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Immune, Endocrine, and Psychological Responses in Civilians Displaced by War

Ante Sabioncello, PhD, Dubravka Kocijan-Hercigonja, MD, PhD, Sabina Rabati, PhD, Jelka Tomai, PhD, Tatjana Jeren, MD, PhD, Ljubica Matijevi, MD, PhD, Majda Rijavec, PhD and Dragan Dekaris, MD, PhD

From the Institute of Immunology (A.S., S.R., J.T., D.D.); Dubrava University Hospital (D.K.-H., L.M.); Fran Mihaljevi University Hospital for Infectious Diseases (T.J.); and the Educational Department, Liberal Arts College (M.R.), University of Zagreb, Zagreb, Croatia.

Address reprint requests to: Ante Sabioncello, Institute of Immunology, Rockefellerova 10, 10000 Zagreb, Croatia. Email: ante.sabioncello{at}imz.tel.hr

	ABSTRACT

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OBJECTIVES: The objectives of this study were to assess the influence of trauma caused by forced expulsion from home in a war-ravaged region on the psychological, hormonal, and immune responses in displaced persons and to analyze the relationships between psychometric, hormonal, and immunologic variables.

METHODS: Participants were 20 displaced and 14 control women. Psychosomatic response was evaluated using the COR-NEX2 test. Serum concentrations of cortisol, prolactin, endorphin, thyroxine, and triiodothyronine were measured by radioimmunoassay. Immunophenotyping and lymphocyte proliferation were determined by flow cytometry, and phagocyte functions (ie, ingestion and antibody-dependent cytotoxicity) against ⁵¹Cr-labeled sheep red blood cells were assessed through radioactivity uptake and release, respectively.

RESULTS: In comparison with control women, displaced women had higher COR-NEX2 test scores; higher serum cortisol, prolactin, and endorphin levels; an increase in activated phenotype within all three measured cell populations (ie, B, T, and natural killer cells); as well as an enhanced proportion of proliferating lymphocytes in freshly isolated samples. However, the phytohemagglutinin-stimulated proliferative response, estimated as the stimulation index, was lower in displaced women. A complex pattern of relations between psychological, hormonal, and immune responses was observed.

CONCLUSIONS: Chronic psychological stress elicited multiple, predominantly stimulatory influences on immune functions.

Key Words: chronic stress • psychoneuroimmunology • immunophenotyping • immune functions

Abbreviations: ADCC = antibody-dependent cytotoxicity; Ig =immunoglobulin; MDD = major depressive disorder; NK = naturalkiller; PHA = phytohemagglutinin; PTSD = posttraumatic stressdisorder; RIA = radioimmunoassay; SI = stimulation index; T₃ = triiodothyronine; T₄ =thyroxine.

	INTRODUCTION

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Neuroendocrine and immune alterations related to stress have been well documented. Acute psychological or physical stress may cause changes in immune, endocrine, or mental status in humans (1–3). Although there are numerous reports on the psychological and/or endocrinologic consequences of long-term or chronic stress (4–10), the immune response to severe chronic stress has not been investigated in detail (11–14). It is widely believed that stressful experiences suppress immune functions. This paradigm has been based mainly on findings of increased plasma levels of antiviral antibodies (11, 15), diminished proliferative responses to mitogens (1, 11, 13), increased numbers of "suppressor" CD8 lymphocytes (3, 16, 17), and a suppressed delayed-type hypersensitivity response in chronic stress (18).

The wars in Croatia and Bosnia-Herzegovina created the largest refugee crisis in Europe since World War II (19). Civilians in war-affected areas suffered multiple losses of their homes, belongings, and family members. They had to flee their homes and native provinces and find shelter, mostly in hotels, dormitories, or refugee camps situated in areas of Croatia not directly affected by war activities. Although no longer exposed to immediate danger, the refugees lived in improvised accommodations for years, unable to return to their towns or villages and resume their normal ways of life.

The aim of the study reported here was to analyze the immune, hormonal, and psychological status of these multiply traumatized, displaced persons.

	METHODS

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Subjects
Study participants were 20 women displaced from the regions of Hrvatska Kostajnica, Vukovar, Osijek, and Glina (mean age, 29 years; range, 18–39 years). Men were not included because they were mostly left on the front lines, and the displaced population was predominantly female. Because of the consistency of gender and age in the study population, the results, particularly hormonal results, were easier to interpret. The women were physically healthy, without a history of psychiatric disorders, and on no medication. Because they had lived in the refugee settlement in Zagreb for 1 to 2 months before the study, their nutritional and sleeping habits, as well as the rhythm of physical activity, were changed. The study was undertaken at the beginning of the war in Croatia, so all displaced women were subjected to a similar intensity of trauma. Their traumatic experiences included loss of home, uncertainty about the future, separation from family members and friends, loss of psychologically important objects (eg, photographs, letters, and pets), disappointment with neighbors and friends who had become enemies, and life in different cultural and social conditions.

