Dehydroepiandrosterone and dehydroepiandrosterone sulfate levels in combat veterans with or without a history of suicide attempt

OBJECTIVE

The goal of this study was to determine whether combat veterans who have made a suicide attempt postdeployment can be distinguished from combat veterans who have never made a suicide attempt based on differences in psychological and biological variables.

METHODS

Demographic and clinical parameters of suicide attempters and non-attempters were assessed. Blood samples were assayed for dehydroepiandrosterone (DHEA) and dehydroepiandrosterone sulfate (DHEAS).

RESULTS

Suicide attempters had higher Scale for Suicidal Ideation and Montgomery-Åsberg Depression Rating Scale (MADRS)-suicidal thoughts item scores in comparison with non-attempters. There was a trend toward higher MADRS scores in the suicide attempter group compared with non-attempters. Suicide attempters had significantly lower levels of DHEA and DHEAS compared with non-attempters. Scale for Suicidal Ideation scores in all study participants combined negatively correlate with DHEA and DHEAS levels. DHEAS levels negatively correlate with Scale for Suicidal Ideation scores in suicide non-attempters but not in suicide attempters. DHEA/DHEAS ratios positively correlate with total adolescence aggression scores, total adulthood aggression scores, and total aggression scale scores in suicide attempters but not in suicide non-attempters.

CONCLUSION

There are psychobiological differences between combat veterans with or without a history of suicidal behaviour.

Longitudinal analyses of the DNA methylome in deployed military servicemen identify susceptibility loci for post-traumatic stress disorder

In order to determine the impact of the epigenetic response to traumatic stress on post-traumatic stress disorder (PTSD), this study examined longitudinal changes of genome-wide blood DNA methylation profiles in relation to the development of PTSD symptoms in two prospective military cohorts (one discovery and one replication data set). In the first cohort consisting of male Dutch military servicemen (n=93), the emergence of PTSD symptoms over a deployment period to a combat zone was significantly associated with alterations in DNA methylation levels at 17 genomic positions and 12 genomic regions. Evidence for mediation of the relation between combat trauma and PTSD symptoms by longitudinal changes in DNA methylation was observed at several positions and regions. Bioinformatic analyses of the reported associations identified significant enrichment in several pathways relevant for symptoms of PTSD. Targeted analyses of the significant findings from the discovery sample in an independent prospective cohort of male US marines (n=98) replicated the observed relation between decreases in DNA methylation levels and PTSD symptoms at genomic regions in ZFP57, RNF39 and HIST1H2APS2. Together, our study pinpoints three novel genomic regions where longitudinal decreases in DNA methylation across the period of exposure to combat trauma marks susceptibility for PTSD.

Largest GWAS of PTSD (N=20 070) yields genetic overlap with schizophrenia and sex differences in heritability

The Psychiatric Genomics Consortium-Posttraumatic Stress Disorder group (PGC-PTSD) combined genome-wide case-control molecular genetic data across 11 multiethnic studies to quantify PTSD heritability, to examine potential shared genetic risk with schizophrenia, bipolar disorder, and major depressive disorder and to identify risk loci for PTSD. Examining 20 730 individuals, we report a molecular genetics-based heritability estimate (h2SNP) for European-American females of 29% that is similar to h2SNP for schizophrenia and is substantially higher than h2SNP in European-American males (estimate not distinguishable from zero). We found strong evidence of overlapping genetic risk between PTSD and schizophrenia along with more modest evidence of overlap with bipolar and major depressive disorder. No single-nucleotide polymorphisms (SNPs) exceeded genome-wide significance in the transethnic (overall) meta-analysis and we do not replicate previously reported associations. Still, SNP-level summary statistics made available here afford the best-available molecular genetic index of PTSD-for both European- and African-American individuals-and can be used in polygenic risk prediction and genetic correlation studies of diverse phenotypes. Publication of summary statistics for ∼10 000 African Americans contributes to the broader goal of increased ancestral diversity in genomic data resources. In sum, the results demonstrate genetic influences on the development of PTSD, identify shared genetic risk between PTSD and other psychiatric disorders and highlight the importance of multiethnic/racial samples. As has been the case with schizophrenia and other complex genetic disorders, larger sample sizes are needed to identify specific risk loci.

