Mind Body & Health

PTSD, SLEEP, AND RISK FOR INCIDENT HYPERTENSION
PI: Matthew Burg, Phd / Steve Cole, PhD, UCLA Co-I
NHLBI
The purpose of this study is to test the prospective relationship of post-traumatic stress disorder (PTSD) to day and night time ambulatory blood pressure (ABP) and thus, risk for hypertension and incident cardiovascular disease (CVD). PTSD occurs consequent to trauma and is characterized in part by hyperarousal, emotional dysregulation, and poor sleep, with a 50% greater risk for CVD, independent of traditional risk factors. Large cohort studies report greater prevalence of hypertension, including our n=200,000 pilot analyses, which also show that PTSD treatment may attenuate this risk. Critical questions concern early detection of hypertension risk, and whether PTSD treatment reduces this risk. Ambulatory blood pressure (ABP) is a better predictor of CVD risk than is the clinic blood pressure of 140/90mmHg on which a diagnosis of hypertension is made. ABP monitoring combined with ecological momentary assessment (EMA) by electronic diary creates a powerful tool, and using this we have found that momentary ratings of anger and anxiety are highly correlated with momentary elevations in blood pressure (BP). When combined with night time actigraphy, another powerful tool is created whereby the effects of sleep on ABP can be determined. These tools together may be particularly useful for testing the prospective relationship of PTSD to ABP and thus CVD risk, since among the hallmarks of PTSD are heightened emotional reactivity to daily events, and disrupted sleep. Leveraging the resources of our recently funded Women Veterans Cohort Study-Wave 2 and our National Center for PTSD, we propose to study 300 recent military veterans with and without a PTSD diagnosis (N=150 each) on 2 occasions, 2-years apart. We hypothesize that, 1) those with vs. without PTSD at baseline will show a greater 2-year increase in day and night time ABP, and 2a) will have a greater ABP response to both momentary negative emotion and PTSD symptoms, and poorer actigraphy-assessed sleep; 2b) negative emotions/PTSD symptoms and poor sleep will in part mediate the prospective association of PTSD to day and night time ABP; 3) improvement in PTSD from baseline to follow-up (e.g., due to PTSD treatment or natural trajectory), will be associated with a decrease or smaller increase in ABP over the 2 years. Upon completion of baseline assessments we will evaluate the cross-sectional relationships of PTSD status and symptom severity to: 1) day and night time ABP, 2) the proportion of EMA reports with PTSD symptoms endorsed 3) mean levels of EMA-reported negative affect, and 4) poor sleep. We will also analyze the effect of poor sleep - short duration, efficiency - on, 1) momentary negative emotions and PTSD symptoms, and 2) the relationship of momentary negative emotions and PTSD symptoms to ABP. Significance. The proposed study will point the way toward risk mitigation clinical trials, whether they test the targeted use of ABPM according to threshold PTSD symptoms, aggressive PTSD treatment, and/or early intervention with pharmaceutical, behavioral, or combined strategies for treating elevated day or night time ABP among individuals with PTSD.

NEURAL, INFLAMMATORY, AND GENOMIC MECHANISMS UNDERLYING RISK FOR DEPRESSION IN ADOLESCENCE
PI: George Slavich, PhD
NIMH
Major depressive disorder (MDD) has a lifetime prevalence rate of approximately 20% in the United States and is the leading cause of non-fatal disease burden worldwide. MDD can be debilitating for all, but beginning in early adolescence, women are twice as likely to experience MDD relative to men. Moreover, as they age, they are at disproportionately high risk for developing several serious medical conditions that frequently co-occur with MDD and presage early mortality, such as hypertension, heart disease, certain cancers, neurodegeneration, and stroke. Understanding mechanisms that may underlie the initial development of depression, especially among women, is therefore of paramount public importance. To address this issue, I will elucidate neural, inflammatory, and genomic processes associated with risk for MDD in adolescence. Recent studies have shown that social stress engages a network of brain regions involved in processing physical and social threat. Social stress also up regulates components of the immune system involved in inflammation, which has been implicated in the pathophysiology of depression. To examine for the first time social stress-induced alterations in neural activity and connectivity, pro-inflammatory cytokine activity, and genome-wide transcriptional activity that are associated with risk for MDD, I will conduct a study in which 25 adolescent girls at high risk for MDD (i.e., no personal history of any affective Axis I disorder, but a positive maternal history of MDD) and 25 adolescent girls at low risk for MDD (i.e., no personal or maternal history of any Axis I disorder) will be exposed to a brief episode of social rejection while undergoing an fMRI scan. In addition, blood samples will be obtained at four time-points during the study to test for social stress-induced changes in (a) levels of the pro-inflammatory cytokines TNF-α, IL-1β, and IL-6, and (b) inflammatory gene expression, using microarray-based genome-wide transcriptional profiling. As such, this study will be the first to examine neural, inflammatory, and genomic responses to social stress that are associated with differential risk for depression (Aims 1 & 2). The study will also be the firstto examine relations between these different stress-related mechanisms in adolescent girls at high and low risk for MDD (Aim 3). Finally, the study will allow me to obtain mentored training in several areas that are critical for pursuing this line of research independently, including: neuroscience and neuroimaging methods, fMRI data analysis, and functional genomics. My goal as a clinical psychologist is to identify mechanisms that underlie the initial emergence of risk fo depression and related disorders in adolescence, which can in turn be modified to reduce the enormous disease burden that is associated with these conditions. This Mentored Clinical Scientist Development Award will enable me to pursue this goal by providing me with protected time to obtain state-of-the-art training at UCLA. This award will also allow me to conduct the firs multi-method, experimental fMRI study on neural, inflammatory, and genomic mechanisms underlying risk for depression in adolescence, which will in turn inform the development of novel strategies for reducing the mounting disease burden associated with depression and depression-related diseases.

