Advertisement
Research Article| Volume 30, ISSUE 10, P1031-1048, November 15, 1991

Download started.

Ok

Hypothalamic-pituitary-adrenal dysfunction in posttraumatic stress disorder

  • Rachel Yehuda
    Correspondence
    Address reprint requests to Rachel Yehuda, Ph.D., Psychiatry Department, Mount Sinai School of Medicine, Bronx VAMC 116A, 130 West Kingsbridge Rd., Bronx, NY 10468
    Affiliations
    Psychiatry Department, Mt. Sinai School of Medicine, New York, N.Y., USA

    Clinical Neuroscience Division, National Center for Posttraumatic Stress Disorder, West Haven Veterans' Administration Medical Center, West Haven, CT, 06516, USA
    Search for articles by this author
  • Earl L. Giller
    Affiliations
    Psychiatry Department, University of Connecticut Health Center, Farmington, CT 06030, USA
    Search for articles by this author
  • Steven M. Southwick
    Affiliations
    Clinical Neuroscience Division, National Center for Posttraumatic Stress Disorder, West Haven Veterans' Administration Medical Center, West Haven, CT, 06516, USA

    Psychiatry Department, Yale University School of Medicine, New Haven, CT 06510, USA
    Search for articles by this author
  • Martin T. Lowy
    Affiliations
    Psychiatry Department. Case Western Reserve University Medical School, Cleveland, OH 44116, USA
    Search for articles by this author
  • John W. Mason
    Affiliations
    Clinical Neuroscience Division, National Center for Posttraumatic Stress Disorder, West Haven Veterans' Administration Medical Center, West Haven, CT, 06516, USA

    Psychiatry Department, Yale University School of Medicine, New Haven, CT 06510, USA
    Search for articles by this author
      This paper is only available as a PDF. To read, Please Download here.

      Abstract

      Neuroendocrine studies examining the hypothalamic-pituitary-adrenal (HPA) axis under baseline conditions and in response to neuroendocrine challenges have supported the hypothesis of altered HPA functioning in posttraumatic stress disorder (PTSD). However, to date, there is much debate concerning the nature of HPA changes in PTSD. Furthermore, in studies showing parallel findings in PTSD and major depressive disorder there is controversy regarding whether the HPA alterations suggest a specific pathophysiology of PTSD, or, rather, reflect comorbid major depressive disorder. This review summarizes findings of HPA axis dysfunction in both PTSD and major depressive disorder, and shows distinct patterns of HPA changes, which are probably due to different mechanisms of action for cortisol and its regulatory factors.
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Biological Psychiatry
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ader R
        The effects of early experience on the adrenocortical response to different magnitude stimulation..
        Physiol. Behav. 1970; 5: 837-839
        • Amir S.
        • Amir Z.
        The pituitary gland mediates acute and chronic pain responsiveness in stressed and nonstressed rats..
        Life Sci. 1979; 24: 439-444
        • APA Task Force On Laboratory in Psychiatry
        The dexamethasome suppression test.
        in: An overview of its current status in psychiatry.Am J Psychiatry. 144. 1987: 1253-1262
        • Arana G.W.
        • Baldessarini R.J.
        • Ornsteen M
        The dexamethasone suppression test for diagnosis and prognosis in psychiatry..
        in: Commentary and review. Arch Gen Psychiatry. 42. 1985: 1193-1204
        • Armario A
        • Restrepo C
        • Castellanos JM
        • Balash J
        • et al.
        Dissociation between adrenocorticotropin and corticosterone response to restrain after previous chronic exposure to stress..
        Life Sci. 1985; 36: 2085-2092
        • Armario A.
        • Hidalgo J.
        • Giralt M.
        Evidence that the pituitary-adrenal axis does not cross-adapt to stressors: Comparison to other physiological variables..
        Neuroendocrinology. 1988; 47: 263-267
        • Banki CM
        • Bissette G.
        • Arato M.
        • O'Connor L.
        • Nemeroff C.B.
        CSF corticotropin-releasing factor-like immunoreactivity in depression and schizophrenia..
        Am J Psychiatry. 1987; 144: 873-877
        • von Bardeleben U.
        • Holsboer F.
        • Stalla G.K.
        • Muller O.A.
        • et al.
        Combined administration of human corticotropin-releasing factor and lysine vasopressin induces cortisol escape from dexamethasone suppression in healthy subjects..
