Advances in Understanding Neuroendocrine Alterations in PTSD and Their Therapeutic Implications

Psychotic and Somatic Symptoms Are Frequent in Refugees With Posttraumatic Stress Disorder: A Narrative Review

OBJECTIVE

In 2021, 89.3 million refugees were vulnerable to posttraumatic stress disorder (PTSD) after exposure to multiple and repeated traumatic experiences. The recent war in Ukraine provoked 7 million refugees to flee their homes. Specific clinical presentations of PTSD in refugee populations may not be familiar to most physicians. The goal of this review is to describe the diagnosis and specific clinical features of PTSD in refugees.

METHODS

This narrative review of 263 articles explores 3 PTSD diagnoses that are frequently described in refugee populations and that have been observed in our clinical practices: complex PTSD, PTSD with psychotic symptoms, and PTSD with somatic symptoms.

RESULTS

While complex PTSD does not seem to be related to individuals' culture and origin, the other 2 diagnoses have been specifically described in refugee populations. PTSD with somatic manifestations appears to be the most frequently described and commonly acknowledged form in refugee populations, whereas PTSD with psychotic symptoms remains more controversial due to its clinical variability and association with comorbid disorders.

CONCLUSIONS

The difficulty of identifying PTSD with psychotic symptoms and PTSD with somatic symptoms in refugee populations may lead to misdiagnosis and explain the moderate effectiveness of care delivered to these populations. Appropriate diagnosis is essential to provide optimal psychiatric care to refugee populations.

Post-Traumatic Stress Disorder/Developmental Trauma Disorder/Complex Post-Traumatic Stress Disorder and Complementary and Integrative Medicine/Functional Medicine

Response to PTSD treatments differ based on the age the abuse occurred, the type of abuse, and the chronicity of the abuse. Even when modifications to treatment are made based on the developmental age when the abuse occurred, therapies may be insufficient. In addition, when diagnostic criteria are modified to identify more children, some children continue to escape detection. Developmental Trauma Disorder, (akin to the RDoC), may be more suitable to identify epigenetic and inflammatory effects of early abuse that may be responsible for the nonresponsive to treatment. Complementary and Integrative Medicine interventions (meditation, EFT, EMDR, PUFAs, etc.) may reverse these effects.

Psychological and biological mechanisms linking trauma with cardiovascular disease risk

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide, and experiences of psychological trauma have been associated with subsequent CVD onset. Identifying key pathways connecting trauma with CVD has the potential to inform more targeted screening and intervention efforts to offset elevated cardiovascular risk. In this narrative review, we summarize the evidence for key psychological and biological mechanisms linking experiences of trauma with CVD risk. Additionally, we describe various methodologies for measuring these mechanisms in an effort to inform future research related to potential pathways. With regard to mechanisms involving posttraumatic psychopathology, the vast majority of research on psychological distress after trauma and CVD has focused on posttraumatic stress disorder (PTSD), even though posttraumatic psychopathology can manifest in other ways as well. Substantial evidence suggests that PTSD predicts the onset of a range of cardiovascular outcomes in trauma-exposed men and women, yet more research is needed to better understand posttraumatic psychopathology more comprehensively and how it may relate to CVD. Further, dysregulation of numerous biological systems may occur after trauma and in the presence of posttraumatic psychopathology; these processes of immune system dysregulation and elevated inflammation, oxidative stress, mitochondrial dysfunction, renin-angiotensin system dysregulation, and accelerated biological aging may all contribute to subsequent cardiovascular risk, although more research on these pathways in the context of traumatic stress is needed. Given that many of these mechanisms are closely intertwined, future research using a systems biology approach may prove fruitful for elucidating how processes unfold to contribute to CVD after trauma.

The dynorphin/kappa opioid receptor mediates adverse immunological and behavioral outcomes induced by repetitive blast trauma

BACKGROUND

Adverse pathophysiological and behavioral outcomes related to mild traumatic brain injury (mTBI), posttraumatic stress disorder (PTSD), and chronic pain are common following blast exposure and contribute to decreased quality of life, but underlying mechanisms and prophylactic/treatment options remain limited. The dynorphin/kappa opioid receptor (KOR) system helps regulate behavioral and inflammatory responses to stress and injury; however, it has yet to be investigated as a potential mechanism in either humans or animals exposed to blast. We hypothesized that blast-induced KOR activation mediates adverse outcomes related to inflammation and affective behavioral response.

METHODS

C57Bl/6 adult male mice were singly or repeatedly exposed to either sham (anesthesia only) or blast delivered by a pneumatic shock tube. The selective KOR antagonist norBNI or vehicle (saline) was administered 72 h prior to repetitive blast or sham exposure. Serum and brain were collected 10 min or 4 h post-exposure for dynorphin A-like immunoreactivity and cytokine measurements, respectively. At 1-month post-exposure, mice were tested in a series of behavioral assays related to adverse outcomes reported by humans with blast trauma.

RESULTS

Repetitive but not single blast exposure resulted in increased brain dynorphin A-like immunoreactivity. norBNI pretreatment blocked or significantly reduced blast-induced increase in serum and brain cytokines, including IL-6, at 4 h post exposure and aversive/anxiety-like behavioral dysfunction at 1-month post-exposure.

CONCLUSIONS

Our findings demonstrate a previously unreported role for the dynorphin/KOR system as a mediator of biochemical and behavioral dysfunction following repetitive blast exposure and highlight this system as a potential prophylactic/therapeutic treatment target.

Posttraumatic Stress Disorder (PTSD) and Instigation of Cardiovascular Events: Ischemic Heart Disease (IHD) and Atrial Fibrillation (AF)

Posttraumatic stress disorder (PTSD) is a disorder with chronic deterioration that arises after exposure to traumatic events. In these events, a persistent maladaptive reaction was found as a result of severe psychological stress and trauma. It is usually accompanied by mood alteration, disturbing memories, evading behavior, and hyperarousal. Many studies found a connection between PTSD and both ischemic heart disease (IHD) and atrial fibrillation (AF). Impairment of the hypothalamic-pituitary-adrenal axis and sympathetic nervous system can contribute to hypercoagulability, elevated cardiac reactivity, hypertension, dyslipidemia, and chronic inflammation, as all of these processes are implicated in IHD and AF risk. PTSD tends to have a more long-term course and is associated with more autonomic reactivity rather than a direct negative impact. More research is needed to understand the mechanisms underlying the increased AF risk in patients with PTSD and to identify supposed objectives for screening, intervention, and treatment. Highlighting the connection between PTSD and cardiovascular events would lead clinicians to develop screening tests that might help with the prevention and treatment of cardiovascular events for these patients.

Invisible wounds: Suturing the gap between the neurobiology, conventional and emerging therapies for posttraumatic stress disorder

A sharp increase in the prevalence of neuropsychiatric disorders, including major depression, anxiety, substance use disorders and posttraumatic stress disorder (PTSD) has occurred due to the traumatic nature of the persisting COVID-19 global pandemic. PTSD is estimated to occur in up to 25% of individuals following exposure to acute or chronic trauma, and the pandemic has inflicted both forms of trauma on much of the population through both direct physiological attack as well as an inherent upheaval to our sense of safety. However, despite significant advances in our ability to define and apprehend the effects of traumatic events, the neurobiology and neuroanatomical circuitry of PTSD, one of the most severe consequences of traumatic exposure, remains poorly understood. Furthermore, the current psychotherapies or pharmacological options for treatment have limited efficacy, durability, and low adherence rates. Consequently, there is a great need to better understand the neurobiology and neuroanatomy of PTSD and develop novel therapies that extend beyond the current limited treatments. This review summarizes the neurobiological and neuroanatomical underpinnings of PTSD and discusses the conventional and emerging psychotherapies, pharmacological and combined psychopharmacological therapies, including the use of psychedelic-assisted psychotherapies and neuromodulatory interventions, for the improved treatment of PTSD and the potential for their wider applications in other neuropsychiatric disorders resulting from traumatic exposure.

