Daily cortisol, stress reactivity and psychotic experiences in individuals at above average genetic risk for psychosis

Overall cortisol, diurnal slope, and stress reactivity in psychosis: An experience sampling approach

OBJECTIVE

Results from experimental studies suggest that psychosis and psychosis liability are associated with increased cortisol levels and blunted cortisol reactivity, and that use of antipsychotics may reduce these aberrations. Here, we report on overall cortisol, diurnal slope, and cortisol stress reactivity in everyday life in psychosis and psychosis liability using the experience sampling method (ESM).

METHODS

Our sample consisted of individuals diagnosed with psychotic disorder currently on (MPD; n = 53) or off antipsychotic medication (NMPD; n = 20), first-degree relatives of psychotic patients (REL; n = 47), and healthy volunteers (HV; n = 67). Saliva samples were collected throughout the day on six consecutive days and analyzed for cortisol levels. Simultaneously, stressfulness of the current activity was assessed with ESM questionnaires.

RESULTS

We found no group differences in overall cortisol level between groups, but REL had a steeper diurnal slope than HV; in MPD a trend was found in the same direction. Regarding reactivity to stressful activities, results indicated attenuation of the cortisol response in both patient groups compared to HV.

CONCLUSION

These results do not confirm reports of increased cortisol levels in psychosis, but provide evidence of stress-related cortisol alterations in everyday life.

Emotion regulation as a predictor of the endocrine, autonomic, affective, and symptomatic stress response and recovery

Stress is associated with the development of mental disorders such as depression and psychosis. The ability to regulate emotions is likely to influence how individuals respond to and recover from acute stress, and may thus be relevant to symptom development. To test this, we investigated whether self-reported emotion regulation predicts the endocrine, autonomic, affective, and symptomatic response to and recovery from a stressor. Social-evaluative stress was induced by the Trier Social Stress Test (TSST) in N = 67 healthy individuals (53.7% female, M_age = 29.9). Self-reported habitual emotion regulation skills were assessed at baseline. We measured salivary cortisol, heart rate, negative affect, state depression and state paranoia at three time points: pre-TSST, post-TSST, and after a 10 min recovery phase. Repeated-measures ANOVA showed all indicators to significantly increase in response to the stressor (p < .001) and decrease during the recovery phase (p < .001), except for salivary cortisol, which showed a linear increase (p < .001). The habitual use of maladaptive emotion regulation (e.g., rumination, catastrophizing) significantly predicted an increased affective and reduced cortisol response. Adaptive emotion regulation (e.g., acceptance, reappraisal) was not predictive of the stress response for any of the indicators. Neither type of emotion regulation predicted response during the stress recovery phase. Individuals who habitually resort to maladaptive emotion regulation strategies show a stronger affective and a blunted endocrine stress response, which may make them vulnerable to mental health problems. However, further research is needed to identify the full scope of skills required for effective stress-regulation before this knowledge can be used to develop effective prevention programs.

Clinical correlates of hypothalamic-pituitary-adrenal axis measures in individuals at risk for psychosis and with first-episode psychosis

Hypothalamic-pituitary-adrenal (HPA) axis alterations in at-risk mental states (ARMS) resemble those observed in established psychosis but are less consistent. We aimed to explore HPA axis abnormalities in both first-episode psychosis (FEP) and ARMS patients, while controlling for psychopathological symptoms. We studied 21 ARMS, 34 FEP patients and 34 healthy subjects. Clinical assessment included psychopathological symptoms (positive, negative, disorganized, excited and depressive symptoms) and stress measures. Saliva cortisol levels were determined at awakening, 30' and 60' post-awakening, 10:00 h, 23:00 h and 10:00 h on the day after the administration of 0.25 mg of dexamethasone, which occurred at 23:00 h. Three HPA axis measures were calculated: cortisol awakening response (CAR), cortisol diurnal slope and cortisol suppression ratio of the dexamethasone suppression test (DST). There were no significant differences between groups in HPA axis measures. However, when exploring the relationship between HPA axis measures and psychopathological symptoms, in ARMS subjects (but not FEP patients), a flatter cortisol slope was associated with more prominent negative symptoms, whereas a blunted CAR was associated with excited symptoms. Although no significant differences in HPA axis measures were found between diagnostic groups, subtle abnormalities in the CAR or circadian cortisol rhythmicity might be important for the phenotype of ARMS individuals.

In the eye of the beholder: Perceptions of neighborhood adversity and psychotic experiences in adolescence

Adolescent psychotic experiences increase risk for schizophrenia and other severe psychopathology in adulthood. Converging evidence implicates urban and adverse neighborhood conditions in the etiology of adolescent psychotic experiences, but the role of young people's personal perceptions of disorder (i.e., physical and social signs of threat) in their neighborhood is unknown. This was examined using data from the Environmental Risk Longitudinal Twin Study, a nationally representative birth cohort of 2,232 British twins. Participants were interviewed at age 18 about psychotic phenomena and perceptions of disorder in the neighborhood. Multilevel, longitudinal, and genetically sensitive analyses investigated the association between perceptions of neighborhood disorder and adolescent psychotic experiences. Adolescents who perceived higher levels of neighborhood disorder were significantly more likely to have psychotic experiences, even after accounting for objectively/independently measured levels of crime and disorder, neighborhood- and family-level socioeconomic status, family psychiatric history, adolescent substance and mood problems, and childhood psychotic symptoms: odds ratio = 1.62, 95% confidence interval [1.27, 2.05], p < .001. The phenotypic overlap between adolescent psychotic experiences and perceptions of neighborhood disorder was explained by overlapping common environmental influences, rC = .88, 95% confidence interval [0.26, 1.00]. Findings suggest that early psychological interventions to prevent adolescent psychotic experiences should explore the role of young people's (potentially modifiable) perceptions of threatening neighborhood conditions.

Experience sampling methodology in mental health research: new insights and technical developments

In the mental health field, there is a growing awareness that the study of psychiatric symptoms in the context of everyday life, using experience sampling methodology (ESM), may provide a powerful and necessary addition to more conventional research approaches. ESM, a structured self-report diary technique, allows the investigation of experiences within, and in interaction with, the real-world context. This paper provides an overview of how zooming in on the micro-level of experience and behaviour using ESM adds new insights and additional perspectives to standard approaches. More specifically, it discusses how ESM: a) contributes to a deeper understanding of psychopathological phenomena, b) allows to capture variability over time, c) aids in identifying internal and situational determinants of variability in symptomatology, and d) enables a thorough investigation of the interaction between the person and his/her environment and of real-life social interactions. Next to improving assessment of psychopathology and its underlying mechanisms, ESM contributes to advancing and changing clinical practice by allowing a more fine-grained evaluation of treatment effects as well as by providing the opportunity for extending treatment beyond the clinical setting into real life with the development of ecological momentary interventions. Furthermore, this paper provides an overview of the technical details of setting up an ESM study in terms of design, questionnaire development and statistical approaches. Overall, although a number of considerations and challenges remain, ESM offers one of the best opportunities for personalized medicine in psychiatry, from both a research and a clinical perspective.

The Cascade of Stress: A Network Approach to Explore Differential Dynamics in Populations Varying in Risk for Psychosis

Stress plays a central role in the development and persistence of psychosis. Network analysis may help to reveal mechanisms at the level of the micro-dynamic effects between stress, other daily experiences and symptomatology. This is the first study to examine time-lagged networks of the relations between minor daily stress, momentary affect/thoughts, psychotic experiences, and other potentially relevant daily life contexts in individuals varying in risk for psychosis. Intensive longitudinal data were obtained through 6 studies. The combined sample consisted of 654 individuals varying in risk for psychosis: healthy control subjects (n = 244), first-degree relatives of psychotic patients (n = 165), and psychotic patients (n = 245). Using multilevel models combined with permutation testing, group-specific time-lagged network connections between daily experiences were compared between groups. Specifically, the role of stress was examined. Risk for psychosis was related to a higher number of significant network connections. In all populations, stress had a central position in the network and showed direct and significant connections with subsequent psychotic experiences. Furthermore, the higher the risk for psychosis, the more variables "loss of control" and "suspicious" were susceptible to influences by other network nodes. These findings support the idea that minor daily stress may play an important role in inducing a cascade of effects that may lead to psychotic experiences.

Stress sensitivity in paranoia: poor-me paranoia protects against the unpleasant effects of social stress

BACKGROUND

The attributional theory of paranoia suggests that paranoid beliefs may protect individuals from low self-esteem and distress (Bentall et al. 2001). The current study tested this theory by investigating a hypothesis that paranoid beliefs in combination with low perceived deservedness of persecution (poor-me beliefs) confer protection against the distress caused by social but not activity related stress.

