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Lange RT, Merritt VC, Brickell TA, Dalgard CL, Soltis AR, Hershaw J, Lippa SM, Gill J, French LM. Apolipoprotein E e4 is associated with worse self-reported neurobehavioral symptoms following uncomplicated mild traumatic brain injury in U.S. military service members. Behav Brain Res 2021; 415:113491. [PMID: 34333069 DOI: 10.1016/j.bbr.2021.113491] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 06/24/2021] [Accepted: 07/25/2021] [Indexed: 11/16/2022]
Abstract
Past research has found a relationship between the apolipoprotein E (APOE) e4 allele and worse neurobehavioral functioning following mild traumatic brain injury (MTBI) in civilian populations. The purpose of this study was to examine this relationship in service members and veterans (SMVs) following MTBI. Participants were 151 SMVs (103 uncomplicated MTBI; 48 Injured Controls [IC]) prospectively enrolled in the DVBIC-TBICoE 15-Year Longitudinal TBI Study. Participants completed a battery of self-reported neurobehavioral symptom measures on average 76.2 months post-injury (SD = 31.8). APOE genotyping was undertaken using non-fasting blood samples. Participants were classified into four subgroups based on injury (MTBI vs. IC) and APOE e4 allele status (e4 present/absent). In the IC group, there were no significant differences across APOE e4 status subgroups for all measures. In the MTBI group, participants with the APOE e4 allele had significantly worse scores on measures of depression, pain, anxiety, grief, positive well-being, social participation, and resilience compared to those without the e4 allele (d = .44 to d = .69). When comparing the number of 'clinically elevated' neurobehavioral measures simultaneously, the MTBI/e4 present subgroup consistently had a higher number of elevated measures compared to the MTBI/e4 absent, IC/e4 present, and IC/e4 absent subgroups. The APOE e4 allele was associated with poorer neurobehavioral outcome in SMVs in the chronic phase of recovery following MTBI. APOE e4 could be incorporated into screening tools to predict SMVs at risk for poor long-term neurobehavioral outcome in an effort to provide early intervention to improve long-term clinical outcome.
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Affiliation(s)
- Rael T Lange
- Traumatic Brain Injury Center of Excellence, 1335 E W Hwy, Silver Spring, MD, 20910, United States; Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD, 20814, United States; National Intrepid Center of Excellence, Palmer Rd S, Bethesda, MD, 20814, United States; University of British Columbia, Vancouver, BC, V6T 1Z4, Canada; Contractor, General Dynamics Information Technology, 3150 Fairview Park Dr, Falls Church, VA, 22042, United States; Centre of Excellence on Post-traumatic Stress Disorder, 1145 Carling Ave, Ottawa, ON, K1Z 7K4, Canada.
| | - Victoria C Merritt
- VA San Diego Healthcare System, 3350 La Jolla Village Dr, San Diego, CA, 92161, United States; University of California San Diego, 9500 Gilman Dr, La Jolla, CA, 92093, United States.
| | - Tracey A Brickell
- Traumatic Brain Injury Center of Excellence, 1335 E W Hwy, Silver Spring, MD, 20910, United States; Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD, 20814, United States; National Intrepid Center of Excellence, Palmer Rd S, Bethesda, MD, 20814, United States; Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, United States; Contractor, General Dynamics Information Technology, 3150 Fairview Park Dr, Falls Church, VA, 22042, United States; Centre of Excellence on Post-traumatic Stress Disorder, 1145 Carling Ave, Ottawa, ON, K1Z 7K4, Canada.
| | - Clifton L Dalgard
- Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, United States; The American Genome Center, 4301 Jones Bridge Rd, Bethesda, MD, 20814, United States.
| | - Anthony R Soltis
- Henry M Jackson Foundation, 6720A Rockledge Dr, Bethesda, MD, 20817, United States; PRIMER, 4301 Jones Bridge Rd, Bethesda, MD, 20814, United States.
| | - Jamie Hershaw
- Traumatic Brain Injury Center of Excellence, 1335 E W Hwy, Silver Spring, MD, 20910, United States; Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD, 20814, United States; National Intrepid Center of Excellence, Palmer Rd S, Bethesda, MD, 20814, United States; Contractor, General Dynamics Information Technology, 3150 Fairview Park Dr, Falls Church, VA, 22042, United States.
