Horm Mol Biol Clin Invest 2012;10(3):301–314 © 2012 by Walter de Gruyter • Berlin • Boston. DOI 10.1515/hmbci-2011-0135
Balancing steroidal hormone cascade in treatment-resistant veteran soldiers with PTSD using a fermented soy product (FSWW08): a pilot study
Anca G. Gocan1, Doris Bachg2, Adolf E. Schindler3 and Uwe D. Rohr1,* 1
The Vienna Stress Relief Clinic, Vienna, Austria BIOFOCUS, Berghäuser Strasse 295, 45659 Recklinghausen, Germany 3 Institute for Medical Research and Education, Hufelandstrasse 55, 45122 Essen, Germany 2
Abstract Introduction: A clinical study was conducted to determine steroidal hormone cascade in the blood to relate them to mental performance with the Clinician-Administered PTSD scale (CAPS), serum lipid concentrations, and steroidal hormones, particularly cortisol, testosterone, estradiol, dehydroepiandrosterone (DHEA), and pregnenolone, in treatment-resistant male veterans with combat-related chronic posttraumatic stress disorder (PTSD) before and after consumption of a special fermented soy formulation (FSWW08). Admitted veterans in the study were resistant to conventional psychological and pharmacological therapies. Method: Ten treatment-resistant soldiers with combatrelated PTSD (according to the International Classification of Diseases, 10th Revision code) for ≤ 1.5 years were enrolled in this study. A specially formulated fermented soy product, FSWW08, was given to the veterans for 3 months and then extended to 6 months. CAPS was used to assess the severity of PTSD. Immunologic cytokines, triglycerides, and 16 steroidal hormones were also determined from the blood of the PTSD patients before, during, and after consumption of the FSWW08. Results: FSWW08 increased blood levels of steroids, such as testosterone, estradiol, and particularly the adrenal hormones cortisol and androstenediol. Decreased steroidal hormones from the upper part of the hormone cascade, such as cholesterol, DHEA, and pregnenolone were experienced. The arteriosclerotic risk was reduced (cholesterol, 280 ± 35 to 205 ± 22 mmol/L, p < 0.001; triglycerides, 645 ± 267 to 161 ± 22 mg/dL, p < 0.001; very-low-density lipoprotein cholesterol, 312 ± 112 to 151 ± 20 mg/dL, p < 0.001; homocysteine in serum (i.s.), 26 ± 4 to 11.8 ± 2.1 μmol/L, p < 0.001). High-density lipoprotein cholesterol concentration was significantly lower after
*Corresponding author: Uwe D. Rohr, MD, PhD, Spiegelgasse 2a, A-1120 Vienna, Austria E-mail: [email protected] Received November 21, 2011; accepted April 19, 2012
consumption of FSWW08 (51 ± 15 to 89 ± 7.8 mg/dL, p < 0.001). FSWW08 significantly reduced mental symptoms according to CAPS after 7 days throughout the 6-month study. Insomnia (estradiol increased from 53 ± 24 to 88 ± 41 pg/L), breathing disorders (may be related to increased aldosterone) are hormone dependent and were corrected in those with insomnia. The increase in testosterone and decrease in prolactin was corroborated by an increase in sex drive and improved partner relationships. Common immunity disorders of the veterans, such as increased herpes labialis, flu-like syndromes, and stomach pain were resolved in all veterans and was corroborated by significant improvements in immunologic cytokines: tumor necrosis factor α was reduced (from 13.5 ± 0.4 to 9.0 ± 1.4 pg/mL, p < 0.001) and interleukin β (from 7.0 ± 0.5 to 4.5 ± 1.8 pg/mL) and interferon γ (from 10.4 ± 2.4 to 6.3 ± 1.5 pg/mL, p < 0.001) were also detected. PTSD is associated with clinically elevated leukocytes and lymphocytes, which are reduced by FSWW08 as well. Conclusion: It is the first time that the normalization of the whole steroidal hormone cascade in the blood could be correlated with improvements in mental and physical parameters (especially metabolic and immunologic disorders) in veterans with combat-related and treatment-resistant PTSD. Studies of FSWW08 in larger cohorts and over longer periods of time, as well as dosing effects, have to be conducted to validate these results. Keywords: anxiety; Clinician-Administered PTSD scale; cortisol; dehydroepiandrosterone (DHEA); dehydroepiandrosterone sulfate (DHEA-S); post-traumatic stress disorder (PTSD); serotonin; soldiers; stress; testosterone.
Introduction Stress-related changes in the endocrine and immune systems are key mediators involved in the development of diseases associated with posttraumatic stress disorder (PTSD) [1]. PTSD is a chronic anxiety disorder that occurs after a traumatic event [2, 3] (Figure 1). The objective of this study was to assess the influence of a fermented soy product (FSWW08) on mental and endocrine marker of male veteran soldiers who developed a treatment-resistant mental trauma after returning home after witnessing a life-threatening situation from warravaged regions in Afghanistan as part of the International Security Assistance Force (ISAF), which was established by the UN Security Council at the end of December 2001 to secure Kabul and the surrounding areas. We analyzed the relationship among psychometric, hormonal, and immunologic
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Trauma
0
~1 3 Month Months
6 Months
20 Years
40 Years
Acute stress disorder Acute PTSD Chronic PTSD Delayed-onset PTSD
Figure 1 Time course and PTSD subtypes. Taken from Ref. Zohar et al. [38].
variables in veteran soldiers with PTSD before and after consumption of FSWW08. PTSD is characterized by a comorbidity of biological alterations of the hypothalamic-pituitary-adrenal (HPA) axis and the immune system, such as increased metabolic disease, causing heart failure and diabetes, and immune alterations, increasing viral infections and inflammation. There is a bidirectional dependency between the HPA axis and immune system [4–6] – communications in a complex feedback system that can be disrupted after a traumatic event, resulting in increased risks to physical and psychological well-being [7–9]. In a healthy individual, there is a balance between the production of inflammatory/cell-mediated (Th1) and humoral (Th2) cytokines [6–9], which is always altered in inflammatory diseases or in mental disease, which is disturbed in PTSD. The immune system affects steroidal hormone balance function in an effort to protect the individual, for example, simultaneously increasing the stress hormones dehydroepiandrosterone (DHEA) and pregnenolone and decreasing cortisol [10–12]. Improved understanding of relations among steroidal hormones, the HPA axis, and immune system in PTSD participants is essential because disruptions may be related to increased morbidity and mortality in PTSD participants. Chronic inflammation has been shown to exert adverse effects on many body systems and may contribute to chronic
pain, arthritis, diabetes, and cardiovascular disease [13–16], all of which have been associated with PTSD [17–19]. A specially fermented soy formulation, FSWW08, has shown tremendous capabilities to reduce stress and improve immunity in patients with cancer [20–23] and hepatitis B, reducing viral infections and liver inflammation even more compared with standard antiviral therapy. FSWW08 caused a strong improvement in immune parameters in these immunologically compromised patients, reducing particularly inflammatory cytokines and improving gene expressions related to immunity [21, 23, 24]. A complete discussion about FSWW08’s immunity-modifying effect surpasses this publication, but it is believed that increase of androstenes (Figure 2) is a key component in the mechanism of action and are increased by FSWW08: the reader is strongly encouraged to get familiar with the work of Loria [25], who showed that androstenes surpass the immunity of cortisones because, aside from their capability to reduce inflammation, they also have strong antiviral effects (Figure 3). Recent publications by experts in the field of mental diseases support that PTSD has a strong immunity-improving component, which served as the basis in the application of FSWW08 in a pilot trial in these patients, because it is now accepted that PTSD is strongly related to disturbances in immunity [1]. To elucidate the mechanism of action, we decided to test the hormonal parameter in this study. Androstenes are adrenal hormones that are part of the HPA axis. Isoflavones are a compound of soy and particularly of FSWW08 (Figure 2). Isoflavones and androstenes are structurally similar and are also estrogen receptor (ER) β-agonist (Figure 2). To start a pilot trial in veteran soldiers with PTSD, it is important that extensive medical records on the study participants existed before their service in Afghanistan. It was established that no mental or physical problem existed before their deployment to Afghanistan and that any comorbidity of severe mental or physical diseases, including brain injury, could be excluded as a result of their experiences after returning from service in Afghanistan. The enlisted cohort was very homogenous with respect to age, sex, weight, before and after returning home from service. Depression, in particular, develops frequently as a comorbidity with time in PTSD patients or may have existed before a traumatic event and is linked
Anti-stress, anti-inflammatory and increase of immunity Human steroids
Plant derived OH
OH
O
H H
OH
H
HO
HO
HO
O
H Androstenediol
Androstanediol
Daidzein
5-Androstene-3β,17β-diol
5-Androstane-3β,17β-diol
4′,7-Dihydroxyisoflavone
Figure 2 Structural formulas of androstenes (ADIOLS) and soy isoflavones. Androstenediol is metabolized from DHEA, whereas androstanediol is metabolized from testosterone. Daidzein is one of the two major isoflavones in soy.
