Sustained urinary norepinephrine and epinephrine elevation in post-traumatic stress disorder

Transtorno de estresse pós-traumático e transtorno de humor bipolar

O Transtorno Bipolar (THB) não é somente uma condição endógena. Severos eventos negativos durante a vida influenciam o desenvolvimento do primeiro episódio e alteram o curso do THB durante a vida. O Transtorno de Estresse Pós-Traumático (TEPT) é uma severa e incapacitante doença mental que afeta uma significativa parcela da população, em algum momento de suas vidas. A presença concomitante de TEPT e THB parece mais freqüente que anteriormente sugerido, e pacientes psicóticos com história de trauma tem sintomas mais severos e maior tendência a abusar de substância psicoativas ilícitas. Pensamentos intrusivos e pesadelos ocorrem com freqüência nos pacientes com TEPT e têm sido associados aos transtornos de humor. O tratamento farmacológico dessa comorbidade ainda está relacionado a estudo empíricos ou não-controlados. Neste artigo, são revisados aspectos atuais relacionados a essa comorbidade e enfatizados aspectos referentes à epidemiologia, etiologia, curso e tratamento farmacológico da comorbidade entre TEPT e THB. Especialmente, este estudo enfatiza a importância de avaliar sistematicamente a história de trauma em pacientes com THB.

The psychological impact of maxillofacial trauma: an overview of reactions to trauma

We provide an overview of the current understanding of posttraumatic psychological problems, such as posttraumatic stress disorder, and the implications for maxillofacial surgeons and allied professionals. Posttraumatic stress disorder is not confined to combat veterans; it is common after all traumatic events-including maxillofacial injury-and can become chronic unless recognized and treated. The neurobiologic underpinnings of and the known vulnerability factors for posttraumatic stress disorder are increasingly understood, assisting the nursing and surgical staff in their assessments. Both psychological and pharmacologic treatments have been shown to have efficacy; nevertheless, intervention by mental health professionals will not be required by all.

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.

Pharmacotherapy of anxious disorders

The present paper is a review of the treatment of anxious disorders by the current pharmaceutical medications; a short epidemiological survey is given for anxious disorders including: general anxiety disorder, panic disorder, obsessive compulsive disorder, social anxiety and post-traumatic stress disorder. For all these disorders there are proposals of treatment built on literature data mainly on meta-analysis as well on personal experience.

Psychopharmacological treatment in PTSD: a critical review

INTRODUCTION

Posttraumatic stress disorder (PTSD) is a prevalent psychiatric disorder that is heterogeneous in its nature, and often presents with other psychiatric comorbidities. As a result, empirical research on effective pharmacotherapy for PTSD has produced complex findings. This article reviews the existing research literature on pharmacological treatments for PTSD, identifies the most effective treatments, and where possible examines their mechanism of action with respect to the neurobiology of PTSD.

METHODS

We examined reports of clinical trials of psychotropic agents carried out with PTSD patients and published in peer-reviewed journals, as well as reports from presentations at scientific meetings between 1966 and 2001.

RESULTS

Numerous medications are effective in treating PTSD. These include tricyclic antidepressants, monoamine oxidase inhibitors, and serotonin reuptake inhibitors. Considering reported overall efficacy and side effects profiles, selective serotonin reuptake inhibitors emerge as the preferred first line treatment for PTSD. Mood stabilizers, atypical neuroleptics, adrenergic agents, and newer antidepressants also show promise, but require further controlled trials to clarify their place in the pharmacopoeia for PTSD.

DISCUSSION

There is clear evidence for effective pharmacotherapy of PTSD. Future improvements in the treatment of this disorder await further clinical trials and neurobiological research.

Urinary cortisol and catecholamines in mothers of child cancer survivors with and without PTSD

Reduced cortisol coupled with elevated catecholamines has been reported for patients with post-traumatic stress disorder (PTSD) precipitated by war and other traumas considered to be "outside the range of usual experiences". It is unclear whether these neuroendocrine abnormalities also occur in PTSD precipitated by more commonly experienced traumas associated with life-threatening illness. Overnight (12-h) urinary cortisol, norepinephrine (NE) and epinephrine (E) were measured in 21 mothers of pediatric cancer survivors with (n = 14) and without PTSD symptoms (n = 7) and in control mothers of healthy children (n = 8). Mothers meeting subthreshold and full PTSD criteria were combined to form the PTSD symptoms group. The PTSD group showed lower total urinary cortisol and a trend for higher total urinary NE than the non-PTSD group, who in turn were no different from controls. There were no significant group effects for E. Cortisol (but not NE) effects remained after controlling for symptoms of co-morbid depression. The finding of reduced cortisol in illness-related PTSD demonstrates neuroendocrine dysregulation similar to that found previously in other types of trauma (e.g., war-related). Future longitudinal studies with repeated urinary collection procedures will be necessary to clarify measurement issues and establish the time course and health implications of the neuroendocrine perturbations.