| | - Sara M Lippa
- Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD, 20814, United States; National Intrepid Center of Excellence, Palmer Rd S, Bethesda, MD, 20814, United States.
| | - Jessica Gill
- National Institutes of Health, National Institute of Nursing Research, 10 Center Dr, Bethesda, MD, 20814, United States.
| | - Louis M French
- Traumatic Brain Injury Center of Excellence, 1335 E W Hwy, Silver Spring, MD, 20910, United States; Walter Reed National Military Medical Center, 4494 Palmer Rd N, Bethesda, MD, 20814, United States; National Intrepid Center of Excellence, Palmer Rd S, Bethesda, MD, 20814, United States; Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd, Bethesda, MD, 20814, United States.
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Chitrala KN, Nagarkatti P, Nagarkatti M. Computational analysis of deleterious single nucleotide polymorphisms in catechol O-Methyltransferase conferring risk to post-traumatic stress disorder. J Psychiatr Res 2021; 138:207-218. [PMID: 33865170 PMCID: PMC8969201 DOI: 10.1016/j.jpsychires.2021.03.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 03/18/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
Post-traumatic stress disorder (PTSD) is one of the prevalent neurological disorder which is drawing increased attention over the past few decades. Major risk factors for PTSD can be categorized into environmental and genetic factors. Among the genetic risk factors, polymorphisms in the catechol-O-methyltransferase (COMT) gene is known to be associated with the risk for PTSD. In the present study, we analysed the impact of deleterious single nucleotide polymorphisms (SNPs) in the COMT gene conferring risk to PTSD using computational based approaches followed by molecular dynamic simulations. The data on COMT gene associated with PTSD were collected from several databases including Online Mendelian Inheritance in Man (OMIM) search. Datasets related to SNP were downloaded from the dbSNP database. To study the structural and dynamic effects of COMT wild type and mutant forms, we performed molecular dynamics simulations (MD simulations) at a time scale of 300 ns. Results from screening the SNPs using the computational tools SIFT and Polyphen-2 demonstrated that the SNP rs4680 (V158M) in COMT has a deleterious effect with phenotype in PTSD. Results from the MD simulations showed that there is some major fluctuations in the structural features including root mean square deviation (RMSD), radius of gyration (Rg), root mean square fluctuation (RMSF) and secondary structural elements including α-helices, sheets and turns between wild-type (WT) and mutant forms of COMT protein. In conclusion, our study provides novel insights into the deleterious effects and impact of V158M mutation on COMT protein structure which plays a key role in PTSD.
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Affiliation(s)
- Kumaraswamy Naidu Chitrala
- Dept. of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC, 29208, USA; Fels Cancer Institute for Personalized Medicine, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, 19140, USA.
| | - Prakash Nagarkatti
- Dept. of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC, 29208, USA
| | - Mitzi Nagarkatti
- Dept. of Pathology, Microbiology and Immunology, University of South Carolina School of Medicine, Columbia, SC, 29208, USA
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Tomas-Roig J, Piscitelli F, Gil V, Quintana E, Ramió-Torrentà LL, Del Río JA, Moore TP, Agbemenyah H, Salinas G, Pommerenke C, Lorenzen S, Beißbarth T, Hoyer-Fender S, Di Marzo V, Havemann-Reinecke U. Effects of repeated long-term psychosocial stress and acute cannabinoid exposure on mouse corticostriatal circuitries: Implications for neuropsychiatric disorders. CNS Neurosci Ther 2018; 24:528-538. [PMID: 29388323 PMCID: PMC5969305 DOI: 10.1111/cns.12810] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 01/02/2018] [Accepted: 01/04/2018] [Indexed: 01/04/2023] Open
Abstract
Introduction Vulnerability to psychiatric manifestations is achieved by the influence of genetic and environment including stress and cannabis consumption. Here, we used a psychosocial stress model based on resident‐intruder confrontations to study the brain corticostriatal‐function, since deregulation of corticostriatal circuitries has been reported in many psychiatric disorders. CB1 receptors are widely expressed in the central nervous system and particularly, in both cortex and striatum brain structures. Aims and methods The investigation presented here is addressed to assess the impact of repeated stress following acute cannabinoid exposure on behavior and corticostriatal brain physiology by assessing mice behavior, the concentration of endocannabinoid and endocannabinoid‐like molecules and changes in the transcriptome. Results Stressed animals urinated frequently; showed exacerbated scratching activity, lower striatal N‐arachidonylethanolamine (AEA) levels and higher cortical expression of cholinergic