MULTILEVEL BIOMARKERS FOR SUICIDAL BEHAVIOR: FROM INTERPERSONAL STRESS TO GENE EXPRESSION IN A LONGITUDINAL STUDY OF ADOLESCENT GIRLS
PI: Mitch Prinstein, PhD, UNC / George Slavich, PhD, UCLA PI
NIMH
In response to public calls from the US President, Congress, Surgeon General, and a recent NIMH-co- sponsored Suicide Research Prioritization Agenda, the proposed research will examine how suicidal ideation and attempts develop within one of the most vulnerable populations at risk for suicide (i.e., adolescent girls). This work will examine how girls' atypical acute stress responses to interpersonal stress at physiological, genomic, and behavioral units of analysis moderate the association between actual experiences of interpersonal stress and suicidal ideation among girls with distal suicide risk factors (i.e., elevated depressive symptoms/lifetime interpersonal adversity). Moreover, this research will examine how these distal risk factors transact with pubertal processes to produce risk for atypical acute stress responses. Last, inhibitory control will be examined as a moderator of the association between suicide ideation and suicide attempts. This research will identify numerous biomarkers of suicide risk, significantly advancing progress towards identification and prevention of an enormous public health issue that has been woefully understudied and for which no evidence- based approaches exist. Using a combination of a RDoC conceptual framework, experimental lab-based stressor paradigm, biological assays, performance-based assessments of executive function, longitudinal methods, and innovative bioinformatics approaches for measuring gene expression, this work offers a substantial advance within a field that almost exclusively has relied on cross-sectional, single-informant, retrospective reports of suicidality. Participants will include 200 girls (age 9-14 years) at pre-, peri-, and post-pubertal stages of development. Recruitment will oversample girls with elevated depressive symptoms/lifetime interpersonal adversity to participate in a lab-based study involving the assessment of physiological, genomic, and behavioral responses following an experimentally-induced social stressor. A multi-wave assessment occurring over a one-year longitudinal interval will be conducted to obtain extensive data on suicidal ideation and attempts over time. Biological data will be collected to measure the autonomic nervous system, hypothalamic-pituitary-adrenal axis system, gene expression (using microarray-based genome-wide transcriptional profiling), and pubertal development. Ongoing research conducted by this investigative team utilizing many of the same recruitment, data collection, and analytic procedures strongly supports the feasibility of the proposed research.

