Low urinary cortisol excretion in Holocaust survivors with posttraumatic stress disorder

Corticosterone administration immediately after peripuberty stress exposure does not prevent protracted stress-induced behavioral alterations

Stress-related disorders are commonly associated with abnormalities in hypothalamic-pituitary-adrenal (HPA) axis activity. Preliminary studies with cortisol administration in the aftermath of trauma suggest that this HPA axis hormone can potentially prevent maladaptive behavioral and biological stress responses. However, the efficacy of glucocorticoid administration during the peripuberty period has not been tested yet, although this lifetime is a critical time window in brain development and is highly sensitive to the harmful effects of stress. To further examine the short and long-lasting impact of glucocorticoids treatment given during the post-peripubertal stress period, the present study utilized a rat model of peripubertal stress-induced psychopathology and animals were subjected to a battery of tests to assess anxiety-like behaviors, exploratory behavior and reactivity to novelty at late adolescence and sociability, anhedonia and stress coping behaviors at adulthood. All the experiments were performed in males and females to evaluate the potential behavioral sex differences. Overall, our results demonstrated that rats exposed to peripubertal stress show decreased sociability in adulthood without differences in anxiety and depression-like behaviors. Moreover, this study shows that the administration of corticosterone after stress exposure at peripuberty does not prevent stress-induced behavioral alterations. However, we observed that some stress-induced behavioural alterations and corticosterone responses are sex-specific. Thus, the data obtained highlight that delineating sex differences in stress-related studies may ultimately contribute to the development of effective therapeutic interventions for each sex.

Innate and adaptive immune system consequences of post-traumatic stress disorder

In the field of psychiatry, biological markers are rarely, if ever, used in the diagnosis of mental health disorders. Clinicians rely primarily on patient histories and behavioral symptoms to identify specific psychopathologies, which makes diagnosis highly subjective. Moreover, therapies for mental health disorders are aimed specifically at attenuating behavioral manifestations, which overlooks the pathophysiological indices of the disease. This is highly evident in posttraumatic stress disorder (PTSD) where inflammation and immune system perturbations are becoming increasingly described. Further, patients with PTSD possess significantly elevated risks of developing comorbid inflammatory diseases such as autoimmune and cardiovascular diseases, which are likely linked (though not fully proven) to the apparent dysregulation of the immune system after psychological trauma. To date, there is little to no evidence that demonstrates current PTSD therapies are able to reverse the increased risk for psychological trauma-induced inflammatory diseases, which suggests the behavioral and somatic consequences of PTSD may not be tightly coupled. This observation provides an opportunity to explore unique mechanisms outside of the brain that contribute to the long-term pathology of PTSD. Herein, we provide an overview of neuroimmune mechanisms, describe what is known regarding innate and adaptive immunity in PTSD, and suggest new directions that are needed to advance the understanding, diagnosis, and treatment of PTSD moving forward.

A late-life neurogenetic signature of exposure to combat stress - A monozygotic discordant twin study

Animal models suggest that experiencing high-stress levels induces changes in amygdalar circuitry and gene expression. In humans, combat exposure has been shown to alter amygdalar responsivity and connectivity, but abnormalities have been indicated to normalize at least partially upon the termination of stress exposure. In contrast, other evidence suggests that combat exposure continues to exert influence on exposed individuals well beyond deployment and homecoming, as indicated by longitudinal psychosocial evidence from veterans, and observation of greater health decline in veterans late in life. Accordingly, the experience of combat stress early in life may affect amygdalar responsivity late in life, a possibility requiring careful consideration of the confounding effects of aging, genetic factors, and symptoms of post-traumatic stress disorder. Here, we investigated amygdalar responsivity in a unique sample of 16 male monozygotic (MZ) twin pairs in their sixties, where one but not the other sibling had been exposed to combat stress in early adulthood. Forty years after combat experience, a generally blunted amygdalar response was observed in combat-exposed veterans compared to their non-exposed twin siblings. Spatial associations between these phenotypical changes and patterns of gene expression in the brain were found for genes involved in the synaptic organization and chromatin structure. Protein-protein interactions among the set of identified genes pointed to histone modification mechanisms. We conclude that exposure to combat stress early in life continues to impact brain function beyond the termination of acute stress and appears to exert prolonged effects on amygdalar function later in life via neurogenetic mechanisms.

Effects of a diet low in excitotoxins on PTSD symptoms and related biomarkers

Post-traumatic stress disorder (PTSD) develops after trauma exposure and involves symptoms of avoidance, intrusive re-experiencing, mood and cognitive dysfunction, and hypervigilance. PTSD is often comorbid with Gulf War Illness (GWI), a neurological condition involving widespread pain, cognitive dysfunction, digestive problems, and other symptoms, in Gulf War veterans. PTSD tends to be more severe when comorbid with GWI. Low cortisol and elevated homocysteine levels have been found in PTSD, making them potential PTSD biomarkers. The low-glutamate diet, which aims to reduce excitotoxicity by eliminating the consumption of free glutamate and aspartate, has been shown to significantly reduce GWI and PTSD symptoms. This study examined whether changes in serum cortisol and homocysteine are associated with reduced PTSD severity in veterans with GWI after one month on the low-glutamate diet, and whether reducing the consumption of dietary excitotoxins was associated changes in PTSD and serum biomarkers. Data were analyzed for 33 veterans. No serum biomarkers significantly changed post-diet; however, cortisol increased as dietary excitotoxin consumption decreased, which held in a multivariable linear regression after adjustment for sex. Reduced dietary excitotoxin consumption was also associated with reduced hyperarousal symptoms, which held in a multivariable linear regression after adjustment for sex. Cortisol increase was associated with reduced avoidance symptoms after adjustment for change in BMI, and was marginally associated with overall PTSD reduction. Change in homocysteine was not significantly related to dietary adherence nor change in PTSD. Results suggest that reducing the consumption of dietary excitotoxins may normalize cortisol levels, which has been associated with alleviating PTSD.

Blunted Glucocorticoid Responsiveness to Stress Causes Behavioral and Biological Alterations That Lead to Posttraumatic Stress Disorder Vulnerability

BACKGROUND

Understanding why only a subset of trauma-exposed individuals develop posttraumatic stress disorder is critical for advancing clinical strategies. A few behavioral (deficits in fear extinction) and biological (blunted glucocorticoid levels, small hippocampal size, and rapid-eye-movement sleep [REMS] disturbances) traits have been identified as potential vulnerability factors. However, whether and to what extent these traits are interrelated and whether one of them could causally engender the others are not known.