Implications of biological findings for psychological treatments of post-traumatic stress disorder

The goal of this article is to initiate dialogue among those conducting research on the biological aspects of post-traumatic stress disorder (PTSD) and clinicians and researchers concerned with developing effective psychological treatments for PTSD. Important biological findings in PTSD are reviewed, paying special attention to the clinical implications of these findings. A discussion of the psychological treatments effective for PTSD follows, focusing on how these empirically supported treatments may address some of the issues raised by the biological findings. Finally, suggestions are made for future directions for psychological treatment development for this disabling condition, examining how these innovative treatment approaches may be relevant to the reviewed biological findings.

The comorbidity of bipolar and anxiety disorders: prevalence, psychobiology, and treatment issues

BACKGROUND

Although symptoms of anxiety as well as anxiety disorders commonly occur in patients with bipolar disorder, the pathophysiologic, theoretical, and clinical significance of their co-occurrence has not been well studied.

METHODS

The epidemiological and clinical studies that have assessed the overlap of bipolar and anxiety disorders are reviewed, with focus on panic disorder and obsessive-compulsive disorder (OCD), and to a lesser extent, social phobia and post-traumatic stress disorder. Potential neural mechanism and treatment response data are also reviewed.

RESULTS

A growing number of epidemiological studies have found that bipolar disorder significantly co-occurs with anxiety disorders at rates that are higher than those in the general population. Clinical studies have also demonstrated high comorbidity between bipolar disorder and panic disorder, OCD, social phobia, and post-traumatic stress disorder. Psychobiological mechanisms that may account for these high comorbidity rates likely involve a complicated interplay among various neurotransmitter systems, particularly norepinephrine, dopamine, gamma-aminobutyric acid (GABA), and serotonin. The second-messenger system constituent, inositol, may also be involved. Little controlled data are available regarding the treatment of bipolar disorder complicated by an anxiety disorder. However, adequate mood stabilization should be achieved before antidepressants are used to treat residual anxiety symptoms so as to minimize antidepressant-induced mania or cycling. Moreover, preliminary data suggesting that certain antimanic agents may have anxiolytic properties (e.g. valproate and possibly antipsychotics), and that some anxiolytics may not induce mania (e.g. gabapentin and benzodiazepines other than alprazolam) indicate that these agents may be particularly useful for anxious bipolar patients.

CONCLUSIONS

Comorbid anxiety symptoms and disorders must be considered when diagnosing and treating patients with bipolar disorder. Conversely, patients presenting with anxiety disorders must be assessed for comorbid mood disorders, including bipolar disorder. Pathophysiological, theoretical, and clinical implications of the overlap of bipolar and anxiety disorders are discussed.

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.

Post-traumatic stress disorder: a review of psychobiology and pharmacotherapy

OBJECTIVE

To review the literature on the psychobiology and pharmacotherapy of PTSD.

METHODS

Relevant studies were identified by literature searches (Pub-med, Web of Science) and through reference lists. The search was ended by May 2001.

RESULTS

There is evidence of involvement of opioid, glutamatergic, GABAergic, noradrenergic, serotonergic and neuroendocrine pathways in the pathophysiology of PTSD. Medications shown to be effective in double-blind placebo-controlled trials includes selective serotonin reuptake inhibitors, reversible and irreversible MAO-inhibitors, tricyclic antidepressants and the anticonvulsant lamotrigine. Still more agents appear promising in open-label trials.

CONCLUSION

The complexity of the psychobiology is reflected by the difficulties in treating the disorder. According to the present knowledge, suggestions for drug treatment of PTSD are made.

Clonidine immediately after immobilization stress prevents long-lasting locomotion reduction in the rat

1. Stress-induced behavioral change in the rat has been utilized as an animal model of anxiety disorder. The authors examined the effect of early intervention by noradrenergic inhibition on stress-induced long-lasting locomotion reduction. 2. Clonidine, an alpha2 agonist, was administered immediately after a single session of 8 min immobilization stress in a restraining box, followed by locomotion measurement on day 1, day 7, and day 14 after the stress session. 3. In the saline-treated control group, locomotion on day 1, day 7, and day 14 after the 8 min stress session was significantly reduced to about 80% in comparison with that before the stress. This finding confirmed the previous report that a single stressful event could lead to long-lasting behavioral changes. When clonidine was administered, locomotion reduction was not observed on any post-stress day. 4. The results suggest that early intervention by noradrenergic inhibition to stressful events may have a preventive effect on subsequent behavioral change which may be considered as an animal model of post-traumatic stress disorder.