BIOBEHAVIORAL INFLUENCES AND THE OVARIAN TUMOR MICROENVIRONMENT
PI: Susan Lutgendorf, PhD, Iowa PI / George Slavich, PhD, UCLA PI
NCI
Ovarian cancer is the second most common gynecologic cancer. Because of low rates of survival for the majority of ovarian cancer patients, identification of factors contributing to tumor progression is of paramount importance. Epidemiologic studies have suggested an association between biobehavioral factors such as life stress, depression, and social support and cancer progression. This study examines a novel pathway that may underlie these links in ovarian cancer, specifically, the relationship of biobehavioral factors with resident macrophages within the tumor microenvironment. It is now acknowledged that the tumor microenvironment is critical in supporting or inhibiting tumor progression. We have previously reported associations of depression and low social support with a poorer cellular immune response in ovarian cancer patients in the tumor microenvironment. We have also demonstrated direct links between biobehavioral factors and cytokines supporting angiogenesis, the formation of new blood vessels that enhance tumor growth and progression. Macrophages are major components of the tumor microenvironment where they are predominantly converted from an anti-tumor phenotype to a pro-tumor phenotype and play a key role in supporting inflammation and tumor progression. However, little is known regarding whether biobehavioral factors influence tumor associated macrophages (TAM) and interactions between TAM and tumor cells in a way that favors tumor growth. Based on compelling preliminary data, we propose that biobehavioral influences on both TAM and tumor cells in the tumor microenvironment have significant effects on production of factors supporting tumor growth and progression. We focus on TAM because of their key role in the tumor microenvironment, and because of indications of macrophage sensitivity to stress factors in the cardiovascular literature and in our preliminary data. Thus, the overarching goal of this proposal is to examine pathways by which biobehavioral factors contribute to a permissive local environment for interactions between resident cells (TAM) and tumor cells that favor tumor growth in ovarian cancer. The proposed project will prospectively examine the relationship of biobehavioral factors (life stress, depression, and social support) and TAM products (inflammatory cytokines and tumor growth factors) in the tumor microenvironment in 206 ovarian cancer patients. Association of biobehavioral factors with upregulation of gene transcripts related to inflammation and proliferation in tumor cells will also be examined. Based on preliminary data we will examine the role of adrenergic signaling as a mediator in these relationships. To determine the clinical significance of these biological alterations, the investigation will assess progression-free and overall survival during the 24 months following diagnosis. Findings will have implications for innovative behavioral and pharmacological intervention strategies for ovarian cancer patients. PUBLIC HEALTH RELEVANCE: There has been very little research examining systemic effects on the tumor microenvironment. This research examines a novel pathway by which biobehavioral factors may contribute to a permissive milieu for tumor growth and disease progression in the tumor microenvironment among ovarian cancer patients. A clearer understanding of biobehavioral risk factors and pathways by which they operate is critical for identifying targets for psychosocial and pharmacological intervention for ovarian cancer patients who may be at risk.

DAILY EXPERIENCE IN ADOLESCENCE AND BIOMARKERS OF EARLY RISK FOR ADULT HEALTH
PI: Andrew Fuligni, PhD / Michael R. Irwin, MD, Co-I
NICHD
Despite calls for the identification of early risk factors for the development of chronic health conditions, there has been little longitudinal research on biomarkers of health that has been conducted in persons younger than 25 years of age. In addition, there is only a minimal understanding of how biological indices of early risk for adult health develop among adolescents with Latin American and Asian backgrounds, the two fastest rising ethnic groups in theUnited States, who are at differential risk for adverse health outcomes as compared to European Americans. An understanding of these processes is necessary for the development of ethnically and culturally relevant prevention efforts. We propose a 3-wave longitudinal study of adolescents and their caregivers from Mexican, Chinese and European backgrounds in order to assess the impact of daily experience on biological indicators of early risk for adult health. Our focus on daily experience stems from the need to identify the mechanisms by which global social factors identified in demographic surveys, such as lower education and income, play themselves out in individuals' daily lives. Daily experiences such as social conflict, excessive demands, emotional distress, threat, and sleep behaviors have been shown to be linked to both global risk factors and multiple biological indices of health risk among adults. The project will include both intensive behavioral assessments and detailed biological markers of health risk from both adolescents and their parents in order to address the following specific aims: (1) describe the development during adolescence of biological indices of early risk for adult health; (2) assess the role of daily experience in the development of early health risk; (3) examine the existence of ethnic disparities in early health risk; and (4) explore the role of potential protective factors in the development of early health risk. Approximately 540 pairs of adolescents and primary caregivers (180 from each ethnic group) will be assessed when the adolescents are approximately 15-16, 17-18, and 19-20 years of age. Each year, both adolescents and caregivers will participate in interviews that include measures of global social factors such as socioeconomic background and potential protective factors such as social connectedness. Participants will report daily experiences using a nightly diary checklist for 9 consecutive days. Salivary cortisol will be obtained at 4 time points each day for 4 of these days in order to analyze HPA activity, and participants will wear wrist actigraphs for the same 4 days to measure objective sleep behaviors. Blood pressure, BMI, and waist/hip ratio will be assessed, and dried blood spots will be obtained for the assessment of c-reactive-protein (CRP), cholesterol, and high density lipoproteins (HDL). Finally, peripheral blood samples will be provided by a subsample of 120 families for the assessment of plasma interleukin-6 (IL-6), a pro-inflammatory cytokine, and for gene expression analyses of molecular signaling pathways driving inflammatory biology. PUBLIC HEALTH RELEVANCE: There is only a minimal understanding of how biological indices of early risk for adult health develop among adolescents with Latin American and Asian backgrounds, the two fastest rising ethnic groups in theUnited States, who are at differential risk for adverse health outcomes as compared to European American. More in-depth examinations of the daily lives of adolescents from these populations could identify both the sources of these disparities as well as unique risk and protective factors. An understanding of these processes is necessary for the development of ethnically and culturally relevant prevention efforts.