The control group consisted of 14 healthy female volunteers, staff members of our institutions (mean age, 27 years; range, 18–35 years). All were residents of Zagreb and were not directly exposed to major war trauma. At the beginning of the war, they experienced air alerts in the Zagreb region as well as consequent encounters with traumatized friends or refugees.

Participation in the study was voluntary. The purpose and methods of the study were fully explained to study participants. After providing informed consent in writing, each participant was interviewed by a psychiatrist, and blood samples were drawn into heparinized (25 IU/ml) and unheparinized tubes between 8 and 9 AM and used for immunoassays within 1 hour. Sera were stored at -20°C until hormone determination.

Psychosomatic Assessment
The self-reported COR-NEX2 test (20), a modification of the original Cornell Selectee Index (21), was used to evaluate the presence and severity of neuropsychiatric and psychosomatic symptoms in the two groups. Detailed psychometric characteristics of the instrument and its validity for the Croatian population are described elsewhere (10). Briefly, the instrument consists of 101 items structured into 10 separate scales determining depression, anxiety, fear, hypersensitivity, hypochondriasis, and personality, adaptational, psychosomatic, cardiovascular, and gastrointestinal disorders. According to our previous experience with the Croatian population, the original classification criteria for severe response (pooled score of 23) was modified to 27, whereas scores between 27 and 13 indicated moderate response.

Determination of Serum Hormone Concentrations
Serum concentrations of cortisol, prolactin, ß-endorphin, total T₄, and T₃ in all study participants were measured on the same day by RIA. Commercial diagnostic RIA kits for cortisol, T₃, and T₄ were from the Institute of Immunology (Zagreb, Croatia), and those for prolactin and ß-endorphin were from Nichols Institute Diagnostics (San Juan Capistrano, CA). All samples were analyzed in duplicate. The precision (intraassay variance) and reproducibility (interassay variance) of the assays were as follows: cortisol, <10% and <12%, respectively; T₃, <6% and <11%; T₄, <5% and <8%; prolactin, <5% and <10%; and ß-endorphin, <5% and <10%.

Hematologic Testing
A complete white blood cell count was obtained using a Coulter T-660 counter (Coulter Electronics, Inc., Hialeah, FL), and a differential leukocyte count was performed using May-Grünwald-Giemsa–stained smears.

Immunophenotyping of Lymphocytes
Populations of T (CD2), B (CD20), NK (CD56, CD16), helper (CD4), and cytotoxic (CD8) lymphocytes and activated subpopulations of these cells coexpressing either CD25, CD71, HLA-DR, or CD23 were determined by flow cytometry (FACScan, Becton Dickinson, Mountain View, CA) after direct two-color staining of whole blood cells. The following panel of Becton Dickinson monoclonal antibodies and isotype controls, conjugated with fluorescein isothiocyanate or phycoerythrin, were used: LeucoGATE (CD45/CD14), anti-Leu-5b (CD2)/anti-HLA-DR, anti-IL-2R (CD25)/anti-Leu-3a (CD4), anti-Leu-2b (CD8)/anti-Leu-19 (CD56), anti-Leu-16 (CD20)/anti-Leu-20 (CD23), anti-transferrin receptor (CD71)/anti-Leu-11b (CD16), and mouse IgG₁/mouse IgG_2a. The percentage of single and double positively stained cells in the lymphocyte population was determined by using SimulSET software (Becton Dickinson) after the light-scatter lymphocyte gate had been optimized with use of LeucoGATE reagent. The absolute count (cells/liter) of each subpopulation was determined as follows: Percentage of Subpopulation x Percentage of Lymphocytes x Total White Blood Cell Count x 10^-4.

Lymphocyte Proliferation
Lymphocyte proliferation was assessed by cultivating lymphocytes (1 x 10⁶ per tube) in 1 ml of culture medium containing 15% human AB serum and 0, 0.9, 9, or 90 µg/ml PHA (HA-15, Wellcome, Dartford, UK) in triplicate samples at 37°C in 5% CO₂ for 72 hours. Nonstimulated and PHA-stimulated lymphocytes were then washed in 1 ml of citrate buffer, resuspended in 0.5 ml of cold (-20°C) 70% ethanol (added slowly, dropwise, while stirring), and left at -20°C for 10 minutes. After centrifugation (300g for 5 minutes), the pellet was washed in 1 ml of citrate buffer, resuspended in 0.5 ml of solution containing 1 mg/ml sodium citrate dihydrate, 1 µL/ml Nonidet P-40, 500 µg/ml spermine tetrahydroxide, 60 µg/ml Tris-amino-methane, and 1 mg/ml ribonuclease A (all from Sigma Chemical Co., St. Louis, MO), and left for 10 minutes. Then, 0.5 ml of propidium iodide (Sigma) solution (500 µg/ml) was added and left for at least 10 minutes at room temperature in the dark before flow cytometry. DNA content of freshly isolated (before cultivation) and cultivated cells was recorded as red fluorescence (FL2) using linear amplification. SimulSET software was used to determine proliferating cells as a percentage of cells in S + G₂ + M phases of the cycle. Proliferative capacity was expressed as the SI, the ratio of proliferating cells in stimulated and nonstimulated cultures.

