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

Individual differences in belief updating and phasic arousal are related to psychosis proneness

Many decisions entail the updating of beliefs about the state of the environment by accumulating noisy sensory evidence. This form of probabilistic reasoning may go awry in psychosis. Computational theory shows that optimal belief updating in environments subject to hidden changes in their state requires a dynamic modulation of the evidence accumulation process. Recent empirical findings implicate transient responses of pupil-linked central arousal systems to individual evidence samples in this modulation. Here, we analyzed behavior and pupil responses during evidence accumulation in a changing environment in a community sample of human participants. We also assessed their subclinical psychotic experiences (psychosis proneness). Participants most prone to psychosis showed overall less flexible belief updating profiles, with diminished behavioral impact of evidence samples occurring late during decision formation. These same individuals also exhibited overall smaller pupil responses and less reliable pupil encoding of computational variables governing the dynamic belief updating. Our findings provide insights into the cognitive and physiological bases of psychosis proneness and open paths to unraveling the pathophysiology of psychotic disorders.

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.

Changes in substance use and engagement in gaming/gambling in persons with severe mental illness during the COVID-19 pandemic and earthquakes: a community study in two points

Introduction

External stressors, such as COVID-19 pandemic and earthquake, can cause an increase in substance use and addictive behavior in persons with severe mental illnesses (SMI). We analyzed the changes and predictors of substance use and addictive behavior in SMI during these double disasters in Croatia.

Methods

Questionnaires exploring the presence of substance or behavior addiction disorder, mental ill health [Depression Anxiety Stress Scales-21 (DASS-21), Insomnia Severity Index (ISI), Perceived Stress Scale (PSS), Obsessive-Compulsive Inventory-Revised], coping mechanisms, and perceived social support [Multidimensional Scale of Perceived Social Support (MSPSS)] were administered among 90 participants with SMI included in the RECOVER-E study in May/June 2020 (first COVID-19 wave, Zagreb earthquake) and in December 2020/January 2021 (second COVID-19 wave, Petrinja earthquake).

Results

In both time points, a major increase was observed in tobacco smoking (25.0%; 28.6%, respectively) predicted by discontinuation of antidepressants and higher DASS-21 score. Increased sedative use was observed (24.4%; 23.8%, respectively) predicted by higher PSS and ISI scores, lower MSPSS scores, antipsychotic discontinuation and not receiving community mental health team (CMHT) service.

Discussion

In persons with SMI during a double disaster special attention needs to be given to reducing mental-ill health and stress, providing social support and continuity of psychiatric care, through medications and CMHTs.

Contributions of Parasympathetic Arousal-Related Activity to Cognitive Performance in Patients With First-Episode Psychosis and Control Subjects

BACKGROUND

Cognitive impairment is integral to the pathophysiology of psychosis. Recent findings implicate autonomic arousal-related activity in both momentary fluctuations and individual differences in cognitive performance. Although altered autonomic arousal is common in patients with first-episode psychosis (FEP), its contribution to cognitive performance is unknown.

METHODS

A total of 24 patients with FEP (46% male, age = 24.31 [SD 4.27] years) and 24 control subjects (42% male, age = 27.06 [3.44] years) performed the Multi-Source Interference Task in-scanner with simultaneous pulse oximetry. First-level models included the cardiac-blood oxygen level-dependent regressor, in addition to task (congruent, interference, and error) and nuisance (motion and CompCor physiology) regressors. The cardiac-blood oxygen level-dependent regressor reflected parasympathetic arousal-related activity and was created by convolving the interbeat interval at each heartbeat with the hemodynamic response function. Group models examined the effect of group or cognitive performance (reaction times × error rate) on arousal-related and task activity, while controlling for sex, age, and framewise displacement.

RESULTS

Parasympathetic arousal-related activity was robust in both groups but localized to different regions for patients with FEP and healthy control subjects. Within both groups, arousal-related activity was significantly associated with cognitive performance across occipital and temporal cortical regions. Greater arousal-related activity in the bilateral prefrontal cortex (Brodmann area 9) was related to better performance in healthy control subjects but not patients with FEP.

