Stress levels in psychosis: Do body and mind diverge?

Do deficits in subjective stress recovery predict subsequent stress sensitivity and symptoms in schizophrenia spectrum disorders?

High levels of stress play a crucial role in the development of psychotic symptoms, such as paranoia, and may stem in part from recovery deficits after stress exposure. However, it remains unclear whether deficient recovery causes a build-up of heightened stress levels that increases stress sensitivity and symptoms when exposed to another stressor. To test this, we investigated the effect of subjective stress recovery on the response to a subsequent stressor and paranoia. We applied two consecutive runs of the same combined physical and cognitive stressor separated by a recovery phase of 60 min in individuals with schizophrenia spectrum disorders (n = 49). We repeatedly assessed self-reported stress, negative affect, heart rate, heart rate variability, salivary cortisol, and paranoia. Recovery of self-reported stress was defined as the geometric mean of the percentage changes of self-reported stress during recovery after the first stressor, and was regressed on the response to the second stressor controlling for self-reported stress during the first stressor. Lower subjective stress recovery predicted higher levels of self-reported stress, negative affect, and paranoia in response to the second stressor. The subjective stress recovery was not predictive of the physiological stress response (heart rate, heart rate variability, or salivary cortisol). Taken together, the findings indicate that recovery deficits could contribute to high levels of self-reported stress, negative affect, and paranoia in schizophrenia spectrum disorders and that the improvement of stress recovery could be a promising approach for interventions.

Recovery After Stress-Autonomic and Subjective Arousal in Individuals With Psychosis Compared to Healthy Controls

BACKGROUND AND HYPOTHESIS

Heightened stress levels in individuals with psychosis (PSY) are associated with psychotic symptom occurrence and may be partially attributed to well-established deficits in resting-state heart rate variability (HRV) and emotion regulation. In healthy participants, resting-state HRV and self-reported emotion regulation skills have been linked to recovery after a stressor; however, it is unclear whether stress recovery is altered in PSY. Thus, we compared the autonomic and subjective recovery of PSY to healthy controls (HC) and investigated the predictive value of resting-state HRV and emotion regulation skills.

STUDY DESIGN

We assessed resting-state HRV and self-reported emotion regulation one week prior to a combined physical and cognitive stress induction. After the stress exposure, we assessed the autonomic (decrease in heart rate [HR], increase in HRV) and subjective (decrease in subjective stress and negative affect) recovery in PSY (n = 50) and HC (n = 50) over 60 min.

STUDY RESULTS

Repeated-measures ANOVA revealed the expected interaction of time × group for subjective stress but not negative affect or autonomic stress. Resting-state HRV predicted recovery of HR, and emotion regulation skills predicted recovery of HRV but not of the other parameters.

CONCLUSIONS

Although subjective stress recovery was delayed in PSY, the absence of autonomic recovery deficits suggests that a prolonged stress response may not contribute to heightened stress levels to the expected extent. Improving resting-state HRV and emotion regulation may support autonomic recovery, but further investigation is required to test the impact of such improvements on psychotic symptoms.

Exhausted Heart Rate Responses to Repeated Psychological Stress in Women With Major Depressive Disorder

Past research links depression and blunted cardiac vagal reactivity to chronic stress. Yet, to our knowledge no experiment investigates heart rate (variability) responses to a repeated laboratory stressor in patients with depression. Repeated exposure may provide valuable information on stress reactivity in depression. Fifty-nine women (30 inpatients diagnosed with depression and 29 matched controls) underwent two consecutive runs of a mental arithmetic stress paradigm consisting of one baseline and two exposures to control, stress, and recovery phases of 5 min each, in a case-control design. Subjective stress and electrocardiography were recorded. Variance of heart rate (HR) and root mean square of successive RR interval differences (RMSSD) were analyzed using linear mixed models. Overall, physiological parameters (HR and RMSSD) and subjective stress showed a strong group effect (all p < 0.001). In both groups, subjective stress and HR increased in response to stress, but the subjective stress levels of patients with depression did not return to baseline levels after the first stressor and for the remainder of the experiment (all p < 0.004 compared to baseline). Patients' HR reactivity responded oppositely: while HR recovered after the first stress exposure, no reactivity was observed in response to the second exposure. These findings may suggest that the often-reported blunted HR/HRV response to stressors results from exhaustion rather than an incapacity to react to stress. The altered HR reactivity could indicate allostatic (over-) load in depression.

An experimental study on the effectiveness of emotion regulation in patients with acute delusions

BACKGROUND

Patients with psychotic disorders report to apply more maladaptive and less adaptive emotion-regulation (ER) strategies compared to healthy controls. However, few studies have used experimental designs to investigate the success in ER and the results of those at hand are equivocal.

AIM

This study investigated whether patients with delusions show problems in downregulating negative affect via cognitive ER-strategies.

METHOD

Patients with schizophrenia spectrum disorders and acute delusions (n = 78) and healthy controls (n = 41) took part in an ER-experiment, in which they were instructed to downregulate anxiety and sadness via three ER-strategies (reappraisal, distraction, acceptance) or not to regulate their emotions (control-condition). ER-success was measured as the change in subjective emotion-intensity and physiological indicators (skin conductance and heart rate) from before to after regulation and was analyzed with mixed-repeated-measures ANOVAs.

RESULTS

We found a significant effect of the ER-strategy in the sense that the subjective emotion-intensity was significantly lower after applying the reappraisal- and distraction-strategies than after the just view-condition (p's < .001). This effect was not found for the acceptance strategy (p = .060). There was no ER-strategy ∗ time ∗ group interaction-effect F(4.918, 575.416) = 0.778, p = .564, ƞ²_partial = 0.007. In all conditions, skin conductance decreased from pre- to post regulation (p < .001).