Near IR fluorescent conjugated poly(ethylene glycol)bisphosphonate nanoparticles for in vivo bone targeting in a young mouse model

Bisphosphonate (BP) compounds are widely used in the treatment of bone disorders. This group of drugs with a high affinity to Ca⁺² ions is rapidly attracted to bone mineral, especially in areas of high resorption. We have engineered unique biodegradable BP nanoparticles (NPs) by dispersion co-polymerization of the monomers methacrylate-PEG-BP) and (3-Aminopropyl)mathacrylamide) with the crosslinker monomer tetra ethylene glycol diacrylate. These NPs possess a dual functionality: (1) covalent attachment of a dye (e.g. near IR dye) or a drug to the nanoparticles through the primary amine groups on the surface of the NPs; (2) chelation to the bone mineral hydroxyapatite through the BP on the surface of the NPs. This study describes the uptake of the unique near IR fluorescent Cy 7-conjugated BP NPs in bone of a young mouse model. Blood half-life studies revealed a relatively long half-life (approximately 5 h) due to a high concentration of PEG in the BP NPs as well as a relatively long whole body clearance (approximately 2 weeks). Body distribution studies showed a specific uptake of the BP NPs in bone. These unique engineered BP NPs are planned to be utilized in future work for diagnostic and drug delivery systems that are targeted to bone disorders.

Ten-year follow-up study of PTSD diagnosis, symptom severity and psychosocial indices in aging holocaust survivors

OBJECTIVE

We performed a longitudinal study of holocaust survivors with and without post-traumatic stress disorder (PTSD) by assessing symptoms and other measures at two intervals, approximately 10 years apart.

METHOD

The original cohort consisted of 63 community-dwelling subjects, of whom 40 were available for follow-up.

RESULTS

There was a general diminution in PTSD symptom severity over time. However, in 10% of the subjects (n=4), new instances of delayed onset PTSD developed between time 1 and time 2. Self-report ratings at both assessments revealed a worsening of trauma-related symptoms over time in persons without PTSD at time 1, but an improvement in those with PTSD at time 1.

CONCLUSION

The findings suggest that a nuanced characterization of PTSD trajectory over time is more reflective of PTSD symptomatology than simple diagnostic status at one time. The possibility of delayed onset trajectory complicates any simplistic overall trajectory summarizing the longitudinal course of PTSD.

Clinical correlates of DHEA associated with post-traumatic stress disorder

OBJECTIVE

Increased plasma dehydroepiandrosterone (DHEA) and dehydroepiandrosterone-sulfate (DHEAS) have been demonstrated in post-traumatic stress disorder (PTSD), but the documented beneficial effects of these steroids in enhancing mood and cognition, as well as neuroprotection, suggest their presence in PTSD may be associated with defensive rather than maladaptive effects.

METHOD

We, therefore, examined plasma DHEA, DHEAS, cortisol, and the DHEA/cortisol ratio in 40 male veterans with or without PTSD, and determined their relationships to PTSD symptom severity and symptom improvement.

RESULTS

The PTSD group showed significantly higher plasma DHEA and non-significantly higher DHEAS levels as well as a significantly lower cortisol/DHEA ratio, controlling for age. Regression analyses demonstrated that DHEA and DHEAS levels could be predicted by symptom improvement and coping, whereas the cortisol/DHEA ratio was predicted by severity of childhood trauma and current symptom severity.

CONCLUSION

That greater symptom improvement was related to DHEA levels may suggest for a role for these hormones in modulating recovery from PTSD.

Influence of Visible Light and Ultraviolet Irradiation on Motility and Fertility of Mammalian and Fish Sperm

OBJECTIVE

The effects of visible light irradiation on sperm motility, fertility, and reactive oxygen species (ROS) formation were investigated and compared in ram and fish (tilapia).

BACKGROUND DATA

Low-energy visible light has previously been found to modulate various processes in different biological systems. In the literature, it is accepted that the first step following visible light irradiation is the formation of ROS by endogenous cellular photosensitizers.

METHODS

Sperm of ram and tilapia were irradiated with various light sources (400-800 nm white light, 660 nm red light, 360 nm blue light, 294 nm UV), and their motility and fertility rates were measured. The amount of ROS generated by irradiation was estimated using electron paramagnetic resonance (EPR) technique.

RESULTS

Sperm taken from tilapia showed higher motility and fertility following red and white light irradiation. In contrast, the motility and fertility of ram sperm were slightly increased only by red light. A negative effect on motility and fertility of sperm of both species was obtained following irradiation with UV and blue light. The amount of ROS produced in irradiated tilapia sperm was much higher than that of ram sperm.

CONCLUSIONS

The results show that different wavelengths differentially affect tilapia and ram sperm motility and fertilization. The difference in response to the various light sources might be explained by the different amounts of ROS formation by ram and tilapia, which are in agreement with the physiology of fertilization appropriate to each of these species. Based on these results, it is suggested that in vitro fertilization in mammals should be performed in darkness or at least under red light.