        Life Sci. 1985; 37: 1613-1617
        • Bohus B.
        Pituitary-adrenal influences on avoidance and approach behavior of the rat..
        Prog Brain Res. 1973; 39: 407-420
        • Bohus B.
        • de Kloet E.R.
        Analysis of the individual variations of adaptation in the rat, on the basis of conditioned reflex and endocrine studies.
        J Endocrinol. 1977; 72: 64P-65P
        • Bohus B.
        • de Wied D.
        Pituitary-adrenal system hormones and adaptive behavior..
        (In Chester)in: Jones I Henderson I.W. General, Comparative and Clinical Endocrinology of the Adrenal Cortex.3. Academic, New York1978
        • Bourne P.B.
        • Rose R.M.
        • Mason J.W.
        Urinary 17-OHCA levels. Data on seven helicopter ambulance medics in combat.
        Arch Gen Psychiatry. 1967; 17: 104-110
        • Bourne P.B.
        • Rose R.M.
        • Mason J.W.
        17-OHCS levels in combat: Special forces “A” team under threat of attack.
        Arch Gen Psychiatry. 1968; 19: 135-140
        • Carroll B.J.
        The dexamethasone suppression test for melancholia.
        Br J Psychiatry. 1982; 140: 292-304
        • Carroll B.J.
        • Feinberg M.
        • Gredan J.F.
        • et al.
        A specific laboratory test for the diagnosis of melancholia.
        Arch Gen Psychiatry. 1981; 38: 15-22
        • Dallman M.F.
        • DeManincor D.
        • Shinsako J.
        Diminishing corticotrope capacity to release ACTH during sustained stimulation: The twenty four hours after bilateral adrenalectomy in the rat.
        Endocrinology. 1973; 95: 65
        • Daniels-Severs A.
        • Goodwin A.
        • Keil L.C.
        • Vernikos-Danellis J.
        Effect of chronic crowding and cold on the pituitary-adrenal system: Responsiveness to an acute stimulus during chronic stress.
        Pharmacology. 1973; 9: 348-353
        • Davidson J.
        • Swartz M.
        • Storck M.
        • et al.
        A diagnostic and family study of posttraumatic stress disorder.
        Am J Psychiatry. 1985; 142: 90-93
        • DeKloet E.R.
        • Reul J.M.H.M.
        Feedback action and tonic influence on corticosteroids on brain function: A concept arising from the heterogeneity of brain receptor systems.
        Psychoneuroendocrinology. 1987; 12: 83-91
        • Endroczi E.
        • Telegdy G.
        • Lissak K.
        Analysis of the individual variations of adaptation in the rat, on the basis of conditioned reflex and endocrine studies.
        Acta Physiol Hung. 1957; 11: 393-398
        • Frankenhaueser M.
        Experimental approaches to the study of catecholamines and emotion.
        in: Levi L. Emotions: Their Parameters and Measurements. Raven, New York1975
        • Frenkl R.
        • Csalay L.
        • Csakvary G.
        A study of the stress reaction elicited by muscular exertion in trained and untrained man and rats.
        Acta Physiol Hung. 1969; 36: 365-370
        • Friedman S.B.
        • Mason J.W.
        • Hanburg D.A.
        Urinary 17-hydroxycorticosteroid levels in parents of children with neoplastic disease: A study of chronic psychological stress.
        Psychosom Med. 1963; 25: 364-376
        • Funkenstein D.H.
        • King S.H.
        • Drollette M.
        The direction of anger during a laboratory stress-inducing situation.
        Psychosom Med. 1954; 16: 404-413
        • Gibbons J.L.
        • McHugh P.R.
        Plasma cortisol in depressive illness.
        J Psychiatr Res. 1962; 1: 162-171
        • Gold P.W.
        • Chrousos G.P.
        Clinical studies with corticotropin releasing factor: Implications for the diagnosis and pathophysiology of depression, Cushing's disease and adrenal insufficiency.
        Psychoneuroendocrinology. 1985; 10: 401-420
        • Gold P.W.
        • Loriaux D.L.
        • Roy A.
        Responses to corticotropin-releasing hormone in the hypercortisolism of depression and Cushing's disease.
        N Engl J Med. 1986; 314: 1329-1335
        • Gold P.W.
        • Goodwin F.K.
        • Chrousos G.P.
        Clinical and biochemical manifestations of depression.