Posttraumatic stress disorder: diagnosis and epidemiology, comorbidity and social consequences, biology and treatment

Epidemiological studies clearly indicate that posttraumatic stress disorder (PTSD) is becoming a major health concern worldwide even if still poorly recognized and not well treated. PTSD commonly co-occurs with other psychiatric disorders, and several symptoms overlap with major depressive disorders, anxiety disorders and substance abuse; this may contribute to diagnostic confusion and underdiagnosis. This anxiety disorder provokes significant occupational, psychiatric, medical and psychosocial disability, and its consequences are enormously costly, not only to the survivors and their families, but also to the health care system and society. Work impairment associated with PTSD is very similar to the amount of work impairment associated with major depression. The pathophysiology of PTSD is multifactorial and involves dysregulation of the serotonergic as well as the noradrenergic system. A rational therapeutic approach should normalize the specific psychobiological alterations associated with PTSD. This can be achieved through the use of antidepressant drugs, mainly of those that potentiate serotonergic mechanisms. Recent double-blind placebo-controlled studies report the efficacy of selective serotonin reuptake inhibitors. Several cognitive-behavioral and psychosocial treatments have also been reported to be efficacious and could be considered when treating PTSD patients.

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.

The psychobiology and psychopharmacology of PTSD

This paper reviews the currently available knowledge about the psychobiology and psychopharmacology of post-traumatic stress disorder (PTSD). It also reviews the various studies that have elucidated changes in brain function and structure in PTSD populations, including position emission tomography (PET), single photon emission computed tomography (SPECT), and event-related potential (ERP) studies. It then reviews the literature on catecholamine and hypothalamic-pituitary-adrenal (HPA) axis abnormalities in PTSD, and finally reviews the literature available on the psychopharmacology of PTSD. It discusses how the pathophysiology of PTSD determines the nature of psychopharmacological interventions. Psychopharmacological interventions in PTSD are largely limited to good studies on the effects of the selective serotonin reuptake inhibitors (SSRIs). In order to effectively intervene in PTSD, studies of other psychopharmacological agents are necessary, specifically of agents which affect limbic activation, decreased frontal lobe functioning, altered HPA activity, and other biological features of PTSD. Copyright 2001 John Wiley & Sons, Ltd.

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.

Initial posttraumatic urinary cortisol levels predict subsequent PTSD symptoms in motor vehicle accident victims

BACKGROUND

This study was designed to examine the relationship between urinary hormone levels collected upon admission to the trauma unit following a motor vehicle accident and posttraumatic stress disorder symptomatology 1 month later.

METHODS

Fifteen-hour urine samples were collected from 63 male and 36 female motor vehicle accident victims and were used to assess levels of catecholamines and cortisol reflecting peritraumatic and acute-phase posttraumatic levels. Presence of posttraumatic stress disorder symptomatology was assessed 1 month after the accident.

RESULTS

Motor vehicle accident victims subsequently diagnosed with acute posttraumatic stress disorder excreted significantly lower levels of cortisol in 15-hour urines collected upon admission to the hospital. In addition, urinary levels of cortisol predicted a significant percentage of the variance in intrusive and avoidant thoughts 1 month after the accident.

CONCLUSIONS

The results of our study suggest that initial cortisol levels in the immediate aftermath of a traumatic event contribute, in part, to subsequent symptoms of posttraumatic stress disorder.

Autonomic dysregulation in panic disorder and in post-traumatic stress disorder: application of power spectrum analysis of heart rate variability at rest and in response to recollection of trauma or panic attacks

Power spectral analysis (PSA) of heart rate variability (HRV) offers reliable assessment of cardiovascular autonomic responses, providing a 'window' onto the interaction of peripheral sympathetic and parasympathetic tone. Alterations in HRV are associated with various physiological and pathophysiological processes, and may contribute to morbidity and mortality. Previous studies of posttraumatic stress disorder (PTSD) found lower resting HRV in patients compared to controls, suggesting increased sympathetic and decreased parasympathetic tone. This article describes the analysis of HRV at rest and after psychological stress in panic disorder (PD) patients, in an enlarged sample of PTSD patients, and in healthy control subjects. Standardized heart rate (HR) analysis was carried out in 14 PTSD patients, 11 PD patients and 25 matched controls. ECG recordings were made while subjects were resting ('rest 1'), while recalling the trauma implicated in PTSD, or the circumstances of a severe panic attack, as appropriate ('recall'), and again while resting ('rest 2'). Controls were asked to recall a stressful life event during recall. While both patient groups had elevated HR and low frequency (LF) components of HRV at baseline (suggesting increased sympathetic activity), PTSD patients, unlike PD patients and controls, failed to respond to the recall stress with increases in HR and LF. HRV analysis demonstrates significant differences in autonomic regulation of PTSD and PD patients compared to each other and to control subjects. HRV analysis may augment biochemical studies of peripheral measures in these disorders.