METHODS

Paranoid symptoms, perceived deservedness of persecution, self-esteem, mood, and stress levels of individuals diagnosed with schizophrenia spectrum disorders (N = 91) and healthy controls (N = 52) were assessed in the context of daily life using the experience sampling method.

RESULTS

Individuals holding poor-me beliefs (poor-me individuals) showed blunted sensitivity to social but not activity stress. In contrast, individuals holding paranoid beliefs in combination with high perceived deservedness of persecution (bad-me individuals) showed heightened sensitivity to social stress. No consistent differences in reactions to activity stress emerged. Although both poor-me and bad-me individuals reported low self-esteem, this disturbance was particularly characteristic of bad-me individuals.

CONCLUSIONS

The results suggest that poor-me paranoid beliefs may protect individuals against the distress associated with unpleasant social situations. The specificity of reactions to social stress is discussed in the context of wider literature. Future directions for research are suggested.

Neural - hormonal responses to negative affective stimuli: Impact of dysphoric mood and sex

BACKGROUND

Maladaptive responses to negative affective stimuli are pervasive, including clinically ill and healthy people, and men and women respond differently at neural and hormonal levels. Inspired by the Research Domain Criteria initiative, we used a transdiagnostic approach to investigate the impact of sex and dysphoric mood on neural-hormonal responses to negative affective stimuli.

METHODS

Participants included 99 individuals with major depressive disorder, psychosis and healthy controls. Functional magnetic resonance imaging (fMRI) was complemented with real-time acquisition of hypothalamo-pituitary-adrenal (HPA) and -gonadal (HPG) hormones. fMRI data were analyzed in SPM8 and task-related connectivity was assessed using generalized psychophysiological interaction.

RESULTS

Across all participants, elevated cortisol response predicted lower brain activity in orbitofrontal cortex and hypothalamus-amygdala connectivity. In those with worse dysphoric mood, elevated cortisol response predicted lower activity in hypothalamus and hippocampus. In women, elevated cortisol response was associated with lower activity in medial prefrontal cortex and low hypothalamo-hippocampal connectivity. In women with high dysphoric mood, elevated cortisol response was associated with low hypothalamo-hippocampal connectivity. There were no interactions with diagnosis or medication.

LIMITATIONS

There was limited power to correct for multiple comparisons across total number of ROIs and connectivity targets; cortisol responses were relatively low.

CONCLUSIONS

We conclude that the pathophysiology in neural-hormonal responses to negative affective stimuli is shared across healthy and clinical populations and varies as a function of sex and dysphoric mood. Our findings may contribute to the development of hormonal adjunctive therapeutics that are sex-dependent, underscoring the importance of one's sex to precision medicine.

Untangling the complex relationships between symptoms of schizophrenia and emotion dynamics in daily life: Findings from an experience sampling pilot study

The unfolding of emotions over time (i.e., emotion dynamics) has been characterized by baseline, intraindividual variability and regulatory tendency (return time to baseline after deflection). Mounting evidence suggests that compared to healthy individuals, individuals with schizophrenia are characterized by a more negatively valenced baseline and a higher intraindividual variability. However, the regulatory tendency has not been investigated in schizophrenia so far. We hypothesize that the severity of positive symptoms is linked to increased emotional variability and that the severity of negative symptoms is associated with an increased regulatory tendency. Fifteen individuals diagnosed with schizophrenia took part in this pilot experience sampling study and reported their emotional state ten times a day. The dynamics of valence and arousal and their relationship with symptomatology were estimated with the DynAffect model. Regulatory tendency in valence and arousal was positively associated with negative symptom severity and negatively associated with positive symptom severity. However, the severity of positive symptoms was not credibly associated with the variability of valence. The study only partly corroborates findings on increased stress reactivity in schizophrenia, which might be due to the small sample size. However, results suggest that negative symptoms could stem from over-regulated emotion dynamics, which may impede goal-directed behavior.

Is sensitivity to daily stress predictive of onset or persistence of psychopathology?

PURPOSE

The aim of the current study was to replicate findings in adults indicating that higher sensitivity to stressful events is predictive of both onset and persistence of psychopathological symptoms in a sample of adolescents and young adults. In addition, we tested the hypothesis that sensitivity to mild stressors in particular is predictive of the developmental course of psychopathology.

METHODS

We analyzed experience sampling and questionnaire data collected at baseline and one-year follow-up of 445 adolescent and young adult twins and non-twin siblings (age range: 15-34). Linear multilevel regression was used for the replication analyses. To test if affective sensitivity to mild stressors in particular was associated with follow-up symptoms, we used a categorical approach adding variables on affective sensitivity to mild, moderate and severe daily stressors to the model.

RESULTS

Linear analyses showed that emotional stress reactivity was not associated with onset (β=.02; P=.56) or persistence (β=-.01; P=.78) of symptoms. There was a significant effect of baseline symptom score (β=.53; P<.001) and average negative affect (NA: β=.19; P<.001) on follow-up symptoms. Using the categorical approach, we found that affective sensitivity to mild (β=.25; P<.001), but not moderate (β=-.03; P=.65) or severe (β=-.06; P=.42), stressors was associated with symptom persistence one year later.

DISCUSSION

We were unable to replicate previous findings relating stress sensitivity linearly to symptom onset or persistence in a younger sample. Whereas sensitivity to more severe stressors may reflect adaptive coping, high sensitivity to the mildest of daily stressors may indicate an increased risk for psychopathology.

Psychological and Biological Validation of a Novel Digital Social Peer Evaluation Experiment (digi-SPEE)

INTRODUCTION

Negative social evaluation is associated with psychopathology. Given the frequency of evaluation through increasingly prevalent virtual social networks, increased understanding of the effects of this social evaluation is urgently required.

METHODS

A new digital social peer evaluation experiment (digi-SPEE) was developed to mimic everyday online social interactions between peers. Participants received mildly negative feedback on their appearance, intelligence, and congeniality. Two hundred and forty-one young people [58.9% female, aged 18.9 years (15 to 34)] from an ongoing novel general population twin study participated in this study. Positive affect (PA), negative affect (NA), implicit self-esteem, and cortisol were assessed before and after exposure to the social evaluation experiment.

RESULTS

The social evaluation experiment decreased PA (B=-5.25, p<.001) and implicit self-esteem (B=-.19; p<.001), whereas it increased NA (B=5.99; p<.001) and cortisol levels (B=.07; p<.001). Females (PA: B=-7.62; p<.001; NA: B=8.28; p<.001) and participants with higher levels of general psychological distress (PA: B=-.04, p=.035; NA: B=.06; p=.028) showed stronger affective responses. Stressor-induced cortisol increase was stronger in adolescents under the age of 18 than in participants 18 years and older (B=-.06, p=.002).

CONCLUSION

The digi-SPEE represents a social evaluation stressor that elicits biological and implicit and explicit mental changes that are relevant to mechanisms of psychopathology.

Altered circadian patterns of salivary cortisol in individuals with schizophrenia: A critical literature review

This article focuses on stress vulnerability in schizophrenia through an integrated clinical and biological approach. The objective of this article is to better understand the relationships between vulnerability, stress and schizophrenia. First, the concept of vulnerability is defined and several models of vulnerability in schizophrenia are reviewed. Second, a section is developed on the biology of stress, and more specifically on the stress responses of the hypothalamo-pitutary adrenal (HPA) axis. Then, studies of cortisol circadian rhythms are summarized, suggesting hyper-reactivity of the HPA axis in patients with schizophrenia and high risk individuals for schizophrenia. The results support the models of stress vulnerability in schizophrenia and the hypothesis of high cortisol levels as an endophenotype in this disorder. In conclusion, this article highlights the interest of studying the cortisol circadian rhythms in schizophrenia and opens the perspective to identify high risk individuals for schizophrenia by measuring circadian patterns of salivary cortisol.

Neurocognitive deficits or stress overload: Why do individuals with schizophrenia show poor performance in neurocognitive tests?