        N Engl J Med. 1988; 319: 413-420
        • Gormley G.J.
        • Lowy M.T.
        • Reder A.T.
        • et al.
        Glucocorticoid receptors in depression: Relationship to the dexamethasone suppression test.
        Am J Psychiatry. 1985; 142: 1278-1284
        • Halbreich U.
        • Olympia J.
        • Carson S.
        • et al.
        Hypothalamo-pituitary-adrenal activity in endogenously depressed post-traumatic stress disorder patients.
        Psychoneuroendocrinology. 1989; 14: 365-370
        • Haltmeyer G.C.
        • Denenberg V.H.
        • Zarrow M.X.
        Modification of the plasma corticosterone response as a function of infantile stimulation and electric shock parameters.
        Physiol Behav. 1967; 2: 61-63
        • Helzer J.E.
        • Robins L.N.
        • Wish E.
        • Hesselbrock M.
        Depression in Vietnam veterans and civilian controls.
        Am J Psychiatry. 1979; 135: 526-529
        • Hess J.L.
        • Denenberg V.H.
        • Zarrow X.
        • Pfeifer W.D.
        Modification of the corticosterone response curve as a function of handling in infancy.
        Physiol Behav. 1969; 4: 109-111
        • Holsboer F.
        • Gerken A.
        • Stalla G.K.
        • et al.
        ACTH, cortisol and corticosterone output after ovine corticotropin-releasing factor challenge during depression and after recovery.
        Biol Psychiatry. 1985; 20: 276-286
        • Holsboer F.
        • Gerken A.
        • von Bardeleben U.
        Human corticotropin-releasing hormone in depression—Correlation with thyrotropin secretion following thyrotropin-releasing hormone.
        Biol Psychiatry. 1986; 21: 601-611
        • Junker K.
        Glucocorticoid receptors of human mononuclear leukocytes in vitro.
        J Clin Endocrinol Metab. 1983; 57: 506-512
        • Kathol R.G.
        Etiologic implications of corticosteroid changes in affective disorder.
        Psychiat Med. 1985; 3: 135-162
        • Kathol R.G.
        • Jaeckle R.S.
        • Lopez W.F.
        • et al.
        Pathophysiology of HPA axis abnormalities in patients with major depression: An update.
        Am J Psychiatry. 1989; 146: 311-317
        • Katz R.J.
        Animal model of depression: effects of electroconvulsive shock therapy.
        Neurosci Behav Rev. 1981; 5: 273-277
        • Katz R.J.
        Effects of zometrapine, a structurally novel antidepressant, in an animal model of depression.
        Pharmacol Biochem Behav. 1984; 21: 487-490
        • Katz R.J.
        • Sibel M.
        Animal model of depression: Tests of three structurally and pharmacologically novel antidepressant compounds.
        Pharmacol Biochem Behav. 1982; 16: 973-977
        • Katz R.J.
        • Roth A.
        • Carrol B.J.
        Acute and chronic stress effects on open field activity in the rat: Implications for a model of depression.
        Neurosci Biobehav Rev. 1981; 5: 247-251
        • Kawakami M.
        • Seto K.
        • Kimura F.
        Influence of repeated immobilization stress upon the circadian rhythmicity of adrenocorticoid biosynthesis.
        Neuroendocrinology. 1972; 9: 207-214
        • Kling M.A.
        • Roy A.
        • Doran A.R.
        • et al.
        Cerebrospinal fluid immunoreactive corticotropin-releasing hormone and adrenocorticotropin secretion in Cushing's disease and major depression: Potential implications.
        J Clin Endocrin Metab. 1991; 72: 260-271
        • Knight R.B.
        • Atkins A.
        • Eagle J.
        Psychological stress, ego defenses and cortisol production in children hospitalized for elective surgery.
        Psychosom Med. 1979; 41: 40-49
        • Kontula K.
        • Pelkonen R.
        • Andersson L.
        • et al.
        Glucocorticoid receptors in adrenocorticoid disorders.
        J Clin Endocrinol Metab. 1980; 51: 654
        • Kosten T.R.
        • Jacobs S.
        • Mason J.
        • Wahby V.
        • Atkins S.
        Psychological correlates of growth hormone response to stress.
        Psychosom Med. 1984; 46: 49-58
        • Kosten T.R.
        • Wahby V.
        • Giller E.
        • et al.
        The dexamethasone test and TRH stimulation test in post-traumatic stress disorder.