CONCLUSIONS

Autonomic arousal circuits contribute to cognitive performance and the pathophysiology of FEP. Arousal-related functional activity is a novel indicator of cognitive ability and should be incorporated into neurobiological models of cognition in psychosis.

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.

Pinpointing affective disturbances in psychosis: A comparison of temporal affect dynamics in individuals with psychotic disorders, individuals with attenuated psychotic symptoms, and clinical and healthy controls

Affective disturbances in psychosis are well-documented but our understanding of their phenotypic nature in everyday life remains limited. Filling this gap could advance mechanistic models of the affective pathway to psychosis and pave the ground for new research avenues. Therefore, this study focused on temporal affect dynamics in psychosis, i.e., the patterns with which affect fluctuates over time. We applied experience-sampling with nine assessments per day over one week in participants with psychotic disorders (PSY), participants with attenuated psychotic symptoms (AS), clinical controls with obsessive compulsive disorders (OCD) and healthy controls (HC; total N = 139) to assess whether in PSY and AS, dynamics in affective valence and arousal are characterized by higher instability (i.e., extreme and frequent moment-to-moment fluctuations of affect intensities), higher affective variability (i.e., larger range of affect intensities), or lower inertia (i.e., higher frequency of affective changes), compared to the clinical and healthy control samples. Mixed-model ANOVAs revealed higher instability in both PSY and OCD compared to HC, but no significant differences for variability and inertia. AS had an intermediate position and did not differ significantly from any other group. We found evidence for small to medium effect sizes for the influence of mean affect levels on the dynamic indicators. Our findings indicate that individuals with psychotic disorders have increased affective instability and that this could be a transdiagnostic phenomenon. Zooming in on the variability and inertia components did not confer additional benefits. Emotion-focused interventions for psychosis should focus on reducing frequent and extreme affective fluctuations.

A systematic review and meta-analysis of the association between emotional stress reactivity and psychosis

AIM

Emotional stress reactivity may be a mediating factor in the association between trauma and psychosis. This review aimed to (i) identify, summarise and critically evaluate the link between emotional stress reactivity and psychotic experiences (ii) examine evidence for a 'dose-response' relationship between stress reactivity and psychosis in the wider psychosis phenotype (i.e., sub-clinical symptoms).

METHODS

Electronic database searches (PsychINFO, MEDLINE, EMBASE) were conducted for studies which investigated the link between stress reactivity and psychosis, psychotic symptoms, or a vulnerability to developing psychosis (wider phenotype). Cross-sectional, experimental and experience sampling method study designs were eligible for inclusion.

RESULTS

Fourty five eligible articles were identified (N participants = 8830). Narrative synthesis showed that increased emotional stress reactivity was associated with psychosis and subclinical psychotic experiences across all study designs, however, findings were inconsistent across studies. The preliminary meta-analysis (k = 4, n = 383) showed increases in emotional stress reactivity was associated with higher negative affect in response to event-related stress, in those with psychosis compared to controls (mean difference in beta coefficients = 0.05, 95% CI 0.02-0.08, p = .004). However, this difference was small with a considerable degree of heterogeneity (p = .001, I²  = 81%) so results should be interpreted with caution.

CONCLUSIONS

Overall, the evidence suggests that there is a link between emotional stress reactivity and psychosis in those with psychosis, those at high risk of developing psychosis and in relation to subclinical psychotic-like experiences in the general population.

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.

Acute Physiological and Psychological Stress Response in Youth at Clinical High-Risk for Psychosis

Deficits in stress-response systems are a characteristic of schizophrenia and psychosis spectrum illnesses, and recent evidence suggests that this impairment may be evident in those at clinical high-risk (CHR) for the development of a psychotic disorder. However, there is limited research specifically investigating biological and subjective stress reactivity in CHR individuals. In the present study, 38 CHR individuals and group of 38 control individuals participated in the Trier Social Stress Test (TSST), an experimentally induced psychosocial stressor. Changes in salivary cortisol and alpha amylase, as well as self-reported units of distress (SUDS), were evaluated. Interestingly, the TSST did not induce a change in cortisol levels in either group, though the CHR group did show higher overall cortisol levels throughout the TSST (pre-anticipation period through recovery period). However, indicative of an effective task manipulation, the TSST did illicit an increase in alpha amylase in both groups. CHR participants exhibited higher levels of subjective stress prior to the stressor compared to the control group and CHR SUDs did not significantly increase in response to the stressor. In contrast, the control group showed an increase in SUDS in response to the stressor. Notably, SUDS for the control group post task mirrored the levels CHR youth endorsed prior to the stressor. Taken together, these findings suggest that there may be a functional relationship between persistently elevated cortisol and chronic high levels of subjective distress in CHR individuals.

