated with general hypercortisolism. Future research examining participants after traumatic events at different follow-up periods is needed to determine the specific influence of time interval since traumatization.

Hydrocortisone suppression of the fear-potentiated startle response and posttraumatic stress disorder

This study examined the effects of oral administration of 20mg hydrocortisone on baseline and fear-potentiated startle in 63 male veterans with or without PTSD. The procedure was based on a two-session, within-subject design in which acoustic startle eyeblink responses were recorded during intervals of threat or no threat of electric shock. Results showed that the magnitude of the difference between startle responses recorded during anticipation of imminent shock compared to "safe" periods was reduced after hydrocortisone administration relative to placebo. This effect did not vary as a function of PTSD group nor were there were any significant group differences in other indices startle amplitude. Findings suggest that the acute elevations in systemic cortisol produced by hydrocortisone administration may have fear-inhibiting effects. This finding may have implications for understanding the role of hypothalamic-pituitary-adrenal (HPA)-axis function in vulnerability and resilience to traumatic stress.

The Utility of Animal Models in Understanding Links between Psychosocial Processes and Cardiovascular Health

A bidirectional association between mood disorders and cardiovascular disease has been described; however, the neurobiological mechanisms that underlie this link have not been fully elucidated. The purpose of this review is first to describe some of the important behavioral neurobiological processes that are common to both mood and cardiovascular disorders. Second, this review focuses on the value of conducting research with animal models (primarily rodents) to investigate potential behavioral, physiological, and neural processes involved in the association of mood disorders and cardiovascular disease. In combination with findings from human research, the study of mechanisms underlying mood and cardiovascular regulation using animal models will enhance our understanding of the association of depression and cardiovascular disease, and can promote the development of novel interventions for individuals with these comorbid conditions.

Meta-analysis and meta-regression of hypothalamic-pituitary-adrenal axis activity in functional somatic disorders

Dysfunction of the hypothalamic-pituitary-adrenal (HPA) axis is the most investigated biological risk marker in functional somatic disorders (FSDs), such as chronic fatigue syndrome (CFS), fibromyalgia (FM), and irritable bowel syndrome (IBS). Our aim was to assess whether there is an association between basal hypocortisolism and FSD and to identify potential moderators of this association. Meta-analysis on 85 studies revealed that although basal cortisol levels were generally lower in FSD subjects compared to controls, this association did not reach statistical significance (SMD -0.07, 95% CI -0.17 to 0.04, p=0.241). However, when the three FSD were assessed separately, statistically significant basal hypocortisolism was observed in CFS subjects compared to controls (SMD -0.14, 95% CI -0.28 to 0.00, p=0.047), but not in FM or IBS. When all potential moderators were entered into a meta-regression analysis, only type of FSD and female gender were significant independent predictors of basal hypocortisolism. In conclusion, we did not find evidence to consider all three main FSD as hypocortisolemic disorders, as significant reduction in basal cortisol compared to healthy controls was only found in CFS and in females with FM, but not in IBS.

Modulating Gene Expression through Psychotherapy: The Contribution of Noninvasive Somatic Interventions

Mapping the relationship between gene expression and psychopathology is proving to be among the most promising new frontiers for advancing the understanding, treatment, and prevention of mental disorders. Each cell in the human body contains some 23,688 genes, yet only a tiny fraction of a cell's genes are active or “expressed” at any given moment. The interactions of biochemical, psychological, and environmental factors influencing gene expression are complex yet relatively accessible technologies for assessing gene expression have allowed the identification of specific genes implicated in a range of psychiatric disorders, including depression, anxiety, and schizophrenia. Moreover, successful psychotherapeutic interventions have been shown to shift patterns of gene expression. Five areas of biological change in successful psychotherapy that are dependent upon precise shifts in gene expression are identified in this article. Psychotherapy ameliorates (a) exaggerated limbic system responses to innocuous stimuli, (b) distortions in learning and memory, (c) imbalances between sympathetic and parasympathetic nervous system activity, (d) elevated levels of cortisol and other stress hormones, and (e) impaired immune functioning. The thesis of this article is that psychotherapies that utilize noninvasive somatic interventions may yield greater precision and power in bringing about therapeutically beneficial shifts in gene expression that control these biological markers. The article examines the manual stimulation of acupuncture points during psychological exposure as an example of such a somatic intervention. For each of the five areas, a testable proposition is presented to encourage research that compares acupoint protocols with conventional therapies in catalyzing advantageous shifts in gene expression.

The hypothalamic-pituitary-adrenal axis and serotonin abnormalities: a selective overview for the implications of suicide prevention

Suicidal behavior and mood disorders are one of the world's largest public health problems. The biological vulnerability for these problems includes genetic factors involved in the regulation of the serotonergic system and stress system. The hypothalamic-pituitary-adrenal (HPA) axis is a neuroendocrine system that regulates the body's response to stress and has complex interactions with brain serotonergic, noradrenergic and dopaminergic systems. Corticotropin-releasing hormone and vasopressin act synergistically to stimulate the secretion of ACTH that stimulates the biosynthesis of corticosteroids such as cortisol from cholesterol. Cortisol is a major stress hormone and has effects on many tissues, including on mineralocorticoid receptors and glucocorticoid receptors in the brain. Glucocorticoids produce behavioral changes, and one important target of glucocorticoids is the hypothalamus, which is a major controlling center of the HPA axis. Stress plays a major role in the various pathophysiological processes associated with mood disorders and suicidal behavior. Serotonergic dysfunction is a well-established substrate for mood disorders and suicidal behavior. Corticosteroids may play an important role in the relationship between stress, mood changes and perhaps suicidal behavior by interacting with 5-HT1A receptors. Abnormalities in the HPA axis in response to increased levels of stress are found to be associated with a dysregulation in the serotonergic system, both in subjects with mood disorders and those who engage in suicidal behavior. HPA over-activity may be a good predictor of mood disorders and perhaps suicidal behavior via abnormalities in the serotonergic system.

Fibromyalgia syndrome is associated with hypocortisolism

BACKGROUND

Fibromyalgia syndrome (FMS) is a disease of unknown pathogenesis characterized by chronic musculoskeletal pain. FMS has been also associated with altered endocrinological responses, but findings are inconsistent.

PURPOSE

The aim of the present study was to investigate free salivary cortisol levels in FMS patients compared with healthy controls with a particular focus on the cortisol awakening response (CAR). The saliva samples were collected in a controlled hospital-hotel setting, in which the participants' compliance was high and a number of potential confounders were analyzed.

METHOD

Twenty-nine chronic female FMS patients and 29 age-matched healthy female controls were recruited. Salivary cortisol samples were investigated eight times: in the afternoon when participants arrived at the hospital, after stress provocation (to be reported separately), in the evening, before they went to sleep, upon awakening, 30 and 60 min later, and during the afternoon of the second day. Questionnaires measuring pain levels, sleeping problems, perceived stress, and personality were administered to the participants. Other psychophysiological measurements were used to assess sleep quality and heart rate.

RESULTS

Patients with FMS had significantly lower cortisol levels during the day, most pronounced in the morning (CAR). The potential confounders analyzed did not influence the results. As expected, FMS patients reported more pain, stress, sleeping problems, anxiety, and depression.

CONCLUSION

The results lend support to the hypothesis of a dysfunction in the hypothalamus-pituitary-adrenal axis in FMS patients, with generally lower cortisol values, most pronounced upon awakening (CAR).