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.

Post-traumatic stress disorder and sleep-what a nightmare!

According to DSM IV criteria, sleep disturbances are incorporated in the definition of post-traumatic stress disorder (PTSD). These include the re-experiencing symptoms (nightmares, criteria B) and a hyperarousal state (difficulty initiating and maintaining sleep, criteria D). PTSD patients commonly complain of sleep disturbances. Moreover, insomnia, restless sleep and trauma-related dreams might be the primary complaint of some patients. However, although subjective sleep disturbances are considered characteristic of PTSD, sleep laboratory studies have provided inconsistent evidence of objective sleep disorders. A variety of sleep architectures and sleep patterns has been reported in PTSD. However, only a few studies have controlled for comorbidities. Thus, uncertainty exists to what extent the sustained complaints of sleep disturbances in chronic PTSD are specifically related to the impact of exposure to traumatic stress, or rather are a consequence of comorbid disorders. Specific changes in REM sleep suggest a pathophysiologic role of REM sleep abnormality in PTSD (e.g. anxiety dreams, increased REM density, exaggerated startle response, decreased dream recall and elevated awakening thresholds from REM sleep). However, again, studies have failed to show consistent changes in percentage of REM sleep or in REM latency. There might be a coexistence of pressure to REM along with inhibitory forces of REM that result in high variability of REM parameters across patients. Alternatively, changes in REM sleep might reflect the effect of comorbid psychiatric disorders that results in inconsistent findings between patients. The current review tries to address these issues based on recent studies carried out in this field.

Low baseline and yohimbine-stimulated plasma neuropeptide Y (NPY) levels in combat-related PTSD

BACKGROUND

Consistent with many studies demonstrating enhanced reactivity of the sympathetic nervous system in posttraumatic stress disorder (PTSD), the administration of yohimbine, a noradrenergic alpha(2)-antagonist, has been shown to increase core symptoms of PTSD and to induce greater increases in plasma 3-methyl-4-hydroxy-phenyl-glycol (MHPG) in subjects with PTSD compared with healthy control subjects. In turn, neuropeptide Y (NPY) has been shown to inhibit the release of norepinephrine from sympathetic noradrenergic neurons.

METHODS

In the following study, plasma NPY responses to yohimbine and placebo were measured in a subgroup of 18 subjects with PTSD and 8 healthy control subjects who participated in the previous study of the effect of yohimbine on plasma MHPG.

RESULTS

The PTSD subjects had lower baseline plasma NPY and blunted yohimbine-stimulated increases in plasma NPY compared with the healthy control subjects. Within the PTSD group, baseline plasma NPY levels correlated negatively with combat exposure scale scores, baseline PTSD and panic symptoms, and yohimbine-stimulated increases in MHPG and systolic blood pressure.

CONCLUSIONS

This study suggests that combat stress-induced decreases in plasma NPY may mediate, in part, the noradrenergic system hyperreactivity observed in combat-related PTSD. The persistence of this decrease in plasma NPY may contribute to symptoms of hyperarousal and the expression of exaggerated alarm reactions, anxiety reactions, or both in combat veterans with PTSD long after war.

Posttraumatic stress disorder and the nature of trauma

The role of psychological trauma (eg, rape, physical assaults, torture, motor vehicle accidents) as an etiological factor in mental disorders, anticipated as early as the 19th century by Janet, Freud, and Breuer, and more specifically during World War I and II by Kardiner, was "rediscovered" some 20 years ago in the wake of the psychological traumas inflicted by the Vietnam war and the discussion "in the open " of sexual abuse and rape by the women's liberation movement, 1980 marked a major turning point, with the incorporation of the diagnostic construct of posttraumatic stress disorder (PTSD) into the 3rd edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and the definition of its main diagnostic criteria (reexperiencing of the traumatic event, avoidance of stimuli associated with the trauma, and symptoms of increased arousal). Initially described as resulting from a onetime severe traumatic incident, PTSD has now been shown to be triggered by chronic multiple traumas as well. This "state-of-the-art" article discusses past and current understanding of the disorder, with particular emphasis on the recent explosive developments in neuroimaging and other fields of the neurosciences that have highlighted the complex interrelationships between the psychological, psychiatric, biological, and neuroanatomical components of the disorder, and opened up entirely new therapeutic perspectives on how to help the victims of trauma overcome their past.

Treatment for posttraumatic stress disorder

OBJECTIVE

To thoroughly and critically review the pharmacologic treatment of posttraumatic stress disorder (PTSD) and to review the symptomatology, diagnosis, epidemiology, pathophysiology, and assessment of PTSD.

