A systematic review of the activity of the hypothalamic-pituitary-adrenal axis in first episode psychosis

Analysis of hair cortisol level in first-episodic and recurrent female patients with depression compared to healthy controls

BACKGROUND

Although accumulating evidence has shown increased cortisol levels in serum, saliva, or 24-h urine samples in depression, a number of studies did not find the association between cortisol levels and depression. Hair cortisol levels reflect long-term and historical information of cortisol and hair cortisol analysis has been applied in the research of psychiatric diseases. The aim of this study is to compare the hair cortisol levels between patients with depression and healthy controls.

METHODS

Hair cortisol levels of 22 first-episodic and 13 recurrent female patients with depression and 30 healthy controls were measured and compared using the electrochemiluminescence immunoassay. The relationship between hair cortisol levels and Hamilton depression scale (HAMD) or Hamilton anxiety scale (HAMA) scores were also examined.

RESULTS

Before disease episode, no significant differences were observed among healthy controls, first-episodic patients and recurrent patients. In disease episode, the hair cortisol level in first-episodic patients was significantly higher than that in healthy controls or recurrent patients, while no significant difference was observed between recurrent patients and healthy controls. No significant correlation was found between HAMD or HAMA scores and hair cortisol levels in patients.

LIMITATIONS

First, long-term effects of antidepressants on the results cannot be excluded without detailed medication information of the recurrent patients. Second, sample sizes might be relatively small.

CONCLUSIONS

Our results indicate that hair cortisol levels increased in disease episode in first-episodic, but not recurrent patients with depression, which may suggest that episodes of disease have influence on cortisol levels.

Pituitary gland volume in at-risk mental state for psychosis: a longitudinal MRI analysis

INTRODUCTION

Pituitary enlargement has been reported in individuals with schizophrenic psychosis or an at-risk mental state for psychosis (ARMS). In a previous study, our group could show pituitary volume increase in first episode and ARMS patients with later transition to psychosis (ARMS-T). However, there are no longitudinal studies on this issue so far. We therefore examined longitudinally whether transition to psychosis would be accompanied by a further increase of pituitary volume in antipsychotic-naïve ARMS patients.

METHODS

Magnetic resonance imaging (MRI) data were acquired from 23 antipsychotic-naïve individuals with an ARMS. Ten subjects developed psychosis (ARMS-T) and 13 did not (ARMS-NT). ARMS-T were re-scanned after the onset of psychosis, and ARMS-NT were re-scanned at the end of the study period.

RESULTS

There was no significant difference of the pituitary volume between ARMS-T and ARMS-NT in our sample, and there were no significant pituitary volume changes over time. Discussion Longitudinally, we could not detect any further volumetric changes in the pituitary volume with transition to psychosis.

CONCLUSIONS

This, together with the result of our previous study, could indicate that the perceived level of stress in ARMS patients is constantly high from very early onward.

Schizophrenia in the spectrum of gene-stress interactions: the FKBP5 example

Many studies have demonstrated that genotype (G) interacts with adverse life experiences (E) to produce individual differences in vulnerability and resilience to mental disorders, including schizophrenia. Genetic susceptibility to stress and the timing of the environmental exposure(s) are relevant for these interactions and represent common risk factors. We take the example of the FKBP5 gene to illustrate G × E interactions that predict pleiotropic psychiatric outcomes, including schizophrenia.

Blunted neuroendocrine stress reactivity in young women with eating disorders

OBJECTIVE

Stress is known to influence risk and progression of eating disorders (EDs). However, studies investigating physiological and psychological stress responses under laboratory conditions in patients with Anorexia nervosa or Bulimia nervosa are scarce and often produce conflicting findings. We therefore aimed to compare the neuroendocrine and affective stress response in ED inpatients and healthy controls.

METHODS

Twenty-eight female inpatients with Anorexia or Bulimia nervosa and 26 healthy women were exposed to the Trier Social Stress Test (TSST). Salivary cortisol and alpha-amylase (sAA) levels were assessed before as well as repeatedly after stress exposure, while heart rate and heart rate variability were determined before and during the TSST. Negative affective state was assessed at baseline and post-TSST.

RESULTS

Compared to healthy controls, ED patients showed blunted cortisol stress responses combined with overall attenuated sAA levels. The latter was reflected in generally enhanced parasympathetic activity indicated by lower heart rate and stronger high-frequency heart rate variability throughout the TSST. Although patients reported more negative affect overall, they did not differ in their affective stress response.

