Abstract
Comorbidity presents significant problems to investigators engaged in the search for biomarkers of post-traumatic stress disorder (PTSD) because it means that multiple overlapping psychiatric phenotypes may be present in any PTSD sample. This chapter reviews research on an internalizing/externalizing model of post-traumatic psychopathology and discusses its relevance to the search for PTSD biomarkers. It focuses on two candidate biomarkers that have been studied extensively in relation to PTSD—basal cortisol level and startle reflex amplitude—but have yielded complicated and mixed results. Our review of the cortisol literature finds evidence for links between disorders of the internalizing spectrum and elevated levels of cortisol and links between externalizing psychopathology and low levels of cortisol. The review of the startle reflex literature reveals an association between exaggerated startle and fear-related disorders of the internalizing spectrum. These findings illustrate how individual differences in internalizing and externalizing comorbidity may moderate associations between these measures and PTSD diagnostic status. The chapter concludes with a discussion of the advantages of studying latent dimensions of comorbidity in future PTSD biomarker research.
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References
Brown, T. A. , Campbell, L. A. , Lehman, C. L. , Grisham, J. R. , and Mancill, R. B. (2001) Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. J Abnorm Psychol 110, 585–99.
Orsillo, S. M. , Weathers, F. W. , Litz, B. T. , Steinberg, H. R. , Huska, J. A. , and Keane, T. M. (1996) Current and lifetime psychiatric disorders among veterans with war zone-related posttraumatic stress disorder. J Nerv Ment Dis 184, 307–13.
Kulka, R. A. , Schlenger, W. E. , Fairbank, J. A. , Hough, R. L. , Jordan, B. K. , Marmar, C. R. , and Weiss, D. S. (1990). Trauma and the Vietnam War Generation: Report on the Findings from the National Vietnam Veterans Readjustment Study. New York: Brunner/Mazel.
Achenbach, T. M. , and Edelbrock, C. S. (1978) The classification of child psychopathology: a review and analysis of empirical efforts. Psychol Bull 85, 1275–1301.
Achenbach, T. M. , and Edelbrock, C. S. (1984) Psychopathology of childhood. Annu Rev Psychol 35, 227–56.
Kendler, K. S. , Prescott, C. A. , Myers, J. , and Neale, M. C. (2003) The structure of genetic and environmental risk factors for common psychiatric and substance use disorders in men and women. Arch Gen Psychiatry 60, 929–37.
Kessler, R. C. , Chiu, W. T. , Demler, O. , Merikangas, K. R. , and Walters, E. E. (2005) Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 62, 617–27.
Krueger, R. F. (1999) The structure of common mental disorders. Arch Gen Psychiatry 56, 921–26.
Krueger, R. F. , Caspi, A. , Moffitt, T. E. , and Silva, P. A. (1998) The structure and stability of common mental disorders (DSM-III-R): a longitudinal-epidemiological study. J Abnorm Psychol 107, 216–27.
Krueger, R. F. , Chentsova-Dutton, Y. E. , Markon, K. E. , Goldberg, D. , and Ormel, J. (2003) A cross-cultural study of the structure of comorbidity among common psychopathological syndromes in the general health care setting. J Abnorm Psychol 112, 437–47.
Krueger, R. F. , McGue, M. , and Iacono, W. G. (2001) The higher-order structure of common DSM mental disorders: internalization, externalization, and their connections to personality. Pers Indiv Differ 30, 1245–59.
Vollebergh, W. A. M. , Idema, J. , Bijl, R. V. , de Graaf, R. , Smit, F. , and Ormel, J. (2001) The structure and stability of common mental disorders: the NEMESIS Study. Arch Gen Psychiatry 58, 597–603.
Cox, B. J. , Clara, I. P. , and Enns, M. W. (2002) Posttraumatic stress disorder and the structure of common mental disorders. Depress Anxiety 15, 168–71.
Slade, T. , and Watson, D. (2006) The structure of common DSM-IV and ICD-10 mental disorders in the Australian general population. Psychol Med 36, 1593–1600.
Miller, M. W. , Fogler, J. M. , Wolf, E. J. , Kaloupek, D. G. , and Keane, T. M. , (2008) The internalizing and externalizing structure of psychiatric comorbidity in combat veterans. J Trauma Stress 21, 58–65.