receptor nicotinic alpha 6. The cannabinoid agonist WIN55212.2 diminished locomotor activity while the inverse agonist increased the distance travelled in the center of the open field. Upon CB1 activation, N‐oleoylethanolamide and N‐palmitoylethanolamide, two AEA congeners that do not interact directly with cannabinoid receptors, were enhanced in the striatum. The co‐administration with both cannabinoids induced an up‐regulation of striatal FK506 binding protein 5. The inverse agonist in controls reversed the effects of WIN55212.2 on motor activity. When Rimonabant was injected under stress, the cortical levels of 2‐arachidonoylglycerol were maximum. The agonist and the antagonist influenced the cortical expression of cholinergic receptor nicotinic alpha 6 and serotonin transporter neurotransmitter type 4 in opposite directions, while their co‐administration tended to produce a null effect under stress. Conclusions The endocannabinoid system had a direct effect on serotoninergic neurotransmission and glucocorticoid signaling. Cholinergic receptor nicotinic alpha‐6 was shown to be deregulated in response to stress and following synthetic cannabinoid drugs thus could confer vulnerability to cannabis addiction and psychosis. Targeting the receptors of endocannabinoids and endocannabinoid‐like mediators might be a valuable option for treating stress‐related neuropsychiatric symptoms.
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Affiliation(s)
- Jordi Tomas-Roig
- Department of Psychiatry and Psychotherapy, University of Göttingen, Göttingen, Germany.,Center Nanoscale Microscopy and Molecular Physiology of the Brain (CNMPB), Göttingen, Germany.,Girona Neuroimmunology and Multiple Sclerosis Unit (UNIEMTG), Dr. Josep Trueta University Hospital and Neurodegeneration and Neuroinflammation Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Fabiana Piscitelli
- Endocannabinoid Research Group, Institute of Biomolecular Chemistry, Consiglio Nazionale delle Ricerche, Pozzuoli, Italy
| | - Vanesa Gil
- Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology, Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Barcelona, Spain.,Department of Cell Biology, Physiology and Immunology, Faculty of Biology, University of Barcelona, Barcelona, Spain
| | - Ester Quintana
- Girona Neuroimmunology and Multiple Sclerosis Unit (UNIEMTG), Dr. Josep Trueta University Hospital and Neurodegeneration and Neuroinflammation Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Lluís L Ramió-Torrentà
- Girona Neuroimmunology and Multiple Sclerosis Unit (UNIEMTG), Dr. Josep Trueta University Hospital and Neurodegeneration and Neuroinflammation Research Group, Girona Biomedical Research Institute (IDIBGI), Girona, Spain
| | - Jose Antonio Del Río
- Institute for Bioengineering of Catalonia (IBEC), The Barcelona Institute of Science and Technology, Centro de Investigación Biomédica en Red de Enfermedades Neurodegenerativas (CIBERNED), Barcelona, Spain.,Department of Cell Biology, Physiology and Immunology, Faculty of Biology, University of Barcelona, Barcelona, Spain
| | - Timothy Patrick Moore
- Department of Psychiatry and Psychotherapy, University of Göttingen, Göttingen, Germany.,Center Nanoscale Microscopy and Molecular Physiology of the Brain (CNMPB), Göttingen, Germany.,Department of Child and Adolescent Psychiatry, University Hospital Münster, Münster, Germany
| | - Hope Agbemenyah
- Laboratory for Aging and Cognitive Diseases, European Neuroscience Institute, Goettingen, Germany
| | - Gabriela Salinas
- Department of Developmental Biochemistry, Georg-August-Universität Göttingen, Göttingen, Germany
| | - Claudia Pommerenke
- Department of Developmental Biochemistry, Georg-August-Universität Göttingen, Göttingen, Germany
| | - Stephan Lorenzen
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany.,Department of Molecular Medicine, Bernhard Nocht Institute for Tropical Medicine, Hamburg, Germany
| | - Tim Beißbarth
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Sigrid Hoyer-Fender
- Johann-Friedrich-Blumenbach Institute for Zoology and Anthropology, Developmental Biology, Göttingen, Germany
| | - Vincenzo Di Marzo
- Endocannabinoid Research Group, Institute of Biomolecular Chemistry, Consiglio Nazionale delle Ricerche, Pozzuoli, Italy
| | - Ursula Havemann-Reinecke
- Department of Psychiatry and Psychotherapy, University of Göttingen, Göttingen, Germany.,Center Nanoscale Microscopy and Molecular Physiology of the Brain (CNMPB), Göttingen, Germany
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Brancu M, Wagner HR, Morey RA, Beckham JC, Calhoun PS, Tupler LA, Marx CE, Taber KH, Hurley RA, Rowland J, McDonald SD, Hoerle JM, Moore SD, Kudler HS, Weiner RD, Fairbank JA. The Post-Deployment Mental Health (PDMH) study and repository: A multi-site study of US Afghanistan and Iraq era veterans. Int J Methods Psychiatr Res 2017; 26:e1570. [PMID: 28656593 PMCID: PMC6492939 DOI: 10.1002/mpr.1570] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 03/21/2017] [Accepted: 04/10/2017] [Indexed: 12/15/2022] Open