Poor performance in neurocognitive tasks is consistently found across studies in all stages of schizophrenia spectrum disorders and is interpreted as an underlying, brain function-related, neurocognitive deficit. However, neurocognitive test performance in schizophrenia might be compromised by patients' increased stress level. We investigated group-differences in neurocognitive performance while accounting for psychophysiological (salivary cortisol, heart rate, skin conductance level) and self-reported stress. We included 35 patients with schizophrenia, 29 participants with attenuated psychotic symptoms, 26 first-degree relatives of individuals with schizophrenia and 28 healthy controls. Participants completed a neurocognitive test battery that assessed processing speed, task switching, attention, working memory, verbal episodic memory, and verbal comprehension. Multivariate analyses of covariance (MANCOVA) were calculated to test for main effects of group on neurocognitive performance thereby not accounting versus accounting for confounding effects of stress. As expected, patients with schizophrenia scored lower than the other groups in all neurocognitive domains. Participants with attenuated psychotic symptoms, first-degree relatives and healthy individuals did not differ from each other in their performance. After accounting for heart rate and self-reported stress, the multivariate effect of group on neurocognition remained significant, but was rendered non-significant for specific domains - working memory capacity, episodic memory, and long-term memory. The findings imply that stress is relevant to neurocognitive performance and this should be taken into account when interpreting the origin of performance deficits in schizophrenia patients.

Modeling the Interplay Between Psychological Processes and Adverse, Stressful Contexts and Experiences in Pathways to Psychosis: An Experience Sampling Study

Several integrated models of psychosis have implicated adverse, stressful contexts and experiences, and affective and cognitive processes in the onset of psychosis. In these models, the effects of stress are posited to contribute to the development of psychotic experiences via pathways through affective disturbance, cognitive biases, and anomalous experiences. However, attempts to systematically test comprehensive models of these pathways remain sparse. Using the Experience Sampling Method in 51 individuals with first-episode psychosis (FEP), 46 individuals with an at-risk mental state (ARMS) for psychosis, and 53 controls, we investigated how stress, enhanced threat anticipation, and experiences of aberrant salience combine to increase the intensity of psychotic experiences. We fitted multilevel moderated mediation models to investigate indirect effects across these groups. We found that the effects of stress on psychotic experiences were mediated via pathways through affective disturbance in all 3 groups. The effect of stress on psychotic experiences was mediated by threat anticipation in FEP individuals and controls but not in ARMS individuals. There was only weak evidence of mediation via aberrant salience. However, aberrant salience retained a substantial direct effect on psychotic experiences, independently of stress, in all 3 groups. Our findings provide novel insights on the role of affective disturbance and threat anticipation in pathways through which stress impacts on the formation of psychotic experiences across different stages of early psychosis in daily life.

Childhood trauma and HPA axis functionality in offspring of bipolar parents

Children of a parent with bipolar disorder (bipolar offspring) have an increased risk for mood disorders. While genetic factors play a significant role in this population, susceptibility to environmental stress may also significantly contribute to this vulnerability for mood disorders. Childhood trauma has consistently been found to increase the risk for mood disorders, with persisting consequences for hypothalamic-pituitary-adrenal (HPA) axis functionality. However, it is currently unknown whether childhood trauma specifically affects HPA axis activity in individuals with a familial risk for bipolar disorder. Therefore, we investigated the effects of childhood trauma on daytime and evening cortisol levels and dexamethasone suppression in bipolar offspring (N=70) and healthy controls (N=44). In our study we found no significant differences in daytime and evening cortisol levels as well as dexamethasone suppression between bipolar offspring and healthy controls (all p-values>0.43). In contrast, childhood trauma differentially affected daytime cortisol levels in the bipolar offspring compared to healthy controls (childhood trauma X bipolar offspring interaction, β=-7.310, p=0.0414) with an effect of childhood trauma on daytime cortisol in bipolar offspring at trend level (p=0.058). In the bipolar offspring group, lifetime or current psychiatric diagnoses, and stressful life events separately did not affect cortisol levels or dexamethasone suppression (all p-values>p=0.50). These findings were independent of current or lifetime psychiatric diagnosis. In conclusion, trauma-related changes in daytime HPA axis activity appear to be a specific trait in bipolar offspring who have increased risk for mood disorders compared to healthy individuals.

Incidence of stressful life events and influence of sociodemographic and clinical variables on the onset of first-episode psychosis

This study presents a quantitative analysis of the incidence of stressful life events (SLEs) and the variables gender, age at onset, family history and psychotic symptoms in patients with first-episode psychosis (FEP). A descriptive, cross-sectional methodology was used to interview 68 patients with FEP between 13 and 47 years of age. The Psychiatric Epidemiology Research Interview Life Events Scale collected one-year period prior to onset of FEP - used to analyse the subcategories academic, work, love and marriage, children, residence, legal affairs, finances and social activities-, Positive and Negative Syndrome Scale, and Clinical Global Impression-Schizophrenia scale were used to assess the relevance of certain SLEs during adolescence. Age at onset showed a significant negative correlation with the categories academic and social activities. By contrast, it showed a positive correlation with work and children. A significant relationship was found between paternal family history and social activities and between maternal family history and academic and love and marriage. Finally, an inverse relationship was observed between negative symptoms and the categories children and finance. Depressive symptoms were significantly correlated with the category academic. Our results show the importance of SLEs during adolescence and suggest that there is a clear need to develop preventive actions that promote effective strategies for dealing with the accumulation of psychosocial stress.

The Very Low-Dose Dexamethasone Suppression Test in the General Population: A Cross-Sectional Study

Determinants of the hypothalamic-pituitary-adrenal (HPA) axis functioning are increasingly explored in population-based studies. However, functional tests measuring the negative feedback of the HPA axis cannot easily be implemented into large observational studies. Furthermore, high doses of dexamethasone often completely suppress the HPA axis in healthy persons. This study aimed to detect the effects of the health, lifestyle and sociodemographic factors, psychiatric problems and cognitive functions on the negative feedback of the HPA axis using a very low-dose (0.25 mg) dexamethasone suppression test (DST).We evaluated the associations of several determinants with the saliva cortisol concentrations after dexamethasone intake in a confounder-adjusted model also corrected for baseline saliva cortisol concentrations in the Rotterdam Study, a large population-based study (N = 1822). We found that female sex, low income, lack of exercise, instrumental disability and smoking were all independently associated with stronger suppression of the HPA axis. Even though there were no linear associations between psychiatric measures and cortisol suppression, we found that depressive symptoms and anxiety disorders were more common in persons with non-suppression of cortisol. Conversely, psychotropic medication use was related to enhanced suppression of cortisol after DST. In this large study, we found that female gender, low socioeconomic status and poor health were all related to suppression of the HPA axis. Non-linear associations were detected between the suppression of the HPA axis and common psychiatric disorders in community-dwelling persons.

Sex differences in morning cortisol in youth at ultra-high-risk for psychosis

Research suggests abnormalities in hypothalamic-pituitary-adrenal (HPA) axis function play an important role in the pathophysiology of psychosis. However, there is limited research on the biological stress system in young people at ultra high risk (UHR) for psychosis. Morning cortisol levels are particularly relevant to study in this context, as these markers reflect HPA regulation. This is the first examination of sex differences in morning cortisol levels in UHR individuals. Twenty-eight UHR and 22 matched healthy control participants were assessed in respect to symptoms and had home-based collection of salivary cortisol over three time points in the morning. It was predicted that the UHR participants would exhibit lower morning cortisol levels and lower cortisol would be associated with greater symptomatology (i.e. higher positive, negative, and depressive symptoms). Additionally, sex differences in morning cortisol levels were explored based on recent evidence suggesting that sex differences may play an important role in the exacerbation of psychosis. While there were no group differences in morning salivary cortisol secretion, there was a sex by time interaction among UHR individuals, such that only UHR males exhibited flat cortisol levels across two hours after awakening, whereas UHR females had a pattern of cortisol secretion similar to healthy controls, even among medication-free individuals (F=6.34, p=0.004). Cortisol AUC (area under the curve) across the three time points had a trend association (medium effect size; r=0.34, p=0.08) with depressive, but not positive or negative, symptom severity. These results stress the importance of considering sex differences in the psychosis-risk period, as they improve understanding of pathogenic processes.

Perceived stress and hair cortisol: Differences in bipolar disorder and schizophrenia

INTRODUCTION

Bipolar disorder (BD) and schizophrenia (SCZ) are psychiatric disorders with shared and distinct clinical and genetic features. In both disorders, stress increases the risk for onset or relapse and dysregulation of the hypothalamus-pituitary-adrenal (HPA) axis has been reported. The latter is frequently investigated by measuring changes in the hormonal end product of the HPA axis, i.e., the glucocorticoid cortisol, whose concentration exhibits diurnal variation. The analysis of hair cortisol concentration (HCC) is a new method, which allows assessment of cumulative cortisol secretion over the preceding three months.

