Individual variation in plasma oxytocin and vasopressin levels in relation to the development of combat-related PTSD in a large military cohort

In an attempt to decrease the risk of developing mental health problems after military deployment, it is important to find biological markers to identify those at risk. Oxytocin (OT) and arginine vasopressin (AVP) are potential biomarkers for the development of posttraumatic stress disorder (PTSD) because they are involved in the regulation of stress and anxiety. Therefore, the aim was to examine whether plasma OT (pOT) and AVP (pAVP) levels before and after deployment are biomarkers for the development of posttraumatic stress symptoms over time in addition to other known risk factors. This study is part of a large prospective cohort study on candidate markers for stress-related mental health symptoms and resiliency after deployment to a combat zone; Prospective Research in Stress-related Military Operations (PRISMO; N = 907). Data was collected prior to deployment and follow-ups were performed at 1 and 6 months, and 1, 2, and 5 years post-deployment. Blood samples were collected in the first three assessments. The levels of pOT and pAVP were not significantly related to the development of PTSD symptoms over time. The results confirm that age, the experience of early life trauma, combat-related stressors and the presence of depressive symptoms are predictive for the development of PTSD symptoms over time. These findings showed that peripherally measured OT and AVP currently do not qualify as useful susceptibility biomarkers for the development of PTSD symptoms over time in military men after combat.

The gut peptide neuropeptide Y and post-traumatic stress disorder

PURPOSE OF REVIEW

This article reviews the role of neuropeptide Y (NPY) in the pathophysiology of post-traumatic stress disorder (PTSD) and gastrointestinal disorders such as irritable bowel syndrome (IBS) with which PTSD is highly comorbid. NPY is low in the cerebrospinal fluid and plasma of male combat veterans with PTSD and correlates negatively with sympathetic nervous system (SNS) hyperreactivity, PTSD symptoms and time to recovery. NPY regulation has not yet been evaluated in women with PTSD.

RECENT FINDINGS

NPY levels in bowel tissue are low in IBS with diarrhea (IBS-D) versus IBS with constipation. The density of ghrelin containing cells of the gastric oxyntic mucosa is markedly increased in IBS-D. PTSD-related SNS hyperreactivity may interact with this substrate to increase ghrelin release, which activates receptors in the lumbosacral spinal cord and basolateral amygdala to increase colonic motility and amygdala hyperreactivity, respectively. Loss of function gene polymorphisms in adrenergic α2-autoreceptors and increased corticotropin-releasing hormone, as observed in PTSD, are also thought to contribute to IBS-D.

SUMMARY

Knowledge of shared underlying NPY system-related neurobiological factors that contribute to the comorbidity of PTSD and gastrointestinal disorders may help guide research, development and prescription of targeted and more effective individualized therapeutic interventions.

Increased pro-inflammatory milieu in combat related PTSD - A new cohort replication study

INTRODUCTION

Several lines of evidence indicate that increased inflammation is associated with Post-Traumatic Stress Disorder (PTSD). We have previously reported that peripheral inflammatory markers are significantly higher in combat-exposed veterans with than without PTSD. This study was designed to replicate these findings in a new study cohort using the same population and recruitment strategies.

METHODS

Sixty-one male war veterans (31 PTSD and 30 control subjects) were included in this replication study. Levels of Interleukin-6, Tumor Necrosis Factor-alpha, Gamma interferon, and high-sensitivity C-reactive protein were quantified in blood samples. A standardized "total pro-inflammatory score" was calculated to limit the number of statistical comparisons. The Clinician Administered PTSD Scale (CAPS) rating scale was used to assess PTSD symptom severity.

RESULTS

PTSD subjects had significantly higher total pro-inflammatory scores compared to non-PTSD subjects in unadjusted analysis (Cohen's d=0.75, p=0.005) as well as after adjusting for potentially confounding effects of age, BMI, smoking, and potentially interfering medications and somatic co-morbidities (p=0.023). There were no significant correlations between inflammatory markers and severity of symptoms within the PTSD group.

CONCLUSIONS

We replicated, in a new sample, our previous finding of increased inflammatory markers in combat-exposed PTSD subjects compared to combat-exposed non-PTSD controls. These findings strongly add to the growing literature suggesting that immune activation may be an important aspect of PTSD pathophysiology, although not directly correlated with current PTSD symptom levels in the PTSD group.

Serum concentrations of TNF-α and its soluble receptors during psychotherapy in German soldiers suffering from combat-related PTSD

BACKGROUND

Changes in serum concentrations of tumor necrosis factor-α (TNF-α) and its soluble receptors (sTNF-R) p55 and p75 have been shown to be associated with various psychiatric treatments.

SUBJECTS AND METHODS

Before and after treatment, serum levels of TNF-α, sTNF-R p55 and sTNF-R p75 were measured in 38 German soldiers who had been deployed abroad and suffered from combat-related post-traumatic stress disorder (PTSD). Patients were randomized either to inpatient psychotherapy (N=21) including eye movement desensitization and reprocessing (EMDR) or to outpatient clinical management (N=17). Symptoms of PTSD were measured using the Post-traumatic Stress Diagnostic Scale (PDS).