Involvement of Nuclear Factor-κB in Inflammation and Neuronal Plasticity Associated with Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a debilitating psychiatric condition which develops either due to stress or witnessing a traumatic situation. PTSD is characterized by acute and chronic stress response exhibit anxiety, fear, and an increased inflammatory etiology. Inflammation contributes a critical role in several parts of the brain that control fear and flashback cognatic function. It is known that impairment of the neurological circuit leads to the development of PTSD. Evidence has suggested that dysregulation of the sympathetic nervous system and hypothalamic-pituitary adrenal (HPA) axis and inflammatory responsiveness are pivotal and a greater risk in PTSD. NF-κB, a master regulator for inflammation, has been showed to modulate memory reconsolidation and synaptic plasticity; however, NF-κB’s association with PTSD remain elusive. In this review, we provide relevant findings regarding NF-κB activity in various components of brain and describe a potential mechanism linking PTSD using preclinical and clinical models. We envisage NF-κB signaling as a crucial mediator for inflammation, cognitive function, memory restoration and behavioral actions of stress and suggest that it could be used for therapeutic intervention in PTSD.

Probing Neuro-Endocrine Interactions Through Remote Magnetothermal Adrenal Stimulation

Exposure to stressful or traumatic stimuli may alter hypothalamic-pituitary-adrenal (HPA) axis and sympathoadrenal-medullary (SAM) reactivity. This altered reactivity may be a component or cause of mental illnesses. Dissecting these mechanisms requires tools to reliably probe HPA and SAM function, particularly the adrenal component, with temporal precision. We previously demonstrated magnetic nanoparticle (MNP) technology to remotely trigger adrenal hormone release by activating thermally sensitive ion channels. Here, we applied adrenal magnetothermal stimulation to probe stress-induced HPA axis and SAM changes. MNP and control nanoparticles were injected into the adrenal glands of outbred rats subjected to a tone-shock conditioning/extinction/recall paradigm. We measured MNP-triggered adrenal release before and after conditioning through physiologic (heart rate) and serum (epinephrine, corticosterone) markers. Aversive conditioning altered adrenal function, reducing corticosterone and blunting heart rate increases post-conditioning. MNP-based organ stimulation provides a novel approach to probing the function of SAM, HPA, and other neuro-endocrine axes and could help elucidate changes across stress and disease models.

Resilience, Trauma, and Coping

The study and use of resilience is of the utmost importance to psychodynamic psychiatry. It is deeply ingrained in ideas about well-being and the treatment and care of patients. However, its neurobiology is incompletely understood, its terminology and relation to trauma and coping not well defined, and its efficacy underutilized in clinical practice. This article reviews the scientific literature on resilience, especially as it relates to trauma and coping. It also attempts to point the way for its greater application in psychiatry and mental health by utilizing resilience in more informed and individualized approaches.

Suicide: Allostatic regulation and resilience

Suicide is a complex public health problem that is the result of a number of intertwined biopsychosocial factors. The diathesis-stress model suggests that suicide is the result of an interaction between genetic vulnerability and environmental stressors. Chronic stress and trauma contribute to biologic adaptations, including hypothalamus-pituitary-adrenal axis dysregulation, that contribute to the degradation of regulatory mechanisms and promote wear and tear the body, represented by allostatic load (AL). AL has been associated with a number of negative outcomes, including mental health problems and suicide. Fortunately, there are pharmacological and non-pharmacological interventions that are effective at reducing AL and reversing its effects. Thus, AL may provide a construct for supporting early risk identification, prevention, and treatment of suicide. AL biomarkers that are amenable to measurable change, effective treatments to reduce AL and perhaps help prevent suicide, and how to best tailor them to the individual and societal levels are important avenues of therapeutic inquiry.

Diverse therapeutic developments for post-traumatic stress disorder (PTSD) indicate common mechanisms of memory modulation

Post-traumatic stress disorder (PTSD), characterized by abnormally persistent and distressing memories, is a chronic debilitating condition in need of new treatment options. Current treatment guidelines recommend psychotherapy as first line management with only two drugs, sertraline and paroxetine, approved by U.S. Food and Drug Administration (FDA) for treatment of PTSD. These drugs have limited efficacy as they only reduce symptoms related to depression and anxiety without producing permanent remission. PTSD remains a significant public health problem with high morbidity and mortality requiring major advances in therapeutics. Early evidence has emerged for the beneficial effects of psychedelics particularly in combination with psychotherapy for management of PTSD, including psilocybin, MDMA, LSD, cannabinoids, ayahuasca and ketamine. MDMA and psilocybin reduce barrier to therapy by increasing trust between therapist and patient, thus allowing for modification of trauma related memories. Furthermore, research into the memory reconsolidation mechanisms has allowed for identification of various pharmacological targets to disrupt abnormally persistent memories. A number of pre-clinical and clinical studies have investigated novel and re-purposed pharmacological agents to disrupt fear memory in PTSD. Novel therapeutic approaches like neuropeptide Y, oxytocin, cannabinoids and neuroactive steroids have also shown potential for PTSD treatment. Here, we focus on the role of fear memory in the pathophysiology of PTSD and propose that many of these new therapeutic strategies produce benefits through the effect on fear memory. Evaluation of recent research findings suggests that while a number of drugs have shown promising results in preclinical studies and pilot clinical trials, the evidence from large scale clinical trials would be needed for these drugs to be incorporated in clinical practice.

School Discipline as a Consequence of Violent Victimization in Adolescence: Understanding the Mediating Roles of Head Injury and Behavior

Pathways from violence to head injury and poor long-term outcomes have been found among numerous populations, however, have not yet been widely examined with youth exposed to violence. Traumatic brain injuries (TBIs) are linked to a range of consequences salient to adolescent development and well-being, such as impulsivity, academic abilities, and emotional processing. This gap in research has led to a missed opportunity to understand the consequences of youth victimization, particularly within the academic setting. The current study examined whether head injury and problem behaviors mediate the relationships between victimization and suspension/expulsion using data from the Pathways to Desistance Study, a multi-site, longitudinal study of serious adolescent offenders age 14-18. A sample of male youth who had witnessed violence (n = 1,094) reported a total score of victimization, number of early behavior problems (i.e., cheating, fighting, etc.), ever having a head injury (32.9%), and number of times suspended (adjusted M = 13.13; SD = 19.31) or expelled (adjusted M = 0.65; SD = 0.99). Structural equation modeling was used to examine direct and indirect pathways from victimization to suspension and expulsion through head injury and behavior. Direct pathways from victimization to school discipline were significant; indirect pathways mediated by only head injury were not significant, but indirect pathways through only problem behavior and through TBI and problem behavior were significant for both expulsion and suspension. Results suggest that youth who have been victimized are at higher risk for both suspension and expulsion and that this risk may be, in part, explained through increased head injury and problem behaviors. TBI screenings/services for violence-exposed youth and trauma-informed school-based services may help to deter trajectories toward suspension and expulsion but should be developed with attention to the influence of racial bias on pathways to school discipline.