DATA SOURCES

A MEDLINE search (1966-October 1999) in the English language specifying PTSD drug treatment as the search term was used to identify articles.

STUDY SELECTION AND DATA EXTRACTION

All articles identified were reviewed; emphasis was given to randomized, double-blind, placebo-controlled studies.

DATA SYNTHESIS

It appears that a five-week medication trial is necessary to assess clinical effects on PTSD symptoms. The monoamine oxidase inhibitors appear to be superior to the tricyclic antidepressants in improving reexperiencing and avoidance symptoms. Most studies used assessment tools that neglected hyperarousal symptoms; therefore, no conclusions regarding this symptom cluster can be drawn. Other pharmacotherapeutic interventions reported in open-label trials have yielded varying success.

CONCLUSIONS

The current literature does not bear a sufficient number of double-blind, placebo-controlled studies using assessment tools that evaluate the three symptom clusters of PTSD to allow for a definite treatment modality to be formulated. Nonetheless, a treatment hierarchy appears to be in order based on the greatest number of double-blind, placebo-controlled studies evaluating antidepressants. Alternate modalities such as mood stabilizers, antipsychotics, anxiolytics, and adrenergic blockers should not be considered the mainstays of therapy.

Sensory gating in chronic posttraumatic stress disorder: reduced auditory P50 suppression in combat veterans

BACKGROUND

Posttraumatic stress disorder (PTSD) may be associated with a general impairment of cognitive function that extends beyond the processing of trauma-specific stimuli. Suppression of the auditory P50 response to repeated stimuli occurs in normal subjects and reflects the central nervous system's ability to screen out repetitive stimuli, a phenomenon referred to as sensory gating. This study examines P50 sensory gating to nonstartle auditory stimuli in PTSD subjects and normal controls.

METHODS

P50 generation and gating were studied using a conditioning/testing paradigm in 15 male subjects with PTSD and 12 male controls. P50 test/conditioning (T/C) ratios were estimated using the Singular Value Decomposition method.

RESULTS

The amplitude of the P50 response to the conditioning stimulus did not differ in subjects with PTSD compared to normal controls. The P50 T/C ratio is increased in PTSD subjects (mean = .408, SD = .275) as compared to the controls (mean = .213, SD = .126, two tailed t, p = .024).

CONCLUSIONS

This study provides evidence that PTSD is associated with impaired gating to nonstartle trauma-neutral auditory stimuli.

The impact of early adverse experiences on brain systems involved in the pathophysiology of anxiety and affective disorders

The relative contribution of genetic and environmental factors to the development of the major psychiatric disorders has long been debated. Recently, considerable attention has been given to the observations that adverse experiences early in life predispose individuals to the development of affective and anxiety disorders in adulthood. Corticotropin-releasing factor (CRF) is the central coordinator of the endocrinologic, autonomic, immunologic, and behavioral stress responses. When centrally administered, CRF produces many physiologic and behavioral changes reminiscent of both acute stress and depression. Moreover, CRF has also been implicated in the pathogenesis of a variety of anxiety disorders, mainly through CRF neurocircuits connecting the amygdala and the locus ceruleus. Clinical studies have provided convincing evidence for central CRF hypersecretion in depression, and, to a lesser extent, in some anxiety disorders. Evidence mainly from preclinical studies suggests that stress early in life results in persistent central CRF hyperactivity and increased stress reactivity in adulthood. Thus, genetic disposition coupled with early stress in critical phases of development may result in a phenotype that is neurobiologically vulnerable to stress and may lower an individual's threshold for developing depression and anxiety upon further stress exposure. This pathophysiologic model may provide novel approaches to the prevention and treatment of psychopathology associated with stress early in life.

Role of norepinephrine in the pathophysiology and treatment of posttraumatic stress disorder

This review focuses on the role of norepinephrine (NE) in traumatic stress. The review is divided into three sections. The first section, "Norepinephrine and Arousal," describes preclinical studies related to norepinephrine's role in arousal, orienting to novel stimuli, selective attention and vigilance. It also contains a brief discussion of NE and its relationship to fear-provoking stimuli followed by preclinical and clinical studies that demonstrate heightened noradrenergic neuronal reactivity, increased alpha 2 receptor sensitivity and exaggerated arousal in organisms that have been exposed to chronic uncontrollable stress. The second section, "Norepinephrine and Memory," describes preclinical and clinical studies related to norepinephrine's role in enhanced encoding of memory for arousing and aversive events and in subsequent re-experiencing symptoms such as, intrusive memories and nightmares. The third section, "Norepinephrine and Pharmacologic Treatment," briefly discusses the use of adrenergic blockers, clonidine and propranol, as well as tricyclic and MAO inhibitors, for the treatment of PTSD. Finally, we attempt to synthesize trauma-related preclinical and clinical studies of norepinephrine. We do this, in part, by focusing on a series of yohimbine studies in subjects with PTSD because data from these studies allow for a discussion that brings together preclinical and clinical findings relevant to trauma-related alterations in arousal and memory.