METHODS

In a genetically selected rat model of reduced corticosterone responsiveness to stress, we explored posttraumatic stress disorder-related biobehavioral traits using ex vivo magnetic resonance imaging, cued fear conditioning, and polysomnographic recordings combined with in vivo photometric measurements.

RESULTS

We showed that genetic selection for blunted glucocorticoid responsiveness led to a correlated multitrait response, including impaired fear extinction (observed in males but not in females), small hippocampal volume, and REMS disturbances, supporting their interrelatedness. Fear extinction deficits and concomitant disruptions in REMS could be normalized through postextinction corticosterone administration, causally implicating glucocorticoid deficiency in two core posttraumatic stress disorder-related risk factors and manifestations. Furthermore, reduced REMS was accompanied by higher norepinephrine levels in the hippocampal dentate gyrus that were also reversed by postextinction corticosterone treatment.

CONCLUSIONS

Our results indicate a predominant role for glucocorticoid deficiency over the contribution of reduced hippocampal volume in engendering both REMS alterations and associated deficits in fear extinction consolidation, and they causally implicate blunted glucocorticoids in sustaining neurophysiological disturbances that lead to fear extinction deficits.

Hypothalamus and Post-Traumatic Stress Disorder: A Review

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

Exposure to war and conflict: The individual and inherited epigenetic effects on health, with a focus on post-traumatic stress disorder

War and conflict are global phenomena, identified as stress-inducing triggers for epigenetic modifications. In this state-of-the-science narrative review based on systematic principles, we summarise existing data to explore the outcomes of these exposures especially in veterans and show that they may result in an increased likelihood of developing gastrointestinal, auditory, metabolic and circadian issues, as well as post-traumatic stress disorder (PTSD). We also note that, despite a potential "healthy soldier effect", both veterans and civilians with PTSD exhibit the altered DNA methylation status in hypothalamic-pituitary-adrenal (HPA) axis regulatory genes such as NR3C1. Genes associated with sleep (PAX8; LHX1) are seen to be differentially methylated in veterans. A limited number of studies also revealed hereditary effects of war exposure across groups: decreased cortisol levels and a heightened (sex-linked) mortality risk in offspring. Future large-scale studies further identifying the heritable risks of war, as well as any potential differences between military and civilian populations, would be valuable to inform future healthcare directives.

Acute stress responses of autonomous nervous system, HPA axis, and inflammatory system in posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) does not only have direct consequences for well-being, but it also comes with a significant risk for severe somatic health consequences. A number of previous studies have pointed to alterations in stress systems in traumatized persons, as well as the inflammatory system, which might be important links in the pathway between trauma, PTSD, and health consequences. The aim of this study was to investigate acute stress responses in PTSD patients compared with healthy controls. Twenty-seven PTSD patients and 15 controls were exposed to the Trier Social Stress Test (TSST), and we measured salivary cortisol, salivary alpha-amylase (sAA), plasma interleukin-6 (IL-6), as well as heart rate and heart rate variability (HRV) at different time points before, during and after the stress test. Results revealed similar stress responses between patients and controls, but lower baseline cortisol levels and higher IL-6 baseline levels in PTSD patients. Increases in sAA stress responses were significantly lower in patients, while sAA concentrations were higher in the PTSD group during intervention. HRV was markedly decreased in patients and showed a significantly blunted acute stress response with a slower recovery after TSST. These results confirm previous findings of marked stress system dysregulations in PTSD and add to the literature on acute stress reactivity in PTSD which appears to show stress system-specific changes. Overall, these results have implications for our understanding of potential risk and resilience factors in the response to trauma.

Examining the relationships between adverse childhood experiences (ACEs), cortisol, and inflammation among young adults

Adverse childhood experiences (ACEs) are associated with dysregulation of inflammation and cortisol. The objectives of this study were to use principal component analysis to explore the inflammatory biomarker data to create inflammation composite variables; to examine the relationship between these composite measures of inflammation with ACEs and cortisol; and to assess whether these relationships were moderated by sex. The analysis included 232 young adults from the Niagara Longitudinal Heart Study (NLHS). After adjusting for covariates, higher exposure to ACEs significantly predicted higher low-grade inflammation. These results further support the use of multiple biomarkers to understand the complex relationships among ACEs, cortisol, and inflammation, which should be further examined in longitudinal studies to study biomarker trajectories.

Understanding virtual patients efficiently and rigorously by combining machine learning with dynamical modelling

Individual biological organisms are characterized by daunting heterogeneity, which precludes describing or understanding populations of ‘patients’ with a single mathematical model. Recently, the field of quantitative systems pharmacology (QSP) has adopted the notion of virtual patients (VPs) to cope with this challenge. A typical population of VPs represents the behavior of a heterogeneous patient population with a distribution of parameter values over a mathematical model of fixed structure. Though this notion of VPs is a powerful tool to describe patients’ heterogeneity, the analysis and understanding of these VPs present new challenges to systems pharmacologists. Here, using a model of the hypothalamic–pituitary–adrenal axis, we show that an integrated pipeline that combines machine learning (ML) and bifurcation analysis can be used to effectively and efficiently analyse the behaviors observed in populations of VPs. Compared with local sensitivity analyses, ML allows us to capture and analyse the contributions of simultaneous changes of multiple model parameters. Following up with bifurcation analysis, we are able to provide rigorous mechanistic insight regarding the influences of ML-identified parameters on the dynamical system’s behaviors. In this work, we illustrate the utility of this pipeline and suggest that its wider adoption will facilitate the use of VPs in the practice of systems pharmacology.

Translation of animal endocannabinoid models of PTSD mechanisms to humans: Where to next?

The endocannabinoid system is known to be involved in mechanisms relevant to PTSD aetiology and maintenance, though this understanding is mostly based on animal models of the disorder. Here we review how human paradigms can successfully translate animal findings to human subjects, with the view that substantially increased insight into the effect of endocannabinoid signalling on stress responding, emotional and intrusive memories, and fear extinction can be gained using modern paradigms and methods for assessing the state of the endocannabinoid system in PTSD.

