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

Abstract

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.

Keywords: Posttraumatic stress disorder; biomarker.; diagnostic; hair cortisol; intervention-related; prognostic; trauma.

Fig. (1)

PRISMA flowchart illustrating the process of study selection.

Fig. (2)

Model a) depicts the original integrative model by Steudte-Schmiedgen and colleagues [4] linking long-term cortisol secretion, trauma exposure, and subsequent PTSD development. The model proposes that trauma exposure leads to an initial hypersecretion of cortisol, which, over time, turns into a dose-dependent attenuation of secretion. Thus, cortisol secretion shows an endocrine “building block effect”, matching the clinical observation of higher PTSD risk with multiple trauma exposure. Model b) reflects the updated and extended model including the proposed trajectory for ongoing traumatic stress with continuous hypersecretion, as well as an alternative plausible secretion pattern following multiple trauma exposure. Currently, the literature cannot conclusively resolve which trajectory is more accurate: the staircase-shaped one proposed in (a), with changes particularly of the baseline secretion, or a sinus-shaped trajectory with changes also in the amplitude, as proposed in (b), is more accurate. Methodologically sound longitudinal studies are needed.