RESULTS

The PDS score significantly decreased across time in both groups. Serum concentrations of TNF-α increased, while sTNF-R p55 and sTNF-R p75 levels decreased significantly. After the treatment period, we could not detect any significant difference regarding TNF-α, sTNF-R p55 or sTNF-R p75 levels between the inpatient psychotherapy group and the outpatient clinical management control group.

CONCLUSIONS

This relatively small clinical study suggests that specific inpatient psychotherapy but also non-specific supportive outpatient treatment for PTSD are associated with changes in the TNF-α system. This may represent an immunological effects or side effects of psychotherapy.

Eicosapentaenoic acid in serum lipids could be inversely correlated with severity of clinical symptomatology in Croatian war veterans with posttraumatic stress disorder

AIM

To explore the association between plasma fatty acids composition and the severity of clinical symptoms in Croatian war veterans with posttraumatic stress disorder (PTSD).

METHODS

This cross-sectional study included 62 men diagnosed with PTSD caused by combat activities during the War in Croatia 1991-1995. Clinician-Administered PTSD Scale (CAPS), Hamilton Anxiety Rating Scale (HAM-A), and Hamilton Depression Rating Scale (HAM-D-17) were used. Plasma fatty acids composition was determined by gas chromatography. Data about life-style habits were collected by a structured interview. To evaluate the association between plasma fatty acid levels and PTSD severity scales, multivariate general linear models (GLM) were applied while controlling for different confounders.

RESULTS

Significant negative correlations were found between plasma eicosapentaenoic acid (EPA, 20:5n-3) level and the scores on psychological scales (τ = -0.326, P<0.001 for CAPS; τ-0.304, P =0 .001 for HAM-A; and τ = -0.345, P<0.001 for HAM-D-17). GLM confirmed that PTSD severity was affected by EPA (Wilks'Λ = 0.763-0.805, P = 0.006-0.018, ηp 0.195-0.237), arachidonic acid (AA)/EPA (Wilks'Λ = 0.699-0.757, P = 0.004, ηp 0.243-0.301), and dairy products consumption (Wilks'Λ = 0.760-0.791, P = 0.045-0.088, ηp 0.128-0.111). No other fatty acid or dietary/lifestyle variable was significant ( P = 0.362-0.633).

CONCLUSION

The study suggests that lower EPA levels are associated with the severity of clinical symptoms in PTSD.

[Blood lipid parameters in combat veterans with posttraumatic stress disorders]

AIM

To study the specific features of blood lipid composition in combat veterans (CVs) with posttraumatic stress disorder (PTSD).

SUBJECTS AND METHODS

One hundred and sixty-one CVs were examined; their mean age was 42.8 +/- 0.7 years. All the patients underwent a clinical and neurological examination using additional studies. I.O. Kotenev's trauma stress questionnaire was used. The mean intensity of PTSD was 65.5 +/- 0.95 scores. Fasting biochemical blood tests were carried out using clinical chemical analyzers.

RESULTS

Dyslipidemias characterized mainly by elevated levels of total cholesterol and low-density lipoproteins are identified in the majority of present-day CVs. Higher triglyceride levels and lower high-density lipoproteins are encountered 2 and 1.5 times more frequently, respectively. A tendency has been found towards an inverse correlation between the degree of PTSD and the levels of total cholesterol and low-density lipoproteins.

CONCLUSION

Neuroendocrine changes accompanying PTSD and leading to intensified adrenergic influences are an important trigger of accelerated hyperlipidemia development in CVs. Age-related changes and metabolic hepatic disorders associated with alcohol abuse and consequences of prior infectious diseases have become to play an important role in the pathogenesis of dyslipidemias in patients over 40-45 years of age.

Baseline level of platelet-leukocyte aggregates, platelet CD63 expression, and soluble P-selectin concentration in patients with posttraumatic stress disorder: a pilot study

Platelets may have an important role in the development of cardiovascular disease (CVD) as a result of chronic stress. We conducted a pilot study to evaluate the effect of posttraumatic stress disorder (PTSD) on baseline platelet activation. Platelet-leukocyte aggregates (PLA) and CD63 expression were measured by flow cytometry, and soluble (s)P-selectin concentration was determined in sera of 20 Croatian male combat veterans with PTSD and 20 healthy civilians. Groups were matched in sex, age, body mass index (BMI) and traditional CVD risk factors. Our data showed no differences in measured parameters. Other platelet activation markers should be determined and a larger sample size used in future studies.

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.