A Modeling and Machine Learning Pipeline to Rationally Design Treatments to Restore Neuroendocrine Disorders in Heterogeneous Individuals

Heterogeneity among individual patients presents a fundamental challenge to effective treatment, since a treatment protocol working for a portion of the population often fails in others. We hypothesize that a computational pipeline integrating mathematical modeling and machine learning could be used to address this fundamental challenge and facilitate the optimization of individualized treatment protocols. We tested our hypothesis with the neuroendocrine systems controlled by the hypothalamic–pituitary–adrenal (HPA) axis. With a synergistic combination of mathematical modeling and machine learning (ML), this integrated computational pipeline could indeed efficiently reveal optimal treatment targets that significantly contribute to the effective treatment of heterogeneous individuals. What is more, the integrated pipeline also suggested quantitative information on how these key targets should be perturbed. Based on such ML revealed hints, mathematical modeling could be used to rationally design novel protocols and test their performances. We believe that this integrated computational pipeline, properly applied in combination with other computational, experimental and clinical research tools, can be used to design novel and improved treatment against a broad range of complex diseases.

Getting under the skin: Physiological stress and witnessing paternal arrest in young children with incarcerated fathers

U.S. jails see nearly 11 million annual admissions, rates that disproportionately affect men of color-more than half of whom are fathers. An estimated 7% of U.S. children experience the incarceration of a parent, increasing their risk for poor developmental and health outcomes. Although stress processes are often suggested as an underlying mechanism linking paternal incarceration to child well-being, few studies have examined such links. To study how witnessing a father's arrest prior to incarceration in jail relates to children's stress processes, we collected data on 123 individuals from 41 families with young children whose father was in jail, including collecting hair from 41 children, and analyzed their cumulative stress hormones, cortisol, and cortisone. Results indicate that children had higher cumulative stress hormone concentrations when they witnessed their father's arrest. Moreover, there was evidence of a blunted stress reaction in children who witnessed the arrest and who also had high levels of ongoing behavioral stress symptoms, similar to findings in Post-Traumatic Stress Disorder studies. Long-term exposure to stress can have deleterious effects on children's brain development, further increasing risk for developmental psychopathology. Findings have implications for criminal justice approaches that safeguard children during parental arrest.

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

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

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.

Cannabis use and posttraumatic stress disorder comorbidity: Epidemiology, biology and the potential for novel treatment approaches

Cannabis use is increasing among some demographics in the United States and is tightly linked to anxiety, trauma, and stress reactivity at the epidemiological and biological level. Stress-coping motives are highly cited reasons for cannabis use. However, with increased cannabis use comes the increased susceptibility for cannabis use disorder (CUD). Indeed, CUD is highly comorbid with posttraumatic stress disorder (PTSD). Importantly, endogenous cannabinoid signaling systems play a key role in the regulation of stress reactivity and anxiety regulation, and preclinical data suggest deficiencies in this signaling system could contribute to the development of stress-related psychopathology. Furthermore, endocannabinoid deficiency states, either pre-existing or induced by trauma exposure, could provide explanatory insights into the high rates of comorbid cannabis use in patients with PTSD. Here we review clinical and preclinical literature related to the cannabis use-PTSD comorbidity, the role of endocannabinoids in the regulation of stress reactivity, and potential therapeutic implications of recent work in this area.

Sex differences in post-traumatic stress disorder risk: autonomic control and inflammation

AIM

Over 7 million U.S. adults and about 20% of the military population have post-traumatic stress disorder (PTSD), a debilitating condition that is independently linked to a significantly greater risk of developing cardiovascular disease (CVD). Women have twice the probability of developing PTSD after experiencing a traumatic event compared to men. Existing literatures have reported higher inflammation and autonomic dysfunction including impaired baroreflex sensitivity, increased sympathetic reactivity and decreased parasympathetic activity in PTSD. However, most of these findings stem from studies conducted predominantly in males.

METHODS

We attempt in this narrative review to summarize the mixed literature available on sex differences in autonomic dysfunction and inflammation in PTSD, at rest and in response to stress in PTSD.

RESULTS

This review reveals that there is a paucity of research exploring autonomic function in females with PTSD. Recent studies have included female participants without probing for sex differences. A small number of studies have been conducted exclusively in women. Available data suggest that sympathetic nervous system output tends to be heightened, while parasympathetic activity and arterial baroreflex sensitivity appear more blunted in females with PTSD. Although few studies have investigated sex differences in inflammation in PTSD, data within females suggest chronic increases in inflammation with PTSD. This autonomic dysregulation and inflammation have also been described in males with PTSD.

CONCLUSION

In sum, given the inherent biological differences in CVD clinical presentation and characteristics between men and women, human and animal studies aiming at elucidating sex differences in the pathophysiology of PTSD are needed.

Early life stress and HPA axis function independently predict adult depressive symptoms in metropolitan Cebu, Philippines

OBJECTIVES

Alterations in adult hypothalamic-pituitary-adrenal (HPA) axis activity have increasingly been linked with early life stress and adult depression, but a limited number of studies have used longitudinal data to explore HPA axis dysregulation as an underlying mechanism driving the long-term depressive impacts of early stressors. Here we address potential long-term impacts of early life, family-based stress on depressive symptoms among young adults in a longitudinal birth cohort study begun in 1983 in the Philippines.

MATERIALS AND METHODS

We relate a composite measure of family-based stressors experienced between birth and adolescence to circadian dynamics in adult salivary cortisol and depressive risk measured at 21-22 years of age. Multiple regression analyses were conducted to examine the relationship between early life stress levels and risk of adult depressive symptoms, as well as the role of adult diurnal cortisol activity in this relationship.

RESULTS

Greater levels of early life familial stress predicted more severe depressive symptomatology at age 21-22 in a dose-response fashion (p < .0001) independent of adult diurnal cortisol patterns. Flatter diurnal cortisol slopes are directly associated with higher adult depressive symptoms, an effect mostly driven by evening cortisol levels (p = .004). When considering the cumulative effects of early life stress measures, however, exposure to more of these stressors during development is associated with even higher depressive symptoms.

DISCUSSION

The long-term depressive effects of early life familial stress extend to this large sample of Cebuano young adults, and early life stress and HPA axis function may shape adult depressive symptoms through independent pathways in this sample. Our findings provide further evidence that HPA axis activity is shaped by early life conditions and is associated with depressive symptoms.

