Psychobiology of cumulative trauma: hair cortisol as a risk marker for stress exposure in women

Bipolar disorder and cumulative trauma: A systematic review of prevalence and illness outcomes

BACKGROUND

The experience of cumulative trauma may be common in bipolar disorder (BD). However, it is not frequently reported as most studies focus on childhood trauma without examining differences in the amount of trauma experienced. This systematic review aimed to determine the prevalence of lifetime cumulative trauma in BD as well as explore associated illness outcomes.

METHODS

A systematic review was completed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Both the prevalence and outcomes of cumulative trauma in BD were assessed. Five electronic databases were searched (Embase, MEDLINE, PsycINFO, Web of Science, and PTSD Pubs) for records from January 2010 until December 2022.

RESULTS

A total of 20 studies, with 9304 participants were included in the narrative synthesis. At least one-third of BD participants had experienced cumulative trauma, with a prevalence range from 29% to 82%. The main outcomes associated with a history of cumulative trauma were earlier age of onset, longer episode duration, more lifetime mood episodes, greater likelihood of experiencing psychotic features, and higher likelihood of past suicide attempts.

LIMITATIONS

This review has been limited by the lack of studies directly assessing cumulative trauma in BD.

CONCLUSIONS

Cumulative trauma is prevalent in BD. Preliminary evidence indicates an association with a range of adverse outcomes, emphasizing the need for clinicians to obtain a detailed trauma history and to consider these risks in the management of the disorder. Future studies should report on the prevalence of cumulative trauma, particularly in adulthood as this area remains unexplored.

Diversity in emotion regulation strategy use: Resilience against posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) is associated with impaired emotion regulation (ER). ER diversity, the variety, prevalence, and relative abundance of ER strategy use, may provide resilience against PTSD. This study examined the prospective relation between ER diversity and PTSD, while accounting for negative and positive life events, in interpersonal violence (IPV) survivors. IPV-exposed women with PTSD onset (PTSD; n = 22), without PTSD onset (IPV; n = 37), and non-traumatized control participants (NTC; n = 41) rated their ER strategy use and experience of negative and positive life events. The ER diversity index differentiated the participant groups. Importantly, group differences in ER diversity depended on the experience of life events. When experiencing fewer positive life events and more negative life events, the IPV and NTC groups, but not the PTSD group, demonstrated higher ER diversity. Thus, greater ER diversity during periods with more negative life events and fewer positive life events may play a protective role against PTSD onset for IPV survivors.

Hair Cortisol Research in Posttraumatic Stress Disorder - 10 Years of Insights and Open Questions. A Systematic Review

BACKGROUND

Cortisol is one of the most extensively studied biomarkers in the context of trauma/posttraumatic stress disorder (PTSD). For more than a decade, hair cortisol concentrations (HCC) have been measured in this context, leading to a two-staged dysregulation model. Specifically, an elevated secretion during/immediately after trauma exposure eventually reverts to hyposecretion with increasing time since trauma exposure has been postulated.

OBJECTIVE

The aim of our systematic review was to re-evaluate the two-staged secretion model with regard to the accumulated diagnostic, prognostic, and intervention-related evidence of HCC in lifetime trauma exposure and PTSD. Further, we provide an overview of open questions, particularly with respect to reporting standards and quality criteria.

METHOD

A systematic literature search yielded 5,046 records, of which 31 studies were included.

RESULTS

For recent/ongoing (traumatic) stress, the predictions of cortisol hypersecretion could be largely confirmed. However, for the assumed hyposecretion temporally more distal to trauma exposure, the results are more ambiguous. As most studies did not report holistic overviews of trauma history and confounding influences, this may largely be attributable to methodological limitations. Data on the prognostic and intervention-related benefits of HCC remain sparse.

CONCLUSION

Over the last decade, important insights could be gained about long-term cortisol secretion patterns following lifetime trauma exposure and PTSD. This systematic review integrates these insights into an updated secretion model for trauma/PTSD. We conclude with recommendations for improving HCC research in the context of trauma/PTSD in order to answer the remaining open questions.

Future Directions in the Mental Health of Transgender Youth: Towards a Social-Affective Developmental Model of Health Disparity

Mental health disparities in transgender and gender diverse (TGD) youth are well-documented. These disparities are often studied in the context of minority stress theory, and most of this research focuses on experiences of trauma and discrimination TGD youth experience after coming out. However, TGD youth may be targets of violence and victimization due to perceived gender nonconformity before coming out. In this Future Directions, we integrate research on attachment, developmental trauma, and effects of racism and homophobia on mental health to propose a social-affective developmental framework for TGD youth. We provide a clinical vignette to highlight limitations in current approaches to mental health assessment in TGD youth and to illustrate how using a social-affective developmental framework can improve clinical assessment and treatment approaches and deepen our understanding of mental health disparities in TGD people.