        Biol Psychiatry. 1990; 28: 657-664
        • Kudler H.
        • Davidson J.
        • Meador K.
        • et al.
        The DST and post-traumatic stress disorder.
        Am J Psychiatry. 1987; 144: 1068-1071
        • LeMevel J.C.
        • Abitbol S.
        • Veraud G.
        • Maneity J.
        Temporal changes in plamsma adrenocorticotropin concentration after repeated neurotropic stress in male and female rats.
        Endocrinology. 1979; 105: 812
        • Levine S.
        • Haltmeyer C.G.
        • Karas G.G.
        • Denenberg V.H.
        Physiological and behavioral effects of infantile stimulation.
        Physiol Behav. 1967; 2: 55-59
        • Levine M.D.
        • Gordon T.P.
        • Peterson R.H.
        • Rose R.M.
        Urinary 17-OHCS response of high and low aggressive rhesus monkeys to shock avoidance.
        Physiol Behav. 1970; 5: 919-924
        • Ling M.H.M.
        • Perry P.J.
        • Tsuang M.T.
        Side effects of corticosteroid therapy.
        Arch Gen Psychiatry. 1981; 38: 471-477
        • Lissak K.
        • Endroczi E.
        • Medgyesi P.
        Somatisches Verhalten und Nebennierenrindentatigkeit.
        Pflugers Arch. 1957; 265: 117-124
        • Lowy M.T.
        Quantification of Type I and II adrenal steroid receptors in neuronal, lymphoid, and pituitary tissues.
        Brain Res. 1989; 503: 191-197
        • Lowy M.T.
        Reserpine induced decrease in Type I and II corticosteroid receptors in neuronal and lymphoid tissue of adrenalectomized rats.
        Neuroendocrinology. 1990; 51: 190-196
        • Lowy M.T.
        • Meltzer H.Y.
        Dexamethasone bioavailability: Implications for DST research.
        Biol Psychiatry. 1987; 22: 373-385
        • Lowy M.T.
        • Reder A.T.
        • Antel J.
        • et al.
        Glucocorticoid resistance in depression: The dexamethasone suppression test and lymphocyte sensitivity to dexamethasone.
        Am J Psychiatry. 1984; 141: 1365-1370
        • Lowy M.T.
        • Gormley G.J.
        • Reder A.T.
        • et al.
        Immune function, glucocorticoid receptor regulation and depression.
        in: Miller A.H. Depressive Disorders and Immunity. American Psychiatric Press, Washington DC1989: 105-134
        • Mason J.W.
        Psychoendocrine approaches in stress research.
        in: Symposium of Medical Aspects of Stress in the Military Climate. Walter Reed Army Institute of Research, U.S. Government Printing Office, Washington, DC1965: 375-417
        • Mason J.W.
        Psychoendocrine approaches in stress research.
        in: Symposium of Medical Aspects of Stress in the Military Climate. Walter Reed Army Institute of Research, U.S. Government Printing Office, Washington, DC1965: 375-417
        • Mason J.W.
        A review of psychoendocrine research on the sympathetic-adrenal medullary system.
        Psychosom Med. 1968; 30: 631-653
        • Mason J.W.
        Psychologic stress and endocrine function.
        in: Sachar E.J. Topics in Psychoendocrinology. Grune & Stratton, New York1975
        • Mason J.W.
        • Brady J.V.
        • Tolliver G.A.
        Plasma and urinary 17-hydroxycorticosteroid responses to 72-hr avoidance sessions in the monkey.
        Psychosom Med. 1968; 30: 608-630
        • Mason J.W.
        • Giller E.L.
        • Kosten T.R.
        • Ostroff R.B.
        • Podd L.
        Urinary free-cortisol levels in posttraumatic stress disorder patients.
        J Nerv Ment Dis. 1986; 174: 145-159
        • McClure D.J.
        The diurnal variation of plasma cortisol levels in depression.
        J Psychosom Res. 1966; 10: 189-195
        • McEwen B.S.
        Adrenal steroid feedback on neuroendocrine tissues.
        NY Acad Sci. 1977; 297: 567-579
        • McEwen B.S.
        • Wallace G.
        • Magnus C.
        Corticosterone binding to hippocampus: Immediate and delayed influences of the absence of adrenal secretion.
        Brain Res. 1975; 70: 321-334
        • McEwen B.S.
        • deKloet R.
        • Wallach G.