Neuroendocrine aspects of PTSD

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

Childhood trauma and risk for PTSD: relationship to intergenerational effects of trauma, parental PTSD, and cortisol excretion

Among the adverse mental health consequences of childhood trauma is the risk related to the development of posttraumatic stress disorder (PTSD) in adulthood. Other risk factors for PTSD. including parental trauma exposure and parental PTSD, can also contribute to the experience of child trauma. We examined associations between childhood trauma and PTSD in 51 adult children of Holocaust survivors and 41 comparison subjects. in consideration of parental trauma exposure and parental PTSD. We also examined these variables in relation to 24-hr urinary cortisol levels. Adult offspring of Holocaust survivors showed significantly higher levels of self-reported childhood trauma, particularly emotional abuse and neglect. relative to comparison subjects. The difference was largely attributable to parental PTSD. Self-reported childhood trauma was also related to severity of PTSD in subjects, and emotional abuse was significantly associated with 24-hr mean urinary cortisol secretion. We conclude that the experience of childhood trauma may be an important factor in the transmission of PTSD from parent to child.

Paroxetine in the treatment of chronic posttraumatic stress disorder: results of a placebo-controlled, flexible-dosage trial

BACKGROUND

The objective of this double-blind, placebo-controlled study was to investigate the efficacy and safety of paroxetine in outpatients with posttraumatic stress disorder (PTSD).

METHOD

Male and female outpatients 18 years and older who met DSM-IV criteria for PTSD and had baseline scores of 50 or greater on the Clinician Administered PTSD Scale (CAPS-2) were randomly assigned to treatment with paroxetine (20-50 mg/day) or placebo for 12 weeks. The primary efficacy variables were the change from baseline to the 12-week endpoint in the CAPS-2 total score and the proportion of responders on the Clinical Global Impressions-Global Improvement scale (CGI-1). Additional key outcome measures were the change from baseline in the reexperiencing, avoidance/ numbing, and hyperarousal scores of the CAPS-2 and in the total scores of the Treatment Outcome PTSD Scale and the patient-rated Davidson Trauma Scale and Sheehan Disability Scale (SDS). Depressive symptoms were assessed with the Montgomery-Asberg Depression Rating Scale. The proportion of patients achieving response and remission was also determined.

RESULTS

307 patients constituted the intent-to-treat population. At week 12, compared with the placebo group (N = 156), the paroxetine group (N = 151) showed significantly greater reduction of PTSD symptoms on both of the primary and all of the secondary outcome measures. Significantly greater improvement on the CAPS-2 total score was observed for paroxetine compared with placebo from week 4 (p < .05), and significantly greater proportions of paroxetine-treated patients achieved response (p < .001) and remission (p = .008) by week 12. The improvement in PTSD symptoms was similar in male and female patients. Functional improvement at the study endpoint was significantly greater (p < .05) in the paroxetine group in all 3 domains of the SDS (work, social life, family life). Treatment with paroxetine was well tolerated, with the frequency and type of adverse events recorded for the paroxetine group corresponding to the known safety profile of this medication.

CONCLUSION

Paroxetine in doses of 20 to 50 mg once daily is effective as a treatment for chronic PTSD. Improvement is obtained for all 3 symptom clusters (reexperiencing, avoidance/numbing, hyperarousal) and is associated with significant reduction in disability after 12 weeks of treatment.

Variability and severity of depression and anxiety in post traumatic stress disorder and major depressive disorder

In order to better characterize the similarities in and differences between the nature of the affective disturbance associated with Posttraumatic Stress Disorder (PTSD) and with Major Depressive Disorder (MDD), self-reported mood and anxiety ratings were examined in PTSD subjects, MDD subjects, and subjects without a psychiatric disorder while they were undergoing a chronobiologic study. Based on serial ratings on visual analogue scales over a 24 hr period, PTSD subjects showed comparable levels of depression as the MDD group, as measured by the mean and maximum levels of mood; however, they had greater mood variability, as measured by the range and coefficients of variation of the mood ratings. The MDD but not the PTSD group had significantly lower mood variability than the non-psychiatric group, as measured by the coefficients of variation. The PTSD group reported higher levels of anxiety than the non-psychiatric or MDD group but showed no differences in any measure of variability of anxiety. These findings suggest there are phenomenologic differences in the affective symptoms experienced by patients with PTSD and with MDD and that mood variability may distinguish between them.