Krueger, R. F. , Hicks, B. M. , Patrick, C. J. , Carlson, S. R. , Iacono, W. G. , and McGue, M. (2002) Etiologic connections among substance dependence, antisocial behavior and personality: modeling the externalizing spectrum. J Abnorm Psychol 111, 411–24.
Deater-Deckard, K. , and Plomin, R. (1999) An adoption study of the etiology of teacher and parent reports of externalizing behavior problems in middle childhood. Child Dev 70, 144–54.
Gjone, H. , Stevenson, J. , and Sundet, J. M. (1996) Genetic influence on parent-reported attention-related problems in a Norwegian general population twin sample. J Am Acad Child Adolesc Psychiatry 35, 588–96.
Barlow, D. H. , Chorpita, B. F. , and Turovsky, J. (1996) Fear, panic, and disorders of emotion. In D. A. Hope, Current Theory and Research in Motivation. Nebraska Symposium on Motivation 43. Lincoln: University of Nebraska Press.
Clark, D. A. , Steer, R. A. , and Beck, A. T. (1994) Common and specific dimensions of self-reported anxiety and depression: implications for the cognitive and tripartite models. J Abnorm Psychol 103, 645–54.
Frances, A. J. , Widiger, T. A. , and Fyer, M. R. (1990) The influence of classification methods on comorbidity. In J. D. Maser and C. R. Cloninger, Comorbidity of Mood and Anxiety Disorders (pp. 41–59). Washington, DC: American Psychiatric Association.
Miller, M. W. , Greif, J. L. , and Smith, A. A. (2003) Multidimensional Personality Questionnaire profiles of veterans with traumatic combat exposure: internalizing and externalizing subtypes. Psychol Assessment 15, 205–15.
Miller, M. W. , Kaloupek, D. G. , Dillon, A. L. , and Keane, T. M. (2004) Externalizing and internalizing subtypes of combat-related PTSD: a replication and extension using the PSY-5 Scales. J Abnorm Psychol 113, 636–45.
Miller, M. W. , and Resick, P. A. (2007) Internalizing and externalizing subtypes of female sexual assault survivors: implications for the understanding of complex PTSD. Behav Ther 38, 58–71.
Forbes, D. , Creamer, M. , Allen, N. , Elliott, P. , McHugh, T. , Debenham, P. , and Hopwood, M. (2003) MMPI-2 based subgroups of veterans with combat-related PTSD. J Nerv Ment Dis 191, 531–537.
Hyer, L. , Davis, H. , Albrecht, W. , Boudewyns, P. , and Woods, G. (1994) Cluster analysis of MCMI and MCMI-II on chronic PTSD victims. J Clin Psychol 50, 502–15.
Piekarski, A. M. , Sherwood, R. , and Funari, D. J. (1993) Personality subgroups in an inpatient Vietnam veteran treatment program. Psychol Rep 72, 667–74.
Yehuda, R. (2001) Biology of posttraumatic stress disorder. J Clin Psychiat 62, 41–46.
Yehuda, R. (1997) Sensitization of the hypothalamic-pituitary-adrenal axis in posttraumatic stress disorder. Ann NY Acad Sci 821, 57–75.
Kaskow, J. W. , Baker, D. , and Geracioti, T. D. (2001) Corticotropin-releasing hormone in depression and post-traumatic stress disorder. Peptides 22, 845–51.
Lovallo, W. R. , and Thomas, T. L. (2000) Stress hormones in psychophysiological research. In J. T. Cacioppo, L. G. Tassinary, and G. G. Bernston, Handbook of Psychophysiology. 2nd ed. New York: Cambridge University Press.
McCann, S. M. (1988) The anterior pituitary and hypothalamus. In J. E. Griffin and S. R. Ojeda, eds. Textbook of Endocrine Physiology. New York: Oxford University Press.
Orth, D. N. , Kovacs, W. J. , and DeBold, C. R. (1992) The adrenal cortex. In J. D. and Wilson D. W. Foster, Textbook of Endocrinology. Philadelphia: Saunders.
Merchenthaler, I. (1984) Corticotropin-releasing factor (CRF)-like immunoreactivity in the rat central nervous system: extrahypothalamic distribution. Peptides 5, 53–69.