Cognitive impairment and World Trade Centre-related exposures

On 11 September 2001 the World Trade Center (WTC) in New York was attacked by terrorists, causing the collapse of multiple buildings including the iconic 110-story 'Twin Towers'. Thousands of people died that day from the collapse of the buildings, fires, falling from the buildings, falling debris, or other related accidents. Survivors of the attacks, those who worked in search and rescue during and after the buildings collapsed, and those working in recovery and clean-up operations were exposed to severe psychological stressors. Concurrently, these 'WTC-affected' individuals breathed and ingested a mixture of organic and particulate neurotoxins and pro-inflammogens generated as a result of the attack and building collapse. Twenty years later, researchers have documented neurocognitive and motor dysfunctions that resemble the typical features of neurodegenerative disease in some WTC responders at midlife. Cortical atrophy, which usually manifests later in life, has also been observed in this population. Evidence indicates that neurocognitive symptoms and corresponding brain atrophy are associated with both physical exposures at the WTC and chronic post-traumatic stress disorder, including regularly re-experiencing traumatic memories of the events while awake or during sleep. Despite these findings, little is understood about the long-term effects of these physical and mental exposures on the brain health of WTC-affected individuals, and the potential for neurocognitive disorders. Here, we review the existing evidence concerning neurological outcomes in WTC-affected individuals, with the aim of contextualizing this research for policymakers, researchers and clinicians and educating WTC-affected individuals and their friends and families. We conclude by providing a rationale and recommendations for monitoring the neurological health of WTC-affected individuals.

Relationship between Post-traumatic Stress Disorder and subsequent myocardial infarction: a systematic review and meta-analysis

BACKGROUND

Each year, nearly 790.000 new cases of myocardial infarction (MI) are recorded in the United States. Better knowledge of the modifiable risk factors for this cardiovascular disease remains a major public health issue. In this perspective, the aim of this systematic review and meta-analysis was to estimate the relationship between post-traumatic stress disorder (PTSD) and risk of subsequent myocardial infarction (MI).

METHODS

A systematic review using PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analysis) guidelines was performed by searching four bibliographic databases (PubMed/Medline, PsycINFO, Science Direct and Proquest Dissertations and Theses).

RESULTS

A total of 14 articles were included. Nine of these included depression as a covariate. Among 13 studies (N = 848.903), the pooled HR for the magnitude of the relationship between PTSD and MI was 1.49 (95% CI 1.31-1.69) before adjustment for depression. The pooled HR estimate for the 9 depression-adjusted estimates (N = 814.441) was 1.32 (95% CI 1.12-1.56).

LIMITATIONS

These results should be considered with caution because there is high heterogeneity between studies and possible publication bias; thus, further research is required to support these results.

CONCLUSIONS

Further research is still needed to identify in more precise terms the mediating factors involved in the direct association between PTSD and the subsequent occurrence of ischemic heart disease.

Association between biopsychosocial factors and self-reported COVID-19 clinical complications in a Brazilian city

ABSTRACT Objective: This study aimed to analyze the existence of an association between the biopsychosocial profile of people affected and the number of self-reported clinical complications from COVID-19 in a Brazilian city. Methods: This is a cross-sectional (baseline) study, nested in a cohort study, carried out with 217 confirmed cases of COVID-19, interviewed from January to October 2021, during home visits, in a city in the south of Minas Gerais, Brazil. A structured questionnaire with the KoboToolbox resource was used. The independent variables were sociodemographic and clinical profile (comorbidities), quality of life, post-traumatic stress, anxiety, depression, and social support. The dependent variable was the number of self-reported clinical complications from COVID-19. The multivariate linear regression technique was adopted for the analyses. Results: The participants reported multiple clinical complications from COVID-19. There were “four or more” complications in 94.6% of the cases. Having a history of high blood pressure was associated with more complications post-SARS-CoV-2 infection, whereas having a caregiver and presenting with post-traumatic stress were associated with fewer COVID-19 complications. Conclusion: The multisystemic nature of the complications caused by COVID-19 and the associations identified emphasizes the need for an integrated approach to patients and for studies that monitor the effects of the disease on the demands placed on health systems, aiming to better understand and address them.

Autonomic dysfunction and cardiovascular risk in post-traumatic stress disorder

BACKGROUND

Patients with post-traumatic stress disorder (PTSD) have an increased risk for cardiovascular disease. The underlying mechanisms are unclear but impaired autonomic function may contribute. However, research in this field has shown contradictory results and the causal links between PTSD, autonomic dysfunction, and cardiovascular risk remain unknown. This brief review summarizes the current knowledge on alterations in autonomic function and cardiovascular risk in patients with PTSD.

LITERATURE SEARCH STRATEGY

A PubMed search of the literature was performed using the following keywords: autonomic function, heart rate variability, blood pressure variability, sympathetic activity, baroreflex function, and cardiovascular risk in combination with PTSD. Evidence-based studies conducted between 2000 and 2021 were selected.

RESULTS

In total 1221 articles were identified and of these, 61 (48 original research papers, 13 review articles) were included in this review. Many, though not all, studies have reported increased activity of the sympathetic nervous system and decreased activity of the parasympathetic nervous system (namely, autonomic imbalance) in PTSD patients. There seems to be enough evidence to suggest impairments in baroreflex function in PTSD, leading to blood pressure dysregulation. It appears that the chronicity of PTSD diagnosis and symptom severity are independent risk factors for cardiovascular disease, which may be linked with impaired autonomic function.

CONCLUSIONS

Increased cardiovascular risk may be associated with autonomic dysfunction in PTSD. Whether autonomic dysfunction can serve as a biomarker for the onset and progression of PTSD remains to be determined. It also needs to determine if autonomic imbalance increases the risk of developing PTSD.

Response and recovery of endocrine, behavioral, and neuronal morphology outcomes after different traumatic stressor exposures in male rats

Preclinical models of organismal response to traumatic stress (threat of death or serious injury) can be monitored using neuroendocrine, behavioral, and structural metrics. While many rodent models of traumatic stress have provided a glimpse into select components of the physiological response to acute and chronic stressors, few studies have directly examined the potential differences between stressors and their potential outcomes. To address this gap, we conducted a multi-level comparison of the immediate and longer-term effects of two types of acute traumatic stressors. Adult male rats were exposed to either underwater trauma (UWT), predator exposure (PE), or control procedural handling conditions. Over the next 7 days, yoked cohorts underwent either serial blood sampling for neuroendocrine evaluation across the circadian cycle, or repeated behavioral testing in the elevated plus maze. In addition, a subset of brains from the latter cohort were assessed for dendritic spine changes in the prefrontal cortex and basolateral amygdala. We observed stressor-dependent patterns of response and recovery across all measures, with divergence between endocrine responses despite similar behavioral outcomes. These results demonstrate that different stressors elicit unique behavioral, neuroendocrine, and neuro-structural response profiles and suggest that specific stress models can be used to model desired responses for specific preclinical applications, such as evaluations of underlying mechanisms or therapeutic candidates.

Association of Posttraumatic Stress Disorder and Incident Ischemic Heart Disease in Women Veterans

Importance

Posttraumatic stress disorder (PTSD) is associated with greater risk of ischemic heart disease (IHD) in predominantly male populations or limited community samples. Women veterans represent a growing, yet understudied, population with high levels of trauma exposure and unique cardiovascular risks, but research on PTSD and IHD in this group is lacking.

Objective

To determine whether PTSD is associated with incident IHD in women veterans.