Biology of posttraumatic stress disorder

Most biological findings in posttraumatic stress disorder (PTSD) are compatible with those of the chronic stress response, such as increased corticotropin-releasing factor (CRF) concentrations, catecholamine depletion within the central nervous system, and reduced hippocampal volume. However, over the last 10 years, biological observations have been made in PTSD that are different from what has been typically associated with chronic stress, notably certain hypothalamic-pituitary-adrenal (HPA) axis findings. In particular, urinary and plasma cortisol levels are considerably lower in PTSD patients than in non-PTSD trauma survivors and normal controls. Furthermore, the circadian pattern of cortisol release from the adrenal glands follows a greater dynamic range in PTSD than in patients with major depression or in normal controls. The reduction in cortisol levels results from an enhanced negative feedback by cortisol, which is secondary to an increased sensitivity of glucocorticoid receptors in target tissues. This HPA axis alteration contrasts with the well-known chronic stress cascade in which CRF release results in erosion of negative feedback and down-regulation of glucocorticoid receptors. Sensitization of the HPA axis is consistent with the clinical picture of hyperreactivity and hyperresponsiveness in PTSD.

Relationship of parental trauma exposure and PTSD to PTSD, depressive and anxiety disorders in offspring

This study examined the relationship of parental trauma exposure and PTSD to the development of posttraumatic stress disorder (PTSD), depressive and anxiety disorders in the adult offspring of Holocaust survivors. One hundred and thirty-five subjects (55 men and 80 women) were divided into three groups according to parental trauma exposure and PTSD: 60 subjects were offspring of Holocaust survivors who endorsed having at least one parent with PTSD, 33 were offspring of Holocaust survivors who reported having no parent with PTSD, and 42 were demographically similar subjects with no parental Holocaust exposure. All subjects underwent a comprehensive psychiatric interview in which information about lifetime psychiatric diagnoses and exposure to traumatic events was obtained. Subjects also completed a checklist based on the 17 DSM-IV symptoms of PTSD, to estimate the symptom severity of PTSD in their parents. A presumptive diagnosis of parental PTSD was assigned according to DSM-IV criteria. Forward and forced entry stepwise logistic regression analyses were used to determine the effects of parental exposure, parental PTSD, and the subject's own history of trauma in the development of PTSD, depressive, and anxiety disorders in the offspring. The findings demonstrate a specific association between parental PTSD and the occurrence of PTSD in offspring. Additionally, parental trauma exposure, more than parental PTSD, was found to be significantly associated with lifetime depressive disorder. The identification of parental PTSD as a risk factor for PTSD in offspring of Holocaust survivors defines a sample in which the biological and psychological correlates of risk for PTSD can be further examined.

CSF norepinephrine concentrations in posttraumatic stress disorder

OBJECTIVE

Despite evidence of hyperresponsive peripheral and central nervous system (CNS) noradrenergic activity in posttraumatic stress disorder (PTSD), direct measures of CNS norepinephrine in PTSD have been lacking. The goal of this study was to determine serial CSF norepinephrine levels in patients with PTSD.

METHOD

CSF samples were obtained serially over a 6-hour period in 11 male combat veterans with chronic PTSD and eight healthy men through an indwelling subarachnoid catheter. Thus the authors were able to determine hourly CSF norepinephrine concentrations under baseline (unstressed) conditions. Severity of the patients' PTSD symptoms was assessed with the Clinician-Administered PTSD Scale.

RESULTS

CSF norepinephrine concentrations were significantly higher in the men with PTSD than in the healthy men. Moreover, CSF norepinephrine levels strongly and positively correlated with the severity of PTSD symptoms. Plasma norepinephrine concentrations showed no significant relationship with the severity of PTSD symptoms.

CONCLUSIONS

These findings reveal the presence of greater CNS noradrenergic activity under baseline conditions in patients with chronic PTSD than in healthy subjects and directly link this pathophysiologic observation with the severity of the clinical posttraumatic stress syndrome.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Clinical treatment of posttraumatic stress disorder: conceptual challenges raised by recent research

OBJECTIVE

This paper highlights some of the recent findings in the field of posttraumatic stress disorder (PTSD) and examines their impact on conceptions of trauma-focused clinical treatment.

METHOD

A series of research findings in the area of epidemiology, phenomenology, neurobiology and treatment are summarised.

RESULTS

The findings from these studies present critical challenges for clinicians who wish to treat trauma survivors using specialised trauma treatments. The major challenge is one of avoiding a simplistic view of PTSD as a singular response to trauma, as this perception may result in an underestimation of the complexity and disabling quality of the disorder, and lead to the formulation of treatment plans that are simplistic or incomplete.

CONCLUSIONS

A more precise characterisation of the nature and range of the stress responses of trauma victims will significantly improve treatments of trauma survivors.