A.E. Bennett Research Award. Developmental traumatology. Part I: Biological stress systems

BACKGROUND

This investigation examined the relationship between trauma, psychiatric symptoms and urinary free cortisol (UFC) and catecholamine (epinephrine [EPI], norepinephrine [NE], dopamine [DA]) excretion in prepubertal children with posttraumatic stress disorder (PTSD) secondary to past child maltreatment experiences (n = 18), compared to non-traumatized children with overanxious disorder (OAD) (n = 10) and healthy controls (n = 24).

METHODS

Subjects underwent comprehensive psychiatric and clinical assessments and 24 hour urine collection for measurements of UFC and urinary catecholamine excretion. Biological and clinical measures were compared using analyses of variance.

RESULTS

Maltreated subjects with PTSD excreted significantly greater concentrations of urinary DA and NE over 24 hours than OAD and control subjects and greater concentrations of 24 hour UFC than control subjects. Post hoc analysis revealed that maltreated subjects with PTSD excreted significantly greater concentrations of urinary EPI than OAD subjects. Childhood PTSD was associated with greater co-morbid psychopathology including depressive and dissociative symptoms, lower global assessment of functioning, and increased incidents of lifetime suicidal ideation and attempts. Urinary catecholamine and UFC concentrations showed positive correlations with duration of the PTSD trauma and severity of PTSD symptoms.

CONCLUSIONS

These data suggest that maltreatment experiences are associated with alterations of biological stress systems in maltreated children with PTSD. An improved psychobiological understanding of trauma in childhood may eventually lead to better treatments of childhood PTSD.

Medial frontal cortex involvement in PTSD symptoms: a SPECT study

The regional cerebral blood flow (rCBF) responses to a combat stress-related auditory stimulus was examined in Vietnam veterans diagnosed with posttraumatic stress disorder (PTSD). Based on prior data in healthy subjects, we hypothesized that the medial prefrontal cortex may be involved in the processing of stress responses. Twelve male veterans diagnosed with PTSD, 11 age-matched, combat-exposed subjects without PTSD, and 12 healthy control subjects were studied with single-photon emission tomography and the blood flow tracer [99mTc]-HMPAO. Subjects were studied twice, while listening to combat sounds or white noise. Significant increases in the blood flow to the medial prefrontal cortex were observed in PTSD patients, but not in the control groups, which correlated at trend levels with psychophysical measures of stress response. These data support the involvement of the medial prefrontal cortex in the pathophysiology of PTSD, possibly mediating some of its symptoms.

Brain activation in PTSD in response to trauma-related stimuli

BACKGROUND

Repetitive recall of traumatic memories and chronic intermittent hyperarousal are characteristic of posttraumatic stress disorder (PTSD). Hyperarousal and memory dysfunction implicates "limbic" brain regions, including the amygdaloid complex, hippocampal formation, and limbic cortex, such as the orbitofrontal and anterior cingulate areas. To investigate the neurobiologic role of these brain regions in PTSD, we measured regional cerebral blood flow in PTSD with single photon emission computerized tomography (SPECT) during a symptom provocation paradigm.

METHODS

Fourteen Vietnam veterans with PTSD, 11 combat control subjects, and 14 normal control subjects were studied with [99mTc]HMPAO in two sessions 48 hours apart: one session after exposure to white noise and the other following exposure to combat sounds. Skin conductance, heart rate, and subjective experience were recorded at the time of the studies.

RESULTS

Activation for all three groups occurred in the anterior cingulate/middle prefrontal gyrus. Activation in the region of the left amygdala/nucleus accumbens was found in PTSD patients only. Deactivation was found in all three groups in the left retrosplenial region.

CONCLUSIONS

These findings implicate regions of the "limbic" brain, which may mediate the response to aversive stimuli in healthy individuals and in patients suffering from PTSD.

Elevated serum interleukin-6 (IL-6) and IL-6 receptor concentrations in posttraumatic stress disorder following accidental man-made traumatic events

BACKGROUND

Recently, it has been reported that serum interleukin-1 beta (IL-1 beta), but not soluble IL-2 receptor (sIL-2R), concentrations were significantly higher in patients with posttraumatic stress disorder (PTSD) than in normal volunteers, and that psychological stress in humans is associated with increased secretion of proinflammatory cytokines, such as IL-6.