Gocan et al.: Balancing steroidal hormone cascade though FSWW08 in PTSD
“ADIOLs” or “Androstenes” control immunity: inflammation and infection Antiviral Antibacterial
Th2
Androstenediol Androstanediol Anti-inflammatory
Th1
Figure 3 Accordingly to Loria [25], androstenediol (metabolite of DHEA) and androstanediol (metabolite of dehydrotestosterone) regulate cellular anti-infective (antiviral and antibacterial) and antiinflammatory response in contrast to cortisones, which only regulate inflammation. Reproduced from Ref. Zohar et al. [38]. New findings support a dominant role on nerve cell immunity.
to an increase of cortisol, whereas PTSD is characterized by a decrease in cortisol [10–12, 26]. All enlisted soldiers experienced a delayed onset of PTSD (Figure 1), where the traumatic incident occurred 6 months to a year before the diagnosis of the first PTSD symptoms but where depression had not developed. All enlisted soldiers were resistant to previous pharmacotherapy (selective serotonin reuptake inhibitors, or SSRIs) or psychological treatment attempts. At the time of enlistment in the study, all soldiers were released from active military service and were not capable of performing regular job employment duties outside the military. They continued to receive military pay and medical help from the military in a certified clinical center. The planned study period was 3 months; however, it was extended to 6 months. The limitations of this study are (1) the number of enlisted veteran soldiers are too few to make any general health claims and (2) a placebo group was not included because the soldiers simply refused to receive any placebo. FSWW08 had a more pronounced beneficial effect on the hormonal parameter of patients with PTSD than antipsychotic medications had on similar hormones in schizophrenia, particularly decreasing DHEA, pregnenolone, triglycerides, prolactin, and Th1 cytokine, and simultaneously increasing estradiol, testosterone, and cortisol. A normalization of the hormone cascade was accompanied by a reduction of PTSD symptoms, which was documented using the ClinicianAdministered PTSD Scale (CAPS) [27–29].
Methods Characteristics of the veterans with PTSD participating in the study
303
To be enlisted in this study, a major inclusion criterion was that the participant himself experienced a life-threatening combat-related event of his own or another person before the disease in addition to being in the military as well as having served in Afghanistan as part of ISAF. In addition, another inclusion criterion is that a soldier should be experiencing PTSD and no other mental disease. The mean age was 34 years (range, 28–43 years). A major requirement was that participating soldiers returned from military service in Afghanistan < 1.5 years before enrollment in the study. In most veterans, PTSD developed within half a year after the traumatic event. The main exclusion criterion was that patients did not experience physical injury to the brain or body during service or after developing signs of PTSD. Also, to participate in the study, no additional severe physical life-threatening diseases were allowed other than those experienced in the military service. All soldiers showed signs of developing metabolic disease: diabetes and hypertension. This was judged as a comorbidity of PTSD. Subjects were required to taper and abstain from all psychotropic medication during their study participation except for the given FSWW08 study medication. Substance abuse in PTSD patients involves nicotine and alcohol in general and was reported by all participating soldiers. Urine drug testing for cocaine, marijuana, amphetamines, opiates, and benzodiazepines was performed during initial screening and after a 3-month experimental session. All screens were negative. A main inclusion criterion was that all soldiers were able to follow instructions given by the study physician. Each soldier received a complete full medical examination before enrollment in the study. This included examination of the head, throat, and skin, testing of nerve reflexes, and palpation of the skin, lymphatic system, and bones. Mental disease within the family was not specifically checked but there appears to be no predisposition in any of the soldiers. PTSD was categorized by CAPS [27–29]. The average CAPS was 80.1 (range, 61–92). All patients signed a document that they participated in the study with informed consent. This included notification that they received, before signing the document, information that the fermented soy was not approved for this indication and its use was purely experimental and no health claim had been issued for PTSD. A Local Ethics Committee, including the head of the local military hospital, approved the study in written form. Investigators and the legal representative of the hospital signed that the Declaration of Helsinki in its current form was applicable and was followed. More importantly, all soldiers were informed that they could leave the trial at any time without having to provide a reason. All information was to be written in a way that each soldier ’s anonymity was ensured. Blood samples for further processing were shipped to Dr. Doris Bachg (BIOFOCUS, Recklinghausen, Germany). Handling, air shipment, and storage were performed according to a procedure developed by BIOFOCUS. The study site was at the Department of Neurology, Military Hospital, Victor Babes¸ University of Medicine and Pharmacy Timis¸oara, Timis¸oara, Romania.
Study medication An army physician examined and diagnosed all the veterans participating in the study using the International Classification of Diseases, 10th Revision code, which resulted in all study participants falling into the category defining PTSD. PTSD was always combat-related. Before our study, all soldiers were treated with SSRIs, psychotherapy, and failed any drug treatment administered and were considered as treatment-resistant.
Study medication (FSWW08) was received from Healan Research Foundation (Woodinville, Washington State, USA). Shipping, storage, and handling protocol were performed according to a procedure developed by Haelan Research Foundation. The study medication was approved and categorized as food for special medical needs by the European Union and as medical food by the FDA in the USA.
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Design
Results
After enrollment, subjects received fermented soy medication. It was initially planned to enlist 10 patients. Although not in agreement with our study plan, the participating soldiers suggested the addition of another soldier, making a total of 11 participants. One soldier, however, did not follow the instructions of the study physician after he was enlisted in the study and was excluded after enlisting, thus again making a total of 10 participants. At study day 1, all soldiers received a box of study medication, which was delivered to his home. Each soldier consumed 120 mL FSWW08 (half a bottle) daily for 90 days. Every month, all soldiers were called by telephone to ask for response and verbal medical checking. None of the soldiers received any additional psychotherapy or pharmacotherapy medicines. After a period of 3 months, the participating soldiers were asked to return to the hospital to receive a full medical examination. Blood analysis and mental checkup were performed.
After 1 year of consuming FSWW08, 6 of the 10 enlisted treatment-resistant soldiers with PTSD had left the military and were working for the first time in a regular paid job outside the military since diagnosed with PTSD. The other four were still in the military, but they were considered as disease free, based on their CAPS testing, and their blood markers were judged as mentally and physically healthy (Tables 1–7 and Figure 4). Additional social and psychological treatment appeared to be necessary but was outside the scope of the trial. All participating soldiers showed considerable improvement in well-being and reduction of anxiety and stress after 7 days of consumption of the fermented soy FSWW08 (Figure 4 and Table 1). We did not see any side effects, but one patient did not like the taste and he applied the FSWW08 solution rectally, whereas others took it orally. Mental well-being was not the only improvement recorded – the appearance of the veterans improved with proper clothing and their personal hygiene improved as well. The veterans lost their general hostility and became cooperative. They also reported an interest in developing normal relationships with their social environment. Although lung function test was initially planned, this had to be excluded because of high stress levels. The untreated veterans experienced feelings of suffocation. Most veterans were experiencing flu-like symptoms before receiving medication, but improvements in breathing were noted in all veterans after the study.
Statistical analysis Statistical analyses of clinical parameters were performed using SPSS 12.0.1 (SPSS, Chicago, IL, USA). Paired sample t-tests were used to detect differences, if any, to determine whether treatment was effective in reducing PTSD.