Yehuda, R. , Soutwick, S. M. , Nussbaum, G. , Wahby, V. , Giller, E. L. , and Mason, J. W. (1990) Low urinary cortisol excretion in patient with posttraumatic stress disorder. J Nerv Ment Dis 178, 366–69.
Yehuda, R. , Kahana, B. , Binder-Brynes, K. , Southwick, S. M. , Mason, J. W. , and Giller, E. L. (1995) Low urinary cortisol excretion in Holocaust survivors with posttraumatic stress disorder. Am J Psychiatry 152, 982–86.
Boscarino, J. A. (1996) Posttraumatic stress disorder, exposure to combat, and lower plasma cortisol among Vietnam veterans: findings and clinical impressions. J Consult Clin Psychol 64, 191–201.
Griffin, M. G. , Resick, P. A. , and Yehuda, R. (2005) Enhanced cortisol suppression following dexamethasone administration in domestic violence survivors. Am J Psychiatry 162, 1192–99.
Olff, M. , Güzelcan, Y. , de Vries, G. -J. , Assies, J. , and Gersons, B. P. R. (2006) HPA- and HPT-axis alterations in chronic posttraumatic stress disorder. Psychoneuroendocrinology 31, 1220–30.
Yehuda, R. , Teicher, M. H. , Trestman, R. L. , Levengood, R. A. , and Siever, L. J. (1996) Cortisol regulation in posttraumatic stress disorder and major depression: a chronobiological analysis. Biol Psychiatry 40, 79–88.
de Kloet, C. S. , Vermetten, E. , Heijnen, C. J. , Geuze, E. , Lentjes, E. G. W. M. , and Westenberg, H. G. M. (2007) Enhanced cortisol suppression in response to dexamethasone administration in traumatized veterans with and without posttraumatic stress disorder. Psychoneuroendocrinlogy 32, 215–26.
Wessa, M. , Rohleder, N. , Kirschbam, C. , and Flor, H. (2006) Altered cortisol awakening response in posttraumatic stress disorder. Psychoneuroendocrinology 31, 209–15.
Stein, M. B. , Yehuda, R. , Koverola, C. , and Hanna, C. (1997) Enhanced dexamethasone suppression of plasma cortisol in adult women traumatized by childhood sexual abuse. Biol Psychiatry 42, 680–86.
Yehuda, R. , Southwick, S. M. , Krystal, J. M. , Charney, D. S. , and Mason, J. W. (1993) Enhanced suppression of cortisol following dexamethasone administration in combat veterans with posttraumatic stress disorder and major depressive disorder. Am J Psychiatry 150, 83–86.
Baker, D. G. , Ekhator, N. N. , Kasckow, J. W. , Dashevsky, B. , Horn, P. S. , Bednarik, L. , and Geracioti, T. D. (2005) Higher levels of basal serial CSF cortisol in combat veterans with posttraumatic stress disorder. Am J Psychiatry 162, 992–94.
Lemieux, A. M. , and Coe, C. L. (1995) Abuse-related posttraumatic stress disorder: evidence for chronic neuroendocrine activation in women. Psychosom Med 57, 105–15.
Maes, M. , Lin, A. , Bonaccorso, S. , van Hunsel, F. , Van Gastel, A. , Delmeire, L. , Biondi, M. , Bosmans, E. , Kenis, G. , and Scharpe, S. (1998) Increased 24-hour urinary cortisol excretion in patients with post-traumatic stress disorder and patients with major depression, but not in patients with fibromyalgia. Acta Psychiatr Scand 98, 328–35.
Pitman, R. K. , and Orr, S. P. (1990) Twenty-four hour urinary cortisol and catecholamine excretion in combat-related posttraumatic stress disorder. Biol Psychiatry 27, 245–47.
Liberzon, I. , Abelson, J. L. , Flagel, S. B. , Raz, J. , and Young, E. A. (1999) Neuroendocrine and psychophysiologic responses in PTSD: a symptom provocation study. Neuropsychopharmacology 21, 40–50.
Lindley, S. E. , Carlson, E. B. , and Benoit, M. (2004) Basal and dexamethasone suppressed salivary cortisol concentrations in a community sample of patients with posttraumatic stress disorder. Biol Psychiatry 55, 940–45.
Young, E. A. , and Breslau, N. (2004) Cortisol and catecholamines in posttraumatic stress disorder: an epidemiologic community study. Arch Gen Psychiatry 61, 394–401.