Post-traumatic stress disorder and diabetes: co-morbidity and outcomes in a male veterans sample

The purpose of this study was to assess the prevalence and correlates of comorbid diabetes and Post-Traumatic Stress disorder(PTSD)and potential relationships between PTSD and diabetes outcomes. Male patients enrolled in a VA primary care database (N = 73,270) were classified as having diabetes from pharmacy records (N = 14,438) and grouped into those with diagnoses of PTSD with depression (N = 649), PTSD-only (N = 480), Depression-only (N = 1696), Other psychiatric diagnosis (N = 736), or No psychiatric diagnosis (N = 10,877) based on the Purpose of Visit diagnoses in the medical record. Outcomes included glycemic control (HbA1c), cholesterol and triglycerides. Correlates were age, substance use disorder, other psychiatric diagnosis, number of primary care encounters, and medications. The prevalence of comorbid diabetes and PTSD was 8% (n = 1129). Of these, 57% (n = 649) had comorbid depression. Patients with PTSD and depression had higher rates of substance use disorder and higher cholesterol and LDL. Patients with depression had poorer glycemic control. Patients with PTSD and depression weighed more and had higher BMI than patients with neither diagnosis. Thus, male diabetes patients with PTSD and depression may be vulnerable to substance use disorders and to weight/lipid problems that can affect health. Depression is a likely contributor to poor glycemic control. Careful screening for mental health comorbidities is needed for diabetes patients.

Platelet serotonin in combat related posttraumatic stress disorder with psychotic symptoms

BACKGROUND

Combat-related posttraumatic stress disorder (PTSD) is severe form of PTSD, frequently associated with psychotic symptoms. Platelet serotonin (5-hydroxytryptamine, 5-HT) was used as a peripheral 5-HT marker to identify particular symptoms in PTSD.

METHODS

Platelet 5-HT was determined fluorimetrically in 67 war veterans with combat related PTSD, 36 combat exposed veterans who did not develop PTSD, 35 veterans with PTSD complicated with psychotic features. PTSD diagnosis of current and chronic PTSD, and clinical symptoms of PTSD and psychoses were assessed according to DSM-IV criteria, using the Clinician Administrated PTSD Scale, and Positive and Negative Syndrome Scale (PANSS).

RESULTS

Platelet 5-HT concentration was significantly higher in veterans with psychotic PTSD than in veterans with non-psychotic PTSD, veterans without PTSD, or in control subjects. Platelet 5-HT was significantly positively correlated with the positive symptoms in PANSS subscale, and with the symptoms of delusions within PANSS positive subscale.

LIMITATIONS

The results were obtained on peripheral 5-HT marker, i.e. platelet 5-HT concentration.

CONCLUSIONS

Since the delusions are the core psychotic symptoms occurring in our psychotic PTSD patients, the result of the increased platelet 5-HT concentration, associated with delusions, indicate that platelet 5-HT might be used as a trait marker of psychotic symptoms in PTSD, but not as a state marker for PTSD.

Alterations in cortisol negative feedback inhibition as examined using the ACTH response to cortisol administration in PTSD

OBJECTIVE

Studies using the dexamethasone suppression test (DST) have demonstrated an enhanced negative feedback inhibition at the pituitary in PTSD, but have not provided information about central feedback effects, since dexamethasone (DEX) does not penetrate the brain well. The authors therefore examined the change in ACTH and cortisol before and after cortisol administration, which acts at central feedback sites in addition to peripheral targets.

METHOD

Blood was obtained from 31 male veterans (18 with PTSD) before, and 8, 40 and 95 min following injection of 17.5 mg cortisol and placebo.

RESULTS

A greater decline in ACTH was observed after cortisol injection in PTSD.

CONCLUSIONS

Central as well as peripheral negative feedback inhibition may be altered in PTSD.

Higher levels of basal serial CSF cortisol in combat veterans with posttraumatic stress disorder

OBJECTIVE

Results of basal peripheral cortisol measures in posttraumatic stress disorder (PTSD) have been variable. The authors' goal was to measure CSF cortisol concentrations, which more accurately reflect brain glucocorticoid exposure, in subjects with or without PTSD.

METHOD

CSF was withdrawn from a subarachnoid catheter and plasma from a venous catheter, both indwelling, over a 6-hour interval to determine hourly plasma ACTH and cortisol concentrations and hourly CSF cortisol levels in eight well-characterized combat veterans with PTSD and eight matched healthy volunteers.

RESULTS

Mean CSF cortisol concentrations were significantly higher in the subjects with PTSD (3.18 ng/ml, SD=0.33) than in the normal volunteers (2.33 ng/ml, SD=0.50), largely due to higher CSF cortisol concentration nadirs. No group differences were observed in either plasma ACTH or peripheral (plasma or urinary free) cortisol. CSF corticotropin-releasing hormone and CSF cortisol concentrations were positively and significantly correlated.

CONCLUSIONS

Despite normal peripheral cortisol indexes in the veterans with PTSD, their CNS exposure to cortisol was greater than that of normal comparison subjects.