Design, Setting, and Participants

In this retrospective, longitudinal cohort study of the national Veterans Health Administration (VHA) electronic medical records, the a priori hypothesis that PTSD would be associated with greater risk of IHD onset was tested. Women veterans 18 years or older with and without PTSD who were patients in the VHA from January 1, 2000, to December 31, 2017, were assessed for study eligibility. Exclusion criteria consisted of no VHA clinical encounters after the index visit, IHD diagnosis at or before the index visit, and IHD diagnosis within 90 days of the index visit. Propensity score matching on age at index visit, number of prior visits, and presence of traditional and female-specific cardiovascular risk factors and mental and physical health conditions was conducted to identify women veterans ever diagnosed with PTSD, who were matched in a 1:2 ratio to those never diagnosed with PTSD. Data were analyzed from October 1, 2018, to October 30, 2020.

Exposures

PTSD, defined by International Classification of Diseases, Ninth Revision (ICD-9), or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), diagnosis codes from inpatient or outpatient encounters.

Main Outcomes and Measures

Incident IHD, defined as new-onset coronary artery disease, angina, or myocardial infarction, based on ICD-9 and ICD-10 diagnosis codes from inpatient or outpatient encounters, and/or coronary interventions based on Current Procedural Terminology codes.

Results

A total of 398 769 women veterans, 132 923 with PTSD and 265 846 never diagnosed with PTSD, were included in the analysis. Baseline mean (SD) age was 40.1 (12.2) years. During median follow-up of 4.9 (interquartile range, 2.1-9.2) years, 4381 women with PTSD (3.3%) and 5559 control individuals (2.1%) developed incident IHD. In a Cox proportional hazards model, PTSD was significantly associated with greater risk of developing IHD (hazard ratio [HR], 1.44; 95% CI, 1.38-1.50). Secondary stratified analyses indicated that younger age identified women veterans with PTSD who were at greater risk of incident IHD. Effect sizes were largest for those younger than 40 years at baseline (HR, 1.72; 95% CI, 1.55-1.93) and decreased monotonically with increasing age (HR for ≥60 years, 1.24; 95% CI, 1.12-1.38).

Conclusions and Relevance

This cohort study found that PTSD was associated with increased risk of IHD in women veterans and may have implications for IHD risk assessment in vulnerable individuals.

Psilocybin and MDMA for the treatment of trauma-related psychopathology

This review examines the role of trauma in psychiatric morbidity and analogous psychoneurobiological changes. Trauma is a necessary criterion for Post-Traumatic Stress Disorder (PTSD), however, trauma history is highly correlated with a variety of psychiatric conditions. Some evidence suggests that Major Depressive Disorder (MDD) is the most common psychiatric condition that arises following trauma. Approximately 50% of PTSD cases present with co-morbid MDD. Overlapping symptomatology and neurobiology between these conditions underlie the debate over whether these phenomena result from problematic nosology or whether comorbid MDD + PTSD is a distinct phenotype of trauma-related psychopathology. Regardless, similar treatment approaches have been employed historically, with varying success. The drug-assisted psychotherapy treatment model, which combines pharmacological and psychotherapeutic approaches, is currently being trialled as a novel treatment approach in psychiatry. Both psilocybin- and 3,4-Methylenedioxymethamphetamine (MDMA)-assisted psychotherapy have received Food and Drug Administration 'breakthrough therapy' designation for the treatment of resistant MDD and PTSD, respectively. This paper reviews the therapeutic rationale of both psilocybin and MDMA for treating both trauma-related MDD and PTSD.

The invisible scars of emotional abuse: a common and highly harmful form of childhood maltreatment

BACKGROUND

Childhood maltreatment (CM) is unfortunately widespread globally and has been linked with an increased risk of a variety of psychiatric disorders in adults, including posttraumatic stress disorder (PTSD). These associations are well established in the literature for some maltreatment forms, such as sexual and physical abuse. However, the effects of emotional maltreatment are much less explored, even though this type figures among the most common forms of childhood maltreatment. Thus, the present study aims to investigate the impact of each type of childhood maltreatment, both individually and conjointly, on revictimization and PTSD symptom severity using a nonclinical college student sample.

METHODS

Five hundred and two graduate and undergraduate students participated in the study by completing questionnaires assessing lifetime traumatic experiences in general, maltreatment during childhood and PTSD symptoms. Bivariate and multivariate negative binomial regressions were applied to examine the associations among childhood maltreatment, revictimization, and PTSD symptom severity.

RESULTS

Our results showed that using bivariate models, all types of CM were significantly associated with revictimization and PTSD symptom severity. Multivariate models showed that emotional abuse was the type of maltreatment associated with the highest incidence rates of revictimization and PTSD symptom severity.

CONCLUSIONS

These data provide additional evidence of the harmful effects of childhood maltreatment and its long-term consequences for individuals' mental health. Notably, the findings highlight the importance of studying the impacts of emotional abuse, which seems to be a highly prevalent, understudied, and chronic form of maltreatment that is as toxic as other maltreatment forms.

Mindfulness and yoga for psychological trauma: systematic review and meta-analysis

Mindfulness-based interventions (MBIs), with postures, breath, relaxation, and meditation, such as Mindfulness-based Stress Reduction (MBSR) and yoga, are complex interventions increasingly used for trauma-related psychiatric conditions. Prior reviews have adopted a disorder-specific focus. However, trauma is a risk factor for most psychiatric conditions. We adopted a transdiagnostic approach to evaluate the efficacy of MBIs for the consequences of trauma, agnostic to diagnosis. AMED, CINAHL, Central, Embase, Pubmed/Medline, PsycINFO, and Scopus were searched to 30 September 2018 for controlled and uncontrolled trials of mindfulness, yoga, tai chi, and qi gong in people specifically selected for trauma exposure. Of >12,000 results, 66 studies were included in the systematic review and 24 controlled studies were meta-analyzed. There was a significant, pooled effect of MBIs (g = 0.51, 95%CI 0.31 to 0.71, p < .001). Similar effects were observed for mindfulness (g = 0.45, 0.26 to 0.64, p < .001), yoga (g = 0.46, 0.26 to 0.66, p < .001), and integrative exercise (g = 0.94, 0.37 to 1.51, p = .001), with no difference between interventions. Outcome measure or trauma type did not influence the effectiveness, but interventions of 8 weeks or more were more effective than shorter interventions (Q = 8.39, df = 2, p = .02). Mindfulness-based interventions, adjunctive to treatment-as-usual of medication and/or psychotherapy, are effective in reducing trauma-related symptoms. Yoga and mindfulness have comparable effectiveness. Many psychiatric studies do not report trauma exposure, focusing on disorder-specific outcomes, but this review suggests a transdiagnostic approach could be adopted in the treatment of trauma sequelae with MBIs. More rigorous reporting of trauma exposure and MBI treatment protocols is recommended to enhance future research.

