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

Self-compassion, self-coldness, and social support and their relationship with depression, anxiety, and PTSD symptoms following a massive terror attack: a prospective study

Background: On 7 October 2023, Israel suffered a massive deadly terror attack with 1400 civilians murdered and 240 kidnapped. Recent studies have documented an increase in depression, anxiety, and posttraumatic symptoms in the aftermath of the attack. In the area of trauma, it has been shown that while some individuals are vulnerable to developing psychopathology following exposure to a traumatic event, the majority are not.Objective: In the present prospective study, we examined the contributions of internal (self-compassion and self-coldness) and external (social support) resources to depression, anxiety, and posttraumatic symptoms among civilians following a massive terror attack.Method: A total of 250 participants - 126 females (50.4%) and 124 males (49.6%); 156 Jews (62.4%) and 94 Arabs (37.6%) - aged 21-60 (M  = 41.7, SD = 10.63) completed questionnaires at two time points: T1 was in September 2023 (3-4 weeks before the attack) and T2 was in February-March 2024 (19-20 weeks after the attack). Participants were assessed using the Multidimensional Scale of Perceived Social Support (MSPSS), Self-Compassion Scale - Short Form (SCS-SF), Depression, Anxiety, and Stress Scale-21 Items (DASS-21), and International Trauma Questionnaire (ITQ).Results: Self-compassion and social support were negatively associated with depression and anxiety, while self-coldness was positively associated with depression and anxiety. In addition, self-coldness uniquely contributed to the prediction of psychopathological outcomes, including the sense of threat symptoms cluster of posttraumatic stress disorder, beyond known risk factors.Conclusions: Our study highlights the role of self-coldness as a vulnerability factor for civilians following a terror attack. It is important to view the distinct facets of self-compassion as a therapeutic target when building both intervention and prevention programs for people exposed directly and indirectly to trauma.

Longitudinal Associations Between Peritraumatic Oestradiol and Fear Responding in Women and Men

PTSD is more prevalent in women than men and associated with autonomic dysfunction. Higher oestradiol levels have been associated with decreased PTSD severity, however, the impact of oestradiol on autonomic function is not well characterised. We examined associations among peritraumatic oestradiol levels and autonomic function in the multi-site AURORA study. Participants (n = 283, 69.6% female) were recruited from the emergency department (ED) following trauma exposure. Skin conductance (SC) was measured during trauma recall at the ED. Oestradiol was assayed from blood collected at ED, 2-week and 6-month. Fear conditioning, including fear potentiated startle (FPS), was completed at 2-week and 6-month. In women, ED oestradiol was significantly positively associated with ED SC and FPS at 6-month. In men, significant negative correlations between ED oestradiol and SC were found. Among women in the study, peritraumatic oestradiol was positively associated with fear responding 6-month. Findings suggest that the protective effects of oestradiol on PTSD may depend on other factors, such as time since trauma. Additional research is needed to elucidate how peritraumatic oestradiol and autonomic function may interact to confer risk for PTSD.

A systematic review on the bidirectional relationship between trauma-related psychopathology and reproductive aging

Objective

Natural variation in ovarian steroid hormones across the female lifespan contributes to an increased risk for depressive and posttraumatic stress disorder (PTSD) symptoms in women. However, minimal work has focused on understanding the impacts of reproductive aging on the brain and behavioral health of trauma-exposed women. This systematic review examines the bidirectional relationship between trauma-related psychopathology and reproductive aging.

Method

Following PRISMA guidelines, a systematic review of PubMed, PsychInfo, and Medline databases was undertaken to identify controlled studies on how trauma history impacts psychopathology and menopause symptoms during reproductive aging.

Results

Twenty-one studies met the eligibility criteria, with only four utilizing the gold standard STRAW+ 10 criteria for defining reproductive aging stages. The peri and postmenopausal periods appear to be particularly vulnerable phases for individuals with trauma exposure. Menopause symptoms and trauma-related psychopathology symptom severity increase during reproductive aging with increases in the degree of trauma exposure. However, mechanistic insights that may explain this interaction are currently neglected in this area of research.