Abstract
The United States (US) Department of Veterans Affairs (VA) Mid-Atlantic Mental Illness Research, Education, and Clinical Center (MIRECC) Post-Deployment Mental Health (PDMH) multi-site study examines post-deployment mental health in US military Afghanistan/Iraq-era veterans. The study includes the comprehensive behavioral health characterization of over 3600 study participants and the genetic, metabolomic, neurocognitive, and neuroimaging data for many of the participants. The study design also incorporates an infrastructure for a data repository to re-contact participants for follow-up studies. The overwhelming majority (94%) of participants consented to be re-contacted for future studies, and our recently completed feasibility study indicates that 73-83% of these participants could be reached successfully for enrollment into longitudinal follow-up investigations. Longitudinal concurrent cohort follow-up studies will be conducted (5-10+ years post-baseline) to examine predictors of illness chronicity, resilience, recovery, functional outcome, and other variables, and will include neuroimaging, genetic/epigenetic, serum biomarker, and neurocognitive studies, among others. To date, the PDMH study has generated more than 35 publications from the baseline data and the repository has been leveraged in over 20 publications from follow-up studies drawing from this cohort. Limitations that may affect data collection for a longitudinal follow-up study are also presented.
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Affiliation(s)
- Mira Brancu
- Durham VA Medical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - H Ryan Wagner
- Durham VA Medical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rajendra A Morey
- Durham VA Medical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jean C Beckham
- Durham VA Medical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Patrick S Calhoun
- Durham VA Medical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Larry A Tupler
- Durham VA Medical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christine E Marx
- Durham VA Medical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Katherine H Taber
- W.G. Hefner VA Medical Center, Salisbury, North Carolina, USA.,Division of Biomedical Sciences, Edward Via College of Osteopathic Medicine, Blacksburg, Virginia, USA.,Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas, USA
| | - Robin A Hurley
- W.G. Hefner VA Medical Center, Salisbury, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA.,Departments of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of Radiology, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Jared Rowland
- W.G. Hefner VA Medical Center, Salisbury, North Carolina, USA.,Departments of Psychiatry and Behavioral Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA.,Department of Neurobiology and Anatomy, Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Scott D McDonald
- Hunter Holmes McGuire VA Medical Center, Richmond, Virginia, USA.,Departments of Psychology and Physical Medicine and Rehabilitation, Virginia Commonwealth University, Richmond, Virginia, USA
| | | | - Scott D Moore
- Durham VA Medical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Harold S Kudler
- Mental Health Services, US Department of Veterans Affairs, Washington, District of Columbia, USA
| | - Richard D Weiner
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - John A Fairbank
- Durham VA Medical Center, Durham, North Carolina, USA.,Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina, USA
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Banerjee SB, Morrison FG, Ressler KJ. Genetic approaches for the study of PTSD: Advances and challenges. Neurosci Lett 2017; 649:139-146. [PMID: 28242325 DOI: 10.1016/j.neulet.2017.02.058] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Revised: 02/15/2017] [Accepted: 02/21/2017] [Indexed: 12/31/2022]
Abstract
Post-traumatic stress disorder (PTSD) is a highly debilitating stress and anxiety-related disorder that occurs in response to specific trauma or abuse. Genetic risk factors may account for up to 30-40% of the heritability of PTSD. Understanding the gene pathways that are associated with PTSD, and how those genes interact with the fear and stress circuitry to mediate risk and resilience for PTSD will enable the development of targeted therapies to prevent the occurrence of or decrease the severity of this complex multi-gene disorder. This review will summarize recent research on genetic approaches to understanding PTSD risk and resilience in human populations, including candidate genes and their epigenetic modifications, genome-wide association studies and neural imaging genetics approaches. Despite challenges faced within this field of study such as inconsistent results and replications, genetic approaches still offer exciting opportunities for the identification and development of novel therapeutic targets and therapies in the future.