Glucocorticoid receptor polymorphisms and post-traumatic stress disorder

Post-traumatic stress disorder (PTSD) is reported in some studies to be associated with increased glucocorticoid (GC) sensitivity. Two common glucocorticoid receptor (GR) polymorphisms (N363S and BclI) appear to contribute to the population variance in GC sensitivity. There is some evidence that there may be a genetic predisposition to PTSD. Hence we studied 118 Vietnam war veterans with PTSD for (i) GR polymorphisms, particularly the N363S and the BclI polymorphisms which are thought to be GC sensitising, and (ii) two measures of GC sensitivity, the low-dose 0.25 mg dexamethasone suppression test (LD-DST) and the dermal vasoconstrictor assay (DVVA). The DST and GR polymorphisms were also performed in 42 combat exposed Vietnam war veterans without PTSD. Basal plasma cortisol levels were not significantly different in PTSD (399.5+/-19.2 nmol/L, N=75) and controls (348.6+/-23.0 nmol/L, N=33) and the LD-DST resulted in similar cortisol suppression in both groups (45.6+/-3.2 vs. 40.8+/-4.1%). The cortisol suppression in PTSD patients does not correlate with Clinician Administered PTSD Scores (CAPS), however there was a significant association between the BclI GG genotype and low basal cortisol levels in PTSD (P=0.048). The response to the DVVA was similar to controls (945+/-122, N=106 vs. 730+/-236, N=28, P=0.42). PTSD patients with the GG genotype, however, tended to be more responsive to DVVA and in this group the DVVA correlated with higher CAPS scores. The only exon 2 GR polymorphisms detected were the R23K and N363S. Heterozygosity for the N363S variant in PTSD, at 5.1% was not more prevalent than in other population studies of the N363S polymorphism in Caucasians (6.0-14.8%). The GG genotype of the BclI polymorphism found to be associated with increased GC sensitivity in many studies showed a tendency towards increased response with DVVA and correlated with higher CAPS scores. In conclusion, the N363S and BclI GR polymorphisms were not more frequent in PTSD patients than controls and reported population frequencies. Our PTSD group did not display GC hypersensitivity, as measured by the LD-DST and DVVA. In a subset of PTSD patients with the BclI GG genotype, CAPS scores and basal cortisol levels were negatively correlated.

Increase of serum triiodothyronine concentration in soldiers with combat-related chronic post-traumatic stress disorder with or without alcohol dependence

BACKGROUND

Post-traumatic stress disorder (PTSD) is a relatively new psychiatric disorder with three clusters of symptoms: trauma re-experiencing, avoidance, and increased arousal. The condition develops after a person sees, is involved in, or hears of an extreme traumatic stressor such as war, torture, natural catastrophe, assault, rape, or serious accident. PTSD is also often comorbid with other psychiatric disorders, especially with alcohol dependence. Several hormonal alterations have been reported in veterans with combat-related PTSD, including elevations in certain thyroid hormones, e.g., total T3; however, previous studies have not controlled for alcohol dependence, a common comorbid psychiatric disorder in this population.

OBJECTIVE

The first aim of our study was to assess possible differences in basal serum levels of free triiodothyronine (FT3), total triiodothyronine (TT3), free thyroxine (FT4), total thyroxine (TT4), and thyroid stimulating hormone (TSH) in Croatian soldiers with combat-related chronic PTSD alone or comorbid with alcohol dependence and in healthy controls. The second purpose of the study was to determine any correlation between duration of combat activities, number of combat traumas, intensity and duration of PTSD symptoms, and serum levels of TT3, FT3, TT4, FT4, and TSH in this sample.

METHOD

We analyzed basal serum FT3, TT3, FT4, TT4, and TSH concentrations in soldiers with combat-related chronic PTSD (N=43), combat-related chronic PTSD comorbid with alcohol dependence (N = 41), and in healthy controls (N = 39) using a luminoimmunochemical assay.

RESULTS

Soldiers with chronic combat-related PTSD with or without comorbid alcohol addiction had significantly higher values of TT3 than the control group (F = 19.556, p<0.01). There was a significant correlation between TT3 levels and number of traumatic events in both the PTSD group (r=0.663, p<0.01) and those with PTSD comorbid with alcohol dependence (r=0.836, p<0.01). There was also a significant correlation between TT3 levels and symptoms of increased arousal in both PTSD (r=0.419, p<0.01) and PTSD comorbid with alcohol dependence (r=0.516, p<0.01).

CONCLUSION

Elevated concentrations of serum TT3 are associated with combat-related PTSD, regardless of its comorbidity with alcohol dependence, and also with the number of traumatic events and symptoms of increased arousal. Given that current pharmacotherapy for PTSD is inadequate, reduction of TT3 may be a new strategy for pharmacologic intervention that could contribute to more effective treatment of this disorder.

Effects of trauma exposure on the cortisol response to dexamethasone administration in PTSD and major depressive disorder

OBJECTIVE

To evaluate cortisol suppression following 0.5 mg of dexamethasone (DEX) in trauma survivors (N=52) with posttraumatic stress disorder (PTSD), major depressive disorder (MDD), both, or neither disorder, and in subjects never exposed to trauma (N=10), in order to examine interactions between diagnosis and trauma history on cortisol negative feedback inhibition.

METHOD

Lifetime trauma exposure and psychiatric diagnoses were assessed and blood samples were obtained at 8:00 a.m. for the determination of baseline cortisol. Participants ingested 0.5 mg of DEX at 11:00 p.m. and blood samples for determination of cortisol and DEX were obtained at 8:00 a.m. the following day.

RESULTS

PTSD was associated with enhanced cortisol suppression in response to DEX. Among trauma survivors, the presence of a traumatic event prior to the "focal" trauma had a substantial impact on cortisol suppression in subjects with MDD. Such subjects were more likely to show cortisol alterations similar to those associated with PTSD, whereas subjects with MDD with no prior trauma were more likely to show alterations in the opposite direction, i.e. relative non-suppression.