AIMS

To explore whether perceived stress and HCC: (i) differ between BD patients, SCZ patients, and controls; (ii) change over disease course; and iii) are associated with an increased genetic risk for BD or SCZ.

METHODS

159 SCZ patients, 61 BD patients and 82 controls were included. Assessment included psychopathology, perceived stress, and HCC. Inpatients with an acute episode (38 BD and 77 SCZ) were assessed shortly after admission to hospital and at 3 and 6 months follow-up. Outpatients in remission and controls were assessed at one time point only. Polygenic risk scores for BD and SCZ were calculated based on results of the Psychiatric Genomic Consortium.

RESULTS

(i) Perceived stress was higher in BD and SCZ patients compared to controls (p<0.02), and was lower in outpatients in remission compared to inpatients on admission. HCC was higher in BD patients compared to SCZ patients and controls (p<0.02), and higher in inpatients on admission than in outpatients in remission (p=0.0012). In BD patients (r=0.29; p=0.033) and SCZ patients (r=0.20; p=0.024) manic symptoms were correlated with HCC. (ii) In both BD and SCZ inpatients, perceived stress decreased over the 6 month study period (p=0.048), while HCC did not change significantly over the 6 month study period. (iii) In controls, but not in the patient groups, the genetic risk score for BD was associated with HCC (r=0.28, p=0.023).

CONCLUSIONS

While our results are consistent with previous reports of increased perceived stress in BD and SCZ, they suggest differential involvement of the HPA axis in the two disorders. The genetic study supports this latter finding, and suggests that this effect is present below the threshold of manifest disorder.

Stress Sensitivity, Aberrant Salience, and Threat Anticipation in Early Psychosis: An Experience Sampling Study

While contemporary models of psychosis have proposed a number of putative psychological mechanisms, how these impact on individuals to increase intensity of psychotic experiences in real life, outside the research laboratory, remains unclear. We aimed to investigate whether elevated stress sensitivity, experiences of aberrant novelty and salience, and enhanced anticipation of threat contribute to the development of psychotic experiences in daily life. We used the experience sampling method (ESM) to assess stress, negative affect, aberrant salience, threat anticipation, and psychotic experiences in 51 individuals with first-episode psychosis (FEP), 46 individuals with an at-risk mental state (ARMS) for psychosis, and 53 controls with no personal or family history of psychosis. Linear mixed models were used to account for the multilevel structure of ESM data. In all 3 groups, elevated stress sensitivity, aberrant salience, and enhanced threat anticipation were associated with an increased intensity of psychotic experiences. However, elevated sensitivity to minor stressful events (χ(2)= 6.3,P= 0.044), activities (χ(2)= 6.7,P= 0.036), and areas (χ(2)= 9.4,P= 0.009) and enhanced threat anticipation (χ(2)= 9.3,P= 0.009) were associated with more intense psychotic experiences in FEP individuals than controls. Sensitivity to outsider status (χ(2)= 5.7,P= 0.058) and aberrantly salient experiences (χ(2)= 12.3,P= 0.002) were more strongly associated with psychotic experiences in ARMS individuals than controls. Our findings suggest that stress sensitivity, aberrant salience, and threat anticipation are important psychological processes in the development of psychotic experiences in daily life in the early stages of the disorder.

Diurnal cortisol variation and cortisol response to an MRI stressor in schizophrenia and bipolar disorder

Markers of HPA axis function, including diurnal cortisol rhythm and cortisol responses to stress or pharmacological manipulation, are increasingly reported as disrupted in schizophrenia (SZ) and bipolar disorder (BD). However, there has been no direct comparison of cortisol responses to stress in SZ and BD in the same study, and associations between cortisol dysfunction and illness characteristics remain unclear. In this study we used spline embedded linear mixed models to examine cortisol levels of SZ and BD participants at waking, during the first 45min after waking (representing the cortisol awakening response; CAR), during the period of rapid cortisol decline post the awakening response, and in reaction to a stressor (MRI scan), relative to healthy controls (HC). Contrary to expectations, neither SZ nor BD showed differences in waking cortisol levels, CAR, or immediate post-CAR decline compared to HC; however, waking cortisol levels were greater in BD relative to SZ. In response to the MRI stressor, the SZ group showed a significant absence of the expected increase in cortisol responsivity to stress, which was seen in both the BD and HC groups. Clinical factors affecting the CAR differed between SZ and BD. In SZ, higher antipsychotic medication dosage was associated with a steeper incline of the CAR, while greater positive symptom severity was associated with a more blunted CAR, and greater levels of anxiety were associated with the blunted cortisol response to stress. In BD, longer illness duration was associated with a steeper incline in CAR and lower levels of waking cortisol. These results suggest that cortisol responses may normalize with medication (in SZ) and longer illness duration (in BD), in line with findings of aberrant cortisol levels in the early stages of psychotic disorders.

The relations of age and pubertal development with cortisol and daily stress in youth at clinical risk for psychosis

BACKGROUND

Prodromal syndromes often begin in adolescence - a period of neurodevelopmental changes and heightened stress sensitivity. Research has shown elevated stress and cortisol in individuals at clinical high risk (CHR) for psychosis. This cross-sectional study examined relations of age and pubertal status with cortisol and self-reported stress in healthy controls (HCs) and CHR adolescents. It was hypothesized that the relations of age and pubertal stage with cortisol and stress would be more pronounced in CHR youth.

METHODS

Participants were 93 HCs and 348 CHR adolescents from the North American Prodrome Longitudinal Study (NAPLS). At baseline, measures of stress (Daily Stress Inventory - DSI), Tanner stage (TS), and salivary cortisol were obtained.

RESULTS

ANCOVA revealed increased DSI scores with age for both groups, and higher DSI scores in CHR adolescents than HCs, with a more pronounced difference for females. Contrary to prediction, with age controlled, HCs showed greater TS-related DSI increases. Analysis of cortisol showed no significant interactions, but a main effect of age and a trend toward higher cortisol in the CHR group. Correlations of cortisol with TS were higher in HC than CHR group.

CONCLUSIONS

Stress measures increased with age in HC and CHR adolescents, and DSI scores also increased with TS in HCs. The results do not support a more pronounced age or TS increase in stress measures in CHR adolescents, but instead suggest that stress indices tend to be elevated earlier in adolescence in the CHR group. Potential determinants of findings and future directions are discussed.

Early-Life Stress Affects Stress-Related Prefrontal Dopamine Activity in Healthy Adults, but Not in Individuals with Psychotic Disorder

Early life stress may have a lasting impact on the developmental programming of the dopamine (DA) system implicated in psychosis. Early adversity could promote resilience by calibrating the prefrontal stress-regulatory dopaminergic neurotransmission to improve the individual's fit with the predicted stressful environment. Aberrant reactivity to such match between proximal and distal environments may, however, enhance psychosis disease risk. We explored the combined effects of childhood adversity and adult stress by exposing 12 unmedicated individuals with a diagnosis of non-affective psychotic disorder (NAPD) and 12 healthy controls (HC) to psychosocial stress during an [18F]fallypride positron emission tomography. Childhood trauma divided into early (ages 0-11 years) and late (12-18 years) was assessed retrospectively using a questionnaire. A significant group x childhood trauma interaction on the spatial extent of stress-related [18F]fallypride displacement was observed in the mPFC for early (b = -8.45, t(1,23) = -3.35, p = .004) and late childhood trauma (b = -7.86, t(1,23) = -2.48, p = .023). In healthy individuals, the spatial extent of mPFC DA activity under acute psychosocial stress was positively associated with the severity of early (b = 7.23, t(11) = 3.06, p = .016) as well as late childhood trauma (b = -7.86, t(1,23) = -2.48, p = .023). Additionally, a trend-level main effect of early childhood trauma on subjective stress response emerged within this group (b = -.7, t(11) = -2, p = .07), where higher early trauma correlated with lower subjective stress response to the task. In the NAPD group, childhood trauma was not associated with the spatial extent of the tracer displacement in mPFC (b = -1.22, t(11) = -0.67), nor was there a main effect of trauma on the subjective perception of stress within this group (b = .004, t(11) = .01, p = .99). These findings reveal a potential mechanism of neuroadaptation of prefrontal DA transmission to early life stress and suggest its role in resilience and vulnerability to psychosis.