        Interactions in vivo and in vitro of corticoids and progesterone with cell nuclei and soluble macromolecules from the rat brain regions and pituitary.
        Brain Res. 1976; 105: 129-136
        • McEwen B.S.
        • deKloet E.R.
        • Rostene W.H.
        Adrenal steroid receptors and actions in the nervous system.
        Physiol Rev. 1986; 66: 1121-1188
        • Meany M.J.
        • Aitken D.H.
        3H Dexamethasone binding in rat frontal cortex.
        Brain Res. 1985; 328: 176-180
        • Meany M.J.
        • Aitken D.H.
        • Bodnoff S.R.
        • Iny L.J.
        • Sapolsky R.M.
        The effects of postnatal handling on the development of the glucocorticoid receptor systems and stress recovery in the rat.
        Prog Neuropsychopharmacol Biol Psychiatry. 1985; 9: 731-734
        • Meaney M.J.
        • Aitken D.H.
        • Bodnoff S.R.
        • Iny L.J.
        • Taterewicz J.E.
        • Sapolsky R.M.
        Early postnatal handling alters glucocorticoid receptor concentrations in selected brain regions.
        Behav Neurosci. 1985; 99: 765-767
        • Meaney M.J.
        • Aitken D.H.
        • vanBerkel C.
        • Bhatnagar S.
        • Sapolsky R.M.
        Effect of neonatal handling on age-related impairments associated with the hippocampus.
        Science. 1988; 239: 766-768
        • Meaney M.J.
        • Aitken D.H.
        • Viau V.
        • Sharma S.
        • Sarieau A.
        Neonatal handling alters adrenocortical negative feedback sensitivity and hippocampal Type II glucocorticoid binding in the rat.
        Neuroendocrinology. 1989; 50: 597-604
        • Meltzer H.Y.
        • Fang V.S.
        • Tricou B.J.
        • Robertson A.
        • Piyaka S.K.
        Effect of dexamethasone on plasma prolactin and cortisol levels in psychiatric patients.
        Am J Psychiatry. 1982; 139: 763-768
        • Mikulaj L.
        • Mitrius A.
        • Murgas K.
        • Dobrakova M.
        Adrenocortical activity during and after stress with respect to adaptation.
        in: Nemeth S. Hormones, Metabolism and Stress, Recent Progress and Perspectives. Publishing House of the Slovak Academy of Sciences, Bratislava, Czeheslovakia1973: 115-128
        • Munck A.
        • Guyre P.M.
        Glucocorticoid physiology, pharmacology and stress.
        in: Chrousos G.P. Loriaus D.L. Lipsett M.B. Steroid Hormone Resistance: Mechanisms and Clinical Aspects. Plenum, New York1986: 81-96
        • Munck A.
        • Guyre P.M.
        • Holbrook N.J.
        Physiological functions of glucocorticoids in stress and their relation to pharmacological actions.
        Endocr Rev. 1984; 93: 9779-9783
        • Natelson B.H.
        • Ottenweller J.W.
        • Cook J.
        • Pirm S.L.
        • McCarty R.
        • Tapp W.N.L.
        Effect of stressor intensity on habituation of the adrenocortical stress response.
        Physiol Behav. 1988; 43: 41-46
        • Nemeroff C.B.
        Corticotropin-releasing factor.
        in: Nemeroff C.B. Neuropeptides and Psychiatric Disorders. American Psychiatric Press, Washington, DC1991: 75-92
        • Nemeroff C.B.
        • Wilderlov E.
        • Bisette G.
        • et al.
        Elevated concentration of CSF corticotropin releasing factor like immunoreactivity in depressed patients.
        Science. 1984; 226: 1342-1344
        • Nemeroff C.B.
        • Owens M.J.
        • Bisette G.
        • et al.
        Reduced corticotropin binding sites in the frontal cortex of suicide victims.
        Arch Gen Psych. 1988; 45: 577-579
        • Nesse R.M.
        • Curtis G.C.
        • Thyer B.A.
        • et al.
        Endocrine and physiologic responses to phobic anxiety (abstract).
        Psychosom Med. 1984; 46: 86
        • Olivera A.A.
        • Fero D.
        Affective disorders, DST, and treatment in PTSD patients: Clinical observations.
        J Traumatic Stress. 1990; 3: 407-414
        • Olpe H.R.
        • McEwen B.S.