Low cortisol and risk for PTSD in adult offspring of holocaust survivors

OBJECTIVE

The study examined the association between cortisol and putative risk factors for posttraumatic stress disorder (PTSD) in a sample of subjects at increased risk for the development of PTSD.

METHOD

Twenty-four-hour urinary cortisol excretion was measured in 35 adult offspring of Holocaust survivors and 15 healthy comparison subjects who were not offspring of Holocaust survivors. Subjects were also characterized with regard to clinical symptoms, presence or absence of psychiatric diagnoses including PTSD, and presence or absence of PTSD in their parents.

RESULTS

Low cortisol levels were significantly associated with both PTSD in parents and lifetime PTSD in subjects, whereas having a current psychiatric diagnosis other than PTSD was relatively, but nonsignificantly, associated with higher cortisol levels. Offspring with both parental PTSD and lifetime PTSD had the lowest cortisol levels of all study groups.

CONCLUSIONS

Parental PTSD, a putative risk factor for PTSD, appears to be associated with low cortisol levels in offspring, even in the absence of lifetime PTSD in the offspring. The findings suggest that low cortisol levels in PTSD may constitute a vulnerability marker related to parental PTSD as well as a state-related characteristic associated with acute or chronic PTSD symptoms.

Biology of posttraumatic stress disorder

An understanding of the biological basis of posttraumatic stress disorder (PTSD) requires an examination of the underlying neurobiology of fear and the factors that might contribute to an unsuccessful termination of the fear response in some individuals. Several factors may lead to an inadequate termination of a stress response, and the failure to contain the biological alterations initiated by stress may have long-term adverse consequences. In particular, a prolonged continuation of biological responses following stress may lead to an inappropriate pairing of the traumatic memory with distress and may then initiate a cascade of secondary biological alterations. This article examines some of the biological alterations in PTSD and develops a framework for understanding the development progression of the neurobiology of this disorder.

Behavioral and endocrine response to cholecystokinin tetrapeptide in patients with posttraumatic stress disorder

BACKGROUND

Given the relationship between posttraumatic stress disorder (PTSD) and panic, it was of interest to examine whether panic provoking agents affect PTSD symptoms. We therefore investigated the behavioral and endocrine response of PTSD patients to the panicogen cholecystokinin tetrapeptide (CCK-4).

METHODS

Eight patients with PTSD (DSM-IV) received 50 micrograms CCK-4 intravenously in a placebo-controlled, double-blind balanced design. Provocation of panic, anxiety, and flashbacks was assessed. Plasma adrenocorticotropin (ACTH) and cortisol levels after CCK-4 were measured and compared to healthy subjects matched for age, gender, and provoked symptoms.

RESULTS

Despite significant effects of CCK-4 on anxiety and panic symptoms, no significant provocation of flashbacks emerged. CCK-4-induced panic symptoms showed an inverse correlation to trait dissociation. The ACTH response after CCK-4 was significantly lower in PTSD patients than in controls. Cortisol was similarly increased in both groups after CCK-4, but PTSD patients showed a more rapid decrease of stimulated cortisol concentrations.

CONCLUSIONS

Panic symptoms or heightened anxiety are not necessarily conditioned stimuli for the provocation of posttraumatic flashbacks. Further studies in PTSD with different panicogens should be controlled for the potential interference of trait dissociation. Our hormone data show further evidence for a corticotropin-releasing hormone (CRH) overdrive and enhanced negative glucocorticoid feedback in PTSD patients.

Linking the neuroendocrinology of post-traumatic stress disorder with recent neuroanatomic findings

It has been hypothesized that stress damages the hippocampus and results in myriad other deleterious consequences owing to the toxic effects of cortisol, presumed to be released in excess in response to traumatic stress. Several studies have now demonstrated that hippocampal volumes of trauma survivors with post-traumatic stress disorder (PTSD) are reduced compared to those of nontraumatized persons. Interestingly, however, there is little evidence of increased cortisol release in either the acute or chronic aftermath of stress in trauma survivors who develop this disorder, raising questions about the etiology of the smaller hippocampal volumes as well as the relationship between the neuroendocrine and neuroanatomic alterations in PTSD. This article will review hypothalamic-pituitary-adrenal alterations in PTSD in an attempt to link the neuroendocrine findings with the observation of reduced hippocampal volume. It will be argued that the resolution of the neuroendocrine and neuroanatomic alterations in PTSD depends on understanding the pivotal role of glucocorticoids and their action at glucocorticoid receptors at target brain areas in response to stress and in PTSD.