Conclusion

There is a significant lack of understanding regarding how reproductive aging and its related neuroendocrine changes impact the brain to influence PTSD and depression symptoms related to trauma exposure. This lack of basic understanding impedes the ability to identify, assess, and treat PTSD and depressive symptoms in trauma-exposed women most effectively, and mitigate the long-term consequences of these behavioral health symptoms on morbidity and mortality in aging women.

PTSD-related differences in resting-state functional connectivity and associations with sex hormones

Background

Posttraumatic stress disorder (PTSD) is a debilitating condition that disproportionately impacts individuals who are female. Prior research indicates that males with PTSD exhibit hypoconnectivity of frontal brain regions measured with resting electroencephalography (EEG). The present study examined functional connectivity among females with PTSD and trauma-exposed controls, as well as the impact of sex hormones.

Methods

Participants included 61 females (Mage = 31.41, SD = 8.64) who endorsed Criterion A trauma exposure. Resting state EEG data were recorded for five minutes in the eyes open position. Using a Linear Mixed Effects model, paired region-of-interest power envelope connectivity of the theta band (4-7 Hz) served as the response variables.

Results

Compared to controls, the PTSD group displayed hyperconnectivity between visual brain regions and the rest of the cerebral cortex (pFDR < 0.05). Additionally, participants with PTSD demonstrated enhanced connectivity between the default mode network and frontoparietal control network compared to controls (pFDR < 0.05), as well as increased connectivity between the ventral attention network and the rest of the cerebral cortex (pFDR < 0.05). Estradiol was associated with higher connectivity, while progesterone was associated with lower connectivity, but these did not survive correction.

Conclusions

Results are consistent with prior research indicating that PTSD is associated with altered connectivity in visual brain regions, which may reflect disrupted visual processing related to reexperiencing symptoms (e.g., intrusive memories). Our findings provide additional support for the relevance of the theta frequency range in PTSD given its role in fear learning and regulation processes.

PTSD symptoms, pain catastrophizing, and pain outcomes after acute orthopedic injury

BACKGROUND

PTSD is associated with greater incidence of chronic pain. Pain catastrophizing often accounts for this association. Less is known about these relationships during the acute phase (1-2 months) following orthopedic traumatic injuries. We sought to understand which orthopedic traumatic injury-related PTSD symptoms were associated with acute pain and physical dysfunction and whether pain catastrophizing accounted for these associations.

METHODS

This secondary analysis uses baseline data from a multisite randomized controlled trial of an intervention for individuals with heightened pain catastrophizing or pain anxiety following acute orthopedic injury. We used partial correlations to examine associations between PTSD symptom clusters (re-experiencing, avoidance, negative alterations in cognitions and mood, and hyperarousal) and pain outcomes (pain intensity and physical dysfunction) controlling for pain catastrophizing. We used hierarchical regressions to evaluate unique associations between PTSD clusters and pain outcomes. In exploratory analysis, we examined the indirect effects of PTSD symptoms on pain outcomes through catastrophizing.

RESULTS

Hierarchical linear regressions indicated that hyperarousal was uniquely associated with greater pain intensity with activity (β = 0.39, p < 0.001, ΔR2 =0.06) and physical dysfunction (β = 0.22, p = 0.04 ΔR2 =0.02). PTSD symptoms were still associated with pain with activity even with pain catastrophizing included in the models, and catastrophizing did not have a significant indirect effect on the relationship between PTSD and physical dysfunction (b=0.06, SEBoot=0.04, 95% CIBoot = [-0.003, 0.14]). Pain catastrophizing did largely account for the association between re-experiencing, avoidance, and negative alterations in cognitions and mood symptoms and pain at rest.

CONCLUSIONS

Pain catastrophizing interventions may be best suited for limiting the impact of PTSD symptoms on pain at rest, but catastrophizing alone may not fully explain the relationship between PTSD symptoms and physical dysfunction after acute orthopedic injury. To prevent the negative association of PTSD symptoms, especially hyperarousal, on physical outcomes in acute pain populations, interventions may require more than solely targeting pain catastrophizing.