CONCLUSIONS

Cortisol hypersuppression in PTSD appears not to be dependent on the presence of traumatic events prior to the focal trauma. However, prior trauma exposure may affect cortisol suppression in MDD. This finding may have implications for understanding why only some depressed patients show non-suppression on the DST.

Trauma exposure rather than posttraumatic stress disorder is associated with reduced baseline plasma neuropeptide-Y levels

BACKGROUND

Exposure to uncontrollable stress reduces baseline plasma neuropeptide-Y levels in animals. We previously reported that baseline plasma neuropeptide-Y levels, as well as neuropeptide-Y responses to yohimbine, were lower in combat veterans with posttraumatic stress disorder, but we were unable to determine whether this was attributable to posttraumatic stress disorder or trauma exposure. The current report addresses this issue.

METHODS

A) Baseline plasma neuropeptide-Y levels were measured in 8 healthy combat veterans compared to 18 combat veterans with posttraumatic stress disorder and 8 healthy nontraumatized subjects; and B) Baseline plasma neuropeptide-Y levels, trauma exposure, and posttraumatic stress disorder symptoms were assessed in 41 active military personnel.

RESULTS

Plasma neuropeptide-Y was negatively associated with trauma exposure but not posttraumatic stress disorder symptoms in active duty personnel. Baseline neuropeptide-Y was reduced in combat veterans with and without posttraumatic stress disorder.

CONCLUSIONS

Trauma exposure rather than posttraumatic stress disorder is associated with reduced baseline plasma neuropeptide-Y levels. Future studies must determine if neuropeptide-Y reactivity differentiates trauma-exposed individuals with and without posttraumatic stress disorder.

Plasma testosterone levels in patients with combat-related posttraumatic stress disorder

BACKGROUND

An abnormal level of androgens has been reported in various psychiatric disorders and the important role of androgens in the regulation of human sexuality, aggression, cognition, emotions and personality have been described. Previous studies in the area of stress and the hypothalamic-pituitary-gonadal (HPG) system in humans indicate that circulating testosterone levels are suppressed by physical and psychological stress. However, there is also evidence that plasma levels of testosterone can increase during potentially stressful events and may be elevated in combat-related posttraumatic stress disorder (CR-PTSD) in comparison with normal subjects and major depressive disorder patients.

METHODS

The aim of the present study was to examine the possible involvement of the HPG system in chronic untreated CR-PTSD. To this end, we assessed the morning plasma levels of testosterone and cortisol in never-treated chronic CR-PTSD outpatients compared with normal healthy controls.

RESULTS

There were no statistically significant differences between the CR-PTSD patients and healthy control subjects in morning plasma testosterone (547.8 +/- 152.2 ng/dl vs. 565.6 +/- 122.4 ng/dl; p = 0.7) and cortisol (19.0 +/- 8.5 microg/dl vs. 15.4 +/- 5.1 microg/dl; p = 0.1) levels. However, a significant correlation between plasma testosterone level and avoidance symptom scores of the Impact of Events Scale (IES) was found in the CR-PTSD patients (r = 0.43, p < 0.05).

CONCLUSIONS

The findings of plasma testosterone levels comparable with normal controls in CR-PTSD patients may indicate that the previously described reduction in testosterone levels in normal subjects under stressful conditions may reflect the acute stress response of the HPG axis, in contrast to an adaptation of the HPG axis under chronic psychological stress.

[Application of natural and preformed physical factors during medical rehabilitation in participants of military conflicts]

The authors have performed individually adjusted complexes of balneophysiotherapeutic procedures in soldiers and officers who had taken part in local military conflicts. Functional and biochemical investigations show that in those military who had no wounds but had a weak posttraumatic stress reaction the above complexes are rather effective.

Elevated serum lipids in veterans with combat-related chronic posttraumatic stress disorder

AIM

To assess possible differences in serum cholesterol, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), triglycerides, arteriosclerosis index, established risk factor (ERF) of arteriosclerosis, and 10-year risk for coronary disease according to the Adult Treatment Panel III (ATP-III) between veterans with combat-related posttraumatic stress disorder (PTSD) and a control group consisting of patients with major depressive disorder.

METHOD

We determined serum cholesterol, LDL-C, HDL-C, and triglycerides in the patients with PTSD (n = 103) and patients with major depressive disorder (n = 92), using the enzyme-assay method. AI, ERF, and ATP-III were calculated from cholesterol, LDL-C, and HDL-C levels. The groups were matched in age and body mass index (BMI). Patients with major depressive disorder were chosen as a control group because they do not have changes in serum lipids.