Fingernail cortisol as a marker of chronic stress exposure in Indigenous and non-Indigenous young adults

Cumulative exposure to stress over a long period can negatively impact an individual's health. Significant advancements in biomarkers of chronic stress have been made, with the use of fingernails recently explored. Cross sectional data from the Australian Aboriginal Birth Cohort (Indigenous) and Top End Cohort (non-Indigenous) were used to investigate the associations (sociodemographic and emotional) of fingernail cortisol in Indigenous and non-Indigenous young adults. Details on sociodemographic (age, gender, and Indigenous identification), smoking and alcohol use, emotional wellbeing, and emotional stress (perceived stress and stressful events), and fingernail samples were obtained face-to-face. Fingernail samples were analyzed for 179 Indigenous and 66 non-Indigenous participants (21-28 years). Indigenous participants were subjected to higher rates of stressful events compared to non-Indigenous (Median 6.0; interquartile range (IQR) 4, 9 vs. 1.0; IQR 0, 2; p < .001). Median cortisol levels were similar between Indigenous and non-Indigenous participants (4.36 pg/mg; IQR 2.2, 10.0 vs. 3.87 pg/mg: IQR 2.0, 9.7; p = .68). However, Indigenous participants had a higher cortisol level on adjustment for emotional distress and exposure to stressful events (Geometric Mean 1.82; 95CI: 1.07-3.09), with a negative association with increasing number of stressful events (Geometric Mean 0.94; 95CI 0.90, 0.99). Collection of fingernails was an easily conducted, well-tolerated method to measure stress markers in this multicultural cohort. Indigenous young adults experienced a high number of stressful events which was associated with a lowering of fingernail cortisol levels.Lay abstractChronic stress can impact negatively on health and emotional wellbeing. A fingernail sample provided a culturally acceptable, noninvasive method of measuring chronic stress in Indigenous and non-Indigenous young adults. Cortisol levels, a marker of chronic stress, were different between Indigenous and non-Indigenous young adults and were influenced by emotional status and occurrence of multiple stressful events.

Cannabinoids as therapeutics for PTSD

Post-traumatic stress disorder (PTSD) is a complex disorder that involves dysregulation of multiple neurobiological systems. The traumatic stressor plays a causal role in producing psychological dysfunction and the pattern of findings suggests that the hypothalamic-pituitary-adrenal (HPA) axis, which is instrumental for stress adaptation, is critically dysfunctional in PTSD. Given the lack of understanding of the basic mechanisms and underlying pathways that cause the disorder and its heterogeneity, PTSD poses challenges for treatment. Targeting the endocannabinoid (ECB) system to treat mental disorders, and PTSD in particular, has been the focus of research and interest in recent years. The ECB system modulates multiple functions, and drugs enhancing ECB signaling have shown promise as potential therapeutic agents in stress effects and other psychiatric and medical conditions. In this review, we focus on the interaction between the ECB-HPA systems in animal models for PTSD and in patients with PTSD. We summarize evidence supporting the use of cannabinoids in preventing and treating PTSD in preclinical and clinical studies. As the HPA system plays a key role in the mediation of the stress response and the pathophysiology of PTSD, we describe preclinical studies suggesting that enhancing ECB signaling is consistent with decreasing PTSD symptoms and dysfunction of the HPA axis. Overall, we suggest that a pharmacological treatment targeted at one system (e.g., HPA) may not be very effective because of the heterogeneity of the disorder. There are abnormalities across different neurotransmitter systems in the pathophysiology of PTSD and none of these systems function uniformly among all patients with PTSD. Hence, conceptually, enhancing ECB signaling may be a more effective avenue for pharmacological treatment.

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.

Confederates in the Attic: Posttraumatic Stress Disorder, Cardiovascular Disease, and the Return of Soldier's Heart

Da Costa originally described Soldier's Heart in the 19th Century as a syndrome that occurred on the battlefield in soldiers of the American Civil War. Soldier's Heart involved symptoms similar to modern day posttraumatic stress disorder (PTSD) as well as exaggerated cardiovascular reactivity felt to be related to an abnormality of the heart. Interventions were appropriately focused on the cardiovascular system. With the advent of modern psychoanalysis, psychiatric symptoms became divorced from the body and were relegated to the unconscious. Later, the physiology of PTSD and other psychiatric disorders was conceived as solely residing in the brain. More recently, advances in psychosomatic medicine led to the recognition of mind-body relationships and the involvement of multiple physiological systems in the etiology of disorders, including stress, depression PTSD, and cardiovascular disease, has moved to the fore, and has renewed interest in the validity of the original model of the Soldier's Heart syndrome.

Stress, the brain, and trauma spectrum disorders

This chapter reviews the relationship between stress and brain function in patients with neuropsychiatric disorders, with an emphasis on disorders that have most clearly been linked to traumatic stress exposure. These disorders, which have been described as trauma spectrum disorders, include posttraumatic stress disorder (PTSD), a subgroup of major depression, borderline personality disorder (BPD) and dissociative disorders; they share in common a neurobiological footprint, including smaller hippocampal volume, and are distinguished from other disorders that may share symptom similarities, like some of the anxiety disorders, but are not as clearly linked to stress. The relationship between environmental events such as stressors, especially in early childhood, and their effects on brain and neurobiology is important to understand in approaching these disorders as well as the development of therapeutic interventions. Addressing patients with stress-related disorders from multiple developmental (age at onset of trauma) as well as levels of analysis (cognitive, cultural, neurobiological) approaches will provide the most complete picture and result in the most successful treatment outcomes.

Stress, cortisol and suicide risk

Suicide is a global health issue accounting for at least 800,000 deaths per annum. Numerous models have been proposed that differ in their emphasis on the role of psychological, social, psychiatric and neurobiological factors in explaining suicide risk. Central to many models is a stress-diathesis component which states that suicidal behavior is the result of an interaction between acutely stressful events and a susceptibility to suicidal behavior (a diathesis). This article presents an overview of studies that demonstrate that stress and dysregulated hypothalamic-pituitary-adrenal (HPA) axis activity, as measured by cortisol levels, are important additional risk factors for suicide. Evidence for other putative stress-related suicide risk factors including childhood trauma, impaired executive function, impulsivity and disrupted sleep are considered together with the impact of family history of suicide, perinatal and epigenetic influences on suicide risk.

Pharmacological rewriting of fear memories: A beacon for post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is a psychopathological response that develops after exposure to an extreme life-threatening traumatic event. Its prevalence ranges from 0.5% to 14.5% worldwide. Due to the complex pathophysiology of PTSD, currently available treatment approaches are associated with high chances of failure, thus further research to identify better pharmacotherapeutic approaches is needed. The traumatic event associated with fear memories plays an important role in the development of PTSD and could be considered as the main culprit. PTSD patient feels frightened in a safe environment as the memories of the traumatic event are revisited. Neurocircuit involving normal processing of fear memories get disturbed in PTSD hence making a fear memory to remain to dominate even after years of trauma. Persistence of fear memories could be explained by acquisition, re-(consolidation) and extinction triad as all of these processes have been widely explored in preclinical as well as clinical studies and set a therapeutic platform for fear memory associated disorders. This review focuses on neurocircuit and pathophysiology of PTSD in context to fear memories and pharmacological targeting of fear memory for the management of PTSD.

