title: Changes in Salivary Cortisol During Psychotherapy for Posttraumatic Stress Disorder: A Pilot Study in 30 Veterans.
abstract: BACKGROUND
  Convergent evidence suggests that the hypothalamic-pituitary-adrenal (HPA) axis is disrupted in posttraumatic stress disorder (PTSD) and that HPA axis normalization may be associated with symptom improvement. Thus, the current study was designed to test the association between HPA axis reactivity and treatment response in psychotherapy for PTSD.
  
  
  METHODS
  Thirty returning veterans with DSM-IV-TR PTSD were randomly assigned to receive 10 sessions of prolonged exposure therapy or present-centered therapy as part of a previously published randomized clinical trial (2008-2010). Treatment groups were collapsed for the current analyses. Salivary cortisol was collected 3 times during 3 therapy sessions. Cortisol reactivity was calculated by area under the curve with respect to ground. Hierarchical linear modeling was used to measure longitudinal change in salivary cortisol nested within patients and to test the effects of treatment responder status at both levels.
  
  
  RESULTS
  Session number was significant in the final model, indicating linear increases in cortisol output across sessions (β = 1.06, P = .02). In addition, responder status significantly predicted slope of cortisol reactivity across sessions (β = 1.35, P = .04). Compared to high responders, low responders exhibited a 1.35 (μg/dL) mean increase in cortisol reactivity between sessions. Responder status accounted for 6% of the previously unexplained variance in cortisol reactivity.
  
  
  CONCLUSIONS
  As compared to high treatment responders, low treatment responders showed greater increases in salivary cortisol output over the course of treatment. These results indicate that increases in HPA axis reactivity over the course of psychotherapy may be associated with worse treatment response. Future work is needed to investigate how modulation of HPA axis reactivity may be targeted in order to optimize PTSD treatment outcomes.
  
  
  BACKGROUND
  ClinicalTrials.gov identifier: NCT00475241​.
authors.affiliation: Emory University School of Medicine, 12 Executive Park Dr, Ste 300, Atlanta, GA 30329. sheila.a.m.rauch@emory.edu.|Emory University School of Medicine, Atlanta, Georgia, USA.|Atlanta VA Medical Center, Atlanta, Georgia, USA.
authors.forename: Sheila A M
authors.initials: SAM
authors.lastname: Rauch
authors.affiliation: University of Michigan Medical School, Ann Arbor, Michigan, USA.|VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.
authors.forename: Anthony P
authors.initials: AP
authors.lastname: King
authors.affiliation: University of Michigan Medical School, Ann Arbor, Michigan, USA.|VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.
authors.forename: Israel
authors.initials: I
authors.lastname: Liberzon
authors.affiliation: University of Michigan Medical School, Ann Arbor, Michigan, USA.|VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA.|VA Center for Clinical Management Research, Ann Arbor, Michigan, USA.
authors.forename: Rebecca K
authors.initials: RK
authors.lastname: Sripada
mesh_terms: D000328:Adult; D003130:Combat Disorders / Q000097:blood / Q000523:psychology / Q000628:therapy*; D005260:Female; D006801:Humans; D006854:Hydrocortisone / Q000097:blood*; D007030:Hypothalamo-Hypophyseal System / Q000503:physiopathology; D007171:Implosive Therapy / Q000379:methods*; D054542:Iraq War, 2003-2011; D008137:Longitudinal Studies; D008297:Male; D010865:Pilot Projects; D010913:Pituitary-Adrenal System / Q000503:physiopathology; D011613:Psychotherapy / Q000379:methods*; D012463:Saliva / Q000737:chemistry; D013313:Stress Disorders, Post-Traumatic / Q000097:blood* / Q000523:psychology / Q000628:therapy*; D016896:Treatment Outcome; D014728:Veterans / Q000523:psychology*
chemical_list: D006854:Hydrocortisone