Young, E. A. , and Breslau, N. (2004) Saliva cortisol in posttraumatic stress disorder: a community epidemiologic study. Biol Psychiatry 56, 205–9.
Miller, G. E. , Chen, E. , and Zhou, E. S. (2007) If it goes up, must it come down? Chronic stress and the hypothalamic-pituitary-adrenocortical axis in humans. Psychol Bull 133, 24–45.
Greaves-Lord, K. , Ferdinand, R. F. , Oldehinkel, A. J. , Sondeijker, F. E. P. L. , Ormel, J. , and Verhulst, F. C. (2007) Higher cortisol awakening response in young adolescents with persistent anxiety problems. Acta Psychiatr Scand 116, 137–44.
Klimes-Dougan, K. , Hastings, P. D. , Granger, D. A. , Usher, B. A. , and Zahn-Waxler, C. (2001) Adrenocortical activity in at-risk and normally developing adolescents: individual differences in salivary cortisol basal levels, diurnal variation, and responses to social challenges. Dev Psychopathol 13, 695–719.
Granger, D. A. , Weisz, J. R. , and Kauneckis, D. (1994) Neuroendocrine reactivity, internalizing behavior problems, and control-related cognitions in clinic-referred children and adolescents. J Abnorm Psychol 103, 267–76.
Kagan, J. , Reznick, J. S. , and Snidman, N. (1988) Biological bases of childhood shyness. Science 240, 167–71.
Schmidt, L. A. , Fox, N. A. , Rubin, K. H. , Sternberg, E. M. , Gold, P. W. , Smith, C. C. , and Schulkin, J. (1997) Behavioral and neuroendocrine responses in shy children. Dev Psychobiol 30, 127–140.
Warren, S. L. , Gunnar, M. R. , Kagan, J. , Anders, T. F. , Simmens, S. J. , Rones, M. , Wease, S. , Aron, E. , Dahl, R. , and Sroufe, A. (2003) Maternal panic disorder: infant temperament, neurophysiology, and parenting behaviors. J Am Acad Child Adolesc Psychiatry 42, 814–25.
Granger, D. A. , Weisz, J. R. , McCracken, J. T. , Ikeda, S. G. , and Douglas, P. (1996) Reciprocal influences among adrenocortical activation, psychosocial processes, and the behavioral adjustment of clinic-referred children. Child Dev 67, 3250–62.
Abelson, J. L. , Khan, S. , Liberzon, I. , and Young, E. A. (2007) HPA axis activity in patients with panic disorder: review and synthesis of four studies. Depress Anxiety 24, 66–76.
Marshall, R. D. , Blanco, C. , Printz, D. , Liebowitz, M. R. , Klein, D. F. , and Coplan, J. (2002) A pilot study of noradrenergic and HPA axis functioning in PTSD vs. panic disorder. Psychiatry Res 110, 219–30.
Bandelow, B. , Wedekind, D. , Sandvoss, V. , Broocks, A. , Hajak, G. , Pauls, J. , Peter, H. , and Rüther, E. (2000) Diurnal variation of cortisol in panic disorder. Psychiatry Res 95, 245–50.
Holsboer, F. (2000) The corticosteroid receptor hypothesis of depression. Neuropsychopharmacology 23, 477–501.
Schweizer, E. E. , Swenson, C. M. , Winokur, A. , Rickels, K. , and Maislin, G. (1986). The dexamethasone suppression test in generalised anxiety disorder. Br J Psychiatry 149, 320– 22.
Tiller, J. W. , Biddle, N. , Maguire, K. P. , and Davies, B. M. (1988) The dexamethasone suppression rest and plasma dexamethasone in generalized anxiety disorder. Biol Psychiatry 23, 261–70.
Quay, H. C. (1965) Psychopathic personality as pathological stimulation-seeking. Am J Psychiatry 122, 180–83.
Hare, R. D. (1970) Psychopathy: Theory and Research. New York: Wiley.
Zuckerman, M. (1999) Vulnerability to Psychopathology: A Biosocial Model. Washington, DC: American Psychiatric Press.
Vanyukov, M. M. , Moss, H. B. , Plail, J. A. , Blackson, T. , Mezzich, A. C. , and Tarter, R. E. (1993) Antisocial symptoms in preadolescent boys and their parents: associations with cortisol. Psychiatry Res 46, 9–17.