Protective effects of morphine in a rat model of post-traumatic stress disorder: Role of hypothalamic-pituitary-adrenal axis and beta- adrenergic system

Post-traumatic stress disorder (PTSD) arises after tremendous traumatic experiences. Recently, we have reported that morphine has time-dependent protective effects against behavioral and morphological deficits in the single prolonged stress (SPS) as an experimental model of PTSD in adult male rats. To find the mechanisms underlying the protective effects of morphine against SPS-induced PTSD-like symptoms, the present study investigated the interaction between morphine and hypothalamic-pituitary-adrenal (HPA) axis and beta - adrenergic system, which crucially involved in the stress response, on PTSD-like symptoms in male rats. The animals were exposed to the SPS procedure (restraint for 2 h, forced swimming for 20 min, and ether anesthesia) and morphine (10 mg/kg) or saline was injected 24 h following the SPS. The glucocorticoid receptor antagonist RU486 (20 mg/kg), the mineralocorticoid receptor antagonist spironolactone (50 mg/kg), and the corticosterone synthesis inhibitor metyrapone (50 mg/kg) were injected 90 min before morphine administration to block the HPA axis activity. The beta - adrenergic receptor blocker propranolol (10 mg/kg) and the peripheral beta-adrenergic receptor blocker nadolol (5 mg/kg) were administered 30 min before morphine injection to block the beta - adrenergic system. Anxiety-like behaviors were evaluated using the elevated plus maze (EPM) 11 days after the SPS. After that, animals were conditioned in a fear-conditioning task and extinction training was performed on days 1, 2, 3, 4 and 11 after fear conditioning. SPS increased anxiety-like behaviors and impaired fear extinction. Morphine injection 24 h after SPS significantly improved anxiety-like behaviors and enhanced fear extinction. The RU486, spironolactone and metyrapone prevented the protective effects of morphine on both SPS-induced anxiety-like behaviors and impaired fear extinction. The propranolol, and nadolol did not prevent the effect of morphine on anxiety-like behaviors, but the propranolol prevented morphine effects on fear extinction in SPS animals. These findings together suggest that the protective effects of morphine on PTSD-like symptoms in rats require a certain level of the HPA axis and central beta - adrenergic activity and any alteration in the function of these systems can impede the protective effects of morphine.

Role of enhanced glucocorticoid receptor sensitivity in inflammation in PTSD: insights from computational model for circadian-neuroendocrine-immune interactions

Although glucocorticoid resistance contributes to increased inflammation, individuals with posttraumatic stress disorder (PTSD) exhibit increased glucocorticoid receptor (GR) sensitivity along with increased inflammation. It is not clear how inflammation coexists with a hyperresponsive hypothalamic-pituitary-adrenal (HPA) axis. To understand this better, we developed and analyzed an integrated mathematical model for the HPA axis and the immune system. We performed mathematical simulations for a dexamethasone (DEX) suppression test and IC₅₀-dexamethasone for cytokine suppression by varying model parameters. The model analysis suggests that increasing the steepness of the dose-response curve for GR activity may reduce anti-inflammatory effects of GRs at the ambient glucocorticoid levels, thereby increasing proinflammatory response. The adaptive response of proinflammatory cytokine-mediated stimulatory effects on the HPA axis is reduced due to dominance of the GR-mediated negative feedback on the HPA axis. To verify these hypotheses, we analyzed the clinical data on neuroendocrine variables and cytokines obtained from war-zone veterans with and without PTSD. We observed significant group differences for cortisol and ACTH suppression tests, proinflammatory cytokines TNFα and IL6, high-sensitivity C-reactive protein, promoter methylation of GR gene, and IC_50-DEX for lysozyme suppression. Causal inference modeling revealed significant associations between cortisol suppression and post-DEX cortisol decline, promoter methylation of human GR gene exon 1F (NR3C1-1F), IC_50-DEX, and proinflammatory cytokines. We noted significant mediation effects of NR3C1-1F promoter methylation on inflammatory cytokines through changes in GR sensitivity. Our findings suggest that increased GR sensitivity may contribute to increased inflammation; therefore, interventions to restore GR sensitivity may normalize inflammation in PTSD.

Alcohol Use Disorder Masks the Effects of Childhood Adversity, Lifetime Trauma, and Chronic Stress on Hypothalamic-Pituitary-Adrenal Axis Reactivity

BACKGROUND

Individuals with alcohol use disorder (AUD) and those who have experienced traumas or chronic stress exhibit dysregulated hypothalamic-pituitary-adrenal (HPA) axis reactivity. Whether and how trauma and stress histories interact with AUD to affect HPA axis reactivity has not been assessed.

METHODS

In the present study, 26 healthy male controls and 70 abstinent men with AUD were administered a pharmacologic probe [ovine corticotropin-releasing hormone (oCRH)] and psychosocial stressor to assess HPA axis reactivity. Plasma adrenocorticotropin hormone (ACTH) and cortisol were assessed every 10-20 minutes. Hierarchical clustering of multiple measures of trauma and stress identified 3 distinct clusters: childhood adversity, lifetime trauma, and chronic stress. General linear model procedures were used to examine main effects of group (AUD/control) and interaction effects of the 3 clusters upon net-integrated ACTH and cortisol response.

RESULTS

We found that higher levels of childhood adversity, lifetime trauma, and chronic stress were each associated with blunted oCRH-induced ACTH reactivity in controls, but not in the AUD group. Recent chronic stress within the prior 6 months had the strongest influence upon ACTH reactivity in the control group, and lifetime trauma, the least.

CONCLUSIONS

Childhood adversity, lifetime trauma, and chronic stress likely exert persistent, measurable effects upon HPA axis functioning in healthy controls. This association appears to be masked in individuals with AUD, potentially confounding studies examining the effects of stress, adversity, and/or trauma upon the HPA axis in this population during the protracted withdrawal phase of recovery. Future work targeting stress exposure and reactivity should consider the heightened effect of previous alcohol use relative to past adversity and trauma.

Nervous and Endocrine System Dysfunction in Posttraumatic Stress Disorder: An Overview and Consideration of Sex as a Biological Variable

Decades of research into the biological mechanisms of posttraumatic stress disorder (PTSD) suggests that chronic activation of the stress response leads to long-lasting changes in the structure and function of the nervous and endocrine systems. While the prevalence of PTSD is twice as high in females as males, little is known about how sex differences in neuroendocrine systems may contribute to PTSD. In response to the paucity of research on sex-related mechanisms, the National Institutes of Health created a policy that asks researchers to consider sex as a biological variable. This review provides an overview of the current understanding of nervous and endocrine dysfunction in PTSD (e.g., neural circuitry, autonomic arousal, hormonal response), highlighting areas where the influence of sex has been characterized and where further research is needed. We also provide recommendations for using the sex-as-a-biological-variable policy to address specific gaps in PTSD neuroscience research.

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.

Reducing Allostatic Load in Depression and Anxiety Disorders: Physical Activity and Yoga Practice as Add-On Therapies

The allostatic load (AL) index constitutes a useful tool to objectively assess the biological aspects of chronic stress in clinical practice. AL index has been positively correlated with cumulative chronic stress (physical and psychosocial stressors) and with a high risk to develop pathological conditions (e.g., metabolic syndrome, cardiovascular pathology, inflammatory disorders) and the so-called stress-related psychiatric disorders, including anxiety and depressive disorders. Chronic stress has negative effects on brain neuroplasticity, especially on hippocampal neurogenesis and these effects may be reversed by antidepressant treatments. Several evidences indicate that non-pharmacological interventions based on physical activity and yoga practice may add synergizing benefits to classical treatments (antidepressant and benzodiazepines) for depression and anxiety, reducing the negative effects of chronic stress. The aim of this review is to provide a general overview of current knowledge on AL and chronic stress in relation to depression and anxiety, physical activity and yoga practice.