BRAIN AND BEHAVIOR IN INDIVIDUALS WITH INTERSEX CONDITIONS
PI: Eileen Lueders, PhD, UCLA PI
NICHD
Studies of non-human mammals show that androgens, particularly testosterone (T), during early development play a major role in sexual differentiation of the brain, with long-term consequences for behavior. Research on clinical populations suggests that prenatal T exposure has similar effects in humans, increasing male-typical behavior and reducing female-typical behavior. Almost nothing is known, however, about the impact of early T exposure on the structure of the human brain. In addition, the brain mechanisms underlying T-related behavioral changes are unknown. This project will study brain structure and behavior in individuals with one of two disorders of sex development (DSD, also called intersex conditions) that are characterized by androgen abnormality beginning prenatally: 1. Congenital adrenal hyperplasia (CAH), which causes overproduction of adrenal androgens; and 2. Complete androgen insensitivity syndrome (CAIS), which involves an inability to respond to androgens, and so an effective lack of androgen exposure. CAH affects both males and females, and 35 men and 35 women with CAH will be compared to 35 male and 35 female controls. Individuals with CAIS are XY females, and 35 females with CAIS will be compared to 35 male and 35 female controls. State-of- the-art imaging technology will be used to map brain structure. Also, aspects of behavior, known to show substantial sex differences, and for which there is evidence of a relationship to prenatal T exposure, will be assessed. Specifically, these are mental rotation ability, targeting ability, and propensities to physical aggression (where men score higher than women), and verbal fluency, fine motor ability and empathy (where women score higher than men). The information obtained will provide convergent evidence regarding the influence of T on human brain and behavior. Convergent evidence is important because ethical considerations preclude experimental manipulations of T during early human development. Instead, naturally occurring conditions that involve T excess or deficiency will be studied. Each condition involves consequences in addition to T abnormality. Therefore, confidence that testosterone caused any brain or behavior differences is strengthened when data from both conditions suggest this conclusion. For instance, prior research indicates that, with respect to physical aggression, men score higher than women, and females with CAH score higher than other females. If XY females with CAIS resemble women rather than men in regard to physical aggression, confidence that T is the responsible agent will be increased. The information obtained will enhance understanding of the neural mechanisms involved in sexual differentiation of human brain and behavior, and so will be relevant to the many psychological disorders that differ by sex. It will also be relevant to clinical management of individuals who have experienced T abnormality before birth, for any of several reasons, including genetic disorders, such as CAH or CAIS, or other disorders of sex development, maternal treatment with hormones during pregnancy, or contact with environmental endocrine disruptors.

PRO-INFLAMMATORY CYTOKINES & NEUROBEHAVIORAL SYMPTOMS IN BREAST CANCER PATIENTS
PI: Sunita Patel, PhD / Elizabeth Breen, PhD, Co-I
NCI
Pro-inflammatory cytokines and neurobehavioral symptoms in women with breast cancer. Abstract Survivors of breast cancer report debilitating behavioral symptoms, such as fatigue and neurocognitive dysfunction, which are evident in some individuals even at pre-treatment baseline. There is sufficient evidence from varied lines of research to propose that cancer-related neurobehavioral symptoms may be driven, at least in part, by activation of the pro-inflammatory cytokine network. Concentrations of specific pro-inflammatory cytokines (IL-6, TNF) and soluble receptors in serum obtained prior to treatment in breast cancer patients are significantly higher than levels found in healthy individuals and have prognostic value; however, these pre- treatment elevations have not yet been evaluated with respect to their association with either acute or chronic behavioral symptoms. Among survivors of breast cancer, elevated levels of circulating sIL-6R and IL-1ra have emerged as prominent biomarkers of persistent fatigue in cross-sectional studies of women several years post chemotherapy. No similar work has identified biomarkers of neurocognitive dysfunction in this patient population, and it is not known if the cytokine links with fatigue, or other behavioral symptoms, exist closer to the diagnosis period or evolve over time as "late effects". In this study, we will address this knowledge gap as we will evaluate this association prior to cancer treatment, and again following treatment completion. We will compare these associations in a minimum of 137 breast cancer patients relative to two comparison groups at pre-treatment, and longitudinally evaluate only the breast cancer group after treatment. Findings are expected to increase our knowledge about the possible biomarkers associated with neurobehavioral symptoms in breast cancer patients, for the purpose of better identifying and treating those at risk for such effects. PUBLIC HEALTH RELEVANCE: Findings are expected to increase knowledge about the possible biomarkers associated with neurobehavioral symptoms in breast cancer patients, for the purpose of better identifying and treating those at risk for such effects.