Polymorphonuclear Phagocytic Activity
Ingestion and ADCC toward opsonized sheep red blood cells labeled with ⁵¹Cr were measured as previously described (22).

Statistics
The normality and equality of variance assumptions for all variables were evaluated by the Shapiro-Wilks’ W test and Levene’s test, respectively. Results obtained in displaced subjects and control subjects were compared with either the Mann-Whitney U test or the t test for independent samples. The relationship between individual psychosomatic scale scores and other measured variables was assessed by means of the Spearman rank order coefficient. Statistica, version 5.0 (StatSoft, Inc., Tulsa, OK) was used for statistical analyses.

	RESULTS

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Psychometric Response
The distribution of COR-NEX2 test scores of the displaced women was multimodal and scattered all over the score range (Figure 1). The variance in the group of residents was significantly lower with Levene’s test, so nonparametric statistics were used. Displaced women had higher scores than resident women. A severe response (score >27) was found in 6 displaced women; a moderate response (score between 13 and 27), in 9 displaced and 2 resident women; and a negative response, in 12 resident and 5 displaced women. Displaced and resident women’s responses differed on most of the psychometric scales but on none of the somatic scales (Table 1).

View larger version (11K): [in this window] [in a new window]   Fig. 1. Distribution of COR-NEX2 test scores among displaced (D, ) and resident (R, •) women. The dashed line depicts the lower limit of moderate response, and the full line, the lower limit of severe response. Because of unequal variances, the difference between groups was assessed by use of the Mann-Whitney U test.

View larger version (10K): [in this window] [in a new window]   Fig. 2. Proliferative capacity expressed as (a) the percentage of proliferating lymphocytes and (b) the SI in displaced persons () and residents (•) after cultivation for 72 hours in the presence of PHA at the indicated concentrations. The percentage of proliferating lymphocytes ex vivo before cultivation (0 hours) is also presented (displaced persons, ; residents, ). Data are expressed as the median; vertical bars indicate the interquartile range (middle 50% of all data). The difference between groups for each PHA concentration or time point was assessed by use of the Mann-Whitney U test.

Relations Between Psychometric, Hormonal, and Immunologic Variables
The Spearman’s correlation matrix shown in Table 4, with the significance criterion raised to .01 to avoid potential spurious correlations due to multiple comparisons, shows a complex pattern of correlation between lymphocyte subsets on one side and psychosomatic and hormonal variables on the other. T helper (CD4) and activated (CD71) lymphocyte counts were positively correlated with cortisol serum concentration, but none of the T cell subpopulations correlated with any psychosomatic variable. On the contrary, activated B (CD20⁺CD23⁺) lymphocytes and NK (CD16⁺CD71⁺) cell counts were positively correlated with the majority of psychosomatic variables but with none of the hormonal variables tested.

Concerning the psychometric test scores and hormone levels, only the severity of personality symptoms was related to cortisol. Cortisol concentration was also positively correlated with prolactin concentration.

	DISCUSSION

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Our study showed that several psychological, hormonal, and immunologic variables were altered in displaced women in comparison to the group of residents not directly exposed to war trauma.

Despite several limitations of our study (small number of subjects; use of COR-NEX2, a rather obsolete instrument; lack of any measure of sympathetic nervous system activity; lack of truly nontraumatized controls; and inability to use parametric multivariate statistics), it is evident that chronic, war-related stress exhibited multiple effects on the number and function of peripheral blood lymphocyte subsets in displaced women. The selection of control subjects for the study was particularly difficult. Because air alerts were frequent and the front line was only about 30 km from Zagreb, it was almost impossible to find relaxed, undisturbed volunteers. Thus, two of the resident women had a moderate COR-NEX2 test response. This was caused by somatic or psychosomatic disturbances in one (9 points of her total score of 14) and psychological symptoms (13 of total 17 points) in the other. The psychometric differences between displaced and resident women were mostly psychological rather than somatic, as reflected by the scores of the respective rating scales (see Table 1). Therefore, war-related traumatic stress events may be a trigger for the onset of psychological disorders other than PTSD. This is consistent with results of studies by McFarlane and Papay (4) on psychiatric disorders after a natural disaster, Bauer et al. (6) on psychological and endocrine abnormalities in refugees from East Germany, and Weine et al. (9) on psychiatric consequences of ethnic cleansing in Bosnian refugees.