Cortisol, moderated by age, is associated with antidepressant treatment outcome and memory improvement in Major Depressive Disorder: A retrospective analysis

BACKGROUND

Studies testing the relationship between cortisol levels, depression, and antidepressant treatment response have yielded divergent results suggesting the possibility of moderators of a cortisol effect. Several studies indicate that age may moderate the relationship between cortisol and depression. In patients with Major Depressive Disorder (MDD), we studied the interactive effects of age and cortisol in association with MDD diagnostic status and mood and memory response to antidepressant treatment.

METHODS

Serum cortisol levels in 66 unmedicated patients with MDD and 75 matched healthy controls (HC) were measured at baseline and retrospectively analyzed. Logistic regression was used to determine an association of age, cortisol and their interaction with MDD diagnosis in the pooled sample of MDD and HC participants. Thirty-four of the MDD participants (age range: 19-65 years; median: 36) underwent treatment with a selective serotonin reuptake inhibitor (SSRl) for 8 weeks. Clinician and self-ratings of depression symptoms, as well as tests of verbal and visual delayed recall were obtained at baseline and post treatment. Moderation analyses determined the effect of age on the relationship between baseline cortisol and treatment outcome.

RESULTS

Cortisol, moderated by age, was associated with MDD diagnosis (p < .05), treatment-associated reduction of depression symptoms (p < .001) and improvement of delayed recall (p < .001). Modeling the Cortisol × Age interaction suggested that for participants below the median age of our sample, lower cortisol levels were associated with a lower rate of MDD diagnosis and higher antidepressant effects. On the contrary, in those above the median sample age, lower cortisol was associated with a higher rate of MDD and less improvement in depression symptoms and memory performance.

CONCLUSIONS

Our results add to the body of literature suggesting that age might be an important factor in moderating the relationship between peripheral cortisol levels, depression, cognition, and prognosis. These results indicate that previous disparities in the literature linking peripheral cortisol levels with depression characteristics and treatment response may critically relate, at least in part, to the age of the participants studied.

In vivo evidence for dysregulation of mGluR5 as a biomarker of suicidal ideation

Recent evidence implicates dysregulation of metabotropic glutamatergic receptor 5 (mGluR5) in pathophysiology of PTSD and suicidality. Using positron emission tomography and [18F]FPEB, we quantified mGluR5 availability in vivo in individuals with PTSD (n = 29) and MDD (n = 29) as a function of suicidal ideation (SI) to compare with that of healthy comparison controls (HC; n = 29). Volume of distribution was computed using a venous input function in the five key frontal and limbic brain regions. We observed significantly higher mGluR5 availability in PTSD compared with HC individuals in all regions of interest (P's = 0.001-0.01) and compared with MDD individuals in three regions (P's = 0.007). mGluR5 availability was not significantly different between MDD and HC individuals (P = 0.17). Importantly, we observed an up-regulation in mGluR5 availability in the PTSD-SI group (P's = 0.001-0.007) compared with PTSD individuals without SI. Findings point to the potential role for mGluR5 as a target for intervention and, potentially, suicide risk management in PTSD.

Hair cortisol and cortisone as markers of stress in Indigenous and non-Indigenous young adults

Chronic, ongoing stress can impact negatively on health and wellbeing. Indigenous Australians are at an increased risk of experiencing multiple stressors. Hair glucocorticoids have been used as a marker for chronic stress. This study aimed to assess the associations of hair cortisol and cortisone with sociodemographic (age, gender, Indigenous Identification), substance use, emotional wellbeing, and emotional stress, in a cohort at increased risk of stressful events and psychological distress. Cross-sectional data (age 21-28 years) are presented from two Australian longitudinal studies; the Aboriginal Birth Cohort (n = 253) and non-Indigenous Top End Cohort (n = 72). A third of the cohort reported psychological distress, with Indigenous participants reporting higher rates of stressful events compared to non-Indigenous (6 vs. 1; p < .001). Significantly higher levels of cortisone were seen in Indigenous women compared to non-Indigenous women (β 0.21; p = .003). A positive association with age was present in hair cortisol and cortisone in Indigenous young adults (β 0.29 and β 0.41; p < .001, respectively). No association with substance use, emotional wellbeing or emotional stress was seen. Sub-analysis in women suggested a possible curvilinear relationship between hair cortisone and the number of stressful events. In this culturally diverse cohort, hair sampling provides a noninvasive, easily conducted and generally well tolerated mechanism to measure stress markers. The association with age, even in this narrow age range, likely represents the manifold changes in circumstances (financial independence, becoming parents, increased risk of substance use and mental illness) that occur during this transitional period of life, particularly for young Indigenous women. LAY ABSTRACT Chronic stress can impact negatively on health and emotional wellbeing. A hair sample is an easy way to measure chronic stress in Indigenous and non-Indigenous young people. The markers of chronic stress, cortisol and cortisone, were different between Indigenous and non-Indigenous, men and women and increased with age in Indigenous young adults.

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.

Intergenerational transmission of trauma effects: putative role of epigenetic mechanisms

This paper reviews the research evidence concerning the intergenerational transmission of trauma effects and the possible role of epigenetic mechanisms in this transmission. Two broad categories of epigenetically mediated effects are highlighted. The first involves developmentally programmed effects. These can result from the influence of the offspring's early environmental exposures, including postnatal maternal care as well as in utero exposure reflecting maternal stress during pregnancy. The second includes epigenetic changes associated with a preconception trauma in parents that may affect the germline, and impact fetoplacental interactions. Several factors, such as sex-specific epigenetic effects following trauma exposure and parental developmental stage at the time of exposure, explain different effects of maternal and paternal trauma. The most compelling work to date has been done in animal models, where the opportunity for controlled designs enables clear interpretations of transmissible effects. Given the paucity of human studies and the methodological challenges in conducting such studies, it is not possible to attribute intergenerational effects in humans to a single set of biological or other determinants at this time. Elucidating the role of epigenetic mechanisms in intergenerational effects through prospective, multi-generational studies may ultimately yield a cogent understanding of how individual, cultural and societal experiences permeate our biology.