The evolution of mental health outcomes across a combat deployment cycle: A longitudinal study of the Guam Army National Guard

In the United States, National Guard soldiers have been called upon at unprecedented rates since 2001 to supplement active duty military forces. Frequent military deployments generate many occupational and environmental stressors for these citizen-soldiers, from serving in a dangerous zone to being away from family and home for long periods of time. Whereas there is a substantial amount of research focused on deployment-related health outcomes in relation to active duty (i.e., full-time) military populations, reserve forces are less understood. This study focuses on a United States Army National Guard combat unit deployed to Afghanistan. This prospective longitudinal study was conducted over the course an operational deployment cycle (i.e., before, during, and after) to document the evolution of salient mental health outcomes (i.e., post-traumatic stress, depression, general anxiety, and aggression). The findings show that both combat (e.g., killing others) and non-combat (e.g., boredom) stressors negatively affect mental health outcomes, and the severity of these outcomes increases over the course of a deployment cycle. Of special note, the study reveals key gender differences in the evolution of post-traumatic stress (PTS), depression, and anxiety across a deployment cycle: females report increased PTS, depression, and anxiety 6 months post-deployment, whereas the levels reported by males stabilize at their mid-deployment levels. The findings offer insights for medical providers and policymakers in developing more targeted health promotion campaigns and interventions, especially at the post-deployment phase.

Effects of a mental stress challenge on brain function in coronary artery disease patients with and without depression

OBJECTIVE

Coronary artery disease (CAD) patients with comorbid depression show an increase in mortality compared to cardiac patients without depression, but the mechanisms mediating this effect remain obscure. One possible explanation for this finding is that depressed patients with CAD exhibit an increased vulnerability to stress. The purpose of this study was to assess the effects of stress and depression on brain function and to explore its relationship with myocardial ischemia in CAD patients.

METHODS

Patients with CAD and depression (N = 13) and CAD without depression (N = 15) underwent imaging of the brain with positron emission tomography and [O-15] water and imaging of the heart with single photon emission computed tomography (SPECT) and [Tc-99m] sestamibi under mental stress task and control conditions.

RESULTS

CAD patients with depression compared to nondepressed showed decreased function with mental stress in the rostral anterior cingulate, the hippocampus, parts of the dorsolateral temporal and parietal cortex, the cerebellum, and the uncus, with increased blood flow in the parahippocampus, visual association cortex, and posterior cingulate. Depressed CAD patients who became ischemic during a mental stress task had relative decreases in the caudal and posterior cingulate, orbitofrontal cortex, and cerebellum, and increased activation in the parietal cortex and precuneus/visual association cortex compared to nonischemic depressed CAD patients.

CONCLUSIONS

These findings are consistent with dysfunction in a network of brain regions involved in the stress response in patients with comorbid CAD and depression that has direct and indirect links to the heart, suggesting a pathway by which stress and depression could lead to increased risk of heart disease related morbidity and mortality. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Reframing PTSD for computational psychiatry with the active inference framework

Introduction: Recent advances in research on stress and, respectively, on disorders of perception, learning, and behaviour speak to a promising synthesis of current insights from (i) neurobiology, cognitive neuroscience and psychology of stress and post-traumatic stress disorder (PTSD), and (ii) computational psychiatry approaches to pathophysiology (e.g. of schizophrenia and autism). Methods: Specifically, we apply this synthesis to PTSD. The framework of active inference offers an embodied and embedded lens through which to understand neuronal mechanisms, structures, and processes of cognitive function and dysfunction. In turn, this offers an explanatory model of how healthy mental functioning can go awry due to psychopathological conditions that impair inference about our environment and our bodies. In this context, auditory phenomena-known to be especially relevant to studies of PTSD and schizophrenia-and traditional models of auditory function can be viewed from an evolutionary perspective based on active inference. Results: We assess and contextualise a range of evidence on audition, stress, psychosis, and PTSD, and bring some existing partial models of PTSD into multilevel alignment. Conclusions: The novel perspective on PTSD we present aims to serve as a basis for new experimental designs and therapeutic interventions that integrate fundamentally biological, cognitive, behavioural, and environmental factors.

Glucocorticoid-induced leucine zipper "quantifies" stressors and increases male susceptibility to PTSD

Post-traumatic stress disorder (PTSD) selectively develops in some individuals exposed to a traumatic event. Genetic and epigenetic changes in glucocorticoid pathway sensitivity may be essential for understanding individual susceptibility to PTSD. This study focuses on PTSD markers in the glucocorticoid pathway, spotlighting glucocorticoid-induced leucine zipper (GILZ), a transcription factor encoded by the gene Tsc22d3 on the X chromosome. We propose that GILZ uniquely "quantifies" exposure to stressors experienced from late gestation to adulthood and that low levels of GILZ predispose individuals to PTSD in males only. GILZ mRNA and methylation were measured in 396 male and female human blood samples from the Grady Trauma Project cohort (exposed to multiple traumatic events). In mice, changes in glucocorticoid pathway genes were assessed following exposure to stressors at distinct time points: (i) CRF-induced prenatal stress (_CRF-inducedPNS) with, or without, additional exposure to (ii) PTSD induction protocol in adulthood, which induces PTSD-like behaviors in a subset of mice. In humans, the number of traumatic events correlated negatively with GILZ mRNA levels and positively with % methylation of GILZ in males only. In male mice, we observed a threefold increase in the number of offspring exhibiting PTSD-like behaviors in those exposed to both _CRF-inducedPNS and PTSD induction. This susceptibility was associated with reduced GILZ mRNA levels and epigenetic changes, not found in females. Furthermore, virus-mediated shRNA knockdown of amygdalar GILZ increased susceptibility to PTSD. Mouse and human data confirm that dramatic alterations in GILZ occur in those exposed to a stressor in early life, adulthood or both. Therefore, GILZ levels may help identify at-risk populations for PTSD prior to additional traumatic exposures.

Early childhood trauma alters neurological responses to mental stress in patients with coronary artery disease

BACKGROUND

Early childhood trauma is known to independently increase adverse outcome risk in coronary artery disease (CAD) patients, although the neurological correlates are not well understood. The purpose of this study was to examine whether early childhood trauma alters neural responses to acute mental stress in CAD patients.

METHODS

Participants (n = 152) with CAD underwent brain imaging with High Resolution Positron Emission Tomography and radiolabeled water during control (verbal counting, neutral speaking) and mental stress (mental arithmetic, public speaking). Traumatic events in childhood were assessed with the Early Trauma Inventory (ETI-SR-SF) and participants were separated by presence (ETI+) or absence (ETI-) of early childhood trauma. Brain activity during mental stress was compared between ETI+ and ETI-.

RESULTS

Compared to ETI-, ETI+ experienced greater (p < 0.005) activations during mental stress within the left anterior cingulate, bilateral frontal lobe and deactivations (p < 0.005) within the left insula, left parahippocampal gyrus, right dorsal anterior cingulate, bilateral cerebellum, bilateral fusiform gyrus, left inferior temporal gyrus, and right parietal lobe. Significant (p < 0.005) positive correlations between brain activation and ETI-SR-SF scores were observed within the left hippocampus, bilateral frontal lobe, left occipital cuneus, and bilateral temporal lobe.

LIMITATIONS

Results in non-CAD samples may differ and ETI may be subject to recall bias.

CONCLUSION

Early childhood trauma exacerbated activations in stress-responsive limbic and cognitive brain areas with direct and indirect connections to the heart, potentially contributing to adverse outcomes in CAD patients.