Managing anger and aggression in patients with posttraumatic stress disorder

Posttraumatic stress disorder was categorized as a clinical entity in 1980 in response to assertions by trauma survivors (particularly Vietnam veterans) and their clinicians that existing diagnostic categories failed to adequately describe their symptoms. The diagnostic features of the current DSM-IV diagnosis have been expanded, and the concept of the disorder is still evolving. Posttraumatic stress disorder rarely occurs in "pure" form, and individuals suffering from the disorder commonly meet criteria for Axis I and Axis II disorders. Research is now emerging that supports the prevalence of aggression in posttraumatic stress disorder. Treatment approaches vary, but pharmacotherapy aimed at targeting individual symptoms or clusters can promote mood stabilization. This article discusses the evolving concept of posttraumatic stress disorder as a clinical entity, the association of anger and aggression with the disorder, and the psychopharmacologic approaches to treatment.

Biological factors associated with susceptibility to posttraumatic stress disorder

Because only a proportion of persons exposed to traumatic events develop posttraumatic stress disorder (PTSD), it has become important to elucidate the factors that increase the risk for the development of PTSD following trauma exposure as well as the factors that might serve to protect individuals from developing this condition. Putative risk factors for PTSD may describe the index traumatic event or characteristics of persons who experience those events. Recent data have implicated biological and familial risk factors for PTSD. For example, our recent studies have demonstrated an increased prevalence of PTSD in the adult children of Holocaust survivors, even though these children, as a group, do not report a greater exposure to life-threatening (Diagnostic and Statistical Manual of Mental Disorders [DSM-IV] Criterion A) events. These studies are reviewed. It is difficult to know to what extent the increased vulnerability to PTSD in family members of trauma survivors is related to biological or genetic phenomena, as opposed to experiential ones, because of the large degree of shared environment in families. In particular, at-risk family members, such as children, may be more vulnerable to PTSD as a result of witnessing the extreme suffering of a parent with chronic PTSD rather than because of inherited genes. But even if the diathesis for PTSD were somehow "biologically transmitted" to children of trauma survivors, the diathesis is still a consequence of the traumatic stress in the parent. Thus, even the most biological of explanations for vulnerability must at some point deal with the fact that a traumatic event has occurred.

Neuroendocrine activity and memory-related impairments in posttraumatic stress disorder

This article reviews memory-related impairments in trauma survivors with posttraumatic stress disorder and their possible association to neuroendocrine alterations seen in this disorder. The neuroendocrine profile in PTSD first described in chronically ill combat veterans is characterized by lower basal cortisol levels, higher glucocorticoid receptor number, enhanced sensitivity to exogenous steroids, and increased variation in basal cortisol levels over the diurnal cycle. The generalizability and time course of these neuroendocrine alterations are explored in longitudinal studies and studies in other traumatized populations. These studies suggest that at least some aspects of this neuroendocrine profile can also be seen in other populations, including women, children, and victims of childhood trauma. Additionally, the alterations may be present early in the course of illness, perhaps even in the immediate aftermath of trauma, and may continue to be manifest in elderly trauma survivors. The mechanisms by which these neuroendocrine alterations may influence the formation and processing of traumatic memories are discussed.

Predicting the development of posttraumatic stress disorder from the acute response to a traumatic event

Posttraumatic stress disorder (PTSD) is a psychiatric condition that is directly precipitated by an event that threatens a person's life or physical integrity and that invokes a response of fear, helplessness, or horror. In recent years it has become clear that only a proportion of those exposed to fear-producing events develop or sustain PTSD. Thus, it seems that an important challenge is to elucidate aberrations in the normal fear response that might precipitate trauma-related psychiatric disorder. This paper summarizes the findings from recent studies that examined the acute and longer term biological response to traumatic stress in people appearing to the emergency room immediately following trauma exposure. In the aggregate, these studies have demonstrated increased heart rate and lower cortisol levels at the time of the traumatic event in those who have PTSD at a follow-up time compared to those who do not. In contrast, certain features associated with PTSD, such as intrusive symptoms and exaggerated startle responses, are only manifest weeks after the trauma. The findings suggest that the development of PTSD may be facilitated by an atypical biological response in the immediate aftermath of a traumatic event, which in turn leads to a maladaptive psychological state.

Vulnerability to posttraumatic stress disorder in adult offspring of Holocaust survivors

OBJECTIVE

There has been considerable controversy regarding the impact of the Holocaust on the second generation, but few empirical data are available that systematically document trauma exposure and psychiatric disorder in these individuals. To obtain such data, the authors examined the prevalence of stress and exposure to trauma, current and lifetime posttraumatic stress disorder (PTSD), and other psychiatric diagnoses in a group of adult offspring of Holocaust survivors (N=100) and a demographically similar comparison group (N=44).