Ecological Interventionist Causal Models in Psychosis: Targeting Psychological Mechanisms in Daily Life

Integrated models of psychotic disorders have posited a number of putative psychological mechanisms that may contribute to the development of psychotic symptoms, but it is only recently that a modest amount of experience sampling research has provided evidence on their role in daily life, outside the research laboratory. A number of methodological challenges remain in evaluating specificity of potential causal links between a given psychological mechanism and psychosis outcomes in a systematic fashion, capitalizing on longitudinal data to investigate temporal ordering. In this article, we argue for testing ecological interventionist causal models that draw on real world and real-time delivered, ecological momentary interventions for generating evidence on several causal criteria (association, time order, and direction/sole plausibility) under real-world conditions, while maximizing generalizability to social contexts and experiences in heterogeneous populations. Specifically, this approach tests whether ecological momentary interventions can (1) modify a putative mechanism and (2) produce changes in the mechanism that lead to sustainable changes in intended psychosis outcomes in individuals' daily lives. Future research using this approach will provide translational evidence on the active ingredients of mobile health and in-person interventions that promote sustained effectiveness of ecological momentary interventions and, thereby, contribute to ongoing efforts that seek to enhance effectiveness of psychological interventions under real-world conditions.

A systematic review on definitions and assessments of psychotic-like experiences

AIMS

Psychotic-like experiences (PLEs) or subclinical psychotic experiences have received increased attention as some studies have suggested continuity between PLEs and psychotic disorders. However, epidemiological and correlational studies of PLEs showed mixed findings - it is observed that different studies use a wide variety of definitions of PLEs, as well as different assessment tools that are designed to capture such described experiences. The differences in definitions and assessment tools adopted could contribute to the discrepancy of findings. The current review aims to examine the definitions and assessment tools adopted in the studies of PLEs.

METHODS

Literature search was conducted between October 2013 and February 2014 using three search engines: Medline, Web of Science and PubMed.

RESULTS

A total of 76 papers met the selection criteria and were included in the current review. It is found that the majority of papers reviewed defined PLEs quantitatively using assessment tools and do not have a specific phenomenological definition, whereas assessment tools adopted have a wide variety. Furthermore, phenomenological studies of PLEs were rare.

CONCLUSIONS

The variations in definitions and assessment tools of PLEs might contribute to mixed findings in researches. Reaching to a consensus through the study of phenomenology of PLEs is essential to further advancement of the research in this area.

Salivary cortisol in early psychosis: New findings and meta-analysis

BACKGROUND

Schizophrenia is a multifactorial disorder and environmental risk factors for it might contribute to hypothalamo-pituitary-adrenal axis (HPA) dysregulation. While increased cortisol levels have been reported in schizophrenia, as well as in early psychosis (compared to healthy controls), a crucial unresolved issue is whether elevated cortisol levels could be related to the distress of an emerging illness, rather than being specific to psychosis. Here, we report new findings from the first French cohort of young help-seekers (ICAAR) including ultra-high risk subjects (UHR), first-episode of psychosis (FEP) and non at-risk help seekers controls (HSC), followed by a meta-analysis of all available reports on salivary basal cortisol levels in early psychosis (UHR and FEP).

METHODS

In the ICAAR study, 169 individuals (15-30 years old) had their basal cortisol levels sampled and they were categorized (at baseline) as either UHR, FEP, or HSC using the criteria of the Comprehensive Assessment of At-Risk Mental States (CAARMS). The three groups were compared at baseline, and the UHR and HSC individuals were also included in a one-year longitudinal follow-up. UHRs who converted to psychosis at the follow up (UHR-P) were compared to non-converters (UHR-NP). We also performed a meta-analysis from case-control studies with basal salivary measures of cortisol, drawing from a systematic bibliographic search using the keywords 'cortisol', 'glucocorticoid', 'HPA' with 'UHR', 'CHR', 'at-risk mental state', 'schizotypal ', 'prodromal schizophrenia', 'first-episode psychosis', 'first episode schizophrenia', 'newly diagnosed schizophrenia', 'recent onset schizophrenia' [in Medline, Web of Knowledge (WOS), EBSCO], followed by a systematic screening of the resulting articles.

RESULTS

Basal cortisol levels were not significantly different between UHR, FEP, and HSC controls in the ICAAR cohort. Interestingly, initial cortisol levels were correlated with positive symptoms at the one year follow-up in the ICAAR cohort. The meta-analysis revealed a significant elevation of the salivary basal cortisol levels in UHR individuals compared to controls (8 studies--1060 individuals), but not between FEP and controls (6 studies--441 individuals). Indirect comparison of salivary basal cortisol levels between UHR and FEP did not yield significant differences. Finally, no differences were detected between the baseline cortisol of UHR-P and UHR-NP (4 studies--301 individuals).

CONCLUSION

The meta-analysis (including new data) indicates that basal cortisol levels were increased in UHR compared to controls, but FEP levels were not different from UHR or controls. Many confounding factors could decrease the effect size in FEP especially medication intake. Taken together with our new results (which made use of help-seeker controls, and not merely healthy controls), the findings indicate that basal cortisol levels may not be a reliable biomarker for early psychosis. Further studies are needed to clarify the precise role of the HPA axis in psychotic conversion.

Abnormalities in neuroendocrine stress response in psychosis: the role of endocannabinoids

The aim of this article is to summarize current evidence regarding alterations in the neuroendocrine stress response system and endocannabinoid system and their relationship in psychotic disorders such as schizophrenia. Exposure to stress is linked to the development of a number of psychiatric disorders including psychosis. However, the precise role of stress in the development of psychosis and the possible mechanisms that might underlie this are not well understood. Recently the cannabinoid hypothesis of schizophrenia has emerged as a potential line of enquiry. Endocannabinoid levels are increased in patients with psychosis compared with healthy volunteers; furthermore, they increase in response to stress, which suggests another potential mechanism for how stress might be a causal factor in the development of psychosis. However, research regarding the links between stress and the endocannabinoid system is in its infancy. Evidence summarized here points to an alteration in the baseline tone and reactivity of the hypothalamic-pituitary-adrenal (HPA) axis as well as in various components of the endocannabinoid system in patients with psychosis. Moreover, the precise nature of the inter-relationship between these two systems is unclear in man, especially their biological relevance in the context of psychosis. Future studies need to simultaneously investigate HPA axis and endocannabinoid alterations both at baseline and following experimental perturbation in healthy individuals and those with psychosis to understand how they interact with each other in health and disease and obtain mechanistic insight as to their relevance to the pathophysiology of schizophrenia.

Utility of Washington Early Recognition Center Self-Report Screening Questionnaires in the Assessment of Patients with Schizophrenia and Bipolar Disorder

Early identification and treatment are associated with improved outcomes in bipolar disorder (BPD) and schizophrenia (SCZ). Screening for the presence of these disorders usually involves time-intensive interviews that may not be practical in settings where mental health providers are limited. Thus, individuals at earlier stages of illness are often not identified. The Washington Early Recognition Center Affectivity and Psychosis (WERCAP) screen is a self-report questionnaire originally developed to identify clinical risk for developing bipolar or psychotic disorders. The goal of the current study was to investigate the utility of the WERCAP Screen and two complementary questionnaires, the WERC Stress Screen and the WERC Substance Screen, in identifying individuals with established SCZ or BPD. Participants consisted of 35 BPD and 34 SCZ patients, as well as 32 controls (CON), aged 18-30 years. Univariate analyses were used to test for score differences between groups. Logistic regression and receiver operating characteristic (ROC) curves were used to identify diagnostic predictors. Significant group differences were found for the psychosis section of the WERCAP (pWERCAP; p < 0.001), affective section of the WERCAP (aWERCAP; p = 0.001), and stress severity (p = 0.027). No significant group differences were found in the rates of substance use as measured by the WERC Substance Screen (p = 0.267). Only the aWERCAP and pWERCAP scores were useful predictors of diagnostic category. ROC curve analysis showed the optimal cut point on the aWERCAP to identify BPD among our participant groups was a score of >20 [area under the curve (AUC): 0.87; sensitivity: 0.91; specificity: 0.71], while that for the pWERCAP to identify SCZ was a score of >13 (AUC: 0.89; sensitivity: 0.88; specificity: 0.82). These results indicate that the WERCAP Screen may be useful in screening individuals for BPD and SCZ and that identifying stress and substance-use severity can be rapidly done using self-report questionnaires. Larger studies in undiagnosed individuals will be needed to test the WERCAP Screen's ability to identify mania or psychosis in the community.