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.

The relevance of chronic stress for the acute stress reaction in people at elevated risk for psychosis

BACKGROUND

Theoretical models and empirical evidence suggest that alterations of the acute stress reaction are a vulnerability indicator of psychosis. However, more studies are needed that use laboratory stressors and a multimodal assessment of the stress reaction. Furthermore, it needs to be clarified whether alterations of the acute stress reaction result from the chronic stress level.

METHODS

We recruited participants at familial (n = 32) and symptomatic risk (n = 43) for psychosis and a low-risk control group (n = 35). We assessed their chronic stress levels (self-report, hair cortisol concentrations) and self-reported (subjective, affective, paranoia) as well as physiological (heart rate, skin conductance level, cortisol) reactions to the Trier Social Stress Test.

RESULTS

The groups did not differ in their acute stress reaction but both at-risk groups showed higher levels of self-reported chronic stress. Chronic stress predicted changes in negative affect, paranoia and skin conductance level in the total sample.

CONCLUSIONS

We could not confirm that alterations of the acute stress reaction are an early vulnerability indicator of psychosis and conclude that they might develop at a later time-point on the trajectory to psychosis. The high chronic stress level of the at-risk groups might constitute an intermediate state that increases the likelihood of altered stress reactions in later risk stages. To test this, future work needs to investigate the temporal order between chronic stress levels, acute stress reactions and symptom development across the psychosis continuum.

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.

Components of schizophrenia liability affect the growth of psychological stress sensitivity following major life events

BACKGROUND

Some argue that physiological and psychological stress sensitivities contribute causally to schizophrenia. Indeed, evidence shows that those with or at risk for schizophrenia have highly sensitive stress responses. However, it is unclear how psychological stress sensitivity develops. Our aim was to test whether psychological stress sensitization develops longitudinally in association with major life events and components of schizophrenia liability. We expected schizophrenia liability to predict higher psychological stress sensitivity; life events to predict subsequent increases in psychological stress sensitivity; and schizophrenia liability to moderate this relationship.

METHODS

In a prospective study, undergraduates (n = 184) completed a measure of schizophrenia liability at baseline. Then at 2-month intervals over 6 months, they reported on the occurrence of major life events and completed measures of psychological stress sensitivity.

RESULTS

Latent variable growth modelling showed that stress sensitivity increased following incident life events when controlling for baseline life events. Higher cognitive-perceptual and interpersonal scores predicted higher baseline sensitivity. Higher cognitive-perceptual features predicted larger increases in psychological stress sensitivity following life events whereas greater disorganization reduced growth.

CONCLUSIONS

This evidence is consistent with the idea that psychological sensitization is involved in the development of schizophrenia and suggests an important link between positive features of schizophrenia liability and the magnification of psychological stress sensitivity.

Hair cortisol concentrations as an indicator of potential HPA axis hyperactivation in risk for psychosis

A chronic hyperactivation of the hypothalamic-pituitary-adrenal (HPA) axis is assumed to be an important indicator of vulnerability for psychosis. Despite the considerable research on this topic, putative social origins of HPA axis hyperactivation have received little attention in the literature so far. Also, the inconsistency of previous findings calls for new and reliable methods in the assessment of HPA axis activation. To address these issues, we used hair cortisol concentrations as an indicator of chronic HPA axis activation in participants at elevated risk for psychosis (clinical risk: n = 43, familial risk: n = 32) and low-risk controls (n = 35), and assessed its relation with a variety of social stressors. We also tested the interaction effect between social stressors and familial risk status on hair cortisol concentrations (moderation analysis). Participants at elevated risk for psychosis did not show significantly higher hair cortisol concentrations than low-risk controls. However, severe social stressors (child abuse experiences, traumatic events) predicted hair cortisol concentrations in the total sample. This relationship was not significantly moderated by familial risk status (as a marker of genetic risk). The results challenge the assumption that HPA axis hyperactivation is an early vulnerability indicator for psychosis but leave the possibility that it manifests only at more severe risk stages. Furthermore, the findings suggest that acquired experiences contribute to the emergence of HPA axis hyperactivation, which might occur via a gene-environment correlation rather than via a gene-environment interaction.