Increased baseline cortisol, prolactin, and ß-endorphin concentrations in displaced women and the positive correlation between cortisol and prolactin indicate elevated hypothalamic-pituitary-adrenal axis activity in chronic stress. The same has been shown for acute stress (2, 3, 23) and MDD (24, 25). Although we did not evaluate MDD in our study, displaced women exhibited depressive and anxiety disturbances (see Table 1). In previous studies, we found decreased cortisol and prolactin concentrations in a group of men immediately after their release from a detention camp (12) and in displaced persons with severe COR-NEX2 test scores compared with those with moderate scores or without psychological symptoms (10). This would suggest a negative relation between these hormones and the severity of psychiatric disorder (10, 26). In this study, a positive relation was found between personality traits and cortisol level. This finding and the absence of a correlation with other psychometric traits was presumably due to the low number of subjects with severe psychometric test scores. Although not examined, the menstrual cycle may have also been disrupted as a consequence of psychological stress, contributing to the increased prolactin level, which can stimulate mitogenesis (27).

The correlation results should be, however, considered with caution. A diverse correlation matrix would probably be obtained if relevant variables of the sympathetic nervous system were included in the study. Also, the multiple regression model with partial correlation would obviously be a more appropriate statistical approach, but assumptions for such an analysis were not met.

The stress- and depression-associated changes in the number of circulating lymphocyte subpopulations and their in vitro functions are well established (1, 13, 14, 16, 17). In general, increased numbers of cytotoxic (CD8) and NK cells, as well as a reduced lymphocyte proliferative response, were characteristic findings in the studies dealing with acute experimental stress (1, 16, 17). An increased number of cytotoxic (CD8) T cells and impaired T cell proliferative capacity have also been reported by Castle et al. (13) in depressed caregivers, although they found a decrease in the NK cell population. Our results on CD8 and NK cells in severe and chronic stress are discordant with those but in agreement with the findings in PTSD (28). Although the number of CD8 lymphocytes was not altered, the relative proportion of these cells was decreased. Contrary to the finding of Castle et al. (13), the number of NK cells was increased, as in the aforementioned studies on acute stress or PTSD. Various patterns of circulating lymphocyte subsets are probably associated with different types of psychological stressors and stress responses, presumably as a consequence of a particular neuroendocrine profile influencing leukocyte trafficking between the peripheral blood and tissues (29). The number of circulating CD4 and activated (CD71) lymphocytes was related to cortisol level, whereas activated B (CD20⁺CD23⁺) and NK (CD16⁺CD71⁺) cells were related to the majority of psychosomatic traits.

Our principal finding was the increase in lymphocyte subsets expressing activation markers (CD71, CD23, and HLA-DR) and in proliferating lymphocytes. It was not surprising, therefore, that activated lymphocyte populations (CD71, CD2⁺DR⁺, and CD4⁺CD25⁺) were correlated with the proliferative response. These findings are most interesting because they oppose the commonly accepted notion that chronic stress suppresses immune functions (11, 13, 18). By using propidium iodide, which intercalates into double-stranded nucleic acids as a marker of cell DNA content, we were able to assess proliferative capacity, ex vivo, of freshly isolated, uncultivated, cells. A remarkably higher percentage of proliferating cells in the peripheral blood of subjects under stress dictated that a higher baseline value be used as a denominator for calculation of the SI. Consequently, the "reduced" proliferative response (SI) to mitogens found in this study might be, in fact, a calculational fallacy rather than a reflection of true biologic activity. The increased ex vivo proliferation reported here is in agreement with the findings of enhanced cell-mediated immunity assessed as a skin response in PTSD patients (31) and in an experimental animal model of acute stress (31). Immune activation could be the consequence of antigenic challenge due to environmental conditions (dormitory living). Because the displaced women included in the study were healthy, without apparent infection, their immune system was not only activated but also operative. The antigen itself is not sufficient to induce immune response, because costimulatory signals decide between activation and anergy. Immune response is modulated by positive and negative signaling from neuroendocrine (and other bodily) tissues induced by distress (31). From our results, we can hypothesize that the trauma-induced strain on the immune system during the 2-month period after expulsion from home was not strong enough to cause suppressive effects.

	ACKNOWLEDGMENTS

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This research was supported in part by Research Grant 021001 from the Ministry of Science and Technology of the Republic of Croatia. We thank Professor Ana Marui for critical reading and stylistic improvement of the manuscript.

Received for publication November 24, 1998.

Revision received November 11, 1999.

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