Tennes, K. , Kreye, M. , Avitable, N. , and Wells, R. (1986) Behavioral correlates of excreted catecholamines and cortisol in second-grade children. J Am Acad Child Adolesc Psychiatry 25, 764–70.
Tennes, K. , and Kreye, M. (1985) Children's adrenocortical responses to classroom activities and tests in elementary school. Psychosom Med 47, 451–60.
Burke, J. D. , Loeber, R. , and Lahey, B. B. (2007) Adolescent conduct disorder and interpersonal callousness as predictors of psychopathy in young adults. J Clin Child Adolesc Psychol 36, 334–46.
Holi, M. , Auvinen-Lintunen, L. , Lindberg, N. , Tani, P. , and Virkkunen, M. (2006) Inverse correlation between severity of psychopathic traits and serum cortisol levels in young adult violent male offenders. Psychopathology 39, 102–4.
King, R. J. , Jones, J. , Scheuer, J. W. , Curtis, D. , and Zarcone, V. P. (1990) Plasma cortisol correlates of impulsivity and substance abuse. Pers Indiv Differ 11, 287–91.
Wisniewski, A. B. , Brown, T. T. , John, M. , Cofranceso, J. , Golub, E. T. , Ricketts, E. P. , Wand, G. , and Dobs, A. S. (2006) Cortisol levels and depression in men and women using heroin and cocaine. Psychoneuroendocrinology 31, 250–55.
Wang, S. , Mason, J. , Charney, D. , Yehuda, R. , Riney, S. , and Southwick, S. (1997) Relationships between hormonal profile and novelty seeking in combat-related posttraumatic stress disorder. Biol Psychiatry 41, 145–51.
Davis, M. , Redmond, D. E. , Jr, and Baraban, J. M. (1979) Noradrenergic agonists and antagonists: effects on conditioned fear as measured by the potentiated startle paradigm. Psychopharmacology 65, 111–18.
Swerdlow, N. R. , Britton, K. T. , and Koob, G. F. (1989) Potentiation of acoustic startle by corticotropin-releasing factor (CRH) and by fear are both reversed by a-helical CRH(9–41). Neuropsychopharmacology 2, 285–92.
Risbrough V. B. , Hauger, R. L. , Roberts, A. J. , Vale, W. W. , and Geyer, M. A. (2004) Corticotropin-releasing factor receptors CRF1 and CRF2 exert both additive and opposing influences on defensive startle behavior. J Neurosci 24, 6545–52.
Pole, N. (2007). The psychophysiology of posttraumatic stress disorder: a meta-analysis. Psychol Bull 137, 725–46.
Morgan, C. A. , Grillon, C. , Southwick, S. M. , Davis, M. , and Charney, D. S. (1995) Fear-potentiated startle in posttraumatic stress disorder. Biol Psychiatry 38, 378–85.
Morgan, A. , Grillon, C. A. , Southwick, S. M. , Davis, M. , and Charney, D. S. (1996) Exaggerated acoustic startle reflex in Gulf War veterans with posttraumatic stress disorder. Am J Psychiatry 153, 64–68.
Grillon, C. , and Morgan, C. A. (1999) Fear-potentiated startle conditioning to explicit and contextual cues in Gulf War veterans with posttraumatic stress disorder. J Abnorm Psychol 108, 134–42.
Grillon, C. , Morgan, C. A. , Davis, M. , and Southwick, S. M. (1998) Effect of darkness on acoustic startle in Vietnam veterans with PTSD. Am J Psychiatry 155, 812–17.
Davis, M. , Walker, D. L. , and Lee, Y. (1997) Role of the amygdala and bed nucleus of the stria terminalis in fear and anxiety measured with the acoustic startle reflex. Ann N Y Academy of Sci 821, 305–33.
Davis, M. Walker, D. L. , and Lee, Y. (1999) Neurophysiology and neuropharmacology of startle and its affective modification. In M. Dawson, A. Schell, and M. Bohmelt, eds. , Startle Modification: Implications for Neuroscience, Cognitive Science, and Clinical Science (pp. 95–113). Cambridge: Cambridge University Press.
Orr, S. P. , Metzger, L. J. , Miller, M. W. , and Kaloupek, D. G. (2004) Psychophysiological assessment of posttraumatic stress disorder. In J. P. Wilson and T. M. Keane, eds. , Assessing Psychological Trauma and PTSD. 2nd ed. , pp. 289–343. New York: Guilford.
