Psychogenic lowering of urinary cortisol levels linked to increased emotional numbing, and a shame-depressive syndrome in combat-related posttraumatic stress disorder

Objective: The purpose of the study was to search for the intrapsychic corr elates of individual differences in cortisol levels in male Vietnam combat veterans with posttraumatic stress disorder. Methods: The study involved me asurement of urinary cortisol levels and clinical assessment with a broad p rofile of psychometric tests during a single 48-hour period in 30 inpatient s. Results: The main finding by both correlation and t test analyses was a significant inverse relationship between urinary cortisol levels and a symp tom complex composed of two closely interrelated clinical subgroupings, "di sengagement" (principally involving emotional numbing) and "shame-laden dep ression." Conclusions: The findings support the concept that cortisol level s reflect the ongoing balance between the undifferentiated emotional arousa l state of engagement (associated with higher cortisol levels) and opposing antiarousal disengagement defense mechanisms (associated with lower cortis ol levels). It appears that the low cortisol levels often seen in patients with posttraumatic stress disorder are psychogenic and reflect a dominating effect of disengagement coping strategies, which represent secondary compe nsatory adaptations during the chronic course of this disorder to counterac t primary arousal symptoms, especially those related to an intractable sham e-laden depressive syndrome. The psychoendocrine findings suggest that the relatively inconspicuous clinical feature of shame resulting from both the primary and secondary traumatizations is a particularly powerful, preoccupy ing, and overwhelming source of emotional engagement, Shame may represent a "sleeper" that is worthy of greater attention in both research and clinica l efforts to understand the pathogenesis and psychopathology of this devast ating stress-related disorder.