METHOD

Subjects were recruited from both community and clinical populations and were evaluated with the use of structured clinical instruments. Stress and trauma history were evaluated with the Antonovsky Life Crises Scale and the Trauma History Questionnaire, PTSD was diagnosed with the Clinician Administered PTSD Scale, and other psychiatric disorders were evaluated according to the Structured Clinical Interview for DSM-IV.

RESULTS

The data show that although adult offspring of Holocaust survivors did not experience more traumatic events, they had a greater prevalence of current and lifetime PTSD and other psychiatric diagnoses than the demographically similar comparison subjects. This was true in both community and clinical subjects.

CONCLUSIONS

The findings demonstrate an increased vulnerability to PTSD and other psychiatric disorders among offspring of Holocaust survivors, thus identifying adult offspring as a possible high-risk group within which to explore the individual differences that constitute risk factors for PTSD.

Plasma norepinephrine and 3-methoxy-4-hydroxyphenylglycol concentrations and severity of depression in combat posttraumatic stress disorder and major depressive disorder

BACKGROUND

Catecholamines are thought to play a significant role in the pathophysiology of posttraumatic stress disorder (PTSD), but findings in PTSD have been discrepant.

METHODS

To obtain more information about catecholamine activity in PTSD, we sampled plasma norepinephrine (NE) and 3-methoxy-4-hydroxyphenylglycol (MHPG) concentrations over a 24-hour period in men with PTSD (n = 15) and major depressive disorder (MDD) (n = 12), and nonpsychiatric comparison subjects (n = 13), under unstimulated conditions. Chronobiological analyses were performed to determine possible changes in the circadian and ultradian release of these hormones.

RESULTS

Significant group differences were present for mean plasma NE levels (p = .03), but not MHPG. NE levels were significantly associated with severity of depression in the PTSD group (p = .002). Therefore, PTSD subjects were further subdivided into those with and without a comorbid secondary depression. Increased NE levels were only present in PTSD subjects who did not have a secondary depression. This study also found no significant group differences on any of the chronobiological parameters.

CONCLUSIONS

The results clarify that increased NE levels in PTSD may be confined to the subgroup of subjects who do not have comorbid depression, and as such, may help resolve some of the discrepancies in the literature regarding basal catecholamine activity.

Predictors of cortisol and 3-methoxy-4-hydroxyphenylglycol responses in the acute aftermath of rape

BACKGROUND

Prospective studies of trauma survivors can provide information about the relationship between rape characteristics and the development of subsequent symptoms.

METHODS

The present study examined the relationship of prior assault, rape severity, posttraumatic stress disorder (PTSD) symptoms following rape, and subsequent PTSD diagnosis, to the acute cortisol and 3-methoxy-4-hydroxyphenylglycol (MHPG) response to this traumatic event in 20 women.

RESULTS

Women with a history of prior physical or sexual assault showed a significantly attenuated cortisol response to the acute stress of rape compared to women without such a history. MHPG appeared to be associated with injury-related rape characteristics, and symptoms of active avoidance, but not prior history. PTSD status at the 3-month follow-up was predicted by both a prior history of assault and high injury rape, but was not directly predicted by either cortisol or MHPG levels. MHPG and cortisol were not correlated in the sample as a whole, but were correlated among individuals who did not subsequently develop PTSD (p = .04)

CONCLUSIONS

The results suggest that different neuroendocrine systems may mediate different components of the response to traumatic stress.

Psychoneuroendocrinology of post-traumatic stress disorder

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

Relationship between posttraumatic stress disorder characteristics of Holocaust survivors and their adult offspring

OBJECTIVE

There is controversy regarding the long-lasting effects of the Holocaust on the adult children of Holocaust survivors. In the present study the authors examined the relationship between posttraumatic stress disorder (PTSD) characteristics of Holocaust survivors and their adult children to determine whether differences in symptom severity or diagnostic status of parents would be associated with similar characteristics in their adult children.

METHOD

Holocaust survivors (N = 22) and their offspring (N = 22) were interviewed with several instruments to assess lifetime trauma history, effect of trauma on one's life, level of intrusive and avoidance symptoms in response to reminders of the Holocaust, current and lifetime PTSD, and current and lifetime axis I psychiatric disorder other than PTSD.

RESULTS

There were significant relationships between parents and children regarding the effect of trauma on one's life and level of intrusive, but not avoidance, symptoms in response to reminders of the Holocaust. Offspring with traumatic events were more likely to develop PTSD if their parents had PTSD.