Capturing behavioral indicators of persecutory ideation using mobile technology

Most existing measures of persecutory ideation (PI) rely on infrequent in-person visits, and this limits their ability to assess rapid changes or real-world functioning. Mobile health (mHealth) technology may address these limitations. Little is known about passively sensed behavioral indicators associated with PI. In the current study, sixty-two participants with schizophrenia spectrum disorders completed momentary assessments of PI on a smartphone that also passively collected behavioral data for one year. Results suggested that PI was prevalent (n = 50, 82% of sample) but had infrequent incidence (25.2% of EMA responses). PI was also associated with changes in several passively sensed variables, including decreases in distance traveled (M_kilometers = -1.20, SD = 18.88), time spent in a vehicle (M_minutes = -4.15, SD = 49.59), length of outgoing phone calls (M_minutes = -0.79, SD = 13.13), time spent proximal to human speech (M_minutes = -6.26, SD = 153.03), and an increase in time sitting still (M_minutes = 4.04, SD = 94.69). The present study suggests changes associated with PI may be detectable by passive sensors, including reductions in moving or traveling, and time spent around others or in self-initiated phone conversations. These constructs might constitute risk for PI.

Cortisol stress response in psychosis from the high-risk to the chronic stage: a systematic review

OBJECTIVES

We review studies of whether cortisol levels following psychosocial stress exposure differ between patients with psychosis and healthy control subjects.

METHODS

Original research published between 1993 and February 2019 was included in the literature search. Studies that used experimentally induced psychosocial stress and reported stress response measures of plasma or saliva cortisol levels in patients at any stage of illness (i.e. high risk, first episode and chronic phase) were included.

RESULTS

A total of 17 studies were included. Although there was evidence of inconsistencies in measures, we observed moderate evidence of an association with stress-induced cortisol blunting response across studies.

CONCLUSIONS

This review highlights recent evidence of blunting of cortisol response following experimentally induced psychosocial stress. While there was some evidence of this blunted response across illness types and stages, the strongest evidence was observed for those with chronic schizophrenia. Due to the low number of studies, in particular in bipolar disorder, much work is still needed to accurately characterise the biological effects of stress in psychosis.

The impact of social and sensory stress on cognitive biases and delusions in schizophrenia

INTRODUCTION

Stress aggravates delusional symptoms, but the exact underlying mechanisms are still not fully understood. One of the routes may be via exacerbation of information processing distortions frequently observed in psychosis. The aim of the present study was thus to investigate the impact of social and sensory stress on specific cognitive processes along with different dimensions of delusional thinking.

METHODS

Nineteen individuals affected by schizophrenia and 15 healthy controls were assessed under 3 experimental conditions (social stress, neutral, noise stress), with counter-balanced presentation of stress conditions across participants of both groups. Under each condition participants performed parallel versions of experimental tasks and had to report their level of paranoid thinking and subjective distress.

RESULTS

Irrespective of condition, patients showed significant impairments in metacognitive accuracy compared with controls. When social stress was applied first, mentalising accuracy decreased significantly in the subsequent condition among patients only. Following exposure to either social or sensory stress, patients reported significantly higher conviction in their paranoid ideas in the subsequent condition.

CONCLUSIONS

Only limited evidence was found for the negative impact of stress on cognitive processes in schizophrenia patients. However, this may not be true for those with more severe information processing abnormalities and/or delusions.