Stress and functional neurological disorders: mechanistic insights

At the interface between mind and body, psychiatry and neurology, functional neurological disorder (FND) remains poorly understood. Formerly dominant stress-related aetiological models have been increasingly challenged, in part due to cases without any history of past or recent trauma. In this perspective article, we review current evidence for such models, and how research into the role of traumatic stress in other disorders and the neurobiology of the stress response can inform our mechanistic understanding of FND. First, we discuss the association between stress and the onset or exacerbation of a variety of physical and mental health problems. Second, we review the role of hypothalamic-pituitary-adrenal axis dysfunction in the neurobiology of ill-health, alongside evidence for similar mechanisms in FND. Third, we advocate a stress-diathesis model, in which biological susceptibility interacts with early life adversity, where FND can be precipitated by traumatic events later in life and maintained by psychological responses. We hypothesise that greater biological susceptibility to FND is associated with less severe remote and recent stress, and that FND precipitated by more severe stress is associated with lower biological vulnerability. This would explain clinical experience of variable exposure to historical and recent traumatic stress among people with FND and requires empirical investigation. A testable, evidence-based stress-diathesis model can inform nuanced understanding of how biological and psychological factors interact at the individual level, with potential to inform personalised treatment pathways. Much-needed research to establish the aetiology of FND will enhance clinical care and communication, facilitate effective treatment and inform prevention strategies.

Individual variability in behavior and functional networks predicts vulnerability using an animal model of PTSD

Only a minority of individuals experiencing trauma subsequently develop post-traumatic stress disorder (PTSD). However, whether differences in vulnerability to PTSD result from a predisposition or trauma exposure remains unclear. A major challenge in differentiating these possibilities is that clinical studies focus on individuals already exposed to trauma without pre-trauma conditions. Here, using the predator scent model of PTSD in rats and a longitudinal design, we measure pre-trauma brain-wide neural circuit functional connectivity, behavioral and corticosterone responses to trauma exposure, and post-trauma anxiety. Freezing during predator scent exposure correlates with functional connectivity in a set of neural circuits, indicating pre-existing circuit function can predispose animals to differential fearful responses to threats. Counterintuitively, rats with lower freezing show more avoidance of the predator scent, a prolonged corticosterone response, and higher anxiety long after exposure. This study provides a framework of pre-existing circuit function that determines threat responses, which might directly relate to PTSD-like behaviors.

How do individual differences affect vulnerability to developing post-traumatic stress disorder (PTSD)? Here, using longitudinal testing in a rat model of PTSD, the authors show patterns of pre-trauma brain connectivity and behaviors that predict PTSD-like responses to trauma exposure.

MicroRNAs in Post-traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a psychiatric disorder that can develop following exposure to or witnessing of a (potentially) threatening event. A critical issue is to pinpoint the (neuro)biological mechanisms underlying the susceptibility to stress-related disorder such as PTSD, which develops in the minority of ~15% of individuals exposed to trauma. Over the last few years, a first wave of epigenetic studies has been performed in an attempt to identify the molecular underpinnings of the long-lasting behavioral and mental effects of trauma exposure. The potential roles of non-coding RNAs (ncRNAs) such as microRNAs (miRNAs) in moderating or mediating the impact of severe stress and trauma are increasingly gaining attention. To date, most studies focusing on the roles of miRNAs in PTSD have, however, been completed in animals, using cross-sectional study designs and focusing almost exclusively on subjects with susceptible phenotypes. Therefore, there is a strong need for new research comprising translational and cross-species approaches that use longitudinal designs for studying trajectories of change contrasting susceptible and resilient subjects. The present review offers a comprehensive overview of available studies of miRNAs in PTSD and discusses the current challenges, pitfalls, and future perspectives of this field.

Glucocorticoids and Hippocampal Structure and Function in PTSD

This review examines the putative link between glucocorticoid and hippocampal abnormalities in posttraumatic stress disorder (PTSD). Increased glucocorticoid receptor (GR) sensitivity in PTSD may permit enhanced negative feedback inhibition of cortisol at the pituitary, hypothalamus, or other brain regions comprising the hypothalamic-pituitary-adrenal (HPA) axis and would be expected to affect other physiological systems that are regulated by glucocorticoids. Molecular and transcriptional studies of cortisol are consistent with the hypothesis that cortisol actions may be amplified in PTSD as a result of enhanced GR sensitivity in monocytes and some brain regions, although cortisol levels themselves are unchanged and oftentimes lower than normal. Concurrently, magnetic resonance imaging studies have demonstrated that individuals with PTSD have smaller hippocampal volume than individuals without PTSD. Initial hypotheses regarding the mechanism underlying hippocampal alterations in PTSD focused on elevated glucocorticoid levels in combination with extreme stress as the primary cause, but this explanation has not been well supported in human studies. Lack of data from neuroimaging studies preclude a firm link between PTSD onset and hippocampal volume changes. Rather, the available evidence is consistent with the possibility that smaller hippocampal volume (like reduced cortisol levels and enhanced GR sensitivity) may be a vulnerability factor for developing the disorder; limitations of hippocampal-based models of PTSD are described. We further review neuroimaging studies examining hippocampal structure and function following manipulation of glucocorticoid levels and also examining changes in the hippocampus in relationship to other brain regions. Evidence that the GR may be an important therapeutic target for the treatment of PTSD, especially for functions subserved by the hippocampus, is discussed. Implications of the current review for future research are described, with an emphasis on the need to integrate findings of glucocorticoid abnormalities with functional-imaging paradigms to formulate a comprehensive model of HPA-axis functioning in PTSD.

Recent advances in the neurobiology of posttraumatic stress disorder: A review of possible mechanisms underlying an effective pharmacotherapy

Recent progress in the field of neurobiology supported by clinical evidence gradually reveals the mystery of human brain functioning. So far, many psychiatric disorders have been described in great detail, although there are still plenty of cases that are misunderstood. These include posttraumatic stress disorder (PTSD), which is a unique disease that combines a wide range of neurobiological changes, which involve disturbances of the hypothalamic-pituitary-adrenal gland axis, hyperactivation of the amygdala complex, and attenuation of some hippocampal and cortical functions. Such multiplicity results in differential symptomatology, including elevated anxiety, nightmares, fear retrieval episodes that may trigger delusions and hallucinations, sleep disturbances, and many others that strongly interfere with the quality of the patient's life. Because of widespread neurological changes and the disease manifestation, the pharmacotherapy of PTSD remains unclear and requires a multidimensional approach and involvement of polypharmacotherapy. Hopefully, more and more neuroscientists and clinicians will study PTSD, which will provide us with new information that would possibly accelerate establishment of well-tolerated and effective pharmacotherapy. In this review, we have focused on neurobiological changes regarding PTSD, addressing the most disturbed brain structures and neurotransmissions, as well as discussing in detail the recently taken and novel therapeutic paths.

Social stability influences the association between adrenal responsiveness and hair cortisol concentrations in rhesus macaques

Hair cortisol concentrations are increasingly being used in both humans and nonhuman animals as a biomarker of chronic stress. However, many details regarding how hair cortisol concentrations relate to the dynamic activity and regulation of the HPA axis are still unknown. The current study explores 1) how the regulation of the HPA axis in infancy relates to hair cortisol concentrations (HCC) in infancy 2) whether this relationship persists into adulthood under conditions of social stability, and 3) how social instability impacts these relationships. All subjects were rhesus monkeys housed in large social groups at the California National Primate Research Center, and all had participated in a 25-hr. long BioBehavioral Assessment (BBA) at 3-4 months of age when four plasma samples were taken to assess HPA regulation, in particular cortisol responses to 1) 2-hour social separation and relocation, 2) sustained challenge, 3) dexamethasone and 4) ACTH administration. In Study 1, hair samples were collected at the end of the BBA testing from 25 infant rhesus monkeys from 2 different stable social groups. In Study 2, hair samples were obtained at three timepoints from 108 adults from 3 different stable social groups (1 in the Spring/Summer and 2 in the Fall/Winter) to examine the temporal stability of the relationship between HCC and HPA axis regulation. In Study 3, subjects included 31 infants and 33 adults from a single social group experiencing social instability following the same procedures as in Studies 1 and 2. Generalized linear models were used to determine if infants' HPA axis activity and regulation predicted HCC in infancy (Study 1), in adulthood with animals living in stable social conditions (Study 2) or in animals living in an unstable social group (Study 3). Results indicated that for both infants and adults living in stable social groups, HCC are associated with the adrenal response to ACTH in infancy. Samples collected in the winter also had higher HCC than those collected in summer. In the unstable social group, adult hair cortisol levels were higher than in the stable social groups. Additionally, there were no consistent relationships between HCC and infant HPA axis regulation among adults or infants living in a group experiencing social instability. These results suggest that the aspects of the HPA axis that drive HCC may differ depending on context. Under stable, non-stressed conditions there seems to be a trait-like association between adrenal responsivity and HCC in infancy and adulthood. However, this association may be reduced or eliminated under conditions of social stress.