Pituitary gland volume and psychosocial stress among children at elevated risk for schizophrenia

BACKGROUND

Pituitary volume enlargements have been observed among individuals with first-episode psychosis. These abnormalities are suggestive of hypothalamic-pituitary-adrenal (HPA) axis hyperactivity, which may contribute to the development of psychosis. However, the extent to which these abnormalities characterize individuals at elevated risk for schizophrenia prior to illness onset is currently unclear, as volume increases, decreases and no volume differences have all been reported relative to controls. The current study aimed to determine whether antipsychotic-naive, putatively at-risk children who present multiple antecedents of schizophrenia (ASz) or a family history of illness (FHx) show pituitary volume abnormalities relative to typically developing (TD) children. An additional aim was to explore the association between pituitary volume and experiences of psychosocial stress.

METHOD

ASz (n = 30), FHx (n = 22) and TD (n = 32) children were identified at age 9-12 years using a novel community-screening procedure or as relatives of individuals with schizophrenia. Measures of pituitary volume and psychosocial stress were obtained at age 11-14 years.

RESULTS

Neither ASz nor FHx children showed differences in pituitary volume relative to TD children. Among FHx children only, pituitary volume was negatively associated with current distress relating to negative life events and exposure to physical punishment.

CONCLUSIONS

The lack of pituitary volume abnormalities among ASz and FHx children is consistent with our previous work demonstrating that these children are not characterized by elevated diurnal cortisol levels. The findings imply that these biological markers of HPA axis hyperactivity, observed in some older samples of high-risk individuals, may emerge later, more proximally to disease onset.

Suicide Risk, Stress Sensitivity, and Self-Esteem among Young Adults Reporting Auditory Hallucinations

Individuals with subthreshold psychotic experiences are at increased risk for suicidal thoughts and behavior, similar to those with schizophrenia and other psychotic disorders. This may be explained by shared risk factors such as heightened stress sensitivity or low self-esteem. Understanding the nature of this relationship could inform suicide prevention in social work practice. In this study, authors examined the relationship between self-reported auditory hallucinations and suicidal thoughts, plans, and attempts, in a nonclinical sample of young adults, controlling for scores on the Psychological Stress Index and Rosenberg Self-Esteem Scale. Auditory hallucinations were associated with approximately double the odds of suicidal ideation and plans and four times the odds for suicide attempts. This relationship was not explained by stress sensitivity or self-esteem, which were independently related to hallucinations and suicidality, respectively. Subthreshold auditory hallucinations may be a useful indicator of suicide risk. This association may represent a clinically significant relationship that may be addressed through social work interventions intended to alleviate stress sensitivity or improve self-esteem.

Exploring the underlying structure of mental disorders: cross-diagnostic differences and similarities from a network perspective using both a top-down and a bottom-up approach

BACKGROUND

It has been suggested that the structure of psychopathology is best described as a complex network of components that interact in dynamic ways. The goal of the present paper was to examine the concept of psychopathology from a network perspective, combining complementary top-down and bottom-up approaches using momentary assessment techniques.

METHOD

A pooled Experience Sampling Method (ESM) dataset of three groups (individuals with a diagnosis of depression, psychotic disorder or no diagnosis) was used (pooled N = 599). The top-down approach explored the network structure of mental states across different diagnostic categories. For this purpose, networks of five momentary mental states ('cheerful', 'content', 'down', 'insecure' and 'suspicious') were compared between the three groups. The complementary bottom-up approach used principal component analysis to explore whether empirically derived network structures yield meaningful higher order clusters.

RESULTS

Individuals with a clinical diagnosis had more strongly connected moment-to-moment network structures, especially the depressed group. This group also showed more interconnections specifically between positive and negative mental states than the psychotic group. In the bottom-up approach, all possible connections between mental states were clustered into seven main components that together captured the main characteristics of the network dynamics.

CONCLUSIONS

Our combination of (i) comparing network structure of mental states across three diagnostically different groups and (ii) searching for trans-diagnostic network components across all pooled individuals showed that these two approaches yield different, complementary perspectives in the field of psychopathology. The network paradigm therefore may be useful to map transdiagnostic processes.

Resting cortisol level, self-concept, and putative familial environment in adolescents at ultra high-risk for psychotic disorders

A growing body of evidence suggests that resting cortisol levels are elevated in patients with schizophrenia and closely tied to symptom severity. However, there is limited research on the biological stress system during the ultra high-risk (UHR) period immediately preceding the onset of psychosis, and cortisol has not been examined in relation to individual characteristics such as self-concept or potential stressors such as putative familial environment in this critical population. In the present study, salivary cortisol samples were collected on 37 UHR and 42 matched control adolescents, and these individuals were assessed with clinical interviews as well as a measure of self-concept. For a subsection of the sample (23 UHR and 20 control adolescents), a participating relative/caretaker was also assessed with an expressed emotion interview designed to gauge psychosocial environment. Consistent with previous studies, UHR participants exhibited elevated resting cortisol levels when compared with controls. In addition, UHR adolescents exhibited increased negative self-concept and their relatives/caretakers endorsed significantly fewer initial positive statements about the participant. Interestingly, a strong trend in the UHR group suggests that higher cortisol levels are associated with higher rates of critical statements from relatives/caretakers. Furthermore, elevated cortisol levels in the participants were associated with increased negative self-concept as well as fewer initial positive comments from relatives/caretakers. Results suggest that hypothalamic-pituitary-adrenal axis (HPA) dysfunction is closely associated with both individual and environmental-level characteristics. Taken together, these findings support a neural diathesis-stress model of psychosis and future studies, designed to examine causal relationships, stand to inform both our understanding of pathogenic processes in the high-risk period as well as early intervention efforts.

Psychophysiological Assessment of Stress Under Ecological Settings

Abstract. Stress can negatively impact one’s health and well-being, however, despite the recent evolution in stress assessment research methodologies, there is still little agreement about stress conceptualization and assessment. In an attempt to summarize and reflect on this evolution, this paper aims to systematically review research evidence of ecological approaches on psychophysiological stress assessment. Thus, a literature search of electronic databases was conducted spanning 22 years (1990–2012) and 55 studies were reviewed. Studies were considered for inclusion if they contemplated both psychological and physiological measures of stress under ecological settings. This review focuses on five themes: methodology terminology, research population, study design, measurement, and technology. Findings support the need to use a common methodology terminology in order to increase scientific rigor. Additionally, there seems to be an increasing tendency for the use of these methods by multidisciplinary teams among both clinical and nonclinical populations aiming to understand the relationship between stress and disease. Most of the studies reviewed contemplated a time-based protocol and different conceptualizations of stress were found, resulting in the use of different subjective measures. Findings reinforce the importance of combining subjective and objective measures while also controlling for possible time- or situation-dependent confounders’. Advances in technology were evident and different assessment techniques were found. The benefits and challenges of ecological protocols to assess stress are discussed and recommendations for future research are provided, aiming to overcome previous limitations and advance scientific knowledge in the area.

Sex differences, hormones, and fMRI stress response circuitry deficits in psychoses

Response to stress is dysregulated in psychosis (PSY). fMRI studies showed hyperactivity in hypothalamus (HYPO), hippocampus (HIPP), amygdala (AMYG), anterior cingulate (ACC), orbital and medial prefrontal (OFC; mPFC) cortices, with some studies reporting sex differences. We predicted abnormal steroid hormone levels in PSY would be associated with sex differences in hyperactivity in HYPO, AMYG, and HIPP, and hypoactivity in PFC and ACC, with more severe deficits in men. We studied 32 PSY cases (50.0% women) and 39 controls (43.6% women) using a novel visual stress challenge while collecting blood. PSY males showed BOLD hyperactivity across all hypothesized regions, including HYPO and ACC by FWE-correction. Females showed hyperactivity in HIPP and AMYG and hypoactivity in OFC and mPFC, the latter FWE-corrected. Interaction of group by sex was significant in mPFC (F = 7.00, p = 0.01), with PSY females exhibiting the lowest activity. Male hyperactivity in HYPO and ACC was significantly associated with hypercortisolemia post-stress challenge, and mPFC with low androgens. Steroid hormones and neural activity were dissociated in PSY women. Findings suggest disruptions in neural circuitry-hormone associations in response to stress are sex-dependent in psychosis, particularly in prefrontal cortex.

Responses to stress in patients with psychotic disorders compared to persons with varying levels of vulnerability to psychosis, persons with depression and healthy controls

BACKGROUND AND OBJECTIVES

An experimental design was used to test whether self-reported, psychophysiological and symptomatic stress-responses increase as a function of the underlying vulnerability to psychosis as proposed by vulnerability-stress-models.