Predicting the Social-Emotional Competence Based on Childhood Trauma, Internalized Shame, Disability/Shame Scheme, Cognitive Flexibility, Distress Tolerance and Alexithymia in an Iranian Sample Using Bayesian Regression

The purpose of this study was to predict Social Emotional Competence based on childhood trauma, internalized shame, disability/shame scheme, cognitive flexibility, distress tolerance, and alexithymia in an Iranian sample using Bayesian regression. The participants in this research were a sample of 326 (85.3% female and 14.7% male) people living in Tehran in 2021 who were selected by convenience sampling through online platforms. The survey assessments included demographic characteristics (age and gender), presence of childhood trauma, social-emotional competence, internalized shame, the Toronto Alexithymia scales, Young's measure of disability/shame together with measures of cognitive flexibility and distress tolerance. The results from Bayesian regression and Bayesian Model Averaging (BMA) indicated that internalized shame, cognitive flexibility and distress tolerance can be predictive of Social Emotional Competence. These results suggested that Social Emotional Competence can be explained by some important personality factors.

Child maltreatment and hypothalamic-pituitary-adrenal axis functioning: A systematic review and meta-analysis

Alterations in hypothalamic-pituitary-adrenal (HPA) axis and its effector hormone cortisol have been proposed as one possible mechanism linking child maltreatment experiences to health disparities. In this series of meta-analyses, we aimed to quantify the existing evidence on the effect of child maltreatment on various measures of HPA axis activity. The systematic literature search yielded 1,858 records, of which 87 studies (k = 132) were included. Using random-effects models, we found evidence for blunted cortisol stress reactivity in individuals exposed to child maltreatment. In contrast, no overall differences were found in any of the other HPA axis activity measures (including measures of daily activity, cortisol assessed in the context of pharmacological challenges and cumulative measures of cortisol secretion). The impact of several moderators (e.g., sex, psychopathology, study quality), the role of methodological shortcomings of existing studies, as well as potential directions for future research are discussed.

Predicting Posttraumatic Stress Disorder Among Survivors of Recent Interpersonal Violence

A substantial minority of women who experience interpersonal violence will develop posttraumatic stress disorder (PTSD). One critical challenge for preventing PTSD is predicting whose acute posttraumatic stress symptoms will worsen to a clinically significant degree. This 6-month longitudinal study adopted multilevel modeling and exploratory machine learning (ML) methods to predict PTSD onset in 58 young women, ages 18 to 30, who experienced an incident of physical and/or sexual assault in the three months prior to baseline assessment. Women completed baseline assessments of theory-driven cognitive and neurobiological predictors and interview-based measures of PTSD diagnostic status and symptom severity at 1-, 3-, and 6-month follow-ups. Higher levels of self-blame, generalized anxiety disorder severity, childhood trauma exposure, and impairment across multiple domains were associated with a pattern of high and stable posttraumatic stress symptom severity over time. Predictive performance for PTSD onset was similarly strong for a gradient boosting machine learning model including all predictors and a logistic regression model including only baseline posttraumatic stress symptom severity. The present findings provide directions for future work on PTSD prediction among interpersonal violence survivors that could enhance early risk detection and potentially inform targeted prevention programs.

Neurobiology of Female Homicide Perpetrators

Neurobiology of female homicide perpetrators is not well understood. Data from private interviews and examinations of females were re-analyzed comparing those who committed homicide (n = 9); other violent crimes, no known homicide (n = 51); nonviolent crimes, no known violent convictions (n = 49); and noncriminals (n = 12). Homicide perpetrators suffered the most childhood sexual abuse (CSA); most recent abuse; had the most neurological histories, mainly traumatic brain injuries (TBIs); most health care access for abuse-related injuries; lowest AM and PM salivary cortisol; and greatest proportion who committed crime under the influence of alcohol. Only CSA, years since last abuse, TBI, neurological histories, and health care access for abuse-related injuries were significant. Those who committed homicide under the influence of alcohol suffered the most recent abuse and had the lowest AM cortisol and flattest diurnal cortisol slope (DCS) compared with others; though the n precludes determining significance. Amount of time since last abuse, AM cortisol and DCS progressively decreased as crime severity increased; other variables progressively increased as crime severity increased. These preliminary findings suggest that low AM cortisol, flat DCS, greater CSA frequency and severity, recent abuse, TBIs, and health care access for abuse-related injuries could be risk factors for females committing homicide. Further study is needed due to the small n of homicide perpetrators. Abuse victims may be at greater risk for alcohol use and cortisol dysregulation associated with perpetrating violence, especially homicide. Frontal lobe damage from TBIs may decrease ability to control behaviors associated with emotions from the limbic system. Health care providers released these women when their abuse-related injuries were not life-threatening; yet, they were life-threatening for victims of their subsequent homicides. Females accessing health care for abuse-related injuries present a critical opportunity for violent crime prevention interventions.