CONCLUSIONS

In summary, patients suffering from eating disorders show a blunted HPA axis reactivity to stress exposure and a generally reduced sympathetic/exaggerated parasympathetic nervous system activity. This combination may contribute to elevated health risks seen in eating disorder patients, such as enhanced inflammatory activity, and thus provide insight into the underlying stress-related mechanisms.

Prolactin variations during risperidone therapy in a sample of drug-naive children and adolescents

The aim of this prospective observational study was to investigate the variations of serum prolactin hormone (PRL) in a sample of 34 drug-naive patients (mean age 13 years) who started risperidone therapy assuming that several factors may favor the increase in serum PRL. Serum PRL and hyperprolactinemia clinical signs were examined at baseline (T0) and after almost 3 months of treatment (T1). We considered sex, pubertal status, risperidone dosage, psychiatric diagnosis, and any personal/family history of autoimmune diseases. The mean serum PRL value increased between T0 and T1 (P=0.004). The mean serum PRL was higher in females in the pubertal/postpubertal stage and for risperidone dosage up 1 mg/day. Hyperprolactinemia was found in 20% of patients at T0 and in 38% of patients at T1 (P=0.03). The mean serum PRL increase was greater in early-onset schizophrenia spectrum psychosis patients compared with no-early-onset schizophrenia spectrum psychosis patients (P=0.04). The increase in PRL was higher in patients with a personal and a family history of autoimmune diseases. This study suggests that the increase in serum PRL in patients treated with risperidone may be linked not only to the drug and its dosage but also to several risk factors such as sex, pubertal stage, psychiatric disease, and autoimmune disorders.

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.

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.

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

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

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

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

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

The role of cortisol in first episode of psychosis: a systematic review

The stress diathesis hypothesis is currently one of the prevailing models of etiology of psychotic disorders. Cortisol is the most researched stress hormone; yet its role in first episode psychosis (FEP) was only recently investigated. The aim of the present study is to systematically review the evidence on the potential role of cortisol in FEP. Higher cortisol levels in blood samples have been consistently replicated, whereas saliva studies measuring baseline cortisol levels have exhibited divergent results. Moreover, longitudinal studies have revealed a cortisol upregulation in FEP with a subsequent decrease induced by antipsychotic treatment. The evidence suggests a role for cortisol in psychosis, although the association of cortisol with psychopathological symptoms is currently non-specific. Future research should focus on more pure diagnostic entities, clearly defined stages of the disorder and refined methods of hormonal measurement.

The journey to psychosis: an exploration of specific psychological pathways

Recent models of psychosis have implicated specific psychological processes in the aetiology of this disorder, and these factors may form a route to later symptoms-either directly or via a mediating pathway after exposure to adversity. Researchers are beginning to bring together findings that look into specific pathways between early experiences of adversity and different symptoms of psychosis, including thought disorder, hallucinations and persecutory delusions. The adversity-specific pathways include parental communication deviance, source monitoring biases, and insecure attachment. Researchers have also begun to utilise specific psychological factors as targets for treatment, and these include a focus on a worrying thinking style, negative beliefs about the self, interpersonal sensitivity, sleep disturbance, anomalous internal experience, and reasoning biases. Research on the impact of psychological processes is beginning to mount and is likely to improve our understanding of aetiology and lead to significant advances in the treatment of psychotic symptoms and disorders.

From stress to psychosis: whom, how, when and why?

The role of stress in precipitating the onset and relapse of psychosis has been now widely recognised. Over the past decade, the major challenge of research in this field has been to elucidate the biological mechanisms involved in the interaction between stress and psychosis onset. Obvious focus of this research has been the study of biological systems involved in the stress response. I will here briefly discuss the current evidence of abnormalities in stress biomarkers, such as cortisol and inflammatory markers, in patients with psychosis and their possible clinical implications. Stress biomarkers appear to hold strong potential as predictors of psychosis as well as of clinical outcome, and may represent optimal targets for the development of novel therapeutic agents for psychosis.