CONCLUSION

Our results indicate that patients with acute delusions can successfully apply cognitive ER-strategies. Before pursuing the relevant clinical implications of this finding, further research is needed to explore the role that the type of instruction has on ER-success and the extent to which the findings can be generalized to real life settings.

Emotion-Regulation in Psychosis: Patients with Psychotic Disorders Apply Reappraisal Successfully

Background

Emotion-regulation is assumed to be impaired in psychosis: patients with psychotic disorders (PD) self-report to use reappraisal less frequently than healthy controls (HC), but it is uncertain whether they are also less successful in applying reappraisal. Moreover, it has not been investigated whether the habitual use of reappraisal is associated with the ability to use reappraisal successfully.

Methods

To address these questions, PD (n = 60), a clinical control group of patients with anxiety disorders (AD; n = 40) and HC (n = 40) completed questionnaires on habitual emotion-regulation and alexithymia, performed tests on neurocognitive functioning and jumping-to-conclusion bias, and were subjected to an emotion-regulation paradigm, in which they were asked to down-regulate induced anxiety and sadness.

Results

No differences were found between PD and HC regarding the habitual use of reappraisal, but PD reported to use reappraisal more frequently than AD. All groups were able to down-regulate anxiety and sadness via reappraisal following instructions. The habitual use of reappraisal and the reduction of anxiety and sadness after instruction were uncorrelated.

Conclusion

These findings question the common assumption that PD use reappraisal less often or less successfully. At least under laboratory condition, PD do not appear to be impaired in reducing negative affect via reappraisal successfully.

Sex Moderates the Relationship of Stress and Perceived Social Support With Neuropsychological Symptoms Among Community-dwelling Persons With Alzheimer Disease in Spain

Neuropsychiatric symptoms (NPS) are common in Alzheimer disease (AD) patients, especially in women. Stress and stress-vulnerability factors (eg, poor social support) may trigger NPS. This cross-sectional study (n=196) aimed to examine the moderating effect of sex on the relationships between both perceived social support and salivary cortisol levels and NPS of AD patients. Only in women, greater cortisol levels were associated with higher scores in Neuropsychiatric Inventory mood, agitation, and frontal subscales whereas higher Psychosocial Support Questionnaire scores were related to lower scores in Neuropsychiatric Inventory mood and psychosis subscales. Given the relevance that sex differences might have on the design of preventive strategies, present findings should be confirmed in longitudinal studies.

Recovery from daily-life stressors in early and chronic psychosis

Initial affective and psychotic reactivity to daily stressors is altered in psychosis, and most notably in early psychosis. In addition to altered initial stress reactivity, results from studies using Experience Sampling Methodology (ESM) and psychophysiological measures indicate that impaired recovery from mild stressors may also be a risk factor for mental illness. The current ESM study investigated affective recovery from daily stressors in chronic psychosis patients (CP; n = 162), individuals at early stages of psychosis (EP; n = 127), and healthy volunteers (HV; n = 220) assessing fluctuations in negative affect (NA), tension, and suspiciousness ten times a day on six consecutive days. Recovery was operationalized for all three variables as the return to baseline (i.e., level at t_-1) following the first stressful event of a day (i.e., t₀). The EP group showed a delayed recovery of NA (t₁-t₃: B = 0.185; p = .007 and B = 0.228; p = .002) and suspiciousness (t₁: B = 0.223; p = .010 and B = 0.291; p = .002) compared to HV and CP, respectively. Delayed recovery was detected for tension as well (t₁-t₂: EP > HV: B = 0.242; p = .040 and EP > CP: B = 0.284; p = .023), but contrary to both other momentary states, this effect disappeared when controlling for subsequent stressful events. There were no significant differences in recovery between HV and CP. These results suggest that in EP, stressful daily events have longer-lasting effects on overall negative affect and subclinical psychotic-like experiences. Future studies should incorporate physiological and endocrine measures in order to integrate recovery patterns of the different stress systems.

Specificity of resting-state heart rate variability in psychosis: A comparison with clinical high risk, anxiety, and healthy controls

Maladaptability, particularly of autonomic activity, is described as a central component of vulnerability-stress-models for the pathogenesis of psychotic symptoms. Investigating heart rate variability (HRV) as an index of autonomic adaptability is thus likely to improve our understanding of psychosis. In clinically vulnerable groups for psychosis, it is unclear whether maladaptability is already evident. Moreover, to investigate specificity, direct comparisons to other mental disorders are required. In the present study, we analyzed 3 min of resting-state heart rate, HRV, and negative affect in 130 participants; consisting of participants with psychotic disorders (PSY; n = 44), clinical high-risk for psychosis (CHR; n = 22), anxiety disorders (anxiety controls, AC; n = 29) and healthy controls (HC; n = 35). ANCOVAs controlling for age revealed significant group differences for both investigated vagal HRV parameters, which were reduced in PSY compared to HC. The high-frequency domain HRV in PSY was also lower than in CHR and - in a non-significant trend - than in AC. Also, ANOVAs for heart rate and negative affect revealed significant increases in PSY compared to HC. Exploratory analyses of medication effects showed moderate dosage associations with heart rate and high-frequency HRV. Thus, in the present study, the activity of the autonomic nervous system was altered in psychosis but not in an at-risk group. A potential specificity of the effect can be speculated in contrast to anxiety disorders. Future studies should investigate the predictive value of HRV for increased stress-sensitivity or transition to clinical symptoms as well as the implications for daily threat perception and symptom maintenance.