METHODS

The aim of the present study was to examine the inflammatory response system in patients with PTSD through measurements of serum IL-6, sIL-6R, sgp130 (the IL-6 signal transducing protein), sIL-1R antagonist (sIL-1RA; an endogenous IL-1 receptor antagonist), CC16 (an endogenous anticytokine), and sCD8 (the T suppressor-cytotoxic antigen).

RESULTS

Serum IL-6 and sIL-6R, but not sgp130, sIL-RA, CC16, or sCD8, concentrations were significantly higher in PTSD patients than in normal volunteers. Serum sIL-6R concentrations were significantly higher in PTSD patients with concurrent major depression than in PTSD patients without major depression and normal volunteers. There were no significant relationships between serum IL-6 or sIL-6R and severity measures of PTSD.

CONCLUSIONS

The results suggest that PTSD is associated with increased IL-6 signaling. It is hypothesized that stress-induced secretion of proinflammatory cytokines is involved in the catecholaminergic modulation of anxiety reactions.

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.

Higher serum prolyl endopeptidase activity in patients with post-traumatic stress disorder

BACKGROUND

It is reported that psychiatric disorders, such as depression and schizophrenia, are associated with changes in serum activity of prolyl endopeptidase (EC 3.4.21.26), a cytosolic endopeptidase, which cleaves peptide bonds on the carboxylside of proline in proteins of relatively small molecular mass.

AIMS AND METHODS

The aims of the present study were to examine serum PEP activity in patients with post-traumatic stress disorder (PTSD) versus healthy volunteers. PEP activity has been determined by a fluorimetric assay.

RESULTS

Serum PEP activity was significantly higher in patients with PTSD than in normal volunteers. Serum PEP activity was significantly higher in patients with PTSD and concurrent major depression than in patients with PTSD without major depression. In PTSD patients, there were no significant correlations between serum PEP activity and severity of PTSD symptoms.

CONCLUSIONS

The results show that PTSD and, in particular, PTSD with concurrent major depression is associated with increased activity of PEP.

RELEVANCE

these results may be of importance for the (i) neuroendocrine pathophysiology of PTSD since PEP degrades neuropeptides, such as arginine vasopressin (AVP) and thyrotropin releasing hormone (TRH); and (ii) etiology of PTSD, since PEP degrades behaviorally active neuropeptides, such as AVP, TRH, oxytocin, neurotensin and substance P, which play a key role in positive reinforcement, social interactions, emotions and stress responsivity.

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.

Analysis of heart rate variability in posttraumatic stress disorder patients in response to a trauma-related reminder

BACKGROUND

Spectral analysis of heart rate variability has recently been shown to be a reliable noninvasive test for quantitative assessment of cardiovascular autonomic regulatory responses, providing a dynamic map of sympathetic and parasympathetic interaction. In a prior study exploring the state of hyperarousal characterizing the posttraumatic stress disorder (PTSD) syndrome, the authors described standardized heart rate analysis carried out in 9 PTSD patients at rest, which demonstrated clear-cut evidence of a baseline autonomic hyperarousal state.

METHODS

To examine the dynamics of this hyperarousal state, standardized heart rate analysis was carried out in 9 PTSD patients compared to a matched control group of 9 healthy volunteers. Twenty-minute recordings of electrocardiogram in response to a trauma-related cue as opposed to a resting state were performed and analyzed. The PTSD patients were asked to recount the presumed triggering traumatic event, and the control subjects recounted a significant stressful negative life event.

RESULTS

Our results show that, whereas the control subjects demonstrated significant autonomic responses to the stressogenic stimulus supplied by the recounting of a major stressful experience, the PTSD patients demonstrated almost no autonomic response to the recounting of the triggering stressful event. The PTSD patients demonstrated a degree of autonomic dysregulation at rest which was comparable to that seen in the control subjects' reaction to the stress model.

CONCLUSIONS

The lack of response to the stress model applied in the study appears to imply that PTSD patients experience so great a degree of autonomic hyperactivation at rest, that they are unable to marshal a further stress response to the recounting of the triggering trauma, as compared to control subjects.

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.

Increased 24-hour urinary cortisol excretion in patients with post-traumatic stress disorder and patients with major depression, but not in patients with fibromyalgia