Cortisol awakening response and diurnal cortisol among children at elevated risk for schizophrenia: relationship to psychosocial stress and cognition

Abnormal hypothalamic-pituitary-adrenal (HPA) axis function, as indexed by elevated diurnal cortisol levels and/or a blunted cortisol awakening response (CAR), has been observed among patients with first episode psychosis and associated with neurocognitive deficits in this population. However, the extent to which these features precede illness onset is unclear. The current study aimed to determine whether children who are at putatively elevated risk for psychosis because they present multiple antecedents of schizophrenia (ASz), and high-risk children with a family history of illness (FHx), are characterized by abnormal cortisol levels when compared with their typically developing (TD) peers. A further aim was to investigate the extent to which cortisol levels are associated with psychosocial stress and neurocognitive function. Thirty-three ASz children, 22 FHx children, and 40 TD children were identified at age 9-12 years using a novel community-based screening procedure or as relatives of individuals with schizophrenia. All participants were antipsychotic-naive and not currently seeking treatment for their symptoms. At age 11-14 years, participants provided salivary cortisol samples and completed psychosocial stress measures and tests of memory and executive function. Results indicated that FHx children, but not ASz children, were characterized by a blunted CAR relative to their TD peers (effect size=-0.73, p=0.01) that was not explained by psychosocial stress exposure or by distress relating to these experiences. Neither FHx nor ASz children were characterized by elevated diurnal cortisol. Among both FHx and ASz children, more pronounced HPA axis function abnormalities (i.e., higher diurnal cortisol levels and greater blunting of the CAR) were associated with poorer performance on tests of verbal memory and executive function. These findings support the notion that at least some HPA axis abnormalities described in psychosis precede illness onset, rather than being a subsequent epiphenomenon. We speculate that the blunted CAR may constitute an early (potentially genetically mediated) marker of psychosis vulnerability, whilst elevated diurnal cortisol levels may emerge only proximally to disease onset.

Inflammatory biomarker profiles of mental disorders and their relation to clinical, social and lifestyle factors

In the last few decades, mental health research has increasingly provided evidence supporting the role of inflammation in pathogenesis, course and treatment of mental disorders. With such a steep incline of research, resulting in a wealth of emerged findings, it has become difficult to follow developments within the field. The present review sets out to present the recent developments and to give an overview of the inflammatory profiles of depression, psychosis and bipolar disorder, as well as variations within these disorders. Moreover, mediating factors such as social environment and childhood experience are discussed, both in terms of their potential in elucidating the complex interface between the inflammation and other closely related biological systems, as well as the possibly confounding impact of various lifestyle factors. Whilst many issues in this fascinating area of research remain to be fully understood and elaborated, all current evidence suggests that inflammation plays a key role in mental disorders and may open up novel avenues for clinical treatment.

The Interface of Stress and the HPA Axis in Behavioural Phenotypes of Mental Illness

Abnormalities of hypothalamic-pituitary-adrenal (HPA) axis function are one of the most consistent biological findings across several mental disorders, but many of the mechanisms underlying this abnormality as well as the potential contribution to behavioural phenotypes remain only partially understood. Interestingly, evidence suggests a U-curve, with dysregulation of the HPA axis towards both hyper- or hypoactivity manifesting as a risk to mental wellbeing. This review will elaborate on both the clinical and molecular role of the neuroendocrine stress system in depressive, psychotic and post-traumatic stress disorders and present some of the most recent findings that have shed light on the complex interface between environmental stressors, molecular mechanisms and clinical presentation. Crucially, plasticity of the HPA axis confers both vulnerability to adverse events, particularly so in early developmental stages, as well as hope for the treatment of mental disorder, as evidenced by changes in HPA functioning associated with remission of symptoms.

Adversity, cannabis use and psychotic experiences: evidence of cumulative and synergistic effects

BACKGROUND

There is robust evidence that childhood adversity is associated with an increased risk of psychosis. There is, however, little research on intervening factors that might increase or decrease risk following childhood adversity.

AIMS

To investigate main effects of, and synergy between, childhood abuse and life events and cannabis use on odds of psychotic experiences.

METHOD

Data on psychotic experiences and childhood abuse, life events and cannabis use were collected from 1680 individuals as part of the South East London Community Health Study (SELCoH), a population-based household survey.

RESULTS

There was strong evidence that childhood abuse and number of life events combined synergistically to increase odds of psychotic experiences beyond the effects of each individually. There was similar, but weaker, evidence for cannabis use (past year).

CONCLUSIONS

Our findings are consistent with the hypothesis that childhood abuse creates an enduring vulnerability to psychosis that is realised in the event of exposure to further stressors and risk factors.