RESULTS

Patients with combat-related PTSD had higher mean concentration of cholesterol (6.2+/-1.1 mmol/L vs 5.3+/-0.9 mmol/L; p<0.001), LDL-C (3.9+/-0.7 mmol/L vs 3.5+/-1.0 mmol/L; p = 0.005), and triglycerides (2.9+/-2.3 mmol/L vs 1.5+/-0.5 mmol/L; p<0.001), and lower HDL-C (1.0+/-0.3 mmol/L vs 1.3+/-0.2 mmol/L; p<0.001) than the control group. Arteriosclerosis index (4.2+/-1.2 vs 3.7+/-1.7; p = 0.050), ERF (6.4+/-1.9 vs 5.5+/-2.4; p = 0.010), and ATP-III (12.1+/-3.3 vs 10.2+/-3.8; p<0.001) were higher in PTSD than in the control group.

CONCLUSION

Elevated concentrations of serum lipids are associated with combat-related PTSD. This may imply that patients with combat-related PTSD are under a higher risk for arteriosclerosis.

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.

Low platelet-poor plasma concentrations of serotonin in patients with combat-related posttraumatic stress disorder

BACKGROUND

Combat-related posttraumatic stress disorder (CR-PTSD) is associated with a dysregulation of various neurotransmitter systems.

METHODS

We assessed levels of platelet-poor plasma (PPP) norepinephrine (NE), and serotonin (5-HT), and 24-hour urinary excretion of NE, dopamine (DA), and homovanillic acid (HVA) in 17 male outpatients with untreated chronic CR-PTSD (age, 33.1 +/- 7.4 years) and 10 normal control subjects (age, 35.8 +/- 2.7 years).

RESULTS

Compared with the control subjects, the PTSD patients showed significantly lower PPP 5-HT levels, elevated PPP NE levels, and significantly higher mean 24-hour urinary excretion of all three catecholamines (NE, DA, and HVA). The 24-hour urinary HVA values of the CR-PTSD patients correlated significantly and positively with the total Impact of Event Scale scores and the avoidance symptoms cluster scores, and the PPP 5-HT levels correlated negatively with the Hamilton Anxiety Rating Scale scores. The PPP NE/5-HT ratio was significantly higher in the study group than in the control subjects.

CONCLUSIONS

We believe this combined enhanced noradrenergic activity and diminished 5-HT activity may be relevant to the neurobiology of CR-PTSD.

D-fenfluramine challenge in posttraumatic stress disorder

BACKGROUND

Much progress has been made in understanding the role of catecholamines in the pathophysiology of posttraumatic stress disorder (PTSD). Recent research has broadened the scope of neuroregulation of PTSD to include serotonin.

METHODS

We used the serotonin-releasing agent and reuptake inhibitor, d-fenfluramine, to assess the integrity of the serotonin-mediated prolactin release in 8 men with combat-induced PTSD and 8 healthy men.

RESULTS

The veterans with PTSD had a significantly lower prolactin response to d-fenfluramine as compared to healthy control subjects. The prolactin response to d-fenfluramine was inversely correlated with the patient's level of PTSD symptomatology and measures of aggression.

CONCLUSIONS

This study demonstrates a central serotonin dysfunction, as reflected in a lower prolactin response to d-fenfluramine, in patients with PTSD.

Elevations of serum T3 levels and their association with symptoms in World War II veterans with combat-related posttraumatic stress disorder: replication of findings in Vietnam combat veterans

OBJECTIVE

In previous serum thyroid studies, we reported an unusual thyroid profile, including elevated levels of total and free triiodothyronine (T3), total thyroxine (T4), and thyroxine-binding globulin (TBG) with no elevations in free T4 and thyrotropin (TSH) in Vietnam veterans with combat-related posttraumatic stress disorder (PTSD) compared to control subjects. In a subsample of Vietnam veterans, we found a significant positive correlation between total T3, free T3, and PTSD symptoms, specifically hyperarousal symptoms. In the present study, we explored the generalizability of our findings to World War II (WWII) veterans with PTSD.

METHOD

Clinical symptoms were assessed in and serum thyroid measures were obtained from 12 WWII veterans with PTSD and 18 WWII veterans without PTSD.

RESULTS

WWII veterans with combat-related PTSD showed elevations of serum total and free T3 with no elevations of free T4 and TSH compared to control subjects, replicating the results of our previous studies. A significant positive relationship between total and free T3 and PTSD symptoms, specifically hyperarousal symptoms, was also replicated in the total WWII group. Elevations of total T4 and TBG were not replicated in the WWII group with PTSD, which may indicate a shift with age in the free/bound dynamics of the thyroid alterations observed.

CONCLUSIONS

This study supports the observation that the thyroid system is altered in chronic combat-related PTSD. The observed alterations of thyroid function along with PTSD symptoms appear to be chronic, detectable 50 years after the war.

Elevated lipid levels in Vietnam veterans with chronic posttraumatic stress disorder

BACKGROUND

Elevated cholesterol levels have been reported in panic disorder and anger attacks, but not major depression. No data have been reported in posttraumatic stress disorder (PTSD).

METHODS

Seventy-three male Vietnam veterans with chronic (PTSD) had serum lipid screening upon entry to a 90-day inpatient program.

RESULTS

Elevated cholesterol, low-density lipoprotein, triglycerides, and reduced high-density lipoprotein, were frequent in Vietnam veterans with chronic PTSD and are significant risk factors for coronary artery disease.

CONCLUSIONS

Routine lipid screening may be warranted in this at-risk population. Altered lipid levels may result from activation of the noradrenergic system.

Elevated levels of serum interleukin-1 beta in combat-related posttraumatic stress disorder

Levels of serum interleukin-1 beta (IL-1 beta) and soluble interleukin-2 receptor (sIL-2R) were assessed in 19 male patients with combat-related posttraumatic stress disorder (PTSD) in comparison to 19 age- and sex-matched healthy volunteers. Serum IL-1 beta levels (but not sIL-2R) were significantly higher (p < .001) in the PTSD patients than in the controls. IL-1 beta levels did not correlate with cortisol levels, severity of PTSD, anxiety, depressive symptoms, or alexithymia score; however, they did correlate significantly (r = .54, p < .005) with the duration of PTSD symptoms. It is possible that desensitization of the hypothalamic-pituitary-adrenal axis in chronic PTSD patients counteracts the stimulatory effect of IL-1 beta on cortisol secretion.

Posttraumatic stress disorder, exposure to combat, and lower plasma cortisol among Vietnam veterans: findings and clinical implications

Several clinical studies suggest that individuals with posttraumatic stress disorder (PTSD) experience neuroendocrine system alterations, resulting in significantly lower plasma cortisol. To test this hypothesis, morning serum cortisol was compared among a national sample of Vietnam "theater" veterans (n = 2,490) and a sample of Vietnam "era" veterans (n = 1,972) without service in Vietnam. Analysis of covariance was used to compare cortisol concentrations after adjusting for 9 covariates (education, income, race, age, smoking status, alcohol use, illicit drug use, medication use, and body mass index). Adjusted cortisol was lower among theater veterans with current PTSD but not era or theater veterans with lifetime PTSD. Among theater veterans, cortisol was inversely related to combat exposure, with veterans exposed to heavy combat having the lowest concentrations. Analysis of plasma cortisol, together with other clinical data, may be instrumental in the future diagnosis and treatment of stress disorders.

Plasma norepinephrine kinetics in patients with posttraumatic stress disorder

To determine whether basal sympathetic nervous system (SNS) function is increased in patients with posttraumatic stress disorder (PTSD), we used a radioisotope dilution technique to assess basal arterialized plasma norepinephrine (NE) kinetics in 12 men who were Viet Nam combat veterans with PTSD and six normal controls. In addition to determining the rates of appearance of NE into, and clearance of NE from, plasma, we measured basal arterialized plasma levels of epinephrine (EPI), and also vital signs, in both groups. Patients with PTSD actually manifested lower arterialized plasma levels of NE, and had lower rates of appearance of NE into plasma, than did controls. The rate of NE clearance from plasma was unaltered in PTSD patients. Patients with PTSD also showed a trend toward lower arterialized EPI levels than controls, but manifested a trend toward higher diastolic blood pressure. Our data indicate that basal SNS activity is not increased in patients with PTSD and that previous reports of increased resting SNS activity in this population may instead reflect SNS reactivity.

Dose-response changes in plasma cortisol and lymphocyte glucocorticoid receptors following dexamethasone administration in combat veterans with and without posttraumatic stress disorder

BACKGROUND

Our previous studies have suggested that combat veterans with posttraumatic stress disorder (PTSD) have alterations in hypothalamic-pituitary-adrenal axis functioning that are different from the well-documented biological changes observed in major depressive disorder and following exposure to stress.

METHODS

In the present study, we examined cortisol and lymphocyte glucocorticoid receptor number before and after the administration of 0.50 and 0.25 mg of dexamethasone in 14 combat veterans with PTSD, 12 combat veterans without PTSD, and 14 nonpsychiatric healthy men. All subjects were medication free at the time of testing and none met diagnostic criteria for major depression or substance dependence.

RESULTS

Combat veterans with PTSD suppressed cortisol to a greater extent than did combat veterans without PTSD and normal controls in response to both doses of dexamethasone. Differences in cortisol suppression could not be attributed to substance dependence history or differences in dexamethasone bioavailability. Combat veterans with PTSD showed a larger number of baseline glucocorticoid receptors compared with normal men. Combat veterans without PTSD also had a larger number of baseline glucocorticoid receptors compared with normal men and in fact were comparable to combat veterans with PTSD on this measure. However, only veterans with PTSD showed a decrease in lymphocyte glucocorticoid receptor number following dexamethasone administration.

CONCLUSION

The data support the hypothesis of an enhanced negative feedback sensitivity of the hypothalamic-pituitary-adrenal axis in PTSD.

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

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

Hypodensity of platelet serotonin uptake sites in posttraumatic stress disorder: associated clinical features

We have previously reported that binding to blood platelets of paroxetine, a selective serotonin (5-HT) reuptake inhibitor which binds to 5-HT uptake sites, is decreased in patients with posttraumatic stress disorder (PTSD). Specifically, we found a lower number of platelet 3H-paroxetine binding sites (Bmax) and a lower dissociation constant (Kd) for 3H-paroxetine binding in combat veterans with PTSD compared to normal control subjects. In the current study we assessed the relationship of platelet 3H-paroxetine binding to clinical features in 41 Vietnam combat veterans with SCID-diagnosed PTSD. The results indicated that Bmax of platelet 3H-paroxetine binding was negatively correlated with both state and trait anxiety, as well as with depressive and overall PTSD symptoms. However, there was no evidence that platelet 3H-paroxetine binding differed as a function of comorbid psychiatric diagnoses including major depression, other anxiety disorders, and substance abuse in these patients.

Elevation of serum free triiodothyronine, total triiodothyronine, thyroxine-binding globulin, and total thyroxine levels in combat-related posttraumatic stress disorder

BACKGROUND

This study was designed to assess both central and peripheral aspects of thyroid function in combat-related posttraumatic stress disorder (PTSD), with the particular purpose of finding a mechanistic explanation for an imbalance between serum levels of free thyroxine (T4) and total T4 previously observed in pilot work.

METHODS

A total of 96 male combat veterans with PTSD diagnosed by DSM-III-R (72 from the West Haven, Conn, Veterans Affairs Medical Center and 24 from the Menlo Park, Calif, Veterans Affairs Medical Center) were compared with 24 male control subjects. One or more serum samples were analyzed by radioimmunoassays for levels of total T4, free T4, total triiodothyronine (T3), free T3, T4-binding globulin, and thyrotropin.

RESULTS

The pilot observation of moderately elevated total T4 levels with no elevation in free T4 levels in patients with PTSD was confirmed, suggesting the hypotheses that (1) there may be an increased peripheral conversion of free T4 by deiodination to T3 or (2) there may be an increased binding of T4 secondary to elevated T4-binding globulin levels. Our findings support both hypotheses. The PTSD groups all showed a marked and sustained elevation in levels of both total T3 and free T3, as well as elevated T3/T4 ratios, supporting the increased T3 conversion hypothesis. The PTSD groups also showed a marked and sustained increase in T4-binding globulin levels, supporting the increased binding hypothesis. Thyrotropin levels did not differ between PTSD and control groups.

CONCLUSIONS

These findings demonstrate an unusual pattern of thyroid alterations, featuring substantial elevations in total T3, free T3, and T4-binding globulin levels, in combat-related PTSD that differs from established endocrinopathies, such as classic hyperthyroidism, T3 thyrotoxicosis, or chronic T4-binding globulin elevation.

Plasma beta-endorphin levels in post-traumatic stress disorder: a preliminary report on response to exercise-induced stress

Post-traumatic stress disorder (PTSD) may be associated with changes in endogenous opioid peptide function. To test this hypothesis, 10 male Vietnam combat veterans with PTSD and 8 age-matched male controls underwent a standard grade-incremented exercise treadmill stress test. Plasma beta-endorphin measurements were obtained at rest and following maximal exercise. Resting plasma beta-endorphin levels were comparable between groups. Post-exercise plasma beta-endorphin levels were significantly higher than resting levels in the PTSD patients only (P less than 0.05). These pilot data suggest a differential alteration in plasma beta-endorphin response to exercise in PTSD.

The dexamethasone suppression test and thyrotropin-releasing hormone stimulation test in posttraumatic stress disorder

Male veterans with posttraumatic stress disorder (PTSD) (n = 11), including 6 with concurrent major depressive disorder (MDD), were compared to veterans with MDD alone (n = 18) and to 28 controls in their response to the dexamethasone suppression test (DST) and thyrotropin-releasing hormone (TRH) stimulation tests. We found higher levels of 4 PM serum cortisol and lower peak thyroid-stimulating hormone (TSH) response to TRH in the MDD patients than in either the PTSD patients or controls, in spite of equivalent levels of depression for MDD and PTSD. DST suppression (cortisol less than 5 mg/dl) occurred in 90% of control, 90% of PTSD, and 78% of MDD subjects, whereas TRH blunting (dTSHmax less than 7 microU/ml) occurred in 28% of control, 27% of PTSD, and 67% of MDD subjects. Rather than blunting, four PTSD patients (36%) and only 10% of the control and MDD subjects had high TSH responses (13-24 microU/ml), which may be linked to high noradrenergic activity, since subclinical hypothyroidism seemed unlikely.

Low plasma beta-endorphin in post-traumatic stress disorder

We compared serum cortisol, ACTH and plasma beta-endorphin in 21 Post-Traumatic Stress Disorder patients and 20 controls. Although we found no important disturbance in diurnal rhythms, the PTSD patients had significantly higher A.M. serum cortisols compared with controls. Both A.M. and P.M. plasma beta-endorphins in PTSD patients were significantly lower compared with controls. These data suggest that plasma beta-endorphin may be a marker for PTSD and that chronic endogenous opioid depletion may play a role in the pathogenesis and perpetuation of this disorder.

The DST and posttraumatic stress disorder

The dexamethasone suppression test (DST) was administered to 28 male combat veterans with posttraumatic stress disorder. Six subjects (21%) were nonsuppressors. The nonsuppression rates for the subgroups with and without major depressive disorder according to the Research Diagnostic Criteria were 50% and 6%, respectively. The authors conclude that cortisol nonsuppression is rare in posttraumatic stress disorder unless there is concomitant major depression.