Involvement of the brain-heart axis in the link between PTSD and cardiovascular disease

Posttraumatic stress disorder (PTSD) has long been associated with a heightened risk of cardiovascular disease (CVD). A number of mechanisms have been implicated to underlie this brain-heart axis relationship, such as altered functioning of the autonomic nervous system and increased systemic inflammation. While neural alterations have repeatedly been observed in PTSD, they are rarely considered in the PTSD-CVD link. The brain-heart axis is a pathway connecting frontal and limbic brain regions to the brainstem and periphery via the autonomic nervous system and it may be a promising model for understanding CVD risk in PTSD given its overlap with PTSD neural deficits. We first provide a summary of the primary mechanisms implicated in the association between PTSD and CVD. We then review the brain-heart axis and its relevance to PTSD, as well as findings from PTSD trials demonstrating that a number of PTSD treatments have effects on areas of the brain-heart axis. Finally, we discuss sex considerations in the PTSD-CVD link. A critical next step in this study is to determine if PTSD treatments that affect the brain-heart axis (e.g., brain stimulation that improves autonomic function) also reduce the risk of CVD.

The neuropeptide landscape of human prefrontal cortex

The neuropeptide system encompasses the most diverse family of neurotransmitters, but their expression, cellular localization, and functional role in the human brain have received limited attention. Here, we study human postmortem samples from prefrontal cortex (PFC), a key brain region, and employ RNA sequencing and RNAscope methods integrated with published single-cell data. Our aim is to characterize the distribution of peptides and their receptors in 17 PFC subregions and to explore their role in chemical signaling. The results suggest that the well-established anatomical and functional heterogeneity of human PFC is also reflected in the expression pattern of the neuropeptides. Our findings support ongoing efforts from academia and pharmaceutical companies to explore the potential of neuropeptide receptors as targets for drug development.

Human prefrontal cortex (hPFC) is a complex brain region involved in cognitive and emotional processes and several psychiatric disorders. Here, we present an overview of the distribution of the peptidergic systems in 17 subregions of hPFC and three reference cortices obtained by microdissection and based on RNA sequencing and RNAscope methods integrated with published single-cell transcriptomics data. We detected expression of 60 neuropeptides and 60 neuropeptide receptors in at least one of the hPFC subregions. The results reveal that the peptidergic landscape in PFC consists of closely located and functionally different subregions with unique peptide/transmitter–related profiles. Neuropeptide-rich PFC subregions were identified, encompassing regions from anterior cingulate cortex/orbitofrontal gyrus. Furthermore, marked differences in gene expression exist between different PFC regions (>5-fold; cocaine and amphetamine–regulated transcript peptide) as well as between PFC regions and reference regions, for example, for somatostatin and several receptors. We suggest that the present approach allows definition of, still hypothetical, microcircuits exemplified by glutamatergic neurons expressing a peptide cotransmitter either as an agonist (hypocretin/orexin) or antagonist (galanin). Specific neuropeptide receptors have been identified as possible targets for neuronal afferents and, interestingly, peripheral blood-borne peptide hormones (leptin, adiponectin, gastric inhibitory peptide, glucagon-like peptides, and peptide YY). Together with other recent publications, our results support the view that neuropeptide systems may play an important role in hPFC and underpin the concept that neuropeptide signaling helps stabilize circuit connectivity and fine-tune/modulate PFC functions executed during health and disease.

Physiological reactions to acute stressors and subjective stress during daily life: A systematic review on ecological momentary assessment (EMA) studies

OBJECTIVE

This review aims to provide an overview of ecological momentary assessment (EMA) studies analyzing stress reactivity during daily life in terms of direct and moderated influence of acute stress on physiological responses.

MATERIALS AND METHODS

A systematic literature search was performed on November 29, 2021 using Web of Science, MEDLINE and PsycINFO to identify prospective EMA studies targeting acute stressors or stress under naturalistic conditions, without restrictions of publication date or population. Study quality was assessed for multiple EMA-specific sources of bias.

RESULTS

Out of 4285 non-duplicate records, 107 publications involving 104 unique studies were included. The majority of studies assessed acute physiological stress responses primarily through salivary cortisol (n = 59) and cardiovascular outcomes (n = 32). Most studies performed at least three measurements per day (n = 59), and had a moderate risk of recall bias (n = 68) and confounding (n = 85). Fifty-four studies reported a compliance of ≥80%. Direct, non-moderated positive associations were observed between acute stress exposure and concurrent cortisol levels (44%, n = 11/25), systolic (44%, 8/18) and diastolic blood pressure (53%, 8/15) and heart rate (53%, 9/17). Several inter- and intra-individual moderators were identified, such as age, gender, health status, chronic stress, work-related resources, physical activity and stress coping indicators.