Affective and physiological reactivity to emotional comments in individuals at elevated risk for psychosis

BACKGROUND

Individuals with schizophrenia are at increased risk of relapse when they live in highly critical (i.e., high expressed emotion; EE) family environments. It remains less clear, however, how individuals at elevated risk for a psychotic disorder react to the social stress of EE. Here we examined whether individuals at elevated risk for developing schizophrenia report greater subjective changes in affect and have increased physiological reactivity after hearing critical, praising and neutral comments.

METHOD

Measures of heart rate, heart rate variability, skin conductance, and self-reported affective ratings were used to assess differential responses to EE-type stimuli in 38 individuals at elevated-risk for psychosis and 38 low-risk controls.

RESULTS

The elevated-risk group and low-risk controls, did not differ in their initial affective and physiological reactivity to criticism. However, during the recovery period following the criticism, the elevated-risk group demonstrated greater heart rate activation. They also showed more sensitivity to praise. Although elevated-risk participants initially had higher baseline levels of negative affect and heart rate, following praise, these levels reduced and became indistinguishable from the levels of low-risk controls.

CONCLUSIONS

These findings suggest that at-risk individuals may have more difficulty recovering from criticism than their self-report data might suggest. They may also derive physiological and affective benefits from praise. Important clinical implications of these findings are discussed.

Emotion perception and overconfidence in errors under stress in psychosis

Vulnerability stress models are well-accepted in psychosis research, but the mechanisms that link stress to psychotic symptoms remain vague. Little is known about how social cognition and overconfidence in errors, two putative mechanisms for the pathogenesis of delusions, relate to stress. Using a repeated measures design, we tested four groups (N=120) with different liability to psychosis (schizophrenia patients [n=35], first-degree relatives [n=24], participants with attenuated positive symptoms [n=19] and healthy controls [n=28]) and depression patients (n=14) as a clinical control group under three randomized experimental conditions (no stress, noise and social stress). Parallel versions of the Emotion Perception and Confidence Task, which taps both emotion perception and confidence, were used in each condition. We recorded subjective stress, heart rate, skin conductance level and salivary cortisol to assess the stress response across different dimensions. Independent of the stress condition, patients with schizophrenia showed poorer emotion perception performance and higher confidence in emotion perception errors than participants with attenuated positive symptoms and healthy controls. However, they did not differ from patients with depression or first-degree relatives. Stress did not influence emotion perception or the extent of high-confident errors, but patients with schizophrenia showed an increase in high-confident emotion perception errors conditional on higher arousal. A possible clinical implication of our findings is the necessity to provide stress management programs that aim to reduce arousal. Moreover, patients with schizophrenia might benefit from interventions that help them to reduce overconfidence in their social cognition judgements in times in which they feel being under pressure.

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.

Paranoid Delusions as an Adaptive Response to Social Evaluative Stress?

Abstract. Learning mechanisms may serve as a framework for understanding the formation of paranoia. Specifically, if paranoid thoughts after social stressors produce a short-term benefit for coping (e.g., downregulating arousal), the encountered negative reinforcement could lead to their excessive application and subsequently to long-term maladaptive convictions. The Trier Social Stress Test was utilized in healthy participants to examine this putative benefit. Participants rated paranoia at baseline and after the stressor. Subjective stress levels, negative affect, heart rate, and heart rate variability were assessed in the following rest phase (N = 59). Semipartial correlations showed that participants who responded with larger increases in paranoia were characterized by a lower heart rate in the subsequent rest phase. No associations were found with heart rate variability or psychological measures. Thus, paranoid thinking in healthy individuals could be an adaptive means for reestablishing some aspects of physiological homeostasis after a social stressor but further research is needed.

Experimental variation of social stress in virtual reality - Feasibility and first results in patients with psychotic disorders

BACKGROUND AND OBJECTIVES

Social interaction might lead to increased stress levels in patients with psychotic disorders. Impaired social stress tolerance is critical for social functioning and closely linked with symptom relapse and hospitalization. We present an interactive office built-up in virtual reality (VR).