There is now firm evidence that major depression is accompanied by increased baseline activity of the hypothalamic-pituitary-adrenal (HPA) axis, as assessed by means of 24-h urinary cortisol (UC) excretion. Recently, there were some reports that fibromyalgia and post-traumatic stress disorder (PTSD), two disorders which show a significant amplitude of depressive symptoms, are associated with changes in the baseline activity of the HPA axis, such as low 24-h UC excretion. The aim of the present study was to examine 24-h UC excretion in fibromyalgia and PTSD patients compared to normal controls and patients with major depression. In the three patient groups, severity of depressive symptoms was measured by means of the Hamilton Depression Rating Scale (HDRS) score. Severity of fibromyalgia was measured using a dolorimetrically obtained myalgic score, and severity of PTSD was assessed by means of factor analytical scores computed on the items of the Composite International Diagnostic Interview (CIDI), PTSD Module. Patients with PTSD and major depression had significantly higher 24-h UC excretion than normal controls and fibromyalgia patients. At a threshold value of > or = 240 micrograms/24 h, 80% of PTSD patients and 80% of depressed patients had increased 24 h UC excretion with a specificity of 100%. There were no significant differences in 24-h UC excretion either between fibromyalgia patients and normal controls, or between patients with major depression and PTSD patients. In the three patient groups, no significant correlations were found between 24-h UC excretion and the HDRS score. In fibromyalgia, no significant correlations were found between 24-h UC excretion and the myalgic score. In PTSD, no significant correlations were found between 24-h UC excretion and severity of either depression-avoidance or anxiety-arousal symptoms. In conclusion, this study found increased 24-h UC excretion in patients with PTSD comparable to that in patients with major depression, whereas in fibromyalgia no significant changes in 24-h UC were found.

Bupropion treatment in veterans with posttraumatic stress disorder: an open study

This study was designed to investigate the efficacy of the antidepressant drug bupropion in the treatment of posttraumatic stress disorder (PTSD). Seventeen male combat veterans with chronic PTSD were treated with bupropion in an open-label fashion for 6 weeks. Patients were evaluated with the Clinical Global Impressions Scale for Improvement (CGI-I) at follow-up and rated blindly at baseline and posttreatment with the Clinician Administered PTSD Scale (CAPS), the Hamilton Rating Scale for Depression (HAM-D), and the Hamilton Rating Scale for Anxiety. Three patients discontinued bupropion prematurely because of side effects. Of the remaining 14 patients, 10 were classified as treatment responders by the CGI-I. HAM-D scores decreased significantly from baseline to follow-up. The improvement seen in hyperarousal symptoms was significant but was less significant than the change in depressive symptoms. There was no significant change in Intrusion, Avoidance, or total CAPS scores. It was concluded that bupropion was well tolerated. Patients who had experienced sexual dysfunction with selective serotonin reuptake inhibitors reported no complaints during bupropion treatment. Bupropion decreased depressive symptoms and most patients reported global improvement, although PTSD symptoms remained mostly unchanged. Controlled trials should further clarify the role of bupropion in the treatment of PTSD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychoneuroendocrinology of post-traumatic stress disorder

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

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.

Internalizing and externalizing characteristics of sexually and/or physically abused children

This study evaluates the behavioral consequences of childhood abuse (sexual, physical, or both), with particular focus on prevalence of posttraumatic stress disorder (PTSD). Three abuse type groups and nonabused controls were contrasted on behavioral rating scales and on structured psychiatric interview data. The participants (109 abused children and 16 normal control children) were recruited from Arkansas Children's Hospital and local agencies for abused children. As expected, proportionately more females than males were sexually abused. Overall, males were rated as more disturbed than females. Type of abuse did not consistently influence behavioral ratings. Externalizing scores were significantly higher than internalizing scores in all abused groups. PTSD was diagnosed in 50% of the abused children, with a higher rate for boys who had been sexually abused as opposed to physically abused only (58% versus 13%). The most frequent comorbid condition with PTSD was Separation Anxiety. Sexually abused boys were hospitalized for psychiatric treatment at a higher rate than were other abused children.

Prolactin response to low-dose dexamethasone challenge in combat-exposed veterans with and without posttraumatic stress disorder and normal controls

The prolactin and cortisol responses to dexamethasone (0.5 mg) were studied in combat veterans with (n = 18) and without (n = 12) posttraumatic stress disorder (PTSD) and normal controls (n = 18). Both veteran groups demonstrated greater prolactin suppression than the normals. In contrast, only veterans with PTSD showed an enhanced cortisol suppression in response to dexamethasone. These findings suggest that the prolactin response to dexamethasone may reflect a feature of combat exposure rather than PTSD per se.

Stages of decompensation in combat-related posttraumatic stress disorder: a new conceptual model

This conceptual article presents a model of severe, chronic combat-related PTSD based on several years of longitudinal clinical observations of Vietnam veterans. The model describes a repeating cycle of decompensation that profoundly disrupts the veteran's life. There appear to be "stages" of decompensation that can be described clinically and may be distinct physiologically. The stages describe a wide range of functioning, from adaptive to totally dysfunctional PTSD core symptoms, as well as several other dimensions of clinical functioning, such as affect regulation, defenses, ego states, interactions with the environment, capacity for self-destruction/suicide and capacity for attachment and insight are described for each stage. Clinical and research implications are discussed.