        Glucocorticoid binding to receptor-like proteins in rat brain and pituitary: Ontogenetic and experimentally induced changes.
        Brain Res. 1976; 105: 121-128
        • Ottenweller J.E.
        • Natelson B.H.
        • Pitman D.L.
        • Drastal S.D.
        Adrenocortical and behavioral responses to repeated stressors: Toward an animal model of chronic stress and stress-related mental illness.
        Biol Psychiatry. 1989; 26: 829-841
        • Pitman R.
        • Orr S.
        Twenty-four urinary cortisol and catecholamine excretion in combat-related posttraumatic stress disorder.
        Biol Psychiatry. 1990; 27: 245-247
        • Pitman D.L.
        • Ottenweller J.E.
        • Natelson B.H.
        Plasma corticosterone levels during repeated presentation of two intensities of restraint stress: Chronic stress and habituation.
        Physiol Behav. 1988; 43: 47-56
        • Pitman D.L.
        • Ottenweller J.E.
        • Natelson B.H.
        Effect of stressor intensity on habituation and sensitization of glucocorticoid responses in rats.
        Behav Neurosci. 1990; 104: 28-36
        • Pitts Jr, F.N.
        Special section: Posttraumatic stress disorder: Editorial.
        J Clin Psychiatry. 1985; 46: 373
        • Poe R.O.
        • Rose R.M.
        • Mason J.W.
        Multiple determinants of 17-OHCS excretion in recruits during basic training.
        Psychosom Med. 1970; 32: 369-378
        • Riegle C.D.
        Chronic stress effects on adrenocortical responsiveness in young and aged rats.
        Neuroendocrinology. 1973; 11: 1-5
        • Risch S.C.
        • Lewine R.J.
        • Jewart R.D.
        • et al.
        The relationship between CSF peptides and neurotransmitters in depressed patients and normal controls.
        in: CNS Peptides in Stress and Depression. Progressive Psychiatry. vol 30. American Psychiatric Press, Washington, DC1991: 93-104
        • Rivier C.
        • Vale W.
        Diminished responsiveness of the hypothalamic pituitary adrenal axis of the rat during exposure to prolonged stress: A pituitary-mediated mechanism.
        Endocrinology. 1987; 121: 1320-1328
        • Robins L.N.
        The Vietnam drug user returns.
        in: Special Action Office Monograph 2, Series A. US Government Printing Office, Washington, DC1974
        • Rose R.M.
        • Poe R.O.
        • Mason J.W.
        Psychological state and body size as determinants of 17-OHCS excretion.
        Arch Intern Med. 1968; 121: 406-413
        • Roy A.
        • Pickar D.
        • Paul S.
        • Doran A.
        • Chrousos G.P.
        • Gold P.W.
        CSF corticotropin-releasing hormone in depressed patients and normal control subjects.
        Am J Psychiatry. 1987; 144: 641-645
        • Sachar E.J.
        • Hellman L.
        • Roffwarg H.P.
        • et al.
        Disrupted 24-hour patterns of cortisol secretion in psychotic depression.
        Arch Gen Psychiatry. 1973; 28: 19-24
        • Sakellaris P.C.
        • Vernikos-Danellis J.
        Increased rate of response of the pituitary-adrenal system in rats adapted to chronic stress.
        Endocrinology. 1975; 97: 597
        • Saplosky R.M.
        • Krey L.C.
        • McEwen B.S.
        Stress down regulates corticosterone receptors in a site specific manner in the brain.
        Endocrinology. 1984; 114: 287-292
        • Sapolsky R.M.
        • Krey L.C.
        • McEwen B.S.
        Prolonged glucocorticoid exposure reduces hippocampal neuron number. Implications for aging.
        J Neurosci. 1985; 5: 1221-1226
        • Schelchte J.A.
        • Sherman B.M.
        Decreased glucocorticoid receptor binding in adrenal insufficiency.
        J Clin Endocrinol Metab. 1982; 54: 145-149
        • Schlechte J.A.
        • Sherman B.
        Lymphocyte glucocorticoid receptor binding in depressed patients with hypercortisolemia.
        Psychoneuroendocrinology. 1985; 10: 469-474
        • Schlechte J.A.
        • Hamilton D.
        The effect of glucocorticoid on corticosteroid binding globulin.
        Clin Endocrinol. 1987; 27: 197-203
        • Schlechte J.A.
        • Ginsburg B.H.
        • Sherman B.M.L.