METHODS

Patients with psychotic disorders (PP, N = 26 including N = 5 dropouts) and matched healthy controls (HC, N = 20) were examined with a VR simulating an open-plan office. In a randomized, controlled cross-over design, participants were introduced to virtual co-workers (avatars) and requested to ask them for task assistance. Social feedback in each of the two sessions was either cooperative or rejective in randomized order.

RESULTS

The office environment was tolerable for most PP and all HC, five PP and none of the HC dropped out for any reason. Drop-outs reported simulator sickness, influence on thoughts and symptom exacerbations. Statistical trends indicated heightened paranoid ideations for PP after social rejection. State measures of paranoid ideations showed high convergent validity with conventional measures of delusions. Of note, measures of presence were higher for PP than for HC.

LIMITATIONS

The exploratory design limits the robustness of the findings. Only statistical trends on paranoid ideation were found.

CONCLUSION

The use of VR to assess the effects of social rejection is feasible and tolerable for most PP (87%). However, its implementation for PP is challenged by increased simulator sickness and an additional stress load for some patients. Further studies continuing on these first results that point towards an increased paranoid ideation evoked by negative social feedback and generally higher subjective presence are needed.

Modulation of HPA axis response to social stress in schizophrenia by childhood trauma

HPA axis functioning plays an important role in the etiology of schizophrenia spectrum disorders (SSD). However, only few studies have examined HPA axis responsivity to psychosocial stress in SSD, and results are heterogeneous. Furthermore, childhood trauma is known to influence psychopathology and treatment outcome in SSD, but studies on the influence of childhood trauma on stress related HPA axis activity are missing. The purpose of this study was to investigate cortisol response to a psychosocial stress challenge in SSD patients, and to examine its association with severity of childhood trauma. The present study included 25 subacutely ill patients with a current episode of a chronic SSD and 25 healthy controls. Participants underwent the modified Trier Social Stress Test, and salivary cortisol levels were assessed. The childhood trauma questionnaire was used to assess severity of adverse life events. Overall, cortisol response was blunted in the patient group compared to the control group (p<0.01). Furthermore, we identified two patient subgroups (cortisol responders (n=12) vs. non-responders (n=13) to the modified TSST) that differed in their severity of childhood trauma experience: responders had experienced more emotional abuse in their past (p<0.042). Therefore, childhood trauma might influence stress-related HPA axis activity in SSD. Our data contribute to the hypothesis that severity of childhood trauma may be of pathophysiological relevance in schizophrenia. In addition, it may be an overlooked factor contributing to inconsistent findings regarding HPA axis response to psychosocial stress in SSD.

High psychosis liability is associated with altered autonomic balance during exposure to Virtual Reality social stressors

BACKGROUND

Social stressors are associated with an increased risk of psychosis. Stress sensitisation is thought to be an underlying mechanism and may be reflected in an altered autonomic stress response. Using an experimental Virtual Reality design, the autonomic stress response to social stressors was examined in participants with different liability to psychosis.

METHOD

Fifty-five patients with recent onset psychotic disorder, 20 patients at ultra-high risk for psychosis, 42 siblings of patients with psychosis and 53 controls were exposed to social stressors (crowdedness, ethnic minority status and hostility) in a Virtual Reality environment. Heart rate variability parameters and skin conductance levels were measured at baseline and during Virtual Reality experiments.

RESULTS

High psychosis liability groups had significantly increased heart rate and decreased heart rate variability compared to low liability groups both at baseline and during Virtual Reality experiments. Both low frequency (LF) and high frequency (HF) power were reduced, while the LF/HF ratio was similar between groups. The number of virtual social stressors significantly affected heart rate, HF, LF/HF and skin conductance level. There was no interaction between psychosis liability and amount of virtual social stress.

CONCLUSION

High liability to psychosis is associated with decreased parasympathetic activity in virtual social environments, which reflects generally high levels of arousal, rather than increased autonomic reactivity to social stressors.

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.

Experimentally induced psychosocial stress in schizophrenia spectrum disorders: A systematic review

BACKGROUND

There is evidence that exposure to social stress plays a crucial role in the onset and relapse of schizophrenia; however, the reaction of patients with schizophrenia spectrum disorder (SSD) to experimentally induced social stress is not yet fully understood.