Cultural trauma and epigenetic inheritance

The question of whether and how the effects of cultural trauma can be transmitted intergenerationally from parents to offspring, or even to later generations, has evoked interest and controversy in academic and popular forums. Recent methodological advances have spurred investigations of potential epigenetic mechanisms for this inheritance, representing an exciting area of emergent research. Epigenetics has been described as the means through which environmental influences “get under the skin,” directing transcriptional activity and influencing the expression or suppression of genes. Over the past decade, this complex environment–biology interface has shown increasing promise as a potential pathway for the intergenerational transmission of the effects of trauma. This article reviews challenges facing research on cultural trauma, biological findings in trauma and posttraumatic stress disorder, and putative epigenetic mechanisms for transmission of trauma effects, including through social, intrauterine, and gametic pathways. Implications for transmission of cultural trauma effects are discussed, focused on the relevance of cultural narratives and the possibilities of resilience and adaptivity.

The public reception of putative epigenetic mechanisms in the transgenerational effects of trauma

There has been great interest in the possibility that effects of trauma might be passed from parent to offspring through epigenetic mechanisms. This topic has stimulated discussion and controversy in the scientific literature, the popular press, and culture at large. This article describes the initial observations that have led to recent examinations of epigenetic mechanisms in association with effects of parental trauma exposure on offspring. Epigenetic research in animals has provided models for how such effects might be transmitted. However, the attribution of any specific epigenetic mechanisms in human studies of offspring of trauma survivors is premature at this time. The article describes some of the ways in which initial epigenetic findings in the offspring of trauma survivors have been represented in the popular media. Reports have ranged from overly simplistic and sensationalistic claims to global dismissals. The authors discuss the importance of clarity in language when describing epigenetic findings for lay audiences, the need to emphasize the limitations as well as the promise of research on intergenerational transmission of trauma effects, and the importance of countering popular interpretations that imply a reductionist biological determinism. Scientists have an obligation to assist in translating important research findings and nascent avenues of research to the public. It is important to recognize the ways in which this research may unintentionally be received as supporting a narrative of permanent and significant damage in offspring, rather than contributing to discussions of potential resilience, adaptability, and mutability in biological systems affected by stress.

Post-Traumatic Stress Disorder Delineating the Progression and Underlying Mechanisms Following Blast Traumatic Brain Injury

Posttraumatic Stress Disorder (PTSD) is a devastating condition that can develop after blast Traumatic Brain Injury (TBI). Ongoing work has been performed to understand how PTSD develops after injury. In this review, we highlight how PTSD affects individuals, discuss what is known about the physiologic changes to the hypothalamic pituitary axis and neurotransmitter pathways, and present an overview of genetic components that may predispose individuals to developing PTSD. We then provide an overview of current treatment strategies to treat PTSD in veterans and present new strategies that may be useful going forward. The need for further clinical and pre-clinical studies is imperative to improve diagnosis, treatment, and management for patients that develop PTSD following blast TBI.

Perturbing the Hypothalamic-Pituitary-Adrenal Axis: A Mathematical Model for Interpreting PTSD Assessment Tests

We use a dynamical systems model of the hypothalamic-pituitary-adrenal (HPA) axis to understand the mechanisms underlying clinical protocols used to probe patient stress response. Specifically, we address dexamethasone (DEX) and ACTH challenge tests, which probe pituitary and adrenal gland responses, respectively. We show that some previously observed features and experimental responses can arise from a bistable mathematical model containing two steady-states, rather than relying on specific and permanent parameter changes due to physiological disruption. Moreover, we show that the timing of a perturbation relative to the intrinsic oscillation of the HPA axis can affect challenge test responses. Conventional mechanistic hypotheses supported and refuted by the challenge tests are reexamined by varying parameters in our mathematical model associated with these hypotheses. We show that (a) adrenal hyposensitivity can give rise to the responses seen in ACTH challenge tests and (b) enhanced cortisol-mediated suppression of the pituitary in subjects with PTSD is not necessary to explain the responses observed in DEX stress tests. We propose a new two-stage DEX/external stressor protocol to more clearly distinguish between the conventional hypothesis of enhanced suppression of the pituitary and bistable dynamics hypothesized in our model.

Association between memory impairment and brain metabolite concentrations in North Korean refugees with posttraumatic stress disorder

Individuals with posttraumatic stress disorder (PTSD) had experiences of enormous psychological stress that can result in neurocognitive and neurochemical changes. To date, the causal relationship between them remains unclear. The present study is to investigate the association between neurocognitive characteristics and neural metabolite concentrations in North Korean refugees with PTSD. A total of 53 North Korean refugees with or without PTSD underwent neurocognitive function tests. For neural metabolite scanning, magnetic resonance spectroscopy of the hippocampus and anterior cingulate cortex (ACC) has been conducted. We assessed between-group differences in neurocognitive test scores and metabolite levels. Additionally, a multiple regression analysis was carried out to evaluate the association between neurocognitive function and metabolite levels in patients with PTSD. Memory function, but not other neurocognitive functions, was significantly lower in the PTSD group compared with the non-PTSD group. Hippocampal N-acetylaspartate (NAA) levels were not different between groups; however, NAA levels were significantly lower in the ACC of the PTSD group than the non-PTSD group (t = 2.424, p = 0.019). The multiple regression analysis showed a negative association between hippocampal NAA levels and delayed recall score on the auditory verbal learning test (β = -1.744, p = 0.011) in the non-PTSD group, but not in the PTSD group. We identified specific memory impairment and the role of NAA levels in PTSD. Our findings suggest that hippocampal NAA has a protective role in memory impairment and development of PTSD after exposure to traumatic events.

The role of Rajyoga meditation for modulation of anxiety and serum cortisol in patients undergoing coronary artery bypass surgery: A prospective randomized control study

Introduction:

Rajyoga meditation is a form of mind body intervention that is promoted by the Brahma Kumaris World Spiritual University. This form of meditation can be easily performed without rituals or mantras and can be practiced anywhere at any time. The practice of Rajyoga meditation can have beneficial effects on modulating anxiety and cortisol level in patients undergoing major cardiac surgery.

Materials and Methods:

A prospective randomized control study was carried out in a single tertiary care center. One hundred and fifty patients undergoing elective coronary artery bypass surgery were enrolled in the study. The patients were randomized in two groups namely, Group 1 (Rajyoga group) and Group 2 (Control Group). Anxiety was measured on a visual analog scale 1–10 before the start of Rajyoga training or patient counseling (T1), on the morning of the day of surgery (T2), on the 2^nd postoperative day (T3), and on the 5^th postoperative day (T4). The serum cortisol level was measured in the morning of the day of surgery (T1), on the 2^nd postoperative day (T2) and on the 5^th postoperative day (T3), respectively.