METHODS

Stress-responses of participants with psychotic disorders (PSY, n = 35) were compared to those of participants with attenuated positive symptoms (AS, n = 29), first-degree relatives of persons with psychotic disorders (REL, n = 26), healthy controls (HC, n = 28) and controls with depression (DEP, n = 30). Using a repeated measures design, participants were assigned to a noise stressor, a social stressor and a no stress condition in random order. Stress-responses were assessed via self-report, salivary cortisol levels, heart rate and skin conductance levels. State-paranoia and depression were assessed with clinical scales.

RESULTS

PSY reported to be significantly more stressed than HC, AS and REL across all conditions which went along with increased heart rate and decreased overall cortisol release. In contrast, AS showed elevated levels of cortisol. PSY showed a stronger response of self-reported stress to the noise condition compared to the no stress condition than HC, but no stronger response than the other samples. Furthermore, the stressors did not trigger stronger psychophysiological responses or symptom-increases in PSY.

LIMITATIONS

The social stressor was brief and not individualized and did not have an effect on cortisol.

CONCLUSIONS

The findings support the notion that subjective stress-responsiveness increases with vulnerability, but not the assumption that symptoms arise directly as a function of stress and vulnerability. Also, the generally high levels of arousal seem to be more relevant to psychosis than the responsiveness to specific stressors.

Role of cortisol in patients at risk for psychosis mental state and psychopathological correlates: A systematic review

During recent decades, much evidence has been accumulated concerning the neuroendocrine basis of schizophrenia. Recently, research has focused on stress hormones, with cortisol being the most widely researched, during the prodromal phase of psychosis. Thus, the present study aims to systematically review the evidence concerning the role of cortisol in patients at risk for psychosis mental state and its associations with psychopathological correlates. We systematically reviewed the published reports referring to both 'at clinical risk for psychosis' and 'at genetic risk for psychosis' mental state. Sixteen studies were identified. A trend towards increased cortisol levels in saliva emerged. Findings concerning cortisol levels in the blood were minimal and less consistent. The longitudinal studies, though with divergent results, hinted towards upregulation of cortisol secretion prior to psychotic conversion. Regarding cortisol's reactivity, evaluated through neuroendocrine, psychosocial and naturalistic stressors, the findings were minimal and divergent. The hypothesized relation of psychotic symptomatology with cortisol in subjects at risk for psychosis was not confirmed by the majority of the studies. On the contrary, the anxiety parameter and stress-intolerance index were both positively associated with cortisol. In conclusion, the published reports related to the evaluation of cortisol levels/function at prodrome are hitherto minimal. Although the evidence favors cortisol's participation in the pathophysiology of psychosis, the exact cause-effect sequence and the intertwining of cortisol with psychopathology are still unclear.

No evidence for attenuated stress-induced extrastriatal dopamine signaling in psychotic disorder

Stress is an important risk factor in the etiology of psychotic disorder. Preclinical work has shown that stress primarily increases dopamine (DA) transmission in the frontal cortex. Given that DA-mediated hypofrontality is hypothesized to be a cardinal feature of psychotic disorder, stress-related extrastriatal DA release may be altered in psychotic disorder. Here we quantified for the first time stress-induced extrastriatal DA release and the spatial extent of extrastriatal DA release in individuals with non-affective psychotic disorder (NAPD). Twelve healthy volunteers (HV) and 12 matched drug-free NAPD patients underwent a single infusion [(18)F]fallypride positron emission tomography scan during which they completed the control and stress condition of the Montreal Imaging Stress Task. HV and NAPD did not differ in stress-induced [(18)F]fallypride displacement and the spatial extent of stress-induced [(18)F]fallypride displacement in medial prefrontal cortex (mPFC) and temporal cortex (TC). In the whole sample, the spatial extent of stress-induced radioligand displacement in right ventro-mPFC, but not dorso-mPFC or TC, was positively associated with task-induced subjective stress. Psychotic symptoms during the scan or negative, positive and general subscales of the Positive and Negative Syndrome Scale were not associated with stress-induced [(18)F]fallypride displacement nor the spatial extent of stress-induced [(18)F]fallypride displacement in NAPD. Our results do not offer evidence for altered stress-induced extrastriatal DA signaling in NAPD, nor altered functional relevance. The implications of these findings for the role of the DA system in NAPD and stress processing are discussed.

Much ado about much: stress, dynamic biomarkers and HPA axis dysregulation along the trajectory to psychosis

OBJECTIVES

In the context of a stress-vulnerability framework, hyperactivation of the hypothalamic-pituitary-adrenal (HPA) axis is thought contribute to the risk, onset and course of psychotic illness. However, recent reports regarding static and dynamic features of the HPA axis suggest a more complex set of phenomena at play in the early phases of psychosis.

METHODS

We review literature regarding structural and functional aspects of the HPA axis in subjects at risk for or experiencing the first episode of psychosis, including evidence favoring as well as that which contradicts a model of HPA axis hyperactivation.

RESULTS

Static measures of diurnal cortisol and hippocampal/pituitary volumes suggest that the HPA axis is in a hyperactivated state in early phases of psychosis. In contrast, the dynamic cortisol response to encountered or anticipated stress is blunted in the same populations. These incongruent findings need to be better understood.

CONCLUSIONS

We consider potential explanations for the seemingly contradictory elevation and blunting of HPA biomarkers in the early course of psychosis. Finally, we propose and explore implications of a conceptual model of tonic HPA hyperactivation and phasic HPA blunting that integrates and reconciles these data.

Stress biomarkers as predictors of transition to psychosis in at-risk mental states: roles for cortisol, prolactin and albumin

Stress and inflammation are thought to play a role in the risk of developing a psychotic disorder. We aimed to identify stress-related biomarkers for psychosis transition in help-seeking individuals with an at-risk mental state (ARMS). We studied 39 ARMS subjects who were attending an Early Intervention Service. We included a control group of 44 healthy subjects (HS) matched by sex and age. Stressful life events and perceived stress were assessed. Stress-related biomarkers were determined in serum (cortisol, prolactin, C-reactive protein and albumin), plasma (fibrinogen) or saliva (morning cortisol, cortisol awakening response). All ARMS were followed-up at our Unit for at least one year. We divided the ARMS group into two subgroups based on the development of a psychotic disorder (ARMS-P, N = 10) or not (ARMS-NP, N = 29). ARMS-P reported more stressful life events and perceived stress than HS and ARMS-NP groups. In relation to baseline stress biomarkers, ARMS-P subjects had increased prolactin and lower albumin levels in serum, when compared to ARMS-NP and HS groups. These results did not change when repeated in a subsample of antipsychotic-naïve ARMS subjects. We also found significant differences between groups in the cortisol secretion after awakening. In a multinomial logistic regression adjusting for age, sex and life stress, prolactin was a predictor of psychosis transition whereas albumin levels had a protective effect. Our study underscores the role of stress and stress-related biomarkers (cortisol awakening response, prolactin and albumin) in the pathogenesis of psychosis.

Testing an mHealth momentary assessment Routine Outcome Monitoring application: a focus on restoration of daily life positive mood states

BACKGROUND

Routine Outcome Monitoring (ROM) is used as a means to enrich the process of treatment with feedback on patient outcomes, facilitating patient involvement and shared decision making. While traditional ROM measures focus on retrospective accounts of symptoms, novel mHealth technology makes it possible to collect real life, in-the-moment ambulatory data that allow for an ecologically valid assessment of personalized and contextualized emotional and behavioural adjustment in the flow daily life (mROM).

METHOD

In a sample of 34 patients with major depressive disorder, treated with antidepressants, the combined effect of treatment and natural course was examined over a period of 18 weeks with Ecological Momentary Assessment (EMA). EMA consisted of repeated, within-subject, mini-measurements of experience (eg positive affect, negative affect, medication side effects) and context (eg stressors, situations, activities) at 10 unselected semi-random moments per day, for a period of six days, repeated three times over the 18-week period (baseline, week 6 and week 18).

RESULTS

EMA measures of emotional and behavioural adjustment were sensitive to the effects of treatment and natural course over the 18-week period, particularly EMA measures focussing on positive mood states and the ability to use natural rewards (impact of positive events on positive mood states), with standardized effect sizes of 0.4-0.5. EMA measures of activities, social interaction, stress-sensitivity and negative mood states were also sensitive to change over time.