Buhlmann, U. , Wilhelm, S. , Deckersbach, T. , Rauch, S. L. , Pitman, R. K. , and Orr, S. P. (2007) Physiologic responses to loud tones in individuals with obsessive-compulsive disorder. Psychosom Med 69, 166–72.
Kumai, V. , Kaviani, H. , Raven, P. W. , Gray, J. A. , and Checkley, S. A. (2001) Enhanced startle reactions to acoustic stimuli in patients with obsessive-compulsive disorder. Am J Psychiatry 158, 134–36.
Grillon, C. , Ameli, R. , Goddard, A. , Woods, S. W. , and Davis, M. (1994) Baseline and fear-potentiated startle in panic disorder patients. Biol Psychiatry 35, 431–39.
Ludewig, S. , Geyer, M. A. , Ramseier, M. , Vollenweider, F. X. , Rechsteiner, E. , and Cattapan-Ludewig, K. (2005) Information-processing deficits and cognitive dysfunction in panic disorder. J Psychiatry Neurosci 30, 37–43.
Melzig, C. A. , Weike, A. I. , Zimmerman, J. , and Hamm, A. O. (2007) Startle reflex modulation and autonomic responding during anxious apprehension in panic disorder patients. Psychophysiology 44, 846–54.
Grillon, C. , Dierker, L. , and Merikangas, K. R. (1997) Startle modulation in children at risk for anxiety disorders and/or alcoholism. J Am Acad Child Adolesc Psychiatry 36, 925–32.
Grillon, C. , Warner, V. , Hille, J. , Merikangas, K. R. , Bruder, G. E. , Tenke, C. E. , Nomura, Y. , Leite, P. , and Weissman, M. M. (2005) Families at high and low risk for depression: a three-generation startle study. Biol Psychiatry 57, 953–60.
Cuthbert, B. N. , Lang, P. J. , Strauss, C. , Drobes, D. , Patrick, C. J. , Bradley, M. M. , (2003) The psychophysiology of anxiety disorder: fear memory imagery. Psychophysiology 40, 407–22.
Plappert, C. F. , Pilz, P. K. D. , and Schnitzler, H. , (1993) Acoustic startle response and habituation in freezing and nonfreezing rats. Behav Neurosci 107, 981–87.
Cloninger, C. R. (1987) Neurogenetic adaptive mechanisms in alcoholism. Science 236, 410–16.
Corr, P. J. , Kumari, V. , Wilson, G. D. , Checkley, S. , and Gray, J. A. (1997) Harm avoidance and affective modulation of the startle reflex: a replication. Pers Indiv Differ 22, 591–93.
Back, S. E. , Sonne, S. C. , and Killeen, T. (2003) Comparative profiles of women with PTSD and comorbid cocaine or alcohol dependence. Am J Drug Alcohol Abuse 29, 169–89.
Brady, K. T. , and Clary, C. M. (2003) Affective and anxiety comorbidity in post-traumatic stress disorder treatment trials of sertraline. Compr Psychiatry 44, 360–69.
Zayfert, C. , Becker, C. B. , Unger, D. L. , and Shearer, D. K. (2002) Comorbid anxiety disorders in civilians seeking treatment for posttraumatic stress disorder. J Trauma Stress 15, 31–38.
Zlotnick, C. , Warshaw, M. , Shea, M. T. , Allsworth, J. Pearlstein, T. , and Keller, M. B. (1999) Chronicity in posttraumatic stress disorder (PTSD) and predictors of course of comorbid PTSD in patients with anxiety disorders. J Trauma Stress 12, 89–100.
Cloitre, M. , and Koenen, K. C. (2001) The impact of borderline personality disorder on the effectiveness of group treatment for women with PTSD related to childhood sexual abuse. Int J Group Psychother 53, 379–98.
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Miller, M., Wolf, E., Fabricant, L., Stein, N. (2009). Low Basal Cortisol and Startle Responding as Possible Biomarkers of PTSD: The Influence of Internalizing and Externalizing Comorbidity. In: LeDoux, J., Keane, T., Shiromani, P. (eds) Post-Traumatic Stress Disorder. Humana Press. https://doi.org/10.1007/978-1-60327-329-9_13
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