Predicting pain among female survivors of recent interpersonal violence: A proof-of-concept machine-learning approach

Interpersonal violence (IPV) is highly prevalent in the United States and is a major public health problem. The emergence and/or worsening of chronic pain are known sequelae of IPV; however, not all those who experience IPV develop chronic pain. To mitigate its development, it is critical to identify the factors that are associated with increased risk of pain after IPV. This proof-of-concept study used machine-learning strategies to predict pain severity and interference in 47 young women, ages 18 to 30, who experienced an incident of IPV (i.e., physical and/or sexual assault) within three months of their baseline assessment. Young women are more likely than men to experience IPV and to subsequently develop posttraumatic stress disorder (PTSD) and chronic pain. Women completed a comprehensive assessment of theory-driven cognitive and neurobiological predictors of pain severity and pain-related interference (e.g., pain, coping, disability, psychiatric diagnosis/symptoms, PTSD/trauma, executive function, neuroendocrine, and physiological stress response). Gradient boosting machine models were used to predict symptoms of pain severity and pain-related interference across time (Baseline, 1-,3-,6- follow-up assessments). Models showed excellent predictive performance for pain severity and adequate predictive performance for pain-related interference. This proof-of-concept study suggests that machine-learning approaches are a useful tool for identifying predictors of pain development in survivors of recent IPV. Baseline measures of pain, family life impairment, neuropsychological function, and trauma history were of greatest importance in predicting pain and pain-related interference across a 6-month follow-up period. Present findings support the use of machine-learning techniques in larger studies of post-IPV pain development and highlight theory-driven predictors that could inform the development of targeted early intervention programs. However, these results should be replicated in a larger dataset with lower levels of missing data.

Non-communicable diseases among women survivors of intimate partner violence: Critical review from a chronic stress framework

A neurobiological framework of chronic stress proposes that the stress-response system can be functionally altered by the repeated presentation of highly stressful situations over time. These functional alterations mainly affect brain processing and include the dysregulation of the hypothalamic-pituitary-adrenal axis and associated processes. In the present critical review, we translate these results to inform the clinical presentation of women survivors of intimate partner violence (IPV). We approach IPV as a scenario of chronic stress where women are repetitively exposed to threat and coping behaviours that progressively shape their neurobiological response to stress. The changes at the central and peripheral levels in turn correlate with the phenotypes of non-communicable diseases. The reviewed studies clarify the extent of the impact of IPV on women's health in large (N > 10,000) population-based designs, and provide observations on experimental neuroendocrine, immune, neurocognitive and neuroimaging research linking alterations of the stress-response system and disease. This evidence supports the prevention of violence against women as a fundamental action to reduce the prevalence of non-communicable diseases.

Reported history of childhood trauma and stress-related vulnerability: Associations with emotion regulation, executive functioning, daily hassles and pre-sleep arousal

Childhood trauma is associated with poor health outcomes in adulthood. Mechanisms for these associations are not well understood because past studies have focused predominantly on populations that have already developed physical and mental health problems. The present study examined the association between childhood trauma and stress-related vulnerability factors in a healthy adult sample (n = 79; 68% female, mean age = 27.5, SD = 6.5). Emotion regulation difficulties were examined as a potential mediator. Participants completed baseline laboratory assessments of reported childhood trauma, emotion regulation difficulties, prior month sleep quality, baseline impedance cardiography and behavioural tests of executive functioning (EF) and a three-day experience sampling assessment protocol that included sleep diary, reported and objective pre-sleep arousal, daily hassles and reported EF difficulties. Reported history of childhood abuse was significantly associated with difficulties in emotion regulation, self-report and objective pre-sleep arousal, diary-assessed sleep quality, daily hassles and reported EF difficulties. Reported history of childhood neglect was associated with greater pre-sleep arousal and poorer EF-behavioural control. Emotion regulation difficulties mediated the relationship between childhood abuse and reported pre-sleep arousal, daily hassles and reported EF difficulties. In conclusion, history of childhood trauma is associated with a variety of stress-related vulnerability factors in healthy adults that may be viable early intervention targets.