CONCLUSION

This study supports the use of mROM as a means to involve the patient in the process of needs assessment and treatment. EMA data are meaningful to the patient, as they reflect daily life circumstances. Assessment of treatment response with mROM data allows for an interpretation of the effect of treatment at the level of daily life emotional and social adjustment--as an index of health, obviating the need for an exclusive focus on traditional measures of 'sickness'.

Reduced hippocampal volume and hypothalamus-pituitary-adrenal axis function in first episode psychosis: evidence for sex differences

Background

Hippocampal volume (HV) decline is an important marker of psychosis and has been associated with hypothalamus–pituitary–adrenal (HPA) axis dysregulation in various disorders. Given recent findings of sex differences in HPA axis function in psychosis, the current study investigated differences in HV in male and female first episode psychosis (FEP) patients and controls and the interaction of HV with the cortisol awakening response (CAR) and symptoms.

Methods

Fifty-eight patients with a diagnosis of FEP (39 men, 19 women) and 27 healthy community controls (15 men, 12 women) underwent structural magnetic resonance imaging (MRI) on a 1.5 T scanner. Hippocampal volume was determined using previously established segmentation protocols. Saliva samples for cortisol assessment were collected at 0, 30 and 60 min after awakening. Psychotic symptoms were assessed with the Scale for Assessment of Positive Symptoms (SAPS), the Scale for Assessment of Negative Symptoms (SANS) and the Global Assessment of Functioning (GAF) scale.

Results

Male patients had significantly smaller left and right HVs compared to male controls, which appeared to be secondary to global brain volume differences. However, even when controlling for overall brain size, male patients showed smaller HV compared to female patients. The CAR was significantly lower in male patients compared to male controls and female patients. Only in male patients, smaller left HV was significantly associated with a blunted CAR, and smaller HV bilaterally was related to positive psychotic symptoms and lower levels of functioning.

Conclusions

We propose that reduced hippocampal volume and an attenuated cortisol awakening response are related markers of increased stress vulnerability in male psychosis patients and that both contribute to the unfavorable clinical picture in men.

•

We examined sex differences in neurobiological markers of stress in psychosis.

•

Hippocampal volume and cortisol levels to awakening are reduced in male patients.

•

Male first episode psychosis patients show markers of high stress vulnerability.

•

Neurobiological deficits relate to poor outcome in male but not female patients.

•

The neural-diathesis stress model of schizophrenia is particularly valid for men.

Ambulatory assessment as a means of longitudinal phenotypes characterization in psychiatric disorders

Ambulatory Assessment (AA) comprises the use of in-field methods to assess individuals' behavior, physiology, and the experience as they unfold in naturalistic settings. We propose that AA is favorable for the investigation of gene-environment interactions and for the search for endophenotypes, being able to assess the experienced environment and to track basic regulatory processes, such as stress reactivity, affective instability, and reward experience, which are potential common factors that underlie psychiatric disorders. In this article, we (a) first describe briefly the rationale of AA and summarize the key advantages of the approach, (b) highlight within-subject regulatory processes, such as stress reactivity, affective instability, and reward experience, (c) describe studies that used AA to examine genetic influences in psychiatric disorders, and (d) briefly review longitudinal studies that have investigated phenotypes of psychiatric disorders. The reported studies yielded promising, although sometimes inconclusive evidence for genetic effects on endophenotypes of psychiatric disorders. Moreover, most studies were twin or family studies, especially in stress-sensitivity research; thus, it is unclear which specific single nucleotide polymorphisms contribute to the endophenotypes of psychiatric disorders. We do hope that within-subject regulatory processes will enable us to clarify the fundamental psychological dimensions that cut across traditional disorders and link them to their genetic underpinnings.

On the transmethylation hypothesis: stress, N,N-dimethyltryptamine, and positive symptoms of psychosis

Past research suggests a relationship between stress and positive symptoms of psychosis. However, the biological substrate of this relationship remains unknown. According to the transmethylation hypothesis, schizophrenia could result from a biochemical disruption in the stress mechanism. This biochemical disruption would lead to the production of a substance that would account for the symptoms of psychosis. Moreover, some studies have tested endogenous N,N-dimethyltryptamine (DMT) in the context of the transmethylation hypothesis. Stress has been found to elevate DMT levels in rodents. Also, elevated DMT levels have been associated with positive features of psychosis in psychiatric patients. Additionally, healthy participants treated with exogenous DMT experience predominantly positive symptoms of psychosis. The present paper examines endogenous DMT as a possible biological mediator of the relationship between stress and positive symptoms of psychosis.

The WERCAP Screen and the WERC Stress Screen: psychometrics of self-rated instruments for assessing bipolar and psychotic disorder risk and perceived stress burden

BACKGROUND

Identification of individuals in the prodromal phase of bipolar disorder and schizophrenia facilitates early intervention and promises an improved prognosis. There are no current assessment tools for clinical risk symptoms of bipolar disorder, and psychosis-risk assessment generally involves semi-structured interviews, which are time consuming and rater dependent. We present psychometric data on two novel quantitative questionnaires: the Washington Early Recognition Center Affectivity and Psychosis (WERCAP) Screen for assessing bipolar and psychotic disorder risk traits, and the accompanying WERC Stress Screen for assessing individual and total psychosocial stressor severities.

METHODS

Prevalence rates of the WERCAP Screen were evaluated among 171 community youth (aged 13-24 years); internal consistency was assessed and k-means cluster analysis was used to identify symptom groups. In 33 participants, test-retest reliability coefficients were assessed, and ROC curve analysis was used to determine the validity of the psychosis section of the WERCAP Screen (pWERCAP) against the Structured Interview of Psychosis-Risk Symptoms (SIPS). Correlations of the pWERCAP, the affectivity section of the WERCAP Screen (aWERCAP) and the WERC Stress Screen were examined to determine the relatedness of scores with cognition and clinical measures.

RESULTS

Cluster analysis identified three groups of participants: a normative (47%), a psychosis-affectivity (18%) and an affectivity only (35%) group. Internal consistency of the aWERCAP and pWERCAP resulted in alphas of 0.87 and 0.92, and test-retest reliabilities resulted in intraclass correlation coefficients of 0.76 and 0.86 respectively. ROC curve analysis showed the optimal cut-point on the pWERCAP as a score of >30 (sensitivity: 0.89; specificity: 1.0). There was a significant negative correlation between aWERCAP scores and total cognition (R=-0.42), and between pWERCAP scores and sensorimotor processing speed. Total stress scores correlated significantly with scores on the aWERCAP (R=0.88), pWERCAP (R=0.62) and total cognition (R=-0.44).

CONCLUSIONS

Our results show that the WERCAP Screen and the WERC Stress Screen are easy to administer and derived scores are related to cognitive and clinical traits. This suggests that their use could have particular benefits for epidemiologic studies and in busy clinical settings. Longitudinal studies would be required to evaluate clinical outcomes with high questionnaire scores.

Biomarkers and clinical staging in psychiatry

Personalized medicine is rapidly becoming a reality in today's physical medicine. However, as yet this is largely an aspirational goal in psychiatry, despite significant advances in our understanding of the biochemical, genetic and neurobiological processes underlying major mental disorders. Preventive medicine relies on the availability of predictive tools; in psychiatry we still largely lack these. Furthermore, our current diagnostic systems, with their focus on well-established, largely chronic illness, do not support a pre-emptive, let alone a preventive, approach, since it is during the early stages of a disorder that interventions have the potential to offer the greatest benefit. Here, we present a clinical staging model for severe mental disorders and discuss examples of biological markers that have already undergone some systematic evaluation and that could be integrated into such a framework. The advantage of this model is that it explicitly considers the evolution of psychopathology during the development of a mental illness and emphasizes that progression of illness is by no means inevitable, but can be altered by providing appropriate interventions that target individual modifiable risk and protective factors. The specific goals of therapeutic intervention are therefore broadened to include the prevention of illness onset or progression, and to minimize the risk of harm associated with more complex treatment regimens. The staging model also facilitates the integration of new data on the biological, social and environmental factors that influence mental illness into our clinical and diagnostic infrastructure, which will provide a major step forward in the development of a truly pre-emptive psychiatry.

[Travel and psychotic disorders: clinical aspects and practical recommendations]

Psychotic disorders are frequent among travelers (10 to 20 % of medical evacuations). The travel is a concentrate of stressors. Psychotic disorders are not a contraindication to travel. Special precautions should be taken for patients with psychotic disorders wishing to travel. These precautions could apply to patients at risk of transition to a psychotic disorder.