https://doi.org/10.1177/1078390317710313 Journal of the American Psychiatric Nurses Association 2018, Vol. 24(1) 35–44 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1078390317710313 journals.sagepub.com/home/jap Literature Review Introduction Early disease morbidity occurs in individuals with trauma- related psychopathology including posttraumatic stress disorder (PTSD; Boscarino, 2012; Kessler, Chiu, Demler, Merikangas, & Walters, 2005). PTSD is frequently comor- bid with other psychiatric disorders such as depression and anxiety disorders (Spinhoven, Penninx, van Hemert, de Rooij, & Elzinga, 2014). It also has been associated with physical health problems, such as general medical conditions, musculoskeletal pain, cardiorespiratory symp- toms, gastrointestinal health, and poor quality of life (Pacella, Hruska, & Delahanty, 2013). Psychiatric nurses would be well positioned to advance bio-behavioral inter- ventions for individuals with PTSD. However, we need better understanding of the underlying pathophysiology to go forward with intervention research. The hypothalamic-pituitary-adrenal (HPA) axis as one of three major stress response systems (Teicher, Andersen, Polcari, Anderson, & Navalta, 2002) has been suggested in relation to trauma-related psychopathology (Yehuda, Halligan, Grossman, Golier, & Wong, 2002). When trau- matic stress occurs, the HPA axis activity is initiated and cortisol is produced and released to play a significant role in both the stress response and the maintenance of homeo- stasis (Sapolsky, Romero, & Munck, 2000). Multiple studies have explored cortisol levels in relation to PTSD. However, in recent four meta-analyses studying associa- tions of cortisol with chronic stress, traumatic stress, and PTSD, patterns of both hyper- and hypocortisolemia have been found, along with findings that there are no differ- ences by PTSD status (Klaassens, Giltay, Cuijpers, van Veen, & Zitman, 2012; Meewisse, Reitsma, de Vries, Gersons, & Olff, 2007; Miller, Chen, & Zhou, 2007; Morris, Compas, & Garber, 2012). The confounding factors that might clarify the con- tradictory findings in research on cortisol and PTSD to date are gender, trauma type, and developmental period of the exposure. Developmental trauma theories suggest that gender, nature of the trauma, and age at exposure to 710313JAP XX X 10.1177/1078390317710313Journal of the American Psychiatric Nurses AssociationLi and Seng research-article 2017 1 Yang Li, BS, University of Michigan, Ann Arbor, MI, USA 2 Julia S. Seng, PhD, CNM, University of Michigan, Ann Arbor, MI, USA Corresponding Author: Yang Li, Department of Systems, Populations and Leadership, School of Nursing, University of Michigan, 1746 McIntyre Street, Ann Arbor, MI 48105, USA. Email: lyx@umich.edu Child Maltreatment Trauma, Posttraumatic Stress Disorder, and Cortisol Levels in Women: A Literature Review Yang Li 1 and Julia S. Seng 2 Abstract BACKGROUND:Studies of the relationship between cortisol and posttraumatic stress disorder (PTSD) have had inconsistent results. Gender, trauma type, and age at trauma exposure may explain the inconsistencies. OBJECTIVE: The objective of the review was to examine cortisol levels in relation to PTSD in women with a history of child maltreatment trauma. DESIGN: A review of literature found 13 articles eligible for inclusion. RESULTS: Despite limiting focus to the relatively homogeneous population, the patterns of associations between PTSD and cortisol levels were still inconsistent. CONCLUSIONS: The reasons for the inconsistencies likely include highly varied methods across studies, small convenience samples, and unmeasured neuroendocrine hormones that may be stronger predictors of PTSD. The review does not point to a clear bio-behavioral target for psychiatric nursing intervention. It is important to continue to address the developmental and clinical stress response aspects of child maltreatment trauma–related PTSD without assuming that these stress responses are hypothalamic-pituitary-adrenal–axis driven. Keywords cortisol, posttraumatic stress disorder, child maltreatment trauma, women, literature review