Analysis of sexual hormones in the plasma Routine somatic screening was performed on the PTSD patients and on the healthy comparison group. Samples for hormones were taken by venipuncture between 08:00 and 10:00 h after an overnight fast. Blood was collected in heparinized tubes. Commercial kits were used for the analysis of the hormones. Inter- and intracoefficients of variation were below 10%. Cortisol was assessed between 08:00 and 10:00 h and at 14:00 h with chemiluminescence immunoassay (DPC, Amsterdam, The Netherlands). Prolactin, free T4, and TSH were assessed with fluorescence immunoassay (Perkin Elmer, Frankfurt, Germany). DHEA and dehydroepiandrosterone sulfate (DHEA-S) were assessed with radioimmunoassay (DPC). Testosterone was determined with a radioimmunoassay kit (Radioassay Systems, Carson, CA, USA). Androstenediol was determined with an ELISA kit from Uscn Life Science (Wuhan, China). Pregnenolone was determined by an ELISA kit from BioVendor Laboratory Medicine (Candler, NC, USA). 17OH-pregnenolone was determined with radioimmunoassay and a kit from GenWay (San Diego, CA, USA). Progesterone was determined by a kit from PerkinElmer Life Sciences (Zaventem, Belgium). Estradiol was determined with a radioimmunoassay kit from PerkinElmer Life Sciences. Estrone was determined with radioimmunoassay from Hölzel Diagnostika GmbH (Cologne, Germany). Dihydrotestosterone and serotonin were determined with an ELISA kit from IBL International (Hamburg, Germany).
Clinical response
Clinical response is defined as > 30% reduction from baseline in the CAPS total severity score [27–29]. The clinical response was 100% after 3 months (Figure 4). A drop in CAPS from 81 ± 12 to 21 ± 8 after 3 months and to 16 ± 5 after 6 months was detected. All soldiers continued to consume the medication for 6 months (Figure 4), although the trial officially ended after 3 months. Of 10 soldiers, 6 returned to regular jobs outside the military after 1 month. Four soldiers did not return to work outside the military, although they were judged as mentally and physically healthy. Additional social and psychological treatment appeared to be necessary but was outside the scope of the trial. 100 80 60 40
Analysis of cytokines Human tumor necrosis factor (TNF-α) was determined in the blood through ELISA, using kit supplied by RayBiotech (Norcross, GA, USA). The interleukin 6 (IL-6) ELISA used here is a solid-phase immunoassay readily applicable to measure IL-6 levels in serum from ANOGEN (Mississauga, Ontario, Canada). IL-1β was determined using an ELISA kit from BD Biosciences (Schwechat, Austria).
20
*
*
*
*
0 Baseline Month 3 Month 4 Month 5 Month 6
Figure 4 CAPS mean scores and SD in veteran soldiers with combat-related PTSD. y-Axis denotes average CAPS scores. *Statistically significantly different from initial value compared with baseline values (p < 0.01 level of significance).
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Table 1 Mental and clinical symptoms related to PTSD before and after consumption of FSWW08: Number of spontaneously reported discomfort during the last 7 days of interview.
Anxiety Decreased concentration Derealization, detachment Diarrhea Dizziness/drowsiness Fatigue General infection
Headache Insomnia Loss of appetite Nausea Panic Upper gastrointestinal burning Upper respiratory infection
Day 0
After 3 months
After 6 months
10/11 8/11 7/11 2/11 3/11 9/11 9/11 Total 7/11 Flu-like symptoms 6/11 Herpes labialis 5/11 10/11 11/11 3/11 1/11 6/11
0/10 1/10 0/10 1/10 1/10 0/10 0/10 Total 0/10 Flu-like symptoms 1/10 Herpes labialis 1/10 1/11 0/10 1/10 0/10 0/10
0/10
0/10 Total 0/10 Flu-like symptoms 0/10 Herpes labialis 0/10 1/11 0/10 1/10 0/10 0/10
0/10
0/10
3/11
Side effects
Soldiers did not report any side effects. There were no compliance problems, and the only complaint was the taste of the fermented soy being unpleasant to 3 soldiers. One soldiers changed from oral intake to rectal administration. This was possible because the fermented soy was applied in a liquid form. PTSD-accompanying symptoms
As summarized in Table 1, all of the participants experienced a reduction of the typical symptoms accompanying PTSD, particularly sleeping disorder, fatigue, headaches, loss of appetite, respiratory problems, and gastrointestinal inflammation. Many soldiers in the study initially experience flulike symptoms, herpes labialis, and skin infections (not listed here), all of which were not only reduced but also completely eliminated (Table 1). Improvements were reported within 7
0/10 1/10
days and lasted throughout the 6-month study. Improvement of sleeping disorders was reported in all veterans, except one (Table 1). Blood lipids
Patients with PTSD are known to be in danger of developing severe metabolic diseases and high triglyceride levels [30, 31]. We detected substantial improvement in blood lipids to normal values after consuming FSWW08 (Table 2). Blood lipids were improved, for example, high-density lipoprotein cholesterol decreased from 51 ± 15 to 89 ± 7.8 mg/dL and homocysteine decreased from 26 ± 4 to 11.8 ± 2.1 μmol/L (Table 2). Rather impressive improvements of triglycerides were detected after consuming FSWW08 (from 645 ± 267 to 161 ± 22 mg/dL) (Figure 5 and Table 2). The improvement in blood lipids was accompanied by an increase in body weight from 78.1 ± 4.2 kg before enlistment to 82.2 ± 5.1 kg after 3 months’ consumption of the fermented soy product.
Table 2 Plasma markers for metabolic disease in PTSD patients before and after 3 months’ consumption of fermented soy product. Blood lipids
Baseline (n = 10)
After 3 months’ consumption of fermented soy (n = 10)
Normal range
Treatment effect, p-Value
Cholesterol, mmol/L
280 ± 35 190 –320 645 ± 267 134 –959 51 ± 15 312 ± 112 189 – 410 0.25 ± 0.1 < 0.15 – 0.5 26 ± 4 21–29
205 ± 22 165 –220 161 ± 22 127–181 89 ± 7.8 151 ± 20 121–183 0.24 ± 0.1 < 0.15 – 0.5 11.8 ± 2.1 7–13
< 200
< 0.01
< 150
< 0.001
40 – 60 < 155
< 0.01 < 0.001
< 0.5
No change
5.5 –17
< 0.01
Triglycerides, mg/dL High-density lipoprotein cholesterol, mg/dL Low-density lipoprotein cholesterol, mg/dL C-reactive protein, mg/dL Homocysteine in serum (i.s.) (HPLC), μmol/L
Values are mean ± SD and range. Statistical significance was investigated with F-test to test for normality and t-test.
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Cholesterol
Triglycerides 1000
300 mg/dL
mg/dL
400
200 100
500
0 1
2 3
0 5
6
7
8
1 9 10
2
3
4
5
6
7
8
9 10
Homocysteine
μmol/L
30 20 10 0 1
2
3
4
5
6
7
8
9
Figure 5 Selected individual blood lipid markers of veterans with combat-related PTSD untreated and after 3 months’ consumption of fermented soy (FSWW08). Black bars, before fermented soy consumption FSWW08; gray bars, after 3 months’ soy consumption.
Marker of thyroid gland activity
The changes caused by soy products in activity of the thyroid gland are under investigation [32]. However, we could not detect any change in the markers for the thyroid gland (Table 3). Either the numbers of participants were too small or the effects were too minimal and therefore difficult to detect. Steroidal hormone biosynthesis
Cortisol decreases with stress and PTSD. After consumption of FSWW08, cortisol increased in plasma more than 2-fold, from below the accepted normal range (4.8 ± 2.1 μg/dL) at 8 AM to a normal range (10.8 μg/dL) (Table 4), indicating a reduction in stress, which was also clinically confirmed in questionnaires and by the treating physician. Figure 6 schematically depicts the biosynthesis of steroidal hormones commonly derived from cholesterol. A series of hormones, listed in Table 4, were determined in the blood. As can be seen in Figure 6, hormones above the black line were elevated and below that line decreased (Table 4 and Figures 7–9). Hormone levels of aldosterone in the blood, however, were not determined in all patients and therefore Table 3
not listed in Table 4 (but a decrease was noted in patients tested after consumption of fermented soy). As shown in Figure 4, the drop in DHEA-S is at the lower end of the defined normal range. In untreated veterans with PTSD, testosterone was initially found to be below the normal range (2.1 ± 0.4 ng/L) but increased 2-fold (similar to cortisol) to normal range (4.1 ± 1.7 ng/L) after consumption of fermented soy (Table 4 and Figure 9). Precursors of testosterone were increased, and metabolites, such as estradiol and estrone increased from “below normal” to “normal” values (Table 5). Metabolites of DHEA and testosterone, such as androstenediol and androstanediol, can modify cytokines and improve immunity (Figure 3). Our investigation suggests that DHEA decreased, whereas androstendiol increased, which up-regulates immunity: Loria [25] expressed that androstenediol has a 100-fold higher antiviral activity than DHEA, which may explain the strong antiviral activity of FSWW08. Adrenal hormones
Although DHEA-S and DHEA were decreased after consumption of FSWW08, we detected a significant increase of the adrenal metabolite androstenediol after consumption by
Influence of consumption of 3 months’ consumption of fermented soy product thyroid hormones in PTSD patients.