CONCLUSIONS

About half of the reviewed EMA studies demonstrated direct associations between everyday acute stress exposure and physiological responses, including increased cortisol levels, blood pressure and heart rate. Results further suggested various moderator variables that could help develop tailored prevention strategies and identify groups at higher risk for dysfunctional stress responses.

REGISTRATION

PROSPERO-Reg.-No.: PROSPERO 2020 CRD42020163178.

Sex hormones and cortisol during experimental trauma memory consolidation: Prospective association with intrusive memories

Background Trauma- and stress-related disorders, such as post-traumatic stress disorder (PTSD), are more common in females than in males. Sex hormones affect learning and emotional memory formation and may be associated with the development of PTSD. Most previous studies have indexed these hormones in isolation. Objectives: To investigate associations of sex hormones and cortisol during memory consolidation on the development of intrusive memories. Methods: We employed an experimental trauma film paradigm in 61 healthy women and indexed salivary testosterone, progesterone, estradiol, and cortisol on day one and day two post experimental trauma exposure and their effects on intrusion frequency, distress, and vividness. Intrusive trauma memories were indexed by means of a diary in which participants documented intrusion frequency, distress, and vividness. Results and conclusion: Participants reported an average of 5.3 intrusions over the course of seven days (SD = 4.6, range 0-26). Progesterone, and estradiol indexed on day one predicted intrusion frequency, with higher progesterone and lower estradiol predicting more intrusive memories (p-values AUC progesterone 0.01 and estradiol 0.02). There was no evidence for associations between hormone concentration indices on day two and intrusion outcomes. Further research on the roles of gonadal and adrenal hormones in trauma memory formation is needed to advance our efforts to understand their influence on PTSD development.

Skin conductance response to trauma interview as a candidate biomarker of trauma and related psychopathology in youth resettled as refugees

Background: Posttraumatic stress symptoms (PTSS) include a constellation of physical and emotional profiles that youth exposed to trauma may experience. An estimated 20% of youth are exposed to trauma, and in refugee populations, up to 54% experience posttraumatic stress. Given the physical and mental health consequences associated with trauma exposure and subsequent psychopathology, identifying biomarkers of symptom severity is a top research priority. Objective: Previous research in adults found that skin conductance responses to trauma interview predicted current and future PTSS. We extended this method to refugee youth exposed to civilian war trauma and forced migration, to examine associations between PTSS and skin conductance in this uniquely vulnerable child and adolescent population. Methods: 86 refugee youth ages 7-17 years completed a trauma interview and assessment of self-reported PTSS. The mobile eSense app on a iPad was used to obtain continuous recordings of skin conductance level (SCL) during a trauma interview (trauma SCL). Skin conductance response (SCR) was calculated by subtracting the baseline SCL from the maximum amplitude of the trauma SCL. Results: SCL during trauma was significantly greater than baseline SCL, Trauma exposure was significantly associated with SCR to trauma interview, R²= .084, p = .042. SCR to trauma interview was positively correlated with reexperiencing (R² = .127, p = .028), and hyperarousal symptoms (R ²= .123, p = .048). Conclusions: The present study provides evidence for feasibility of SCR to trauma interview as a candidate biomarker of PTSS in youth. This is the first study to look at SCR to trauma interview in youth resettled as refugees and is part of the limited but growing body of research to look at biomarkers in refugee cohorts more broadly. As the number of forcibly displaced persons surges, early detection and prevention of trauma-related psychology is becoming more important than ever.

HIGHLIGHTS

Using the mobile eSense app, we demonstrate that skin conductance is measurable in a variety of research settings and that skin conductance response may be a biological indicator of trauma and related psychopathology - namely re-experiencing symptoms - in youth resettled as refugees.