CONCLUSIONS

Symptoms in offspring may be related to presence and severity of symptoms in the parent. Furthermore, PTSD in the parent may be a risk factor for PTSD in offspring.

Relationship between 3-methoxy-4-hydroxyphenylglycol and homovanillic acid in saliva and plasma of healthy volunteers

Plasma 3-methoxy-4-hydroxyphenylglycol (MHPG) and homovanillic acid (HVA) levels may reflect changes in central noradrenergic and dopaminergic activity, respectively. The relationship between MHPG and HVA in saliva and plasma was investigated to evaluate the utility of salivary metabolite measurement as a relatively noninvasive and useful alternative to plasma analysis. MHPG and HVA in saliva and plasma, collected concurrently, from 12 healthy volunteers, were measured by high-performance liquid chromatography. Concentration of free MHPG in saliva correlated significantly with plasma free MHPG. Salivary free MHPG was significantly higher than in plasma. Enzymatic hydrolysis of conjugated MHPG corroborated other work that plasma free MHPG, MHPG-glucuronide, and MHPG-sulfate were in roughly equal proportions. Unpredictably, in saliva, free MHPG was greater than 80% of the total. Salivary and plasma free HVA concentrations also correlated significantly, but salivary HVA levels were significantly lower than in plasma. Conjugated HVA was consistently less than 10% of total both in saliva and plasma. These findings suggest that salivary MHPG and HVA can reflect plasma metabolite levels. Although local factors may influence their formation and concentration in saliva, large changes in plasma free MHPG or HVA could be reflected by parallel changes in saliva.

Enhanced dexamethasone suppression of plasma cortisol in adult women traumatized by childhood sexual abuse

A study was undertaken to determine if female survivors of childhood and/or adolescent sexual abuse (CSA) would exhibit hypothalamic-pituitary-adrenal (HPA) axis abnormalities characteristic of patients with combat-related posttraumatic stress disorder (PTSD)--i.e., enhanced cortisol suppression to low-dose dexamethasone and increased density of lymphocyte glucocorticoid receptors. Nineteen women who reported experiencing severe CSA and 21 nonvictimized women participated in a low-dose (0.5 mg) dexamethasone suppression test and donated blood for measurement of lymphocyte glucocorticoid receptor binding. Women with CSA had significantly enhanced suppression of plasma cortisol in response to 0.5 mg dexamethasone compared to the nonvictimized women. These observations are consistent with findings in male veterans with combat-related PTSD. They suggest that this pattern of HPA axis dysfunction may be a characteristic sequel of psychiatric disorders that occur following a range of traumatic experiences. This HPA axis profile is different than that associated with acute stress or with major depressive disorder.

Reduced sensitivity to glucocorticoid feedback and reduced glucocorticoid receptor mRNA expression in the luteal phase of the menstrual cycle

We examined the effects of the menstrual cycle on hypothalamic-pituitary adrenal axis regulation in healthy women with no history of psychiatric illness by measuring plasma cortisol responses to a low-dose (0.25 mg) of dexamethasone (N = 23) and by measuring glucocorticoid receptor (type II) mRNA expression in lymphocytes using Northern blotting (N = 19). Both measures were performed in the early follicular and mid-luteal phases of the menstrual cycle. Dexamethasone suppression of plasma cortisol was greater in the follicular phase of the menstrual cycle compared to the mid-luteal phase (p < .01). In addition, type II glucocorticoid receptor mRNA expression in lymphocytes was 78% higher in the follicular phase compared to the mid-luteal phase (p < .02). These results indicate that glucocorticoid feedback regulation of the hypothalamic-pituitary-adrenal axis is reduced in the mid-luteal phase of the menstrual cycle. Reduced feedback regulation of central stress response systems may play a role in generation of common premenstrual symptoms of irritability and dysphoria.

Individual differences in posttraumatic stress disorder symptom profiles in Holocaust survivors in concentration camps or in hiding

Symptom patterns were compared between Holocaust survivors in concentration camp (n = 70) and those who were in "hiding" (n = 30) during the war. The impact of age at the time of the trauma, gender, and cumulative lifetime stress, and the effect of each of these variables controlling for the others, on posttraumatic stress disorder (PTSD) symptoms were also evaluated. A significant negative relationship between age at the time of the trauma and symptoms of psychogenic amnesia, hypervigilence and emotional detachment, and a positive correlation between age and intrusive thoughts, were observed. Cumulative lifetime stress was positively associated with symptoms of avoidance. The study provides the first empirical data regarding the factors that potentially explain individual differences in PTSD symptom patterns in Holocaust survivors.

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

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