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Affiliation(s)
- Sunayana B Banerjee
- Behavioral Neuroscience and Psychiatric Disorders, Emory University, Atlanta, GA 30329, USA
| | - Filomene G Morrison
- Behavioral Neuroscience and Psychiatric Disorders, Emory University, Atlanta, GA 30329, USA; McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA
| | - Kerry J Ressler
- Behavioral Neuroscience and Psychiatric Disorders, Emory University, Atlanta, GA 30329, USA; McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA.
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Hauser MA, Garrett ME, Liu Y, Dennis MF, Kimbrel NA, Veterans Affairs Mid-Atlantic Mental Illness Research Education And Clinical Center Workgroup, Beckham JC, Ashley-Koch AE. Further evidence for a role of the ADRB2 gene in risk for posttraumatic stress disorder. J Psychiatr Res 2017; 84:59-61. [PMID: 27701011 DOI: 10.1016/j.jpsychires.2016.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 09/14/2016] [Accepted: 09/14/2016] [Indexed: 12/20/2022]
Abstract
The aim of the present study was to attempt to replicate the recently reported finding associating rs2400707 of the Adrenoceptor Beta 2, Surface (ADRB2) gene and childhood trauma on PTSD symptoms. Participants included a predominantly veteran cohort of non-Hispanic blacks (NHB; n = 949) and a pre-dominantly veteran cohort of non-Hispanic whites (NHW; n = 759). No main effects were observed for rs2400707 on PTSD diagnosis. Among the NHB participants, we observed an interaction between rs2400707 and history of childhood trauma, whereby with each additional A allele, the odds of having PTSD increased by 1.31, but only among those who had experienced childhood trauma (p = 0.038). The interaction with rs2400707 and childhood trauma was not observed among the NHW study participants (p = 0.892). Taken together, the findings from the present research provide further evidence that the adrenergic system may be an important modulator of PTSD risk; however, additional work is still needed to clarify the exact nature of the relationship between PTSD and rs2400707 of the ADRB2 gene.
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Affiliation(s)
- Michael A Hauser
- Department of Medicine, Duke University Medical Center, Durham, NC, United States; Duke Molecular Physiology Institute, Durham, NC, United States.
| | - Melanie E Garrett
- Department of Medicine, Duke University Medical Center, Durham, NC, United States; Duke Center for Human Disease Modeling, Durham, NC, United States
| | - Yutao Liu
- Department of Medicine, Duke University Medical Center, Durham, NC, United States
| | - Michelle F Dennis
- Durham Veterans Affairs Medical Center, Durham, NC, United States; The VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, United States; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, United States
| | - Nathan A Kimbrel
- Durham Veterans Affairs Medical Center, Durham, NC, United States; The VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, United States; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, United States
| | | | - Jean C Beckham
- Durham Veterans Affairs Medical Center, Durham, NC, United States; The VA Mid-Atlantic Mental Illness Research, Education, and Clinical Center, Durham, NC, United States; Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, United States
| | - Allison E Ashley-Koch
- Department of Medicine, Duke University Medical Center, Durham, NC, United States; Duke Center for Human Disease Modeling, Durham, NC, United States
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