Results:

In the study, it was seen that the anxiety level of the patients before the surgery (T₁) and on the day of surgery (T₂) were comparable between the two groups. However on the 2^nd postoperative day (T₃), the patients who underwent Rajyoga training had lower anxiety level in comparison to the control group (3.12 ± 1.45 vs. 6.12 ± 0.14, P < 0.05) and on the 5^th postoperative day (T₄) it was seen that Rajyoga practice had resulted in significant decline in anxiety level (0.69 ± 1.1 vs. 5.6 ± 1.38, P < 0.05). The serum cortisol level was also favorably modulated by the practice of Rajyoga meditation.

Conclusion:

Mindbody intervention is found to effective in reducing the anxiety of the patients and modulating the cortisol level in patients undergoing wellknown stressful surgery like coronary artery bypass surgery.

Positive parenting predicts cortisol functioning six years later in young adults

Research which indicates that adverse experiences influence hypothalamic-pituitary-adrenal (HPA) axis functioning illustrates the social environment 'getting under the skin'. The present study extended this literature by examining whether positive social forces within the caregiving environment can also impact cortisol functioning. We conducted a prospective investigation of over 300 youth, half of whom were White and half were Black. Attachment, bonding and parental rewards for positive behaviors were observed or reported by the youth as an 8th grader. Twelve repeated measures of salivary cortisol were examined six years later when youth were young adults (mean age 20). Race differences were explored. Stronger attachment, bonding and teen-reported positive parenting were predictive of high waking cortisol and steeper diurnal slopes six years later. This effect was nonlinear and additive, such that youth whose social contexts were characterized by the strongest attachment, bonding and rewarding parental relationships had the highest waking cortisol. When effects were moderated by race, findings were such that links of positive parenting with HPA functioning were more consistent for White than Black youth. Findings suggest that positive aspects of the caregiving environment can also 'get under the skin' and these effects are additive across a range of caregiving indices. These findings dovetail with an emerging literature on the powerful role of social support for shaping the body's stress response system and are interpreted as consistent with the Adaptive Calibration Model which suggests that cortisol regulation can have adaptive significance. A video abstract of this article can be viewed at: https://youtu.be/8evHXpt_TXM.

Context Processing and the Neurobiology of Post-Traumatic Stress Disorder

Progress in clinical and affective neuroscience is redefining psychiatric illness as symptomatic expression of cellular/molecular dysfunctions in specific brain circuits. Post-traumatic stress disorder (PTSD) has been an exemplar of this progress, with improved understanding of neurobiological systems subserving fear learning, salience detection, and emotion regulation explaining much of its phenomenology and neurobiology. However, many features remain unexplained and a parsimonious model that more fully accounts for symptoms and the core neurobiology remains elusive. Contextual processing is a key modulatory function of hippocampal-prefrontal-thalamic circuitry, allowing organisms to disambiguate cues and derive situation-specific meaning from the world. We propose that dysregulation within this context-processing circuit is at the core of PTSD pathophysiology, accounting for much of its phenomenology and most of its biological findings. Understanding core mechanisms like this, and their underlying neural circuits, will sharpen diagnostic precision and understanding of risk factors, enhancing our ability to develop preventive and "personalized" interventions.

Altered metabotropic glutamate receptor 5 markers in PTSD: In vivo and postmortem evidence

Posttraumatic stress disorder (PTSD) is a prevalent and highly disabling disorder, but there is currently no targeted pharmacological treatment for it. Dysfunction of the glutamate system has been implicated in trauma and stress psychopathology, resulting in a growing interest in modulation of the glutamate system for the treatment of PTSD. Specifically, the metabotropic glutamate receptor 5 (mGluR5) represents a promising treatment target. We used [¹⁸F]FPEB, a radioligand that binds to the mGluR5, and positron emission tomography (PET) to quantify in vivo mGluR5 availability in human PTSD vs. healthy control (HCs) subjects. In an independent sample of human postmortem tissue, we investigated expression of proteins that have a functional relationship with mGluR5 and glucocorticoids in PTSD. We observed significantly higher cortical mGluR5 availability in PTSD in vivo and positive correlations between mGluR5 availability and avoidance symptoms. In the postmortem sample, we observed up-regulation of SHANK1, a protein that anchors mGluR5 to the cell surface, as well as decreased expression of FKBP5, implicating aberrant glucocorticoid functioning in PTSD. Results of this study provide insight into molecular mechanisms underlying PTSD and suggest that mGluR5 may be a promising target for mechanism-based treatments aimed at mitigating this disorder.

The Impact of Complicated Grief on Diurnal Cortisol Levels Two Years After Loss: A Population-Based Study

OBJECTIVE

Few studies have focused on the effect of complicated grief-unresolved and prolonged grief-on the neuroendocrine systems. The present study examined the association of complicated grief and normal grief with the diurnal cortisol patterns in a large population-based study.

METHODS

This study was set in the Rotterdam Study and comprised 2084 persons aged older than 55 years (mean [SD] age, 64.9 [5.5] years). Participants were assessed with the Complicated Grief Inventory and classified into no grief (n = 1922), normal grief (n = 131), or complicated grief (n = 31) if they experienced the loss in the past 2 years. Saliva samples were collected to measure cortisol levels. Morning cortisol and summary measures (area under the curve and the slope) were studied to account for the diurnal pattern of cortisol. Persons with depressive disorders were excluded, and analyses were additionally adjusted for depressive symptoms.

RESULTS

Compared to normal grievers, participants with complicated grief showed lower levels of morning cortisol (11.26 vs 15.51 nmol/L; difference, -4.24; 95% confidence interval [CI] = -7.87 to -0.62; p = .022), and lower levels of overall diurnal cortisol (6.89 vs 8.98 nmol/L; difference, -2.09; 95% CI = -3.81 to -0.37; p = .017). No difference was observed in slope between both groups. Participants with complicated grief also showed lower levels of morning cortisol than the nongrievers (11.26 vs 14.71; difference, -3.46; 95% CI = -6.78 to -0.13; p = .042). In contrast, cortisol secretion patterns did not differ between persons with normal grief and nongrieving controls.

CONCLUSIONS

Participants with complicated grief showed low levels of morning cortisol and low overall diurnal cortisol levels characteristic for a chronic stress reaction.