METHOD

Original research published between January 1993 and August 2015 was included in this systematic literature research. Social stress paradigms, reporting subjective responses to stress measures, plasma or saliva cortisol, or heart rate (HR) in patients with SSD were included. 1528 articles were screened, 11 papers (390 patients) were included.

RESULTS

Three main findings were attained concerning chronically ill patients: (1) overall similar subjective responses to stress ratings between SDD patients and controls, (2) no group differences in cortisol response to psychosocial stress and (3) an increase in HR after the stress exposure was seen in patients and controls. The study examining first-episode patients found higher subjective responses to stress and lower stress-induced cortisol levels.

CONCLUSION

The results indicate that first-onset medication free patients may show differences in subjective responses to stress measures and cortisol release while chronically ill patients display no differences in subjective and cortisol response. This may be the correlate of a pathophysiological dysfunction of the hypothalamic-pituitary-adrenal axis prior or at the onset of SSD and a subsequent change in dysregulation during the course of the illness. Given the paucity of studies investigating psychosocial stress in SSD and the pathophysiological relevance of psychosocial stress for the illness, there is need for further research. (PROSPERO registration number: CRD42015026525).

Parental and God Representations Among Individuals with Psychosis: A Grounded Theory Analysis

Religiousness, spirituality, and social support have all been identified as having a positive impact on overall mental health outcomes. The current study describes quantitative and qualitative assessment of parental and God representations among individuals diagnosed with schizophrenia or schizoaffective disorder (N = 46). Six salient themes emerged; participants described the importance of caregiver love and nurturance, need for God, loss of family members, love of God, concrete support provided by parents, and the ability to tolerate ambivalent feelings toward parents. Participants linked their relationships with parents and God to their process of recovery. Implications for clinical practice are discussed.

A randomized-controlled trial of heart rate variability biofeedback for psychotic symptoms

Arousal and the way it is coped with are relevant to the emergence of psychotic symptoms. Heart rate variability (HRV) stems from autonomic responses to environmental demands such as stress and is an index of physiological arousal, adaptability, and homeostatic reflexes forming autonomic balance. A randomized-controlled between-subjects trial that compared HRV-biofeedback (BF) to an active relaxation and to a waiting control condition was conducted in a sample with attenuated subclinical psychotic symptoms (N = 84). A 20-min intervention was preceded and followed by repeated assessments of stress responses. Change scores of the post-stress periods were analyzed using ANOVAs for HRV, subjective stress, perceived control, and state paranoia. As expected, BF participants showed greater improvements in perceived control than waiting controls (p = 0.006). However, no group differences occurred in HRV, paranoid symptoms or subjective stress. In exploratory analyses in a subset of participants who were breathing per protocol, the expected effects were found for total HRV and state paranoia. Thus, this trial of HRV-BF for people with attenuated psychotic symptoms indicates that the intervention may hold potential if conducted per protocol. To reach this, longer training might be inevitable. Future studies are needed to further elucidate efficacy and applicability of HRV-BF in clinical samples.

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.

Bridging psychophysiological and phenomenological characteristics of psychosis--Preliminary evidence for the relevance of emotion regulation

In psychosis, the alleged increased subjective stress-sensitivity is reflected in abnormal physiological arousal such as higher heart rate, elevated skin conductance levels, decreased vagal activity, and unusual cortisol levels. Despite ongoing research, possible mechanisms that explain the interplay between the phenomenological (i.e., subjective stress and symptoms) and psychophysiological processes are not thoroughly understood. Building on the model of neurovisceral integration by Thayer and Lane (2000) that focuses on regulative mechanisms, we postulate that emotion regulation will be associated with vagal activity, and with both subjective and physiological stress. In the present analysis, we used data from a baseline relaxation period including a 5-minute assessment of heart rate variability (HRV), salivary cortisol, and momentary subjective stress ratings from a sample of 19 participants with psychosis (mean age=40.9, SD=11.1; 36.8% female). Emotion regulation modification skills were assessed for specific emotions (i.e., stress and arousal, anxiety, anger, sadness, shame) if these were present during the previous week. Vagal HRV was significantly and moderately associated with emotion regulation. Both stress parameters (i.e., cortisol, subjective stress) were significantly associated with emotion regulation, but not with HRV. We provide preliminary support for the notion that emotion regulatory processes represent a crucial link between phenomenological and psychophysiological phenomena in psychosis. A potential model that ascribes emotion regulation a central role in the restoration of homeostasis is discussed. Future studies are needed to verify its generalizability and predictive value.