        Regulation of the glucocorticoid receptor in human lymphocytes.
        J Steroid Biochem. 1982; 16: 69-74
        • Seligman M.E.P.
        Helplessness.
        Freeman, San Francisco1975
        • Selye H.
        Thymus and adrenals in the response of the organisms to injuries and intoxications.
        Br J Exp Pathol. 1936; 17: 234-246
        • Sierles F.S.
        • Chen J.
        • McFarland R.T.
        • Taylor M.A.
        Post-traumatic stress disorder and concurrent psychiatric illness: A preliminary report.
        Am J Psychiatry. 1983; 140: 1177-1179
        • Smith M.A.
        • Davidson J.
        • Ritchie J.C.
        • et al.
        The corticotropin releasing hormone test in patients with posttraumatic stress disorder.
        Biol Psychiatry. 1989; 26: 349-355
        • Southwick S.M.
        • Yehuda R.
        • Giller E.L.
        Characterization of depression in war-related posttraumatic stress disorder.
        Am J Psychiatry. 1991; 148: 179-182
        • Stark E.
        • Fachet J.
        • Makara G.B.
        • Mihaly K.
        An attempt to explain differences in the hypophyseal-adrenocortical response to repeated stressful stimuli by their dependence of differences in pathways.
        Acta Med Hung. 1968; 25: 251-260
        • Vernikos J.
        • Dallman M.F.
        • Bonner C.
        • Katzen A.
        • Shinsako J.
        Pituitary-adrenal function in rats chronically exposed to cold.
        Endocrinology. 1972; 110: 413
        • Vernikos-Danellis J.
        • Heyback J.P.
        Psychophysiologic mechanisms regulating the hypothalamic-pituitary-adrenal response to stress.
        in: Selye H. Selye's Guide to Stress Research. Van Nostrand Reinhold, New York1980
        • Vernikos Danellis J.
        • Goldenrath W.L.
        • Dolkas C.B.
        The physiological cost of flight stress and flight fatigue.
        US Navy Med J. 1975; 66: 12-16
        • Wassef W.
        • Smith E.M.
        • Rose R.M.
        • et al.
        Mononuclear leukocyte glucocorticoid receptor binding characteristics and down-regulation in major depression.
        Psychoneuroendocrinology. 1990; 15: 59-68
        • Whalley L.J.
        • Borthwick N.
        • Copolov D.
        • et al.
        Glucocorticoid receptors and depression.
        Br Med J. 1986; 292: 859-861
        • Williams R.B.
        Neuroendocrine response patterns and stress: Biobehavioral mechanisms of disease.
        in: Williams R.B. Perspectives on Behavioral Medicine: Neuroendocrine Controls and Behavior. Academic, New York1983
        • Wolff C.T.
        • Friedman S.B.
        • Hofer M.A.
        • Mason J.W.
        Relationship between psychological defenses and mean urinary 17-OHCS excretion rates: A predictive study of parents of fatally ill children.
        Psychosom Med. 1964; 26: 576-591
        • Wolkowitz O.M.
        • Reus V.I.
        • Weingartner H.
        • et al.
        Cognitive effects of corticosteroids.
        Am J Psychiatry. 1990; 147: 1297-1303
        • Yehuda R.
        • Southwick S.M.
        • Nussbaum G.
        • et al.
        Low urinary cortisol excretion in PTSD.
        J Nerv Ment Dis. 1990; 178: 366-369
        • Yehuda R.
        • Southwick S.M.
        • Mason J.W.
        • Giller E.L.
        Interactions of the hypothalamic-pituitary-adrenal axis and the catecholaminergic system in posttraumatic stress disorder.
        in: Giller E.L. Biological Assessment and Treatment of PTSD. American Psychiatric Press, Washington DC1990: 117-134
        • Yehuda R.
        • Lowy M.T.
        • Southwick S.M.
        • Shaffer S.
        • Giller E.L.
        Increased number of glucocorticoid receptor number in post-traumatic stress disorder.
        Am J Psychiatry. 1991; 149: 499-504
        • Young E.A.
        • Akil H.
        Corticotropin-releasing factor stimulation of adrenocorticotropin and β-endorphin release: Effects of acute and chronic stress.
        Endocrinology. 1985; 117: 23-30
        • Young E.
        • Akil H.
        Changes in releasability of ACTH and beta-endorphin with chronic stress.
        Neuropeptides. 1985; 5: 545