Attenuated cortisol response to acute psychosocial stress in individuals at ultra-high risk for psychosis

Personal Recovery Among People at Risk for Developing Serious Mental Health Problems: A Qualitative Systematic Review

OBJECTIVE

Personal recovery refers to a person's pursuit of a full, meaningful life despite the potentially debilitating impact of a mental illness. An evidence base describing personal recovery among people at risk for developing a mental illness is lacking, limiting the potential for mental health services to support personal recovery. To address this gap, the authors synthesized the extant research describing personal recovery among people at risk for developing a mental illness.

METHODS

A systematic search of several literature databases (MEDLINE, Embase, APA PsycInfo, Web of Science Core Collection, and Cochrane Library) was conducted to retrieve qualitative and case studies and first-person accounts. The Joanna Briggs Institute guidelines for systematic reviews were followed. Included studies reported on participants at variable risk for developing a schizophrenia spectrum, bipolar, major depressive, or borderline personality disorder. Articles were retrieved through a librarian-assisted search and through use of additional strategies (e.g., expert consultation). Abstracts were screened by the research team, and themes were developed by using thematic synthesis.

RESULTS

The 36 included articles were synthesized, and six themes were generated: difficulties and challenges; establishing an understanding of, and finding ways to cope with, one's mental health challenges; reestablishing a sense of agency and personhood; receiving support from people and services, as well as restoring relationships; reestablishing hope, meaning, and purpose; and overcoming stigma and destigmatizing mental illness in others.

CONCLUSIONS

These findings provide a conceptual foundation that can guide future research on personal recovery and clinical interventions that foster it among people at risk for mental illness.

Exploring causal mechanisms of psychosis risk

Robust epidemiological evidence of risk and protective factors for psychosis is essential to inform preventive interventions. Previous evidence syntheses have classified these risk and protective factors according to their strength of association with psychosis. In this critical review we appraise the distinct and overlapping mechanisms of 25 key environmental risk factors for psychosis, and link these to mechanistic pathways that may contribute to neurochemical alterations hypothesised to underlie psychotic symptoms. We then discuss the implications of our findings for future research, specifically considering interactions between factors, exploring universal and subgroup-specific factors, improving understanding of temporality and risk dynamics, standardising operationalisation and measurement of risk and protective factors, and developing preventive interventions targeting risk and protective factors.

Examining the psychobiological response to acute social stress across clinical stages and symptom trajectories in the early psychosis continuum

The stress-vulnerability model has been repeatedly highlighted in relation to the risk, onset and course of psychosis, and has been independently studied in clinical high-risk (CHR) and first-episode psychosis (FEP) populations. Notable in this literature, however, is that there are few studies directly comparing markers of stress response across progressive stages of illness. Here we examined the psychobiological response to the Trier Social Stress Test in 28 CHR (mean age 19.1) and 61 FEP (age 23.0) patients, in order to understand the stage(s) or trajectories in which differences in subjective stress or physiological response occur. The overall clinical sample had greater perceived stress and blunted cortisol (FEP + CHR, n = 89, age 21.7) compared with healthy controls (n = 45, age 22.9). Additional analyses demonstrated elevated heart rate and systolic blood pressure in FEP compared with CHR, but there were no further differences in physiological parameters (cortisol, heart rate, or blood pressure) between stage- or trajectory-based groups. Together, this suggests that individual stress response markers may differentially emerge at particular stages en route to psychosis - and demonstrates how stage-based analyses can shed light on the emergence and evolution of neurobiological changes in mental illness.

Hair cortisol concentration and its association with acute stress responses and recovery in a sample of medical students in Germany

INTRODUCTION

Experiencing acute and chronic stress can contribute to adverse health outcomes. Responses to acute stress differ between individuals (i.e., stress reactivity) and the experience of chronic stress has been discussed to be associated with acute stress responses and stress recovery. This study thus aims to investigate whether hair cortisol concentration (HCC), being an indicator for hypothalamus-pituitary-adrenal (HPA) axis activity over a prolonged period of time, is associated with acute stress responses and recovery in a sample of medical students.

MATERIAL AND METHODS

From July 2020 to July 2021, medical students (n = 54) underwent a virtual-reality Trier Social Stress Test in which their blood pressure and heart rate variability (HRV) were measured, and hair samples were taken to determine HCC. Piecewise linear growth analyses were used to investigate whether HCC (categorized into low, medium and high levels) is associated with acute stress responses and recovery regarding blood pressure and HRV.

RESULTS

Significant interaction effects in piecewise linear growth analyses showed that participants with higher levels of HCC had lower systolic and diastolic blood pressure responses compared to participants with medium levels of HCC. No significant interaction effects were observed for HRV responses or for recovery measures.

CONCLUSIONS

The study suggests that higher levels of HCC are associated with a lower cardiovascular response in terms of blood pressure to an acute stressor in medical students. Therefore, long-term HPA-axis activity may contribute to different magnitudes of acute stress responses in the autonomic nervous system. As the shown lower blood pressure responses to acute stress in individuals with increased long-term HPA-axis activity may represent inadequate stress responses, these should be further studied in order to find out more about their interaction and potential subsequent disease risks.

Subjective, behavioral and neurobiological effects of cannabis and cannabinoids in social anxiety

Social anxiety disorder (SAD) is a debilitating disorder, characterized by fear and anxiety in social situations. Evidence suggests that the levels of SