Elevation of urinary norepinephrine/cortisol ratio in posttraumatic stress disorder

Thyroid hormone levels and psychological symptoms in sexually abused adolescent girls

OBJECTIVE

To explore the relationships between psychological symptoms and thyroid hormone levels in adolescent girls who had experienced the traumatic stress of sexual abuse.

METHOD

The study design was cross-sectional/correlational. Subjects (N=22; age range=12-18 years) had their blood drawn, and they completed 2 psychological tests (depression and general distress/posttraumatic stress disorder [PTSD]). A pediatrician completed a sexual abuse questionnaire after reviewing law enforcement and Child Protective Services reports and conducting forensic interviews and medical examinations.

RESULTS

Girls' average free T4, total T4, free T3, total T3, and TSH levels were within age-specific laboratory reference range limits, as were most individual concentrations. The strongest correlations (p<.05) were between free T3 and PTSD total score (-.50), PTSD-avoidance/numbing (-.49), and general distress (-.48); and between total T3 and depression (-.46), general distress (-.45), and PTSD-arousal (-.44).

CONCLUSIONS

Our findings support one of the two contemporary models of the relationships between thyroid hormones (i.e., free and total T3) and psychological symptoms (i.e., depression, general distress, and PTSD)--one of "shutting down" (vs. "activation") in the face of trauma.

Gender-specific association of alexithymia and norepinephrine/cortisol ratios. A preliminary report

OBJECTIVE

Alexithymia and posttraumatic stress disorder (PTSD) might share a neuroendocrine pattern characterized by increased urinary norepinephrine (N) and decreased cortisol (C) levels, resulting in a high N/C ratio, at least among male alcoholics. We aimed to explore if this association can also be found in other populations.

METHODS

Twenty-four-hour urine samples were obtained from 12 major depressive disorder (MDD) patients and 23 healthy controls (HC) and tested for N and free C. Participants completed the 20-item Toronto Alexithymia Scale (TAS) and the Symptom Check List (SCL).

RESULTS

Controlling for depression, the neuroendocrine parameters did not differ between the MDD and HC participants nor between women and men. The TAS was not associated with N, C or the N/C ratio in the MDD and HC participants nor in females alone. However, in men, the N/C ratio correlated significantly with the TAS (r = .80).

CONCLUSIONS

Our preliminary findings indicate that alexithymia is associated with an increased noradrenergic activity and a decreased basal activity of the hypothalamic-pituitary-adrenal (HPA) axis among men. This gender difference may reflect divergent underlying neurobiological processes of alexithymia in men and women.

The psychobiology of children exposed to marital violence

We examined the psychological and physiological functioning of a community sample of children exposed to marital violence, comparing them to a clinical comparison group without marital violence exposure. Results replicated past findings of elevated levels of trauma symptomatology in this population. Further, children exposed to marital violence differed significantly from comparison children with respect to sympathetic nervous system functioning and hypothalamic-pituitary-adrenal (HPA) axis functioning. Specifically, elevations were seen in heart rate and salivary cortisol levels, but not in orthostatic challenge response or blood pressure. These results indicate that children exposed to marital violence have a different physiological presentation than controls and may be physiologically "traumatized" by virtue of marital violence exposure.

An animal model of posttraumatic stress disorder: the use of cut-off behavioral criteria

Considerable heterogeneity exists in the response of human subjects exposed to extreme traumatizing events. Posttraumatic stress disorder (PTSD) is diagnosed in 20-30% of those exposed. Clinical studies of this population employ stringent inclusion/exclusion criteria, yet animal studies have routinely included the entire exposed population as the study population. We examined the effect of grouping stressed rats according to the magnitude of their response on the statistical analysis of behavioral models. Exposure to a predator stimulus was used as the stress paradigm. Response magnitude was assessed in two consecutive behavioral tests measuring anxiety- and stress-related behaviors and was used to divide the animals into groups. The two extremes were studied, that is, those clearly "maladapted" and those clearly "well-adapted," using arbitrarily selected severity-measures, the "cut-off behavioral criteria" (CBC). Data for the partially affected middle group were discarded for reasons of clarity. The hypothalamic-pituitary-adrenal axis and heart rate variability were analyzed for the entire exposed population and then reexamined according to the CBCs. When the CBCs were applied, we found PTSD-like symptoms in only 22.0% of exposed rats. Compared to controls and to well-adapted exposed rats, the behaviorally maladapted rats displayed disordered physiological measures. They had significantly higher plasma corticosterone and ACTH levels, increased sympathetic activity, diminished vagal tone, and increased sympathovagal balance. These differences surfaced only when data were analyzed according to the CBCs. Animals respond to stress heterogeneously, resembling humans. Overlooking heterogeneity in responses obscures the results of biobehavioral data analysis. We submit that animals exposed to trauma should be divided into groups according to the magnitude of their response and be studied accordingly.

Posttraumatic Stress Disorder and Physical Illness: Results from Clinical and Epidemiologic Studies

Research indicates that exposure to traumatic stressors and psychological trauma is widespread. The association of such exposures with posttraumatic stress disorder (PTSD) and other mental health conditions is well known. However, epidemiologic research increasingly suggests that exposure to these events is related to increased health care utilization, adverse health outcomes, the onset of specific diseases, and premature death. To date, studies have linked traumatic stress exposures and PTSD to such conditions as cardiovascular disease, diabetes, gastrointestinal disease, fibromyalgia, chronic fatigue syndrome, musculoskeletal disorders, and other diseases. Evidence linking cardiovascular disease and exposure to psychological trauma is particularly strong and has been found consistently across different populations and stressor events. In addition, clinical studies have suggested the biological pathways through which stressor-induced diseases may be pathologically expressed. In particular, recent studies have implicated the hypothalamic-pituitary-adrenal (HPA) and the sympathetic-adrenal-medullary (SAM) stress axes as key in this pathogenic process, although genetic and behavioral/psychological risk factors cannot be ruled out. Recent findings, indicating that victims of PTSD have higher circulating T-cell lymphocytes and lower cortisol levels, are intriguing and suggest that chronic sufferers of PTSD may be at risk for autoimmune diseases. To test this hypothesis, we assessed the association between chronic PTSD in a national sample of 2,490 Vietnam veterans and the prevalence of common autoimmune diseases, including rheumatoid arthritis, psoriasis, insulin-dependent diabetes, and thyroid disease. Our analyses suggest that chronic PTSD, particularly comorbid PTSD or complex PTSD, is associated with all of these conditions. In addition, veterans with comorbid PTSD were more likely to have clinically higher T-cell counts, hyperreactive immune responses on standardized delayed cutaneous hypersensitivity tests, clinically higher immunoglobulin-M levels, and clinically lower dehydroepiandrosterone levels. The latter clinical evidence confirms the presence of biological markers consistent with a broad range of inflammatory disorders, including both cardiovascular and autoimmune diseases.

Prophecies of childhood: how children's social environments and biological propensities affect the health of populations

During the past decade, important steps have been taken globally to improve the status of children. Concurrently, significant advances have been made toward understanding how child development is shaped by transactions between biological and environmental influences. Despite such advances, ongoing adversities in the lives of children worldwide undermine the development of individuals and thus the health of nations. The primary tenets of this paper are that: children continue to suffer a disproportionate share of the world's adversities; exposure to early adversities is not only associated with increased morbidity during childhood, but also across the lifespan; and recent advances in understanding the operation and ontogeny of stress-response systems can help explain how adversity is translated into lifelong effects on health. Acknowledging the long-lasting sequelae of childhood adversity has important implications for public health and society.

Brain environment interactions: stress, posttraumatic stress disorder, and the need for a postmortem brain collection

Stress, especially the extreme stress of traumatic events, can alter both neurobiology and behavior. Such extreme environmental situations provide a useful model for understanding environmental influences on human biology and behavior. This paper will review some of the evidence of brain alterations that occur with exposure to environmental stress. This will include recent studies using neuroimaging and will address the need for histological confirmation of imaging study results. We will review the current scientific approaches to understanding brain environment interactions, and then make the case for the collection and study of postmortem brain tissue for the advancement of our understanding of the effects of environment on the brain. Creating a brain tissue collection specifically for the investigation of the effects of extreme environmental stressors fills a gap in the current research; it will provide another of the important pieces to the puzzle that constitutes the scientific investigation of negative effects of environmental exposures. Such a resource will facilitate new discoveries related to the psychiatric illnesses of acute stress disorder and posttraumatic stress disorder, and can enable scientists to correlate structural and functional imaging findings with tissue abnormalities, which is essential to validate the results of recent imaging studies.

A Diathesis-Stress Model of Posttraumatic Stress Disorder: Ecological, Biological, and Residual Stress Pathways

The symptoms captured within the contemporary diagnostic definition of posttraumatic stress disorder (PTSD) have been studied for more than 100 years. Yet, even with increasingly advanced discoveries regarding the etiology of PTSD, a comprehensive and up-to-date etiological model that incorporates both medical and psychological research has not been described and systematically studied. The diathesis-stress model proposed here consolidates existing medical and psychological research data on etiological factors associated with PTSD into 3 causal pathways: residual stress, ecological, and biological. In combination, these pathways illuminate how PTSD might develop and who might be at higher risk for developing the disorder. Research and treatment implications related to the diathesis-stress model are discussed.

The relevance of differential response to trauma in an animal model of posttraumatic stress disorder

BACKGROUND

Posttraumatic stress disorder affects 20%-30% of those exposed. Clinical studies employ stringent inclusion-exclusion criteria, yet animal studies include the entire exposed population as the study population. We examined the effect of grouping prestressed rats according to magnitude of response on the statistical analysis of results.

METHOD

Response magnitude to predator exposure was assessed and used to group the animals into "diagnostic" groups. Two extremes were studied (clearly "maladapted" and clearly "well adapted" rats) using arbitrarily selected cutoff behavioral criteria (CBC). The data for the middle group were discarded for reasons of clarity. Hypothalamic-pituitary-adrenal axis and heart-rate variability were analyzed for the entire exposed population and then according to the CBC.

RESULTS

A single 10-min exposure to a predator caused fear-related behaviors in only 25.3% of exposed rats. Compared with control subjects and well-adapted exposed rats, maladapted rats exhibited significantly higher plasma corticosterone and corticotropin concentrations, increased sympathetic activity, diminished vagal tone, and increased sympathovagal balance. These differences surfaced only when data were analyzed according to CBC. Animals respond to stress heterogeneously, resembling humans. Overlooking this heterogeneity may obscure the results of data analysis.

CONCLUSIONS

Animals can be divided into distinct groups according to magnitude of response and be studied accordingly.

Circuits and systems in stress. II. Applications to neurobiology and treatment in posttraumatic stress disorder

This paper follows the preclinical work on the effects of stress on neurobiological and neuroendocrine systems and provides a comprehensive working model for understanding the pathophysiology of posttraumatic stress disorder (PTSD). Studies of the neurobiology of PTSD in clinical populations are reviewed. Specific brain areas that play an important role in a variety of types of memory are also preferentially affected by stress, including hippocampus, amygdala, medial prefrontal cortex, and cingulate. This review indicates the involvement of these brain systems in the stress response, and in learning and memory. Affected systems in the neural circuitry of PTSD are reviewed (hypothalamic-pituitary-adrenal axis (HPA-axis), catecholaminergic and serotonergic systems, endogenous benzodiazepines, neuropeptides, hypothalamic-pituitary-thyroid axis (HPT-axis), and neuro-immunological alterations) as well as changes found with structural and functional neuroimaging methods. Converging evidence has emphasized the role of early-life trauma in the development of PTSD and other trauma-related disorders. Current and new targets for systems that play a role in the neural circuitry of PTSD are discussed. This material provides a basis for understanding the psychopathology of stress-related disorders, in particular PTSD.

Associations between physiological reactivity and children's behavior: advantages of a multisystem approach

The past decade has seen a notable increase in interest in and research concerning the physiological correlates of behavior problems in childhood. The present article reviews what this growing body of research has revealed. The main tenet is that disruptions in both sympathetic and adrenocortical regulation appear to be common among children with internalizing and externalizing behavior problems. The associations between such neuroendocrine alterations and behavior are discussed and their implications for the fields of stress physiology, neuroendocrinology, and developmental psychopathology are outlined. It is proposed that substantial advances can be made by investigating patterns of physiological responses among multiple, concurrent systems rather than individual response systems.

The effect of stress doses of hydrocortisone during septic shock on posttraumatic stress disorder in survivors

BACKGROUND

Exposure to intense physical and psychological stress during septic shock can result in posttraumatic stress disorder in survivors. Patients with chronic posttraumatic stress disorder often show sustained reductions in serum cortisol concentration. This investigation examines whether increasing serum cortisol levels with hydrocortisone treatment during septic shock reduces the incidence of posttraumatic stress disorder in survivors.

METHODS

Patients (n = 20) were recruited from a prospective, randomized double-blind study on the hemodynamic effects of hydrocortisone during septic shock. Eleven patients had received placebo and nine stress doses of hydrocortisone. Posttraumatic stress disorder was diagnosed 31 months (median) after intensive care unit discharge using SCID-IV (DSM-IV-criteria). Furthermore, the number of categories of traumatic memory from ICU treatment was determined in both groups at that time.

RESULTS

Only one of nine patients from the hydrocortisone group developed posttraumatic stress disorder, compared with seven of 11 patients in the placebo group (p =.02). There was no significant difference with regard to the number of categories of traumatic memory between the hydrocortisone and placebo groups.

CONCLUSIONS

The administration of hydrocortisone during septic shock in a dosage similar to the endogenous maximal production rate was associated with a lower incidence of posttraumatic stress disorder in long-term survivors, which seems to be independent of the number of categories of traumatic memory.

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.

C-reactive protein and interleukin 6 receptor in post-traumatic stress disorder: a pilot study

BACKGROUND

it has been reported that psychological stress in humans is associated with a derangement of biological homeostasis. This pilot study aimed to examine the inflammatory response to post-traumatic stress disorder (PTSD) through measurements of the serum levels of the receptor to interleukin 6 (sIL-6r) and C-reactive protein (CRP), in relation to measures of psychological disturbance.

METHODS

15 patients with established PTSD and eight control patients with musculoskeletal injuries were studied at least three months after their index trauma. All completed revised impact of events scale (RIES), Davidson's trauma scale (DTS) and the general health questionnaire (GHQ), and gave blood samples that were assayed for CRP and sIL-6r. Statistical analysis was by the Mann-Whitney U-Wilcoxon rank sum tests.

RESULTS

positive relationships were found between sIL-6r and the RIES intrusion score (P=0.026), and between CRP and DTS intrusion scores (P=0.016), GHQ depression (P=0.028), and RIES intrusion (P=0.044) in the case group.

DISCUSSION

we have demonstrated a relationship between post-traumatic psychological and biological disturbance, which provides the basis for further research on the effects of psychological disturbance on physical recovery after injury.

Administration of high-dose ketoconazole, an inhibitor of steroid synthesis, prevents posttraumatic anxiety in an animal model

Acute psychological stress is the presumed immediate cause of post-traumatic stress disorder (PTSD), and may also contribute to other anxiety disorders. Abnormal activity of the hypothalamic-pituitary-adrenal (HPA) axis has been tentatively implicated in some of the features of these disorders. Ketoconazole (KTCZ), an imidazole derivative, is a potent inhibitor of gonadal and adrenal steroidogenesis. The aim of this study was to explore the effects of KTCZ blockade of adrenal steroidogenesis, and consequent elevation of adreno-corticotropic hormone (ACTH), on a model of chronic post-traumatic anxiety in rats. Amelioration of anxious behaviors after reduction of corticosterone would suggest that corticosterone (and by implication cortisol in humans) is an important mediator of anxious symptoms: exacerbation of such behaviors would suggest that corticosterone elevations are only secondary, and possibly implicate corticotropin releasing hormone (CRH) and/or ACTH in the pathogenesis of anxious symptoms. We exposed rats for 10 min to cat scent, a prima facie valid model for acute psychological stress, with and without high dose KTCZ for 14 days. Treatment with KTCZ abolished the chronic behavioral effects of acute exposure to a cat scent. Lower levels of anxious behavior in KTCZ-treated and exposed rats were accompanied by lower plasma corticosterone, ACTH and prolactin (PRL) levels compared to untreated exposed rats. Results in this model implicate corticosterone, but not ACTH, in the pathogenesis of chronic anxiety following acute psychological stress.

Urinary catecholamines and cortisol in recent-onset posttraumatic stress disorder after motor vehicle accidents

OBJECTIVE

This study examined relationships among stress hormone levels, posttraumatic stress disorder (PTSD) diagnosis and symptoms, and gender shortly after a common civilian trauma.

METHODS

Levels of catecholamines and cortisol in 15-hour urine samples were examined in 55 adults who had been in serious motor vehicle accidents and in 22 age-matched control.

RESULTS

Catecholamines were related to PTSD diagnosis and symptoms, but only among men: PTSD-symptomatic men who had been in an accident exhibited elevated levels of epinephrine and norepinephrine 1 month after the accident and had higher epinephrine levels 5 months later. Intrusive thoughts predicted catecholamine levels at 1 month, and avoidance of trauma-relevant stimuli was associated with higher epinephrine levels 5 months later. These effects were not significant among women. Urinary cortisol was also elevated among PTSD-symptomatic men, but not women, and only immediately (1 month) after the accident. For men and women, greater emotional numbing predicted a lower cortisol level 6 months after the accident.

CONCLUSIONS

These findings were interpreted as limited support for the generalizability of findings in men with chronic, combat-related PTSD and indicate the need for additional research on psychoendocrine assessment of traumatized women and specific dimensions of PTSD symptomatology.

Electrocardiogram abnormalities among men with stress-related psychiatric disorders: implications for coronary heart disease and clinical research

Research suggests psychological distress could result in arterial endothelial injury and coronary heart disease (CHD). Studies also show Posttraumatic Stress Disorder (PTSD) victims have higher circulating catecholamines and other sympathoadrenal-neuroendocrine bioactive agents implicated in arterial damage. Here we analyzed resting 12-lead electrocardiographic (ECG) results among a national sample of 4,462 nonhospitalized male veterans (mean age = 38) about 20 years after military service by current posttraumatic stress (n = 54), general anxiety (n = 186), and depression (n = 157) disorders. ECGs were interpreted by board-certified cardiologists and summarized using the Minnesota Code Manual of Electrocardiographic Findings. Psychiatric disorders were diagnosed based on the Diagnostic Interview Schedule, Version III. Controlling for age, place of service, illicit drug use, medication use, race, body mass index, alcohol use, cigarette smoking, and education, PTSD (odds ratio [OR] = 2.23, 95% confidence interval [CI] = 1.17-4.26, p < 0.05), anxiety (OR = 1.51, 95% CI = 1.03-2.22, p < 0.05), and depression (OR = 1.71, 95% CI = 1.13-2.58, p < 0.01) were associated with having a positive ECG finding. Specific results indicate PTSD was associated with atrioventricular (AV) conduction defects (OR = 2.81, 95% CI = 1.03-7.66, p < 0.05) and infarctions (OR = 4.44, 95% CI = 1.20-16.43, p < 0.05), while depression was associated with arrhythmias (OR = 1.98, 95% CI = 1.22-3.23, p < 0.01). The PTSD associations for AV conduction defects and infarctions held, even after controlling for current anxiety and depression. These findings suggest psychological distress may result in CHD, because we controlled for obvious biases and confounders, the men studied had current PTSD due to combat exposures 20 years ago, combat exposure was associated with anxiety and depression among these men, and the men were disease free a military induction. These findings suggest the need for clinical surveillance among combat veterans, better psychobiologic models of CHD pathogenesis, and additional research.

The potential role of hypocortisolism in the pathophysiology of stress-related bodily disorders

Representing a challenge for current concepts of stress research, a number of studies have now provided convincing evidence that the adrenal gland is hypoactive in some stress-related states. The phenomenon of hypocortisolism has mainly been described for patients, who experienced a traumatic event and subsequently developed post-traumatic stress disorder (PTSD). However, as presented in this review, hypocortisolism does not merely represent a specific correlate of PTSD, since similar findings have been reported for healthy individuals living under conditions of chronic stress as well as for patients with several bodily disorders. These include chronic fatigue syndrome, fibromyalgia, other somatoform disorders, rheumatoid arthritis, and asthma, and many of these disorders have been related to stress. Although hypocortisolism appears to be a frequent and widespread phenomenon, the nature of the underlying mechanisms and the homology of these mechanisms within and across clinical groups remain speculative. Potential mechanisms include dysregulations on several levels of the hypothalamic-pituitary adrenal axis. In addition, factors such as genetic vulnerability, previous stress experience, coping and personality styles may determine the manifestation of this neuroendocrine abnormality. Several authors proposed theoretical concepts on the development or physiological meaning of hypocortisolism. Based on the reviewed findings, we propose that a persistent lack of cortisol availability in traumatized or chronically stressed individuals may promote an increased vulnerability for the development of stress-related bodily disorders. This pathophysiological model may have important implications for the prevention, diagnosis and treatment of the classical psychosomatic disorders.

Suffering: the contributions of persistent pain

Pain is a perceived threat or damage to one's biological integrity. Suffering is the perception of serious threat or damage to the self, and it emerges when a discrepancy develops between what one expected of one's self and what one does or is. Some patients who experience sustained unrelieved pain suffer because pain changes who they are. At a physiological level, chronic pain promotes an extended and destructive stress response characterised by neuroendocrine dysregulation, fatigue, dysphoria, myalgia, and impaired mental and physical performance. This constellation of discomforts and functional limitations can foster negative thinking and create a vicious cycle of stress and disability. The idea that one's pain is uncontrollable in itself leads to stress. Patients suffer when this cycle renders them incapable of sustaining productive work, a normal family life, and supportive social interactions. Although patients suffer for many reasons, the physician can contribute substantially to the prevention or relief of suffering by controlling pain. Suffering is a nebulous concept for most physicians, and its relation to pain is unclear. This review offers a medically useful concept of suffering that distinguishes it from pain, accounts for the contributory relation of pain to suffering by describing pain as a stressor, and explores the implications of these ideas for the care of patients.

Higher abnormal leukocyte and lymphocyte counts 20 years after exposure to severe stress: research and clinical implications

OBJECTIVES

Research suggests that individuals with posttraumatic stress disorder (PTSD) are more likely to develop medical conditions and other stress-related psychiatric disorders. Given these findings and others suggesting that PTSD victims may have altered neuroendocrine and immune systems, the hypothesis that Vietnam veterans with PTSD have abnormally high leukocyte and lymphocyte counts was tested.

METHODS

The leukocyte and lymphocyte status of male Vietnam "theater" veterans with current partial posttraumatic stress (N = 286), anxiety (N = 274), and depression disorders (N = 192) were compared with those of Vietnam veterans without these disorders 20 years after military service (N = 2190), controlling for intelligence, race, age, income, education, type of enlistment, Vietnam volunteer status, region of birth, cigarette smoking, illicit drug use, body mass index, and alcohol consumption. Abnormal values were defined using standard laboratory reference ranges. Adjusted mean differences also were compared.

RESULTS

Based on the results of two-tailed tests, PTSD-positive veterans are more likely to have adjusted leukocyte (OR = 1.83, p = .04) and T-cell (OR = 1.82, p = .045) counts above the normal range and higher mean adjusted leukocyte (p = .042), lymphocyte (p = .01), T-cell (p = .008), and CD4 cell (p = .027) counts. Those with anxiety disorders have adjusted lymphocyte (OR = 1.68, p = .048) and T-cell (OR = 2.06, p = .011) counts above range. They also have test results indicating reactive delayed cutaneous hypersensitivity (OR = 1.77, p = .006), which suggests the presence of highly sensitized T-cell lymphocytes. Finally, depressed veterans are less likely to have B-cell counts above the reference range (OR = 0.55, p = .006). Results of one-tailed tests further suggest that PTSD-positive men also have abnormally high CD4 and CD8 T-cell lymphocyte counts as well (p < .05).

CONCLUSIONS

Our findings suggest that chronic, primarily combat-related PTSD is associated with clinically elevated leukocyte and total T-cell counts. Those with current anxiety also have some of these abnormalities in addition to highly sensitized T-cell lymphocytes. Additional research is needed to specify the mechanisms involved here and to investigate the health risks associated with these findings.

Dysregulation of cardiovascular and neuroendocrine responses to stress in premenstrual dysphoric disorder

Twelve women with prospectively confirmed premenstrual dysphoric disorder (PMDD or PDD) were compared with 12 healthy control subjects for cardiovascular and neuroendocrine responses to speech and mental arithmetic (Paced Auditory Serial Addition Task) stressors during both the follicular and luteal phases of the menstrual cycle. Structured clinical interview was used to assess psychiatric and abuse histories, and standardized questionnaires were administered to assess current life stress. Results revealed that PMDD women had significantly lower stroke volume, cardiac output and cortisol levels but significantly elevated norepinephrine and total peripheral resistance at rest and also during mental stressors compared with control subjects. These effects were evident in both cycle phases. Significantly more women with PMDD had histories of sexual abuse, and they also reported greater current life stress than control subjects. Consistent with a history of trauma, the PMDD women exhibited significantly greater ratios of norepinephrine to cortisol at rest and during stress. These results are interpreted as reflecting dysregulation of the stress response and may be related to histories of severe and/or chronic exposure to stress for a subgroup of PMDD women.

Effects of early stress on adult affiliative behavior

The recently evolved mammalian species preservative behavior as opposed to the ancient self preservative behavior involves parental care, nursing, social interaction, pair bonding and mutual defense. Gonadal steroids together with oxytocin are critical for this affiliative, attachment behavior. When there is stressful loss of control, gonadotrophins are diminished, and the self preservative, fight-flight catecholamine coping response takes priority. It is suggested that self preservation is associated with left hemispheric brain function and that species preservation is associated with right hemispheric function. Stress during infancy that is severe enough to create insecure attachment has a dissociative effect, disrupting right hemispheric emotional functioning and species preservative behavior, and a permanent bias towards self preservation can become an adult trait. In such a person with impaired affiliation, corticoid responses may be deficient. The coronary type A behavior pattern common in our society exhibits some of this deficiency in species preservative activity.

Blunted cardiovascular and catecholamine stress reactivity in women with bulimia nervosa

Cardiovascular and catecholamine responses to mental stressors were investigated in women with bulimia nervosa (BN) and in healthy control subjects. Fifteen women with BN and 15 control subjects completed psychosocial questionnaires before laboratory testing, where they were exposed to an interpersonally based speech stressor and a serial math task. Blood pressure, heart rate, epinephrine, norepinephrine and, via impedance cardiography, systolic time intervals, cardiac output and total peripheral resistance were measured at rest and during stress. Results indicated that BN was associated with blunted sympathetic activation in response to mental stress, indicated by increased pre-ejection period responses and blunted systolic blood pressure, heart rate and epinephrine responses. In contrast, women with BN had elevated cortisol levels when compared with control women. In addition, despite equivalent performance between groups, bulimic women reported feeling significantly more confused, frustrated, inadequate and dissatisfied with their performance during tasks. Psychosocial questionnaires also indicated that women with BN perceived more stress, had worse coping skills, lower self-esteem and sense of mastery, reported less social support, had worse mood, had greater anxiety and were more depressed when compared with control women. These results are interpreted as reflecting physiological and psychological profiles indicative of distress vs. active effort coping in BN.

Psychoendocrinology. A commentary

This article provides an outline of both the descriptive and the therapeutic sides of human psychoendocrinology. Attention is given to both the history and future prospects of the discipline. Examples are chosen from both basic and clinical science to illustrate the accomplishments and promise of the field as well as its relationship to its cognate discipline psychopharmacology and the dependence of both on progress in psychiatric nosology.

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.

Diseases among men 20 years after exposure to severe stress: implications for clinical research and medical care

OBJECTIVE

Epidemiologic studies have linked exposure to severe environmental stress, such as natural disasters and combat operations, to the onset of specific psychiatric disorders. Some research also suggests that these exposures may be associated with the onset of chronic diseases as well. However, these chronic disease outcome studies often have been obscured by bias and confounding.

METHOD

The medical histories of 1399 male Vietnam veterans approximately 20 years after combat exposure (mean years = 17) were analyzed by lifetime posttraumatic stress disorder (PTSD) status (lifetime PTSD = 332 cases). These men were included in a national, random in-person study of United States Army veterans of the Vietnam War (study completion rate = 65%).

RESULTS

After controlling for preservice, in-service, and postservice factors (including intelligence, race, region of birth, enlistment status, volunteer status, Army marital status, Army medical profile, hypochondriasis, age, smoking history, substance abuse, education, and income), associations were found for reported circulatory [odds ratio (OR) = 1.62, p = .007], digestive (OR = 1.47, p = .036), musculoskeletal (OR = 1.78, p = .008), endocrine-nutritional-metabolic (OR = 1.58, p = .10), nervous system (OR = 2.47, p < .001), respiratory (OR = 1.54, p = .042), and nonsexually transmitted infectious diseases (OR = 2.14, p < .004) after military service.

CONCLUSION

Although this study has some limitations, it suggests that there is a direct link between severe stress exposures and a broad spectrum of human diseases. In the future, medical researchers and clinicians should focus more on the medical consequences of exposure to severe environmental stress and seek to better integrate psychobiologic models of disease pathogenesis.

Jean-Martin Charcot's contributions to the interface between neurology and psychiatry

Although much has been written about Jean-Martin Charcot (1825-1893) as a neurologist and his commitment to the hysterics of the Salpêtrière, his influence on modern psychiatric thought has been misunderstood. His contributions range from the diagnosis and understanding of certain aspects of hysteria, which influenced psychoanalysis, to insights into the psychopathology of trauma that foreshadow modern concepts of post-traumatic stress disorder and somatoform disorders. This article reviews these aspects in the context of his contributions as a founder of modern neurology, neuropathology and proponent of the anatomo-clinical approach.

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.

Noradrenergic mechanisms in stress and anxiety: II. Clinical studies

Studies in animals have shown a relationship between alterations in noradrenergic brain system function and behaviors of anxiety and fear. These findings have generated the hypothesis that the symptoms seen in patients with anxiety disorders may be related to alterations in noradrenergic function. A number of clinical studies have tested this hypothesis, utilizing measures of catecholaminergic function such as heart rate and blood pressure, measurement of norepinephrine and its metabolites in urine and plasma and adrenergic receptor binding in platelets, as well as pharmacological challenge to the noradrenergic system. Acute stressors, such as public speaking, have been associated with an increase in heart rate, blood pressure, and norepinephrine and its metabolites in urine and plasma. Findings in patients with panic disorder at baseline related to heart rate, blood pressure, baseline norepinephrine and its metabolites, and platelet adrenergic receptors have been mixed, while the most consistent findings have been blunted growth hormone response to clonidine and increased 3-methoxy-4-hydroxy-phenylethylene-glucol (MHPG) and anxiety following stimulation of the noradrenergic system with yohimbine. Baseline measures of noradrenergic function in patients with posttraumatic stress disorder (PTSD) have also been mixed, while an increased heart, blood pressure and norepinephrine response to traumatic reminders, as well as increased behavioral (as well as different brain metabolic) response to yohimbine, have been found in PTSD. There are fewer studies of noradrenergic function in the other anxiety disorders, and the findings there have not been consistent. These studies provide evidence for increased noradrenergic responsiveness in panic disorder and PTSD, although there does not appear to be an alteration in baseline noradrenergic function in these patients.

Self-reported stressors, symptom complaints and psychobiological functioning-II: Psychoneuroendocrine variables

The present study examined resting endocrinological functioning and endocrine responsivity to new challenges as a function of self-reported stress load and symptomatology. Following a baseline period, four groups of male subjects (low-load/low-symptoms; low-load/high-symptoms; high-load/low-symptoms; high-load/high-symptoms) were exposed to stressful films, followed by a rest period. Blood samples were drawn after each film and after the rest condition, and urinary samples were collected during two nights preceding the experimental session. Neuroendocrine variables measured in plasma included adrenaline, noradrenaline, ACTH, cortisol, growth hormone, prolactin, and testosterone. The urinary samples were assayed for noradrenaline and adrenaline (in relation to creatinin). High-symptom subjects had significantly higher plasma levels of noradrenaline and overnight urinary adrenaline levels, whereas their cortisol levels tended to be lower as compared to the low-symptom group. The plasma noradrenaline/cortisol ratio was higher among the high-symptom subjects. However, upon controlling for neuroticism and life style factors (smoking and alcohol consumption), all but the effects on cortisol failed to meet significance criteria. Higher stress load was associated with higher plasma adrenaline responses during the laboratory session, irrespective of neuroticism or life-style measures. These results therefore suggest that in addition to measuring exposure to real-life stressors, it is also necessary to measure outcomes, such as symptoms, and to be aware of the effects of neuroticism and life-style when attempting to understand which specific psychosocial factors effect psychoendocrinological functioning.

Delayed startle sensitization distinguishes rats exposed to one or three stress sessions: further evidence toward an animal model of PTSD

Posttraumatic stress disorder (PTSD) may occur in humans exposed chronically to stressors or after a single exposure to a traumatic event. A distinguishing feature of patients with PTSD is an exaggerated startle response, evident long after the traumatic event. We have observed similar abnormalities in our animal model of a chronic stress state. Rats exposed to 3 days (3DS) of our stress regimen (2-hr sessions of 40, 2 mA tailshocks) have exhibited a consistent pattern of persistent physiological and behavioral abnormalities including an exaggerated startle response several days after stressor cessation. In contrast, rats exposed to a single stress session (1DS) have exhibited many, but not all, of the persistent abnormalities displayed by 3DS rats. The present experiment compared the startle responding of 3DS and 1DS rats 4, 7, and 10 days after stressor cessation. Consistent with previous work, stressed rats exhibited elevated basal plasma corticosterone (CORT) levels the first day poststressor. These CORT levels were sensitive to the number of stressor exposures with higher CORT levels in 3DS rats than in 1DS rats. As for startle responding, the 1DS rats exhibited an exaggerated startle response 7 days poststressor, whereas startle sensitization was apparent 10 days poststressor in 3DS rats. Thus, the appearance of an exaggerated startle response after stressor cessation appears to be related to the number of stress session exposures. These animal models, the 3DS and 1DS rats, may be useful to gain insight into the neurobehavioral changes associated with PTSD.

Effect of chronic stress associated with unemployment on salivary cortisol: overall cortisol levels, diurnal rhythm, and acute stress reactivity

This study examined the effect of chronic stress associated with unemployment on the magnitude of salivary cortisol excretion, on the diurnal rhythm of cortisol, and on cortisol reactivity to acute naturalistic stressors using Experience Sampling Methodology (ESM). Employed (N = 60) and unemployed (N = 60) subjects were studied for 2 days. Subjects were beeped 6 times per day by a preprogrammed wristwatch to assess acute stressors; 25 minutes after each ESM-beep, subjects were beeped a second time for saliva samples. The groups did not differ in their overall cortisol excretion or in cortisol reactivity to acute daily stressors. Compared to employed subjects, unemployed subjects had a diurnal pattern of cortisol excretion with relatively higher morning and lower evening levels. Subjects' daily activities and their locations were associated with diurnal rhythm differences.

Stress and the erectile response to intracavernosal prostaglandin E1 in men with erectile dysfunction

The erectile response to intracavernosal injection (ICI) of smooth muscle relaxants is often impaired in men with presumed psychogenic erectile dysfunction. This study tests the hypothesis that such impairment results from stress-related increase in circulating norepinephrine (NE). Fifty-nine men with erectile dysfunction had their nocturnal penile tumescence (NPT) monitored over 2 nights, and ICI of 10 micrograms prostaglandin E1 was given on the second morning. Psychometric and neuroendocrine measures of stress, including plasma and urinary catecholamines, were taken on both mornings. Inhibition of the ICI response was determined by the difference between NPT and ICI responses, and two groups of "high inhibition" and "low inhibition" men were compared. The high inhibition group showed higher "Trait" and "State" anxiety and a neuroendocrine profile of higher initial cortisol and lower plasma catecholamine levels than the low inhibition group. These differences were evident on both mornings and hence were not specifically related to the ICI. There was no support for the hypothesis that inhibition of response to ICI results from increased circulating NE, though the possibility that increased NE release occurred specifically in the erectile tissues could not be excluded.

Abuse-related posttraumatic stress disorder: evidence for chronic neuroendocrine activation in women

The following study tested the hypothesis that women with post-traumatic stress disorder (PTSD) related to childhood sexual abuse would display elevated norepinephrine-to-cortisol ratios similar to that found in male combat veterans diagnosed with PTSD. Twenty-four-hour urine samples were collected from 28 women: 11 women with PTSD who experienced childhood sexual abuse (PTSD+), 8 women who experienced childhood sexual abuse without PTSD (PTSD-), and 9 nonabused controls. All urine samples were tested for creatinine, total catecholamines, free-cortisol, and 17-ketosteroid levels. Psychological testing validated that the PTSD+ group was significantly elevated on all three subscales of the Impact of Events Scale. Both abused groups (PTSD+ and PTSD-) showed a tendency for polyuria, and the PTSD+ group showed a tendency towards obesity. Thus, neuroendocrine values (micrograms/day) were adjusted by creatinine clearance rates (creatinine mg/day/kg body weight). The corrected values indicated that the PTSD+ group had significantly elevated daily levels of norepinephrine, epinephrine, dopamine, and cortisol. However, because of the parallel elevation in cortisol, the norepinephrine-to-cortisol ratio was not significantly elevated in the PTSD+ diagnosed women in contrast to the findings reported for male PTSD patients. This discrepancy may reflect an important gender difference, an interaction between gender and age at onset of the traumatic experience (childhood abuse in females vs. combat experience in young adult males), or physiological variation related to phase of the disorder.

Persistent stress-induced sensitization of adrenocortical and startle responses

We assessed the functional adrenocortical and behavioral state of rats previously exposed to repeated stressor presentations. In Experiment 1, the whole-body startle response to threshold (91 dB) and suprathreshold (96 dB) stimuli was assessed in rats given 3 daily sessions (3DS) of 40, 2-mA tailshocks. The 3DS rats showed an exaggerated startle response to the threshold auditory stimulus 4 days poststressor compared to nonshocked controls (CON). An exaggerated startle response in stressed rats was not evident either 1 day or 10 days poststressor. In Experiment 2, adrenocortical sensitization and behavioral reactivity were assessed in rats exposed to 1 day (1DS) or 3 days of our stress regimen. Stressed rats exhibited elevated basal plasma corticosterone (CORT) levels 1 day poststressor which recovered by 9 days poststressor. Stressed rats also exhibited suppressed open-field activity 4 days poststressor. On the 10th day poststressor, rats were exposed to a single tailshock. The 1DS and 3DS rats showed both a sensitized and prolonged CORT response to stressor reexposure compared to control rats which received only the single tailshock. In addition, on the 11th day poststressor 3DS rats exhibited a moderate recapitulation of the elevated basal CORT levels seen after the initial stressor exposures. Thus, exposure to our stress regimen produces a chronic stress state in rats characterized by persistent behavioral and adrenocortical sensitization, as well as suppressed open-field activity and elevated basal CORT levels. Rats exhibiting a chronic stress state may be appropriate as a model for the study of stress-related psychophysiological illnesses, such as posttraumatic stress disorder.

Psychological and physiological responses to stress: the right hemisphere and the hypothalamo-pituitary-adrenal axis, an inquiry into problems of human bonding

In addition to repeated reexperiencing of the event, the delayed effects of severe psychological trauma, i.e., post traumatic stress disorder (PTSD), present a paradoxical mix of symptoms. There is enhancement of the self-preservative catecholamine states; anger and fear with a contrasting sense of meaninglessness and a blunting of the emotional responses of the attachment behavior so critical for species preservation. Hormonally, there is a striking separation of the catecholamine response, which stays elevated and that of the hypothalamo-pituitary-adrenal (HPA) axis, which may remain at normal levels. Pathophysiologically, the reexperiencing of the trauma and the arousal may be associated with dysfunction of the locus coeruleus, amygdala and hippocampal systems. This article explores the consequences of an additional dysfunction: a dissociation of the hemispheres that appears to be responsible for the alexithymic avoidance and failure of the cortisol response that so often follow severe psychological trauma. There is neurophysiological evidence that the left and right hemispheres subserve different emotional sets that correspond to "control" and "appraisal," i.e., very approximately to the self and species preservative behavioral complexes, respectively. Several studies point to physiological dissociation of hemispheric functions during alexithymia. This raises the question: What has been lost if in this condition the right side no longer fully contributes to integrated cerebral function? Right hemispheric damaged children lose critical social skills and in adults the related sense of familiarity critical for bonding is lost. Such losses of social sensibilities may account for the lack of empathy and difficulties with bonding found in sociopathy and borderline personality: conditions now believed to result from repeated psychological trauma during development. On the other hand, systems that promote right hemispheric contributions provide solacing access to a "Higher Power." They also appear to protect against socially disordered behavior, substance abuse, the failure of the HPA axis and some aspects of the pathophysiology of chronic disease.

Psychoneuroendocrine assessment of posttraumatic stress disorder: current progress and new directions

1. Studies in our laboratory have used the psychoendocrine strategy to explore differences in basal hormone levels between patients with posttraumatic stress disorder (PTSD) and other groups. This approach has allowed us to explore the relationship between hormone levels and specific psychological and biological processes which appear to develop following exposure to extreme trauma. 2. The concurrent assessment of several hormonal systems provides an opportunity to explore differences in hormonal patterns in various psychiatric disorders. PTSD appears to be characterized by a specific profile of hormonal changes that is distinct from that of other diagnostic groups and normal controls. These findings raise the possibility that the psychoendocrine approach may be useful in further exploring the pathophysiology and diagnosis of PTSD. 3. This paper reviews psychoendocrine changes in PTSD and describes updated multivariate methods that further elucidate psychological and neurochemical correlates of hormonal alterations in this disorder.

Paroxetine binding in the blood platelets of post-traumatic stress disorder patients

Platelet serotonin (5-HT) uptake, as determined by 3H-paroxetine (PA) binding, was studied in 20 Post-traumatic Stress Disorder (PTSD) patients and 20 normal controls. Kd (an inverse measure of affinity of 3H-PA binding to uptake sites) and Bmax (maximum number of 3H-PA binding sites) of 3H-PA binding were significantly decreased in PTSD patients as compared to normal controls. However, there was no difference in Kd or Bmax between PTSD patients with and without a diagnosis of major depression. The Bmax of 3H-PA binding was negatively correlated with state dependent anxiety score whereas Kd was positively correlated with the Mississippi Scale for Combat-Related PTSD score. The role of serotonergic processes in the psychobiology of PTSD is discussed.

Biological basis of the stress response

Chronic, as well as acute emotional arousal, is a consequence of various types of social interaction, i.e., those between mother and infant and between controlling dominant and less effective subordinate. The neurohumoral accompaniments of this social stress include the sympathetic adrenal medullary and hypothalamic pituitary adrenal responses. A common ensuing pathophysiological state involves a chronic increase of blood pressure. Although Selye's General Adaptation Syndrome presupposed the same response to a variety of stimuli; recent work shows that specific perceptions of control result in different patterns of neuroendocrine activation. A challenge perceived as easy to handle will elicit an active coping response and release of the neurosympathetic system's norepinephrine. Testosterone will rise as the subject savors success. With increasing anxiety this active coping shifts to a more passive mode and the behavior becomes less assured as the animal loses control. The norepinephrine/epinephrine ratio decreases as epinephrine, prolactin, renin and fatty acids rise. As the outcome becomes still less certain and distress grows, adrenocorticotropic hormone and cortisol levels arise. Thus, the effort required on the one hand and the degree of frustration conflict and uncertainty on the other, determine the ratio of catecholamines to corticoids. With severe emotional trauma, brain dysfunction may occur. These effects can be lasting, and corticoids paradoxically return to normal as the behavior changes to that of post-traumatic stress disorder. Repression and denial set in and the organism responds with decreased concern of impaired attachment and increased irritability.

Multidimensional hormonal discrimination of paranoid schizophrenic from bipolar manic patients

The search for biological markers of psychiatric disorders has traditionally involved univariate approaches, usually focusing upon one measure at a time, and to date has been primarily directed towards the assessment of depressive rather than psychotic illnesses. The present study explores a multidimensional psychoendocrine strategy, using a profile of five hormones, including cortisol, epinephrine, norepinephrine, testosterone, and free thyroxine, and is directed at the differentiation of two major psychotic illnesses, bipolar manic disorder and paranoid schizophrenia. When the levels of these hormones were assessed at admission and biweekly during hospitalization, the mean values for all five hormones were found to differ markedly between the two diagnostic groups. There was, however, always a zone of overlap in levels between the two groups when each of the five hormones were viewed individually, so that at best only about 70% of patients were correctly separated by diagnostic group using any single hormone alone. By contrast, multivariate approaches combining mean values of three or more hormones, using either stepwise discriminant analysis or multidimensional scaling, yielded 95% correct classification of the two diagnostic groups. Similar but not quite as great accuracy of classification was achieved with only the initial hormone sample obtained at the time of hospital admission. These preliminary findings provide encouragement for further exploration of multidimensional hormonal strategies in the search for useful biological criteria to assist in the diagnosis of psychiatric disorders.