Stress is a bad advisor. Stress primes poor decision making in deluded psychotic patients

Stress is implicated in the onset of psychosis but the complex links between stress and psychotic breakdown are yet poorly understood. For the present study, we examined whether two prominent cognitive biases in psychosis, jumping to conclusions and distorted attribution, in conjunction with neuropsychological deficits play a role in this process. Thirty participants with schizophrenia and acute delusional symptoms were compared with 29 healthy controls across three conditions involving a noise stressor, a social stressor or no stressor. Under each condition participants had to perform parallel versions of cognitive bias tasks and neuropsychological tests including a probabilistic reasoning task (jumping to conclusions), the revised Internal, Personal and Situational Attributions Questionnaire (IPSAQ-R; attributional style), and the Corsi block-tapping task (nonverbal memory). Stress, particularly noise, aggravated performance differences of patients relative to controls on memory. Participants with psychosis demonstrated an escalated jumping to conclusion bias under stress. At a medium effect size, patients made more monocausal attributions, which increased under social stress. The present study is partially in line with prior studies. It suggests that stress negatively affects cognition in psychosis more than in controls, which is presumably insufficiently realized by patients and thus not held in check by greater response hesitance. Raising patients' awareness about these response tendencies and encouraging them to be more cautious in their judgments under conditions of increased stress may prove beneficial for improving positive symptoms.

Dealing with feeling: Specific emotion regulation skills predict responses to stress in psychosis

Elevated negative affect is an established link between minor stressors and psychotic symptoms. Less clear is why people with psychosis fail to regulate distressing emotions effectively. This study tests whether subjective, psychophysiological and symptomatic responses to stress can be predicted by specific emotion regulation (ER) difficulties. Participants with psychotic disorders (n=35) and healthy controls (n=28) were assessed for ER-skills at baseline. They were then exposed to a noise versus no stressor on different days, during which self-reported stress responses, state paranoia and skin conductance levels (SCL) were assessed. Participants with psychosis showed a stronger increase in self-reported stress and SCL in response to the stressor than healthy controls. Stronger increases in self-reported stress were predicted by a reduced ability to be aware of and tolerate distressing emotions, whereas increases in SCL were predicted by a reduced ability to be aware of, tolerate, accept and modify them. Although paranoid symptoms were not significantly affected by the stressors, individual variation in paranoid responses was also predicted by a reduced ability to be aware of and tolerate emotions. Differences in stress responses in the samples were no longer significant after controlling for ER skills. Thus, interventions that improve ER-skills could reduce stress-sensitivity in psychosis.

Arousal Predisposition as a Vulnerability Indicator for Psychosis: A General Population Online Stress Induction Study

Explanatory models ascribe to arousability a central role for the development of psychotic symptoms. Thus, a disposition to hyperarousal (i.e., increased arousal predisposition (AP)) may serve as an underlying vulnerability indicator for psychosis by interacting with stressors to cause symptoms. In this case, AP, stress-response, and psychotic symptoms should be linked before the development of a diagnosable psychotic disorder. We conducted a cross-sectional online study in a population sample (N = 104; M age = 27.7 years, SD = 11.2, range 18-70). Participants rated their AP and subclinical psychotic symptoms. Participants reported their stress-levels before and after two stress inductions including an arithmetic and a social stressor. The participants with an increased AP generally felt more stressed. However, AP was not associated with the specific stress-response. As expected, positive psychotic symptoms were significantly associated with AP, but this was not mediated by general stress-levels. Its association to subtle, nonclinical psychotic symptoms supports our assumption that AP could be a vulnerability indicator for psychosis. The trait is easily accessible via a short self-report and could facilitate the identification of people at risk and be a promising target for early stress-management. Further research is needed to clarify its predictive value for stress-responses.