Association of Acyl-Ghrelin With Posttraumatic Stress Disorder in Adolescents Who Experienced Severe Trauma

August 20, 2020

Muhammad Omar Malik, MBBS, PhD1Mohsin Shah, PhD1Muhammad Irfan ul Akbar Yousufzai, MBBS, MPhil1et alNajeeb Ullah, PhD1JoColl A. Burgess, MS2Ki Ann Goosens, PhD2Author AffiliationsArticle InformationJAMA Netw Open. 2020;3(8):e2013946. doi:10.1001/jamanetworkopen.2020.13946


Chronic stress, the occurrence of trauma and its adverse consequences over a prolonged period, is associated with the development of posttraumatic stress disorder (PTSD), even when many years have elapsed since the initial stress exposure.1 Acyl-ghrelin levels increase in rodents and humans during chronic stress exposure.2,3 Elevated acyl-ghrelin remains long after the primary stressful event ceases (months in rodents, years in humans). Acyl-ghrelin, which is released mostly by the gut during times of energy depletion,4 is the only form of ghrelin that can bind to the ghrelin receptor. In rodents, stress-related increases in acyl-ghrelin underlie a long-term vulnerability to excessive fear.3,5 Here, we sought to determine whether elevated levels of acyl-ghrelin were associated with the development of PTSD or its severity in adolescents who experienced severe trauma.


This study was approved by the institutional review board of Khyber Medical University. All participants and their respective caregivers gave written informed consent. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines.

We conducted a cross-sectional study on 49 adolescents who experienced severe trauma and 39 healthy, matched control participants. Adolescents in the trauma group experienced a terror attack and were injured, or lost a parent, relative, or close friend. Adolescents in the control group had no terror-associated losses or injuries. Blood and saliva samples were collected for analyses of acyl-ghrelin and cortisol, respectively, and all participants were administered the PTSD CheckList–Civilian Version (PCL-C).

Statistical analyses were performed with Prism statistical software version 6.0 (GraphPad Software) and JMP Pro statistical software version 14 (SAS Institute). Statistical significance was determined by the Kruskal-Wallis test, Mann-Whitney test, one-way ANOVA, Pearson χtest, or Dunn multiple comparisons, as appropriate. For all tests, testing was 2-sided and adjusted P < .05 was considered significant. Recruitment began December 2014, and data collection was completed in July 2015. Statistical analyses were performed February 2019 to May 2020. Further details of the experiment and analyses are included in the eAppendix in the Supplement.


The 88 study participants had a mean (SD) age of 14.31 (2.81) years; 85 (96%) were male. Within the trauma group, 14 adolescents (36%) did not meet the criteria for PTSD; no adolescents met the criteria for PTSD in the control group (Table). In the trauma group, adolescents with or without PTSD did not differ from controls or each other, except for body mass index. Adolescents in the trauma group without PTSD had levels of acyl-ghrelin (mean [SD], 61.36 [26.22] pg/mL [to convert acyl-ghrelin to picomoles per liter, multiply by 0.3]) (Figure, panel A, and Table) and cortisol (mean [SD], 43.34 [25.79] ng/mL [to convert cortisol to micromoles per liter, multiply by 2.7]) (Table) that were statistically indistinguishable from those of adolescents in the control group (75.13 [47.38] pg/mL acyl-ghrelin and 41.52 [29.01] ng/mL cortisol), whereas adolescents in the trauma group with PTSD had higher levels of both hormones (acyl-ghrelin: mean [SD], 166.1 [93.19] pg/mL and cortisol: mean [SD], 140.4 [158.5] ng/mL; median [interquartile range] of 65 [32.5-185]). The PCL-C scores of adolescents with trauma but without PTSD (mean [SD], 38.71 [5.73]) were higher than those of adolescents in the control group (mean [SD], 19.67 [2.20]), but lower than those of adolescents with trauma and PTSD (mean [SD], 55.03 [6.42]) (Figure, panel B). Acyl-ghrelin alone accounted for 76.3% of the variability in PCL-C score (Figure, panel C). A regression analysis of the PCL-C scores in the trauma group that included acyl-ghrelin, morning cortisol, body mass index, age, and their 2-way interactions (F10,36 = 9.52; P < .001) accounted for only an additional 2.24% of the variability in PCL-C scores; only acyl-ghrelin retained a significant association with PCL-C score (B, 26.77; 95% CI, 18.16-34.68; P < .001). There was a significantly elevated risk of PTSD when comparing adolescents with trauma and low levels of acyl-ghrelin with those with moderately elevated levels (Figure, panel C) (odds ratio, 7.94; 95% CI, 1.60-39.42; χ2 = 6.43; P = .01). All adolescents in the trauma group with high levels of acyl-ghrelin had PTSD.


We observed an association between acyl-ghrelin and PTSD symptom severity in adolescents who experienced severe trauma. These data motivate additional research to investigate the mechanisms underlying trauma-associated elevation of acyl-ghrelin; these data also suggest that blood banks collecting samples from patients with PTSD should use methods that preserve acyl-ghrelin for analysis. This study’s limitations include the low number of female adolescents and the assessment of acyl-ghrelin at only a single posttrauma time point. It is unknown whether the adolescents who experienced severe trauma without PTSD never displayed trauma-associated elevation of acyl-ghrelin or whether acyl-ghrelin decreased over time since the initial trauma. It is also of interest to determine whether obesity, which dysregulates acyl-ghrelin,6 alters the role of acyl-ghrelin in stress and trauma.

Article Information

Accepted for Publication: June 6, 2020.

Published: August 20, 2020. doi:10.1001/jamanetworkopen.2020.13946

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Malik MO et al. JAMA Network Open.

Corresponding Authors: Mohsin Shah, PhD, Department of Physiology, Institute of Basic Medical Sciences, Khyber Medical University, Peshawar, Pakistan (; Ki Ann Goosens, PhD, Department of Psychiatry, Friedman Brain Institute, Center for Affective Neuroscience Icahn School of Medicine at Mount Sinai, One Gustave Levy Pl, Annenberg 22-76A, New York, NY 10029 (

Author Contributions: Drs Shah and Goosens had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Drs Malik and Shah contributed equally to this work.

Concept and design: Shah, Goosens.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Shah, Goosens.

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About S. R. Zelenz 119 Articles
S.R. Zelenz has worked in education for 20 years. Working with students from all walks of life, cultures, races, and social diversity, Zelenz’s research in Educational Leadership led to finding a better way to approach learning for students with trauma histories. Many were juvenile offenders, gang members, diagnosed with varying behavioral disorders, or had family histories of violence, murder, or narcissistic parenting. This research could not be effectively accomplished without further understanding: how epigenetic trauma inheritance may be impacting these students; how brain development from trauma may be impacting their behavioral and emotional development; as well as deep understanding of psychology and its varying classifications for behavioral and personality disorders. The goal is to find solutions for changing the conversation and making a real difference for these students. She has also worked with nonprofits of varying focus areas for the last 25 years. Her undergraduate degree in Arts Administration and Music prepared her for managing nonprofits of any size as well as procuring funding so that they can achieve their goals. Pairing her nonprofit background with her education background, she has been able to make a difference for over 200 nonprofits worldwide, written curriculum for schools across the globe, and assisted many arts organizations through performance and management.