Biological markers for anxiety disorders, OCD and PTSD: A consensus statement. Part II: Neurochemistry, neurophysiology and neurocognition

OBJECTIVE

Biomarkers are defined as anatomical, biochemical or physiological traits that are specific to certain disorders or syndromes. The objective of this paper is to summarise the current knowledge of biomarkers for anxiety disorders, obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD).

METHODS

Findings in biomarker research were reviewed by a task force of international experts in the field, consisting of members of the World Federation of Societies for Biological Psychiatry Task Force on Biological Markers and of the European College of Neuropsychopharmacology Anxiety Disorders Research Network.

RESULTS

The present article (Part II) summarises findings on potential biomarkers in neurochemistry (neurotransmitters such as serotonin, norepinephrine, dopamine or GABA, neuropeptides such as cholecystokinin, neurokinins, atrial natriuretic peptide, or oxytocin, the HPA axis, neurotrophic factors such as NGF and BDNF, immunology and CO2 hypersensitivity), neurophysiology (EEG, heart rate variability) and neurocognition. The accompanying paper (Part I) focuses on neuroimaging and genetics.

CONCLUSIONS

Although at present, none of the putative biomarkers is sufficient and specific as a diagnostic tool, an abundance of high quality research has accumulated that should improve our understanding of the neurobiological causes of anxiety disorders, OCD and PTSD.

The role of glucocorticoids and corticotropin-releasing hormone regulation on anxiety symptoms and response to treatment

The stress response has been linked to the expression of anxiety and depression, but the mechanisms for these connections are under continued consideration. The activation and expression of glucocorticoids and CRH are variable and may hold important clues to individual experiences of mood disorders. This paper explores the interactions of glucocorticoids and CRH in the presentation of anxiety and depressive disorders in an effort to better describe their differing roles in each of these clinical presentations. In addition, it focuses on ways in which extra-hypothalamic glucocorticoids and CRH, often overlooked, may play important roles in the presentation of clinical disorders.

Characteristics of objective daytime sleep among individuals with earthquake-related posttraumatic stress disorder: A pilot community-based polysomnographic and multiple sleep latency test study

Little is known about the objective sleep characteristics of patients with posttraumatic stress disorder (PTSD). The present study examines the association between PTSD symptom severity and objective daytime sleep characteristics measured using the Multiple Sleep Latency Test (MSLT) in therapy-naïve patients with earthquake-related PTSD. A total of 23 PTSD patients and 13 trauma-exposed non-PTSD (TEN-PTSD) subjects completed one-night in-lab polysomnography (PSG) followed by a standard MSLT. 8 of the 23 PTSD patients received paroxetine treatment. Compared to the TEN-PTSD subjects, no significant nighttime sleep disturbances were detected by PSG in the subjects with PTSD; however, a shorter mean MSLT value was found in the subjects with PTSD. After adjustment for age, sex, and body mass index, PTSD symptoms, particularly hyperarousal, were found to be independently associated with a shorter MSLT value. Further, the mean MSLT value increased significantly after therapy in PTSD subjects. A shorter MSLT value may be a reliable index of the medical severity of PTSD, while an improvement in MSLT values might also be a reliable marker for evaluating therapeutic efficacy in PTSD patients.

Salivary Cortisol and Regional Brain Volumes Among Veterans With and Without Posttraumatic Stress Disorder

BACKGROUND

Human studies have often found that brain regions rich in glucocorticoid receptors exhibit smaller volume in samples with past trauma and ongoing stress; however, relatively little research has addressed the hypothesis that such smaller volumes can be traced to elevated circulating glucocorticoid hormones (GCs). This issue takes on renewed interest in light of recent proposals to treat symptoms of stress disorders such as posttraumatic stress disorder (PTSD) with exogenous synthetic GCs. We sought to examine the relation of circulating GCs to brain macrostructure among veterans with and without PTSD.

METHODS

Participants (n = 90) included combat veterans with and without PTSD. Veterans completed self-report surveys, home-based cortisol samples, reactive cortisol samples over the course of two serial Trier Social Stress Tests, a low-dose dexamethasone suppression test, and structural magnetic resonance brain imaging over the course of 3 to 5 days.

RESULTS

No associations were observed between any salivary cortisol index and the volumes of the hippocampus or amygdala. A negative association was observed between evening basal cortisol and both FreeSurfer global volume and BrainImage supratentorial tissue volume. This effect was moderated by PTSD. Also observed was a positive association between reactive cortisol and these same brain volumes.

CONCLUSIONS

Estimates of cortical but not hippocampal or amygdala volume were moderately associated with evening basal salivary cortisol and cortisol reactivity to a social stressor. Existing models relating GC receptor density, circulating cortisol levels, and regional brain volumes received little support.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Borderline and cluster C personality disorders manifest distinct physiological responses to psychosocial stress

BACKGROUND

Maladaptive emotional control is a defining feature of personality disorders. Yet little is known about the underlying physiological dynamics of emotional reactivity to psychosocial stress across distinct personality disorders. The current study compared subjective emotional responses with autonomic nervous system and HPA axis physiological responses to psychosocial stress in women with cluster C personality disorder (CPD) and borderline personality disorder (BPD).

METHODS

Subjective mood ratings, salivary cortisol, heart rate (HR), and skin conductance level (SCL) were assessed before, during, and after exposure to a standardized psychosocial stress paradigm (Trier Social Stress Test, TSST) in 26 women with BPD, 20 women with CPD, and 35 healthy female controls. Subjects were free of any medication including hormonal contraceptives, had a regular menstrual cycle, and were tested during the luteal phase of their menstrual cycle.

RESULTS

Both CPD and BPD patients reported a similar burden of subjective mood disturbance. However, only BPD patients demonstrated reduced baseline cortisol levels with a blunted cortisol and HR reactivity to the TSST. In addition, BPD patients exhibited a generalized increase of SCL. No significant differences in baseline or TSST reactivity of cortisol, HR, or SCL were observed between CPD patients and healthy controls.

CONCLUSION

These findings indicate that patients with BPD have significant alterations in their physiological stress reactivity, which is notably distinct from patients with CPD and those of healthy controls.

The Medicine Wheel

Accidents, violence, and certain chronic diseases kill American Indians greatly out of proportion to other racial groups. Complex interactions between previously adaptive survival mechanisms, historical and cultural factors, and U.S. policy must be understood to respond effectively to these health issues. The traditional medicine wheel provides a conceptual framework that is culturally grounded and also supported by solid scientific research. Research related to complex neuroendocrine and behavioral responses to the stressors of life provides a basis for effective treatment programs for American Indians.