Prenatal and childhood predictors of hair cortisol concentration in mid-childhood and early adolescence

Background

Hair cortisol concentration (HCC) is an increasingly used measure of systemic cortisol concentration. However, determinants of HCC in children and adolescents are unclear because few prospective studies have been conducted to date.

Study design

We followed 725 children in Project Viva, a pre-birth cohort study of mothers and children, who provided hair samples at mid-childhood (median age: 7.7 years) or early adolescence (median age: 12.9 years). We examined associations of various factors measured from pregnancy to mid-childhood with HCC in mid-childhood and early adolescence, as well as change in HCC between these time points (ΔHCC).

Results

There were 426 children with HCC measurements in both mid-childhood and early adolescence, 173 children with measures only in mid-childhood, and 126 with measures only in early adolescence. HCC was lower in mid-childhood (median 1.0pg/mg [interquartile range, IQR: 0.5, 2.4]) than early adolescence (2.2pg/mg [1.1, 4.4]). In multivariable-adjusted regression models, female sex (β = -0.41, 95% CI: -0.67, -0.15) and birth weight-for-gestational age z-score (β = -0.19, 95% CI: -0.33, -0.04) were associated with lower mid-childhood HCC, while prenatal smoking was associated with higher mid-childhood HCC (β = 0.53, 95% CI: 0.04, 1.01). In early adolescence, child age (β = 0.34 per year, 95% CI: 0.21, 0.46) female sex (β = 0.33, 95% CI: 0.10, 0.57), and maternal pre-pregnancy body mass index (β = 0.15 per 5-kg/m², 95% CI: 0.01, 0.29) were positively associated with HCC. Child anthropometric measures and biomarker concentrations were not associated with HCC.

Conclusion

Maternal pre-pregnancy BMI, maternal prenatal smoking, and low birth weight were associated with higher mid-childhood and adolescent HCC. However, few postnatal characteristics were associated with HCC.

The association between adversity and hair cortisol levels in humans: A meta-analysis

Adverse life events are associated with a constellation of negative health outcomes. Theory and research suggest that the hypothalamic-pituitary-adrenal (HPA) axis acts as one mechanism connecting adverse experiences with negative health outcomes. However, this relation is complicated by the potential for adversity to be associated with both hyperactivity and hypoactivity of the HPA axis, as assessed in both animal and human studies. Over the past decade, methodological advances have enabled the sampling of cortisol stored in hair, which provides a marker of HPA axis activity over a several-month period. The present meta-analysis included 28 studies to assess the strength and direction of the relation between adverse experiences and hair cortisol levels. Analyses were conducted using multilevel modeling (MLM) to quantify the magnitude of effects and mixture modeling to identify distinct subgroups of studies. Results of MLM analyses indicated that the overall effect size was small but significant d = 0.213, 95% CI [0.034, 0.397]. There was also significant between-study variance (τ = 0.155, 95% CI [0.065, 0.367]). Mixture modeling to identify distinct classes of studies based on effect size and direction resulted in a 2-class model: The first class included four studies with an overall negative and moderate effect size (d = -0.478, 95% CI [-0.639, -0.318]), and the second class included the remaining 24 studies with an overall positive and significant, albeit small, effect size (d = 0.141, 95% CI [0.084, 0.199]). Moderator analyses indicated that the strength and direction of the association between adversity and hair cortisol were moderated by features of the adversity exposure (e.g., type of adversity, timing of adversity), characteristics of the samples (e.g., clinical status, racial distribution), and features of the publication (e.g., publication type, geographic region of study). The findings refine our understanding of the long-term impact of adversity on dysregulation of the HPA axis, particularly as reflected in hair cortisol measures.

Weight stigma and acculturation in relation to hair cortisol among Asian Americans with overweight and obesity: A cross-sectional study

Weight stigma is a pervasive problem for Americans, but little is known about its impact on the health of Asian Americans. Authors examined the relationship between weight stigma and cortisol and whether acculturation moderated this relationship. Asian Americans (n = 166) with overweight or obesity completed questionnaires and provided a 50-mg hair sample to assay cortisol. Results revealed a negative correlation between weight stigma and cortisol. However, this was no longer significant after controlling of relevant covariates. The level of acculturation did not significantly moderate this relationship. The non-significant relationships among weight stigma, cortisol, and acculturation are discussed along with future directions.