Hormone, units
Baseline (n = 10)
After 3 months’ consumption of fermented soy (n = 10)
Normal range
Statistically significant change
Free triiodothyronine i.s., pg/mL
2.92 ± 1.7 1.5 – 4.2 1.6 ± 1.2 1.1–2.2 2.0 ± 1.2 1.0 –3.1
3.1 ± 0.9 1.4 – 4.0 1.5 ± 0.5 0.9 –2.1 2.0 ± 1.0 1.1–2.8
2.3 – 4.2
No change
0.89 –1.76
No change
0.4 – 4.0
No change
Free thyroxine i.s. (T4), ng/dL TSH (basal), mU/L
Values are mean ± SD and range. Statistical significance was investigated with F-test to test for normality and t-test on the 0.05 level of significance.
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Table 4 Plasma values of hormones in PTSD patients before and after 3 months’ consumption of fermented soy. Hormone
Baseline (n = 10)
After 3 months’ consumption of fermented soy (n = 10)
Normal range
Statistically significant treatment effect, p < 0.01
Cholesterol, mmol/L
280 ± 35 190 –320 4.8 ± 0.7 2.5 – 6.1 163 ± 61 125 –200 3.8 ± 1.1 2.8 –5.1 2120 ± 752 1550 –2912 15.8 ± 3.1 12.5 –19.0 1.1 ± 0.4 0.6 –2.1 2.1 ± 0.4 1.8 –3.5 53 ± 24 27– 87 41 ± 19 8 – 67 0.41 ± 0.2 0.18 – 0.51
210 ± 22 170 –220 3.2 ± 0.5 2.5 –3.9 95 ± 30 61–130 1.5 ± 0.6 1.1–2.1 1098 ± 336 550 –1415 7.1 ± 2.1 4.9 – 8.1 3.4 ± 1.2 1.2 – 4.8 4.1 ± 1.7 3.2 – 6.5 88 ± 41 45 –121 61 ± 31 39 – 82 1.2 ± 0.3 0.77–1.5
< 200
< 0.01
0.38 –3.5
< 0.01
30 –350
< 0.001
< 1.2
< 0.01
800 –5600
< 0.001
6.24 – 43.3
< 0.001
1.78 –7.24
< 0.001
1.81–7.72
< 0.001
< 198
< 0.001
37–370
< 0.001
0.39 –1.76
< 0.001
4.8 ± 2.1 3.1–7.8 1.7 ± 0.6 1.1–3.1
10.8 7.8 –15.9 3.5 ± 0.5 2.9 –7.1
5.0 –25.0
< 0.001
2.0 –12.0
< 0.001
Pregnenolone, ng/mL 17OH-pregnenolone, ng/100 mL Progesterone, nmol/L DHEA-S, ng/mL DHEA, nmol/L Androstenediol, nmol/L Testosterone i.s. age 20 – 40 years, ng/mL Estradiol, pg/L Estrone, pg/L Dihydrotestosterone, nmol/L Cortisol, μg/dL 8:00 AM 2:00 PM
Values are mean ± SD and range. Statistical significance was investigated with F-test to test for normality and t-test.
veterans with PTSD. As androstenediol is 100 times more potent to modulate immunity than DHEA (Figure 3), its increase may be clinically related to improvement in Th1/Th2 cytokines balance [25].
Other hormones related to well-being
The serotonin levels of untreated soldiers with PTSD were in the normal range (Table 5) and did not change after
Cholesterol
Anxiety Water-Retention, Edema
down UP
Stress 17OH-Pregnenolone
Pregnenolone
Progesterone DHEA
ANDROSTENEDIOL
Corticosterone Aldosterone
17OH-Progesterone
Cortisol
ANDROSTENEDIOL
Estrone
TESTOSTERONE
Estradiol
Dihydro-testosterone ANDROSTENETRIOL
Androstanediol Immunity
Figure 6 Treatment-resistant veterans with combat-related PTSD show increased steroidal hormones at the upper part of hormone synthesis, whereas hormones at the lower part are decreased, such as cortisol and particularly androstenes (androstenediol and androstanediol), which are extremely anti-inflammatory and anti-infective, particularly antiviral.
Gocan et al.: Balancing steroidal hormone cascade though FSWW08 in PTSD
Mean±SEM 3000
2500
2500
2000
2000 ng/mL
ng/mL
Individual values 3000
1500
Normal range
308
1500
1000
1000
500
500
0
0 1
2
3
4
5
6
7
8
9 10
Figure 7 Individual plasma values of DHEA-S, mean, and SEM in veterans with combat-related PTSD before and after consumption of FSWW08, compared with normal range. Black lines, untreated; gray lines, after 3 months’ consumption of fermented soy.
consumption of fermented soy. This supports the clinical observation that participating veterans did not show signs of depression or treatments response with SSRIs. A statistically significant drop in prolactin levels was detected, from 14.5 ± 2.9 to 10.7 ± 2.1 ng/mL (Table 5). Correlating to the increase of testosterone and estradiol, a significant decrease to normal range of luteinizing hormone (LH) was detected, from 11.1 ± 4.7 to 5.1 ± 4.1 mU/mL. The decrease in LH correlates with the increase in testosterone and estradiol.
Cytokines
Cytokine are often related to PTSD. They were determined in plasma before and after consumption of fermented soy (Table 6). The consumption of FSWW08 statistically significantly decreased TNF-α, IL-1β, and IFN-γ but did not change IL-6 (Table 7). As the IL-6 increase is mostly related to depression, this is another support that veterans were not experiencing depression. Mean±SEM
Individual 250
200
150
Untreated
100
Fermented soy after 3 months
ng/100 mL
200 ng/100 mL
Normal range
250
150 100
50
50
0
0
Figure 8 Individual plasma values of 17OH-pregnenolone, mean, and SEM in NATO-ISAF soldiers with PTSD before and after treatment compared with normal range. Black lines, untreated; gray lines, after 3 months’ consumption of fermented soy.
6
6
5
5
4 Untreated After 3 months
3
ng/mL
ng/mL
7
4 3
2
2
1
1
0
Normal range
Mean±SEM
Individual 7
0 1
2
3
4
5
6
7
8
9 10
Figure 9 Individual plasma values of testosterone, mean, and SEM in veterans with combat-related PTSD before and after treatment compared with normal range. Black lines, untreated; gray lines, after 3 months’ consumption of fermented soy.
Gocan et al.: Balancing steroidal hormone cascade though FSWW08 in PTSD
Table 5
309
Plasma hormones related to mental disorders in PTSD patients before and after 3 months’ consumption of fermented soy product.