Metabolomic and glycomic findings in posttraumatic stress disorder

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

The opioid system in stress-induced memory disorders: From basic mechanisms to clinical implications in post-traumatic stress disorder and Alzheimer's disease

Cognitive and emotional impairment are a serious consequence of stress exposure and are core features of neurological and psychiatric conditions that involve memory disorders. Indeed, acute and chronic stress are high-risk factors for the onset of post-traumatic stress disorder (PTSD) and Alzheimer's disease (AD), two devastating brain disorders associated with memory dysfunction. Besides the sympathetic nervous system and the hypothalamic-pituitary-adrenal (HPA) axis, stress response also involves the activation of the opioid system in brain regions associated with stress regulation and memory processing. In this context, it is possible that stress-induced memory disorders may be attributed to alterations in the interaction between the neuroendocrine stress system and the opioid system. In this review, we: (1) describe the effects of acute and chronic stress on memory, and the modulatory role of the opioid system, (2) discuss the contribution of the opioid system to the pathophysiology of PTSD and AD, and (3) present evidence of current and potential therapies that target the opioid receptors to treat PTSD- and AD-associated symptoms.

The Association of Post-traumatic and Postmigration Stress with Pain and Other Somatic Symptoms: An Explorative Analysis in Traumatized Refugees and Asylum Seekers

Objective

Post-traumatic stress disorder (PTSD) and somatic symptoms, such as pain, are frequently seen in refugees. Their relationship is poorly understood, and the treatment of these comorbid conditions can be very challenging. The current cross-sectional study examined pain and other somatic symptoms and their relationship with trauma history, PTSD symptom clusters, and current living difficulties among treatment-seeking refugees.

Methods

One hundred thirty-four treatment-seeking traumatized refugees (78% male, mean age = 42 years) were assessed regarding lifetime traumatic experiences, symptoms of post-traumatic stress, overall pain and somatic symptoms, and postmigration living difficulties.

Results

An exploratory factor analysis of the 12 somatic symptoms revealed two distinct factors: somatic symptoms related to bodily dysfunction ("weakness") and somatic symptoms related to increased sympathetic activity ("arousal"). DSM-5 PTSD Criteria D "alterations in cognitions and mood" and E "alterations in arousal and reactivity" were primarily related to "weakness," while PTSD Criterion E "alterations in arousal and reactivity" and postmigration living difficulties were associated with "arousal." Overall pain was associated primarily with living difficulties and PTSD Criterion D and Criterion E.

Conclusions

Results indicate that somatic symptoms are of considerable concern among traumatized refugees and that different patterns of somatic symptoms are associated with different clusters of PTSD symptoms. The findings contribute to the better understanding of the symptom presentation of traumatized people who are experiencing somatization and potentially inform treatment directions and highlight the importance of screening for PTSD in refugees presenting with pain and somatic symptoms.

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.

Glucocorticoid receptor-mediated amygdalar metaplasticity underlies adaptive modulation of fear memory by stress

Glucocorticoid receptor (GR) is crucial for signaling mediated by stress-induced high levels of glucocorticoids. The lateral nucleus of the amygdala (LA) is a key structure underlying auditory-cued fear conditioning. Here, we demonstrate that genetic disruption of GR in the LA (LAGRKO) resulted in an auditory-cued fear memory deficit for strengthened conditioning. Furthermore, the suppressive effect of a single restraint stress (RS) prior to conditioning on auditory-cued fear memory in floxed GR (control) mice was abolished in LAGRKO mice. Optogenetic induction of long-term depression (LTD) at auditory inputs to the LA reduced auditory-cued fear memory in RS-exposed LAGRKO mice, and in contrast, optogenetic induction of long-term potentiation (LTP) increased auditory-cued fear memory in RS-exposed floxed GR mice. These findings suggest that prior stress suppresses fear conditioning-induced LTP at auditory inputs to the LA in a GR-dependent manner, thereby protecting animals from encoding excessive cued fear memory under stress conditions.

Music therapy versus treatment as usual for refugees diagnosed with posttraumatic stress disorder (PTSD): study protocol for a randomized controlled trial

BACKGROUND

Meta-analyses of studies on psychological treatment of refugees describe highly varying outcomes, and research on multi-facetted and personalized treatment of refugees with post-traumatic stress disorder (PTSD) is needed. Music therapy has been found to affect arousal regulation and emotional processing, and a pilot study on the music therapy method Trauma-focused Music and Imagery (TMI) with traumatized refugees resulted in significant changes of trauma symptoms, well-being and sleep quality. The aim of the trial is to test the efficacy of TMI compared to verbal psychotherapy.

METHODS

A randomized controlled study with a non-inferiority design is carried out in three locations of a regional outpatient psychiatric clinic for refugees. Seventy Arabic-, English- or Danish-speaking adult refugees (aged 18-67 years) diagnosed with PTSD are randomized to 16 sessions of either music therapy or verbal therapy (standard treatment). All participants are offered medical treatment, psychoeducation by nurses, physiotherapy or body therapy and social counseling as needed. Outcome measures are performed at baseline, post therapy and at 6 months' follow-up. A blind assessor measures outcomes post treatment and at follow-up. Questionnaires measuring trauma symptoms (HTQ), quality of life (WHO-5), dissociative symptoms (SDQ-20, DSS-20) and adult attachment (RAAS) are applied, as well as physiological measures (salivary oxytocin, beta-endorphin and substance P) and participant evaluation of each session.

DISCUSSION

The effect of music therapy can be explained by theories on affect regulation and social engagement, and the impact of music on brain regions affected by PTSD. The study will shed light on the role of therapy for the attainment of a safe attachment style, which recently has been shown to be impaired in traumatized refugees. The inclusion of music and imagery in the treatment of traumatized refugees hopefully will inform the choice of treatment method and expand the possibilities for improving refugee health and integration.

TRIAL REGISTRATION

ClinicalTrials.gov ID number NCT03574228, registered retrospectively on 28 June 2016.

DBS in Treatment of Post-Traumatic Stress Disorder

Post-traumatic stress disorder (PTSD) is a debilitating psychiatric condition for which pharmacological therapy is not always solvable. Various treatments have been suggested and deep brain stimulation (DBS) is currently under investigation for patients affected by PTSD. We review the neurocircuitry and up-to-date clinical concepts which are behind the use of DBS in posttraumatic stress disorder (PTSD). The role of DBS in treatment-refractory PTSD patients has been investigated relying on both preclinical and clinical studies. DBS for PTSD is in its preliminary phases and likely to provide hope for patients with medical refractory PTSD following the results of randomized controlled studies.