Neurobiological Alterations in Females With PTSD: A Systematic Review

Most females experience at least one traumatic event in their lives, but not all develop PTSD. Despite considerable research, our understanding of the key factors that constitute risk for PTSD among females is limited. Previous research has largely focused on sex differences, neglecting within group comparisons, thereby obviating differences between females who do and do not develop PTSD following exposure to trauma. In this systematic review, we conducted a search for the extent of existing research utilizing magnetic resonance imaging (MRI) to examine neurobiological differences among females of all ages, with and without PTSD. Only studies of females who met full diagnostic criteria for PTSD were included. Fifty-six studies were selected and reviewed. We synthesized here findings from structural MRI (sMRI), functional MRI (fMRI), diffusion tensor imaging (DTI), and resting state functional connectivity (rs-FC MRI) studies, comparing females with and without PTSD. A range of biopsychosocial constructs that may leave females vulnerable to PTSD were discussed. First, the ways timing and type of exposure to trauma may impact PTSD risk were discussed. Second, the key role that cognitive and behavioral mechanisms may play in PTSD was described, including rumination, and deficient fear extinction. Third, the role of specific symptom patterns and common comorbidities in female-specific PTSD was described, as well as sex-specific implications on treatment and parenting outcomes. We concluded by identifying areas for future research, to address the need to better understand developmental aspects of brain alterations, the differential impact of trauma types and timing, the putative role of neuroendocrine system in neurobiology of PTSD among females, and the impact of social and cultural factors on neurobiology in females with PTSD.

A prospective examination of sex differences in posttraumatic autonomic functioning

BACKGROUND

Cross-sectional studies have found that individuals with posttraumatic stress disorder (PTSD) exhibit deficits in autonomic functioning. While PTSD rates are twice as high in women compared to men, sex differences in autonomic functioning are relatively unknown among trauma-exposed populations. The current study used a prospective design to examine sex differences in posttraumatic autonomic functioning.

METHODS

192 participants were recruited from emergency departments following trauma exposure (Mean age = 35.88, 68.2% female). Skin conductance was measured in the emergency department; fear conditioning was completed two weeks later and included measures of blood pressure (BP), heart rate (HR), and high frequency heart rate variability (HF-HRV). PTSD symptoms were assessed 8 weeks after trauma.

RESULTS

2-week systolic BP was significantly higher in men, while 2-week HR was significantly higher in women, and a sex by PTSD interaction suggested that women who developed PTSD demonstrated the highest HR levels. Two-week HF-HRV was significantly lower in women, and a sex by PTSD interaction suggested that women with PTSD demonstrated the lowest HF-HRV levels. Skin conductance response in the emergency department was associated with 2-week HR and HF-HRV only among women who developed PTSD.

CONCLUSIONS

Our results indicate that there are notable sex differences in autonomic functioning among trauma-exposed individuals. Differences in sympathetic biomarkers (BP and HR) may have implications for cardiovascular disease risk given that sympathetic arousal is a mechanism implicated in this risk among PTSD populations. Future research examining differential pathways between PTSD and cardiovascular risk among men versus women is warranted.

Reversed patterns of resting state functional connectivity for females vs. males in posttraumatic stress disorder

Background

Posttraumatic stress disorder (PTSD) is twice as prevalent among females as compared to males following potentially traumatic events. While there is evidence for aberrant functional connectivity between hubs of the central executive network (CEN), salience network (SN), and the default mode network (DMN) in PTSD, little is known regarding sex-specificity of this connectivity. The current study aims to directly examine sex-specific resting-state functional connectivity (rs-FC) in trauma exposed males and females, with and without PTSD.

Methods

One hundred and seventy-eight individuals underwent functional magnetic resonance imaging (fMRI) at rest, of them 85 females (45 with PTSD) and 93 males (57 with PTSD). We conducted whole-brain seed-based analysis using CEN (lateral prefrontal cortex [lPFC]), SN (anterior cingulate cortex [ACC], insula, amygdala [AMG]), and DMN (medial prefrontal cortex [mPFC], posterior parietal cortex [PCC], and hippocampus [HIP]) hubs as seed regions. Group-by-Sex ANOVA was conducted.

Results

The amygdala-precuneus, ACC-precuneus, and hippocampus-precuneus pathways exhibited significant group-by-sex interaction effects, with females with PTSD consistently differing in connectivity patterns from males with PTSD and from trauma-exposed healthy females.

Conclusions

Sex-specific neural connectivity patterns were found within and between key nodes of the CEN, DMN, and the SN, suggesting opposite patterns of connectivity in PTSD and trauma-exposed controls as a function of sex as a biological variable (SABV). This may point to mechanistic sex differences in adaptation following trauma and may inform differential neural targets for treatment of females and males with PTSD.

Prognostic neuroimaging biomarkers of trauma-related psychopathology: resting-state fMRI shortly after trauma predicts future PTSD and depression symptoms in the AURORA study

Neurobiological markers of future susceptibility to posttraumatic stress disorder (PTSD) may facilitate identification of vulnerable individuals in the early aftermath of trauma. Variability in resting-state networks (RSNs), patterns of intrinsic functional connectivity across the brain, has previously been linked to PTSD, and may thus be informative of PTSD susceptibility. The present data are part of an initial analysis from the AURORA study, a longitudinal, multisite study of adverse neuropsychiatric sequalae. Magnetic resonance imaging (MRI) data from 109 recently (i.e., ~2 weeks) traumatized individuals were collected and PTSD and depression symptoms were assessed at 3 months post trauma. We assessed commonly reported RSNs including the default mode network (DMN), central executive network (CEN), and salience network (SN). We also identified a proposed arousal network (AN) composed of a priori brain regions important for PTSD: the amygdala, hippocampus, mamillary bodies, midbrain, and pons. Primary analyses assessed whether variability in functional connectivity at the 2-week imaging timepoint predicted 3-month PTSD symptom severity. Left dorsolateral prefrontal cortex (DLPFC) to AN connectivity at 2 weeks post trauma was negatively related to 3-month PTSD symptoms. Further, right inferior temporal gyrus (ITG) to DMN connectivity was positively related to 3-month PTSD symptoms. Both DLPFC-AN and ITG-DMN connectivity also predicted depression symptoms at 3 months. Our results suggest that, following trauma exposure, acutely assessed variability in RSN connectivity was associated with PTSD symptom severity approximately two and a half months later. However, these patterns may reflect general susceptibility to posttraumatic dysfunction as the imaging patterns were not linked to specific disorder symptoms, at least in the subacute/early chronic phase. The present data suggest that assessment of RSNs in the early aftermath of trauma may be informative of susceptibility to posttraumatic dysfunction, with future work needed to understand neural markers of long-term (e.g., 12 months post trauma) dysfunction. Furthermore, these findings are consistent with neural models suggesting that decreased top-down cortico-limbic regulation and increased network-mediated fear generalization may contribute to ongoing dysfunction in the aftermath of trauma.

Sex differences in post-traumatic stress disorder risk: autonomic control and inflammation

AIM

Over 7 million U.S. adults and about 20% of the military population have post-traumatic stress disorder (PTSD), a debilitating condition that is independently linked to a significantly greater risk of developing cardiovascular disease (CVD). Women have twice the probability of developing PTSD after experiencing a traumatic event compared to men. Existing literatures have reported higher inflammation and autonomic dysfunction including impaired baroreflex sensitivity, increased sympathetic reactivity and decreased parasympathetic activity in PTSD. However, most of these findings stem from studies conducted predominantly in males.

METHODS

We attempt in this narrative review to summarize the mixed literature available on sex differences in autonomic dysfunction and inflammation in PTSD, at rest and in response to stress in PTSD.

RESULTS

This review reveals that there is a paucity of research exploring autonomic function in females with PTSD. Recent studies have included female participants without probing for sex differences. A small number of studies have been conducted exclusively in women. Available data suggest that sympathetic nervous system output tends to be heightened, while parasympathetic activity and arterial baroreflex sensitivity appear more blunted in females with PTSD. Although few studies have investigated sex differences in inflammation in PTSD, data within females suggest chronic increases in inflammation with PTSD. This autonomic dysregulation and inflammation have also been described in males with PTSD.

CONCLUSION

In sum, given the inherent biological differences in CVD clinical presentation and characteristics between men and women, human and animal studies aiming at elucidating sex differences in the pathophysiology of PTSD are needed.