Hormone
Baseline (n = 10)
After 3 months’ consumption of fermented soy (n = 10)
Normal range
Statistically significant treatment, p-Value
Serotonin, μg/L
103 ± 22 53 –123 14.5 ± 2.9 8.3 –18.7 11.1 ± 4.7 3.4 –16.2
95 ± 35 77–133 10.7 ± 2.1 6.7–13.5 5.1 ± 4.1 2.1–9.4
40 –200
No change
2.5 –17.0
0.01
0.8 –7.6
0.01
Prolactin i.s., ng/mL LH, mU/mL
Values are mean ± SD and range. Statistical significance was investigated with F-test to test for normality and t-test. Table 6 Plasma cytokines markers related to general immunity, cachexia, depression, and severe mental disturbances measured in PTSD patients before and after 3 months’ consumption of fermented soy product. Cytokine
Untreated (n = 10)
After 3 months’ consumption of fermented soy (n = 10)
Recommended range
Related to physiological effects
TNF-α, pg/mL IL-1β, pg/mL IL-6, pg/mL IFN-γ, pg/mL
13.5 ± 0.4 7.0 ± 0.5 2.3 ± 0.3 10.4 ± 2.4
9.0 ± 1.4 4.5 ± 1.8 2.2 ± 0.5 6.3 ± 1.5
< 9.5
Balancing steroidal hormone cascade in treatment-resistant veteran soldiers with PTSD using a fermented soy product (FSWW08): a pilot study
Anca G. Gocan1, Doris Bachg2, Adolf E. Schindler3 and Uwe D. Rohr1,* 1
The Vienna Stress Relief Clinic, Vienna, Austria BIOFOCUS, Berghäuser Strasse 295, 45659 Recklinghausen, Germany 3 Institute for Medical Research and Education, Hufelandstrasse 55, 45122 Essen, Germany 2
Abstract Introduction: A clinical study was conducted to determine steroidal hormone cascade in the blood to relate them to mental performance with the Clinician-Administered PTSD scale (CAPS), serum lipid concentrations, and steroidal hormones, particularly cortisol, testosterone, estradiol, dehydroepiandrosterone (DHEA), and pregnenolone, in treatment-resistant male veterans with combat-related chronic posttraumatic stress disorder (PTSD) before and after consumption of a special fermented soy formulation (FSWW08). Admitted veterans in the study were resistant to conventional psychological and pharmacological therapies. Method: Ten treatment-resistant soldiers with combatrelated PTSD (according to the International Classification of Diseases, 10th Revision code) for ≤ 1.5 years were enrolled in this study. A specially formulated fermented soy product, FSWW08, was given to the veterans for 3 months and then extended to 6 months. CAPS was used to assess the severity of PTSD. Immunologic cytokines, triglycerides, and 16 steroidal hormones were also determined from the blood of the PTSD patients before, during, and after consumption of the FSWW08. Results: FSWW08 increased blood levels of steroids, such as testosterone, estradiol, and particularly the adrenal hormones cortisol and androstenediol. Decreased steroidal hormones from the upper part of the hormone cascade, such as cholesterol, DHEA, and pregnenolone were experienced. The arteriosclerotic risk was reduced (cholesterol, 280 ± 35 to 205 ± 22 mmol/L, p < 0.001; triglycerides, 645 ± 267 to 161 ± 22 mg/dL, p < 0.001; very-low-density lipoprotein cholesterol, 312 ± 112 to 151 ± 20 mg/dL, p < 0.001; homocysteine in serum (i.s.), 26 ± 4 to 11.8 ± 2.1 μmol/L, p < 0.001). High-density lipoprotein cholesterol concentration was significantly lower after
*Corresponding author: Uwe D. Rohr, MD, PhD, Spiegelgasse 2a, A-1120 Vienna, Austria E-mail: [email protected] Received November 21, 2011; accepted April 19, 2012
consumption of FSWW08 (51 ± 15 to 89 ± 7.8 mg/dL, p < 0.001). FSWW08 significantly reduced mental symptoms according to CAPS after 7 days throughout the 6-month study. Insomnia (estradiol increased from 53 ± 24 to 88 ± 41 pg/L), breathing disorders (may be related to increased aldosterone) are hormone dependent and were corrected in those with insomnia. The increase in testosterone and decrease in prolactin was corroborated by an increase in sex drive and improved partner relationships. Common immunity disorders of the veterans, such as increased herpes labialis, flu-like syndromes, and stomach pain were resolved in all veterans and was corroborated by significant improvements in immunologic cytokines: tumor necrosis factor α was reduced (from 13.5 ± 0.4 to 9.0 ± 1.4 pg/mL, p < 0.001) and interleukin β (from 7.0 ± 0.5 to 4.5 ± 1.8 pg/mL) and interferon γ (from 10.4 ± 2.4 to 6.3 ± 1.5 pg/mL, p < 0.001) were also detected. PTSD is associated with clinically elevated leukocytes and lymphocytes, which are reduced by FSWW08 as well. Conclusion: It is the first time that the normalization of the whole steroidal hormone cascade in the blood could be correlated with improvements in mental and physical parameters (especially metabolic and immunologic disorders) in veterans with combat-related and treatment-resistant PTSD. Studies of FSWW08 in larger cohorts and over longer periods of time, as well as dosing effects, have to be conducted to validate these results. Keywords: anxiety; Clinician-Administered PTSD scale; cortisol; dehydroepiandrosterone (DHEA); dehydroepiandrosterone sulfate (DHEA-S); post-traumatic stress disorder (PTSD); serotonin; soldiers; stress; testosterone.
Introduction Stress-related changes in the endocrine and immune systems are key mediators involved in the development of diseases associated with posttraumatic stress disorder (PTSD) [1]. PTSD is a chronic anxiety disorder that occurs after a traumatic event [2, 3] (Figure 1). The objective of this study was to assess the influence of a fermented soy product (FSWW08) on mental and endocrine marker of male veteran soldiers who developed a treatment-resistant mental trauma after returning home after witnessing a life-threatening situation from warravaged regions in Afghanistan as part of the International Security Assistance Force (ISAF), which was established by the UN Security Council at the end of December 2001 to secure Kabul and the surrounding areas. We analyzed the relationship among psychometric, hormonal, and immunologic
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Gocan et al.: Balancing steroidal hormone cascade though FSWW08 in PTSD
Trauma
0
~1 3 Month Months
6 Months
20 Years
40 Years
Acute stress disorder Acute PTSD Chronic PTSD Delayed-onset PTSD
Figure 1 Time course and PTSD subtypes. Taken from Ref. Zohar et al. [38].
variables in veteran soldiers with PTSD before and after consumption of FSWW08. PTSD is characterized by a comorbidity of biological alterations of the hypothalamic-pituitary-adrenal (HPA) axis and the immune system, such as increased metabolic disease, causing heart failure and diabetes, and immune alterations, increasing viral infections and inflammation. There is a bidirectional dependency between the HPA axis and immune system [4–6] – communications in a complex feedback system that can be disrupted after a traumatic event, resulting in increased risks to physical and psychological well-being [7–9]. In a healthy individual, there is a balance between the production of inflammatory/cell-mediated (Th1) and humoral (Th2) cytokines [6–9], which is always altered in inflammatory diseases or in mental disease, which is disturbed in PTSD. The immune system affects steroidal hormone balance function in an effort to protect the individual, for example, simultaneously increasing the stress hormones dehydroepiandrosterone (DHEA) and pregnenolone and decreasing cortisol [10–12]. Improved understanding of relations among steroidal hormones, the HPA axis, and immune system in PTSD participants is essential because disruptions may be related to increased morbidity and mortality in PTSD participants. Chronic inflammation has been shown to exert adverse effects on many body systems and may contribute to chronic
pain, arthritis, diabetes, and cardiovascular disease [13–16], all of which have been associated with PTSD [17–19]. A specially fermented soy formulation, FSWW08, has shown tremendous capabilities to reduce stress and improve immunity in patients with cancer [20–23] and hepatitis B, reducing viral infections and liver inflammation even more compared with standard antiviral therapy. FSWW08 caused a strong improvement in immune parameters in these immunologically compromised patients, reducing particularly inflammatory cytokines and improving gene expressions related to immunity [21, 23, 24]. A complete discussion about FSWW08’s immunity-modifying effect surpasses this publication, but it is believed that increase of androstenes (Figure 2) is a key component in the mechanism of action and are increased by FSWW08: the reader is strongly encouraged to get familiar with the work of Loria [25], who showed that androstenes surpass the immunity of cortisones because, aside from their capability to reduce inflammation, they also have strong antiviral effects (Figure 3). Recent publications by experts in the field of mental diseases support that PTSD has a strong immunity-improving component, which served as the basis in the application of FSWW08 in a pilot trial in these patients, because it is now accepted that PTSD is strongly related to disturbances in immunity [1]. To elucidate the mechanism of action, we decided to test the hormonal parameter in this study. Androstenes are adrenal hormones that are part of the HPA axis. Isoflavones are a compound of soy and particularly of FSWW08 (Figure 2). Isoflavones and androstenes are structurally similar and are also estrogen receptor (ER) β-agonist (Figure 2). To start a pilot trial in veteran soldiers with PTSD, it is important that extensive medical records on the study participants existed before their service in Afghanistan. It was established that no mental or physical problem existed before their deployment to Afghanistan and that any comorbidity of severe mental or physical diseases, including brain injury, could be excluded as a result of their experiences after returning from service in Afghanistan. The enlisted cohort was very homogenous with respect to age, sex, weight, before and after returning home from service. Depression, in particular, develops frequently as a comorbidity with time in PTSD patients or may have existed before a traumatic event and is linked
Anti-stress, anti-inflammatory and increase of immunity Human steroids
Plant derived OH
OH
O
H H
OH
H
HO
HO
HO
O
H Androstenediol
Androstanediol
Daidzein
5-Androstene-3β,17β-diol
5-Androstane-3β,17β-diol
4′,7-Dihydroxyisoflavone
Figure 2 Structural formulas of androstenes (ADIOLS) and soy isoflavones. Androstenediol is metabolized from DHEA, whereas androstanediol is metabolized from testosterone. Daidzein is one of the two major isoflavones in soy.
Gocan et al.: Balancing steroidal hormone cascade though FSWW08 in PTSD
“ADIOLs” or “Androstenes” control immunity: inflammation and infection Antiviral Antibacterial
Th2
Androstenediol Androstanediol Anti-inflammatory
Th1
Figure 3 Accordingly to Loria [25], androstenediol (metabolite of DHEA) and androstanediol (metabolite of dehydrotestosterone) regulate cellular anti-infective (antiviral and antibacterial) and antiinflammatory response in contrast to cortisones, which only regulate inflammation. Reproduced from Ref. Zohar et al. [38]. New findings support a dominant role on nerve cell immunity.
to an increase of cortisol, whereas PTSD is characterized by a decrease in cortisol [10–12, 26]. All enlisted soldiers experienced a delayed onset of PTSD (Figure 1), where the traumatic incident occurred 6 months to a year before the diagnosis of the first PTSD symptoms but where depression had not developed. All enlisted soldiers were resistant to previous pharmacotherapy (selective serotonin reuptake inhibitors, or SSRIs) or psychological treatment attempts. At the time of enlistment in the study, all soldiers were released from active military service and were not capable of performing regular job employment duties outside the military. They continued to receive military pay and medical help from the military in a certified clinical center. The planned study period was 3 months; however, it was extended to 6 months. The limitations of this study are (1) the number of enlisted veteran soldiers are too few to make any general health claims and (2) a placebo group was not included because the soldiers simply refused to receive any placebo. FSWW08 had a more pronounced beneficial effect on the hormonal parameter of patients with PTSD than antipsychotic medications had on similar hormones in schizophrenia, particularly decreasing DHEA, pregnenolone, triglycerides, prolactin, and Th1 cytokine, and simultaneously increasing estradiol, testosterone, and cortisol. A normalization of the hormone cascade was accompanied by a reduction of PTSD symptoms, which was documented using the ClinicianAdministered PTSD Scale (CAPS) [27–29].
Methods Characteristics of the veterans with PTSD participating in the study
303
To be enlisted in this study, a major inclusion criterion was that the participant himself experienced a life-threatening combat-related event of his own or another person before the disease in addition to being in the military as well as having served in Afghanistan as part of ISAF. In addition, another inclusion criterion is that a soldier should be experiencing PTSD and no other mental disease. The mean age was 34 years (range, 28–43 years). A major requirement was that participating soldiers returned from military service in Afghanistan < 1.5 years before enrollment in the study. In most veterans, PTSD developed within half a year after the traumatic event. The main exclusion criterion was that patients did not experience physical injury to the brain or body during service or after developing signs of PTSD. Also, to participate in the study, no additional severe physical life-threatening diseases were allowed other than those experienced in the military service. All soldiers showed signs of developing metabolic disease: diabetes and hypertension. This was judged as a comorbidity of PTSD. Subjects were required to taper and abstain from all psychotropic medication during their study participation except for the given FSWW08 study medication. Substance abuse in PTSD patients involves nicotine and alcohol in general and was reported by all participating soldiers. Urine drug testing for cocaine, marijuana, amphetamines, opiates, and benzodiazepines was performed during initial screening and after a 3-month experimental session. All screens were negative. A main inclusion criterion was that all soldiers were able to follow instructions given by the study physician. Each soldier received a complete full medical examination before enrollment in the study. This included examination of the head, throat, and skin, testing of nerve reflexes, and palpation of the skin, lymphatic system, and bones. Mental disease within the family was not specifically checked but there appears to be no predisposition in any of the soldiers. PTSD was categorized by CAPS [27–29]. The average CAPS was 80.1 (range, 61–92). All patients signed a document that they participated in the study with informed consent. This included notification that they received, before signing the document, information that the fermented soy was not approved for this indication and its use was purely experimental and no health claim had been issued for PTSD. A Local Ethics Committee, including the head of the local military hospital, approved the study in written form. Investigators and the legal representative of the hospital signed that the Declaration of Helsinki in its current form was applicable and was followed. More importantly, all soldiers were informed that they could leave the trial at any time without having to provide a reason. All information was to be written in a way that each soldier ’s anonymity was ensured. Blood samples for further processing were shipped to Dr. Doris Bachg (BIOFOCUS, Recklinghausen, Germany). Handling, air shipment, and storage were performed according to a procedure developed by BIOFOCUS. The study site was at the Department of Neurology, Military Hospital, Victor Babes¸ University of Medicine and Pharmacy Timis¸oara, Timis¸oara, Romania.
Study medication An army physician examined and diagnosed all the veterans participating in the study using the International Classification of Diseases, 10th Revision code, which resulted in all study participants falling into the category defining PTSD. PTSD was always combat-related. Before our study, all soldiers were treated with SSRIs, psychotherapy, and failed any drug treatment administered and were considered as treatment-resistant.
Study medication (FSWW08) was received from Healan Research Foundation (Woodinville, Washington State, USA). Shipping, storage, and handling protocol were performed according to a procedure developed by Haelan Research Foundation. The study medication was approved and categorized as food for special medical needs by the European Union and as medical food by the FDA in the USA.
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Design
Results
After enrollment, subjects received fermented soy medication. It was initially planned to enlist 10 patients. Although not in agreement with our study plan, the participating soldiers suggested the addition of another soldier, making a total of 11 participants. One soldier, however, did not follow the instructions of the study physician after he was enlisted in the study and was excluded after enlisting, thus again making a total of 10 participants. At study day 1, all soldiers received a box of study medication, which was delivered to his home. Each soldier consumed 120 mL FSWW08 (half a bottle) daily for 90 days. Every month, all soldiers were called by telephone to ask for response and verbal medical checking. None of the soldiers received any additional psychotherapy or pharmacotherapy medicines. After a period of 3 months, the participating soldiers were asked to return to the hospital to receive a full medical examination. Blood analysis and mental checkup were performed.
After 1 year of consuming FSWW08, 6 of the 10 enlisted treatment-resistant soldiers with PTSD had left the military and were working for the first time in a regular paid job outside the military since diagnosed with PTSD. The other four were still in the military, but they were considered as disease free, based on their CAPS testing, and their blood markers were judged as mentally and physically healthy (Tables 1–7 and Figure 4). Additional social and psychological treatment appeared to be necessary but was outside the scope of the trial. All participating soldiers showed considerable improvement in well-being and reduction of anxiety and stress after 7 days of consumption of the fermented soy FSWW08 (Figure 4 and Table 1). We did not see any side effects, but one patient did not like the taste and he applied the FSWW08 solution rectally, whereas others took it orally. Mental well-being was not the only improvement recorded – the appearance of the veterans improved with proper clothing and their personal hygiene improved as well. The veterans lost their general hostility and became cooperative. They also reported an interest in developing normal relationships with their social environment. Although lung function test was initially planned, this had to be excluded because of high stress levels. The untreated veterans experienced feelings of suffocation. Most veterans were experiencing flu-like symptoms before receiving medication, but improvements in breathing were noted in all veterans after the study.
Statistical analysis Statistical analyses of clinical parameters were performed using SPSS 12.0.1 (SPSS, Chicago, IL, USA). Paired sample t-tests were used to detect differences, if any, to determine whether treatment was effective in reducing PTSD.
Analysis of sexual hormones in the plasma Routine somatic screening was performed on the PTSD patients and on the healthy comparison group. Samples for hormones were taken by venipuncture between 08:00 and 10:00 h after an overnight fast. Blood was collected in heparinized tubes. Commercial kits were used for the analysis of the hormones. Inter- and intracoefficients of variation were below 10%. Cortisol was assessed between 08:00 and 10:00 h and at 14:00 h with chemiluminescence immunoassay (DPC, Amsterdam, The Netherlands). Prolactin, free T4, and TSH were assessed with fluorescence immunoassay (Perkin Elmer, Frankfurt, Germany). DHEA and dehydroepiandrosterone sulfate (DHEA-S) were assessed with radioimmunoassay (DPC). Testosterone was determined with a radioimmunoassay kit (Radioassay Systems, Carson, CA, USA). Androstenediol was determined with an ELISA kit from Uscn Life Science (Wuhan, China). Pregnenolone was determined by an ELISA kit from BioVendor Laboratory Medicine (Candler, NC, USA). 17OH-pregnenolone was determined with radioimmunoassay and a kit from GenWay (San Diego, CA, USA). Progesterone was determined by a kit from PerkinElmer Life Sciences (Zaventem, Belgium). Estradiol was determined with a radioimmunoassay kit from PerkinElmer Life Sciences. Estrone was determined with radioimmunoassay from Hölzel Diagnostika GmbH (Cologne, Germany). Dihydrotestosterone and serotonin were determined with an ELISA kit from IBL International (Hamburg, Germany).
Clinical response
Clinical response is defined as > 30% reduction from baseline in the CAPS total severity score [27–29]. The clinical response was 100% after 3 months (Figure 4). A drop in CAPS from 81 ± 12 to 21 ± 8 after 3 months and to 16 ± 5 after 6 months was detected. All soldiers continued to consume the medication for 6 months (Figure 4), although the trial officially ended after 3 months. Of 10 soldiers, 6 returned to regular jobs outside the military after 1 month. Four soldiers did not return to work outside the military, although they were judged as mentally and physically healthy. Additional social and psychological treatment appeared to be necessary but was outside the scope of the trial. 100 80 60 40
Analysis of cytokines Human tumor necrosis factor (TNF-α) was determined in the blood through ELISA, using kit supplied by RayBiotech (Norcross, GA, USA). The interleukin 6 (IL-6) ELISA used here is a solid-phase immunoassay readily applicable to measure IL-6 levels in serum from ANOGEN (Mississauga, Ontario, Canada). IL-1β was determined using an ELISA kit from BD Biosciences (Schwechat, Austria).
20
*
*
*
*
0 Baseline Month 3 Month 4 Month 5 Month 6
Figure 4 CAPS mean scores and SD in veteran soldiers with combat-related PTSD. y-Axis denotes average CAPS scores. *Statistically significantly different from initial value compared with baseline values (p < 0.01 level of significance).
Gocan et al.: Balancing steroidal hormone cascade though FSWW08 in PTSD
305
Table 1 Mental and clinical symptoms related to PTSD before and after consumption of FSWW08: Number of spontaneously reported discomfort during the last 7 days of interview.
Anxiety Decreased concentration Derealization, detachment Diarrhea Dizziness/drowsiness Fatigue General infection
Headache Insomnia Loss of appetite Nausea Panic Upper gastrointestinal burning Upper respiratory infection
Day 0
After 3 months
After 6 months
10/11 8/11 7/11 2/11 3/11 9/11 9/11 Total 7/11 Flu-like symptoms 6/11 Herpes labialis 5/11 10/11 11/11 3/11 1/11 6/11
0/10 1/10 0/10 1/10 1/10 0/10 0/10 Total 0/10 Flu-like symptoms 1/10 Herpes labialis 1/10 1/11 0/10 1/10 0/10 0/10
0/10
0/10 Total 0/10 Flu-like symptoms 0/10 Herpes labialis 0/10 1/11 0/10 1/10 0/10 0/10
0/10
0/10
3/11
Side effects
Soldiers did not report any side effects. There were no compliance problems, and the only complaint was the taste of the fermented soy being unpleasant to 3 soldiers. One soldiers changed from oral intake to rectal administration. This was possible because the fermented soy was applied in a liquid form. PTSD-accompanying symptoms
As summarized in Table 1, all of the participants experienced a reduction of the typical symptoms accompanying PTSD, particularly sleeping disorder, fatigue, headaches, loss of appetite, respiratory problems, and gastrointestinal inflammation. Many soldiers in the study initially experience flulike symptoms, herpes labialis, and skin infections (not listed here), all of which were not only reduced but also completely eliminated (Table 1). Improvements were reported within 7
0/10 1/10
days and lasted throughout the 6-month study. Improvement of sleeping disorders was reported in all veterans, except one (Table 1). Blood lipids
Patients with PTSD are known to be in danger of developing severe metabolic diseases and high triglyceride levels [30, 31]. We detected substantial improvement in blood lipids to normal values after consuming FSWW08 (Table 2). Blood lipids were improved, for example, high-density lipoprotein cholesterol decreased from 51 ± 15 to 89 ± 7.8 mg/dL and homocysteine decreased from 26 ± 4 to 11.8 ± 2.1 μmol/L (Table 2). Rather impressive improvements of triglycerides were detected after consuming FSWW08 (from 645 ± 267 to 161 ± 22 mg/dL) (Figure 5 and Table 2). The improvement in blood lipids was accompanied by an increase in body weight from 78.1 ± 4.2 kg before enlistment to 82.2 ± 5.1 kg after 3 months’ consumption of the fermented soy product.
Table 2 Plasma markers for metabolic disease in PTSD patients before and after 3 months’ consumption of fermented soy product. Blood lipids
Baseline (n = 10)
After 3 months’ consumption of fermented soy (n = 10)
Normal range
Treatment effect, p-Value
Cholesterol, mmol/L
280 ± 35 190 –320 645 ± 267 134 –959 51 ± 15 312 ± 112 189 – 410 0.25 ± 0.1 < 0.15 – 0.5 26 ± 4 21–29
205 ± 22 165 –220 161 ± 22 127–181 89 ± 7.8 151 ± 20 121–183 0.24 ± 0.1 < 0.15 – 0.5 11.8 ± 2.1 7–13
< 200
< 0.01
< 150
< 0.001
40 – 60 < 155
< 0.01 < 0.001
< 0.5
No change
5.5 –17
< 0.01
Triglycerides, mg/dL High-density lipoprotein cholesterol, mg/dL Low-density lipoprotein cholesterol, mg/dL C-reactive protein, mg/dL Homocysteine in serum (i.s.) (HPLC), μmol/L
Values are mean ± SD and range. Statistical significance was investigated with F-test to test for normality and t-test.
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Gocan et al.: Balancing steroidal hormone cascade though FSWW08 in PTSD
Cholesterol
Triglycerides 1000
300 mg/dL
mg/dL
400
200 100
500
0 1
2 3
0 5
6
7
8
1 9 10
2
3
4
5
6
7
8
9 10
Homocysteine
μmol/L
30 20 10 0 1
2
3
4
5
6
7
8
9
Figure 5 Selected individual blood lipid markers of veterans with combat-related PTSD untreated and after 3 months’ consumption of fermented soy (FSWW08). Black bars, before fermented soy consumption FSWW08; gray bars, after 3 months’ soy consumption.
Marker of thyroid gland activity
The changes caused by soy products in activity of the thyroid gland are under investigation [32]. However, we could not detect any change in the markers for the thyroid gland (Table 3). Either the numbers of participants were too small or the effects were too minimal and therefore difficult to detect. Steroidal hormone biosynthesis
Cortisol decreases with stress and PTSD. After consumption of FSWW08, cortisol increased in plasma more than 2-fold, from below the accepted normal range (4.8 ± 2.1 μg/dL) at 8 AM to a normal range (10.8 μg/dL) (Table 4), indicating a reduction in stress, which was also clinically confirmed in questionnaires and by the treating physician. Figure 6 schematically depicts the biosynthesis of steroidal hormones commonly derived from cholesterol. A series of hormones, listed in Table 4, were determined in the blood. As can be seen in Figure 6, hormones above the black line were elevated and below that line decreased (Table 4 and Figures 7–9). Hormone levels of aldosterone in the blood, however, were not determined in all patients and therefore Table 3
not listed in Table 4 (but a decrease was noted in patients tested after consumption of fermented soy). As shown in Figure 4, the drop in DHEA-S is at the lower end of the defined normal range. In untreated veterans with PTSD, testosterone was initially found to be below the normal range (2.1 ± 0.4 ng/L) but increased 2-fold (similar to cortisol) to normal range (4.1 ± 1.7 ng/L) after consumption of fermented soy (Table 4 and Figure 9). Precursors of testosterone were increased, and metabolites, such as estradiol and estrone increased from “below normal” to “normal” values (Table 5). Metabolites of DHEA and testosterone, such as androstenediol and androstanediol, can modify cytokines and improve immunity (Figure 3). Our investigation suggests that DHEA decreased, whereas androstendiol increased, which up-regulates immunity: Loria [25] expressed that androstenediol has a 100-fold higher antiviral activity than DHEA, which may explain the strong antiviral activity of FSWW08. Adrenal hormones
Although DHEA-S and DHEA were decreased after consumption of FSWW08, we detected a significant increase of the adrenal metabolite androstenediol after consumption by
Influence of consumption of 3 months’ consumption of fermented soy product thyroid hormones in PTSD patients.
Hormone, units
Baseline (n = 10)
After 3 months’ consumption of fermented soy (n = 10)
Normal range
Statistically significant change
Free triiodothyronine i.s., pg/mL
2.92 ± 1.7 1.5 – 4.2 1.6 ± 1.2 1.1–2.2 2.0 ± 1.2 1.0 –3.1
3.1 ± 0.9 1.4 – 4.0 1.5 ± 0.5 0.9 –2.1 2.0 ± 1.0 1.1–2.8
2.3 – 4.2
No change
0.89 –1.76
No change
0.4 – 4.0
No change
Free thyroxine i.s. (T4), ng/dL TSH (basal), mU/L
Values are mean ± SD and range. Statistical significance was investigated with F-test to test for normality and t-test on the 0.05 level of significance.
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307
Table 4 Plasma values of hormones in PTSD patients before and after 3 months’ consumption of fermented soy. Hormone
Baseline (n = 10)
After 3 months’ consumption of fermented soy (n = 10)
Normal range
Statistically significant treatment effect, p < 0.01
Cholesterol, mmol/L
280 ± 35 190 –320 4.8 ± 0.7 2.5 – 6.1 163 ± 61 125 –200 3.8 ± 1.1 2.8 –5.1 2120 ± 752 1550 –2912 15.8 ± 3.1 12.5 –19.0 1.1 ± 0.4 0.6 –2.1 2.1 ± 0.4 1.8 –3.5 53 ± 24 27– 87 41 ± 19 8 – 67 0.41 ± 0.2 0.18 – 0.51
210 ± 22 170 –220 3.2 ± 0.5 2.5 –3.9 95 ± 30 61–130 1.5 ± 0.6 1.1–2.1 1098 ± 336 550 –1415 7.1 ± 2.1 4.9 – 8.1 3.4 ± 1.2 1.2 – 4.8 4.1 ± 1.7 3.2 – 6.5 88 ± 41 45 –121 61 ± 31 39 – 82 1.2 ± 0.3 0.77–1.5
< 200
< 0.01
0.38 –3.5
< 0.01
30 –350
< 0.001
< 1.2
< 0.01
800 –5600
< 0.001
6.24 – 43.3
< 0.001
1.78 –7.24
< 0.001
1.81–7.72
< 0.001
< 198
< 0.001
37–370
< 0.001
0.39 –1.76
< 0.001
4.8 ± 2.1 3.1–7.8 1.7 ± 0.6 1.1–3.1
10.8 7.8 –15.9 3.5 ± 0.5 2.9 –7.1
5.0 –25.0
< 0.001
2.0 –12.0
< 0.001
Pregnenolone, ng/mL 17OH-pregnenolone, ng/100 mL Progesterone, nmol/L DHEA-S, ng/mL DHEA, nmol/L Androstenediol, nmol/L Testosterone i.s. age 20 – 40 years, ng/mL Estradiol, pg/L Estrone, pg/L Dihydrotestosterone, nmol/L Cortisol, μg/dL 8:00 AM 2:00 PM
Values are mean ± SD and range. Statistical significance was investigated with F-test to test for normality and t-test.
veterans with PTSD. As androstenediol is 100 times more potent to modulate immunity than DHEA (Figure 3), its increase may be clinically related to improvement in Th1/Th2 cytokines balance [25].
Other hormones related to well-being
The serotonin levels of untreated soldiers with PTSD were in the normal range (Table 5) and did not change after
Cholesterol
Anxiety Water-Retention, Edema
down UP
Stress 17OH-Pregnenolone
Pregnenolone
Progesterone DHEA
ANDROSTENEDIOL
Corticosterone Aldosterone
17OH-Progesterone
Cortisol
ANDROSTENEDIOL
Estrone
TESTOSTERONE
Estradiol
Dihydro-testosterone ANDROSTENETRIOL
Androstanediol Immunity
Figure 6 Treatment-resistant veterans with combat-related PTSD show increased steroidal hormones at the upper part of hormone synthesis, whereas hormones at the lower part are decreased, such as cortisol and particularly androstenes (androstenediol and androstanediol), which are extremely anti-inflammatory and anti-infective, particularly antiviral.
Gocan et al.: Balancing steroidal hormone cascade though FSWW08 in PTSD
Mean±SEM 3000
2500
2500
2000
2000 ng/mL
ng/mL
Individual values 3000
1500
Normal range
308
1500
1000
1000
500
500
0
0 1
2
3
4
5
6
7
8
9 10
Figure 7 Individual plasma values of DHEA-S, mean, and SEM in veterans with combat-related PTSD before and after consumption of FSWW08, compared with normal range. Black lines, untreated; gray lines, after 3 months’ consumption of fermented soy.
consumption of fermented soy. This supports the clinical observation that participating veterans did not show signs of depression or treatments response with SSRIs. A statistically significant drop in prolactin levels was detected, from 14.5 ± 2.9 to 10.7 ± 2.1 ng/mL (Table 5). Correlating to the increase of testosterone and estradiol, a significant decrease to normal range of luteinizing hormone (LH) was detected, from 11.1 ± 4.7 to 5.1 ± 4.1 mU/mL. The decrease in LH correlates with the increase in testosterone and estradiol.
Cytokines
Cytokine are often related to PTSD. They were determined in plasma before and after consumption of fermented soy (Table 6). The consumption of FSWW08 statistically significantly decreased TNF-α, IL-1β, and IFN-γ but did not change IL-6 (Table 7). As the IL-6 increase is mostly related to depression, this is another support that veterans were not experiencing depression. Mean±SEM
Individual 250
200
150
Untreated
100
Fermented soy after 3 months
ng/100 mL
200 ng/100 mL
Normal range
250
150 100
50
50
0
0
Figure 8 Individual plasma values of 17OH-pregnenolone, mean, and SEM in NATO-ISAF soldiers with PTSD before and after treatment compared with normal range. Black lines, untreated; gray lines, after 3 months’ consumption of fermented soy.
6
6
5
5
4 Untreated After 3 months
3
ng/mL
ng/mL
7
4 3
2
2
1
1
0
Normal range
Mean±SEM
Individual 7
0 1
2
3
4
5
6
7
8
9 10
Figure 9 Individual plasma values of testosterone, mean, and SEM in veterans with combat-related PTSD before and after treatment compared with normal range. Black lines, untreated; gray lines, after 3 months’ consumption of fermented soy.
Gocan et al.: Balancing steroidal hormone cascade though FSWW08 in PTSD
Table 5
309
Plasma hormones related to mental disorders in PTSD patients before and after 3 months’ consumption of fermented soy product.
Hormone
Baseline (n = 10)
After 3 months’ consumption of fermented soy (n = 10)
Normal range
Statistically significant treatment, p-Value
Serotonin, μg/L
103 ± 22 53 –123 14.5 ± 2.9 8.3 –18.7 11.1 ± 4.7 3.4 –16.2
95 ± 35 77–133 10.7 ± 2.1 6.7–13.5 5.1 ± 4.1 2.1–9.4
40 –200
No change
2.5 –17.0
0.01
0.8 –7.6
0.01
Prolactin i.s., ng/mL LH, mU/mL
Values are mean ± SD and range. Statistical significance was investigated with F-test to test for normality and t-test. Table 6 Plasma cytokines markers related to general immunity, cachexia, depression, and severe mental disturbances measured in PTSD patients before and after 3 months’ consumption of fermented soy product. Cytokine
Untreated (n = 10)
After 3 months’ consumption of fermented soy (n = 10)
Recommended range
Related to physiological effects
TNF-α, pg/mL IL-1β, pg/mL IL-6, pg/mL IFN-γ, pg/mL
13.5 ± 0.4 7.0 ± 0.5 2.3 ± 0.3 10.4 ± 2.4
9.0 ± 1.4 4.5 ± 1.8 2.2 ± 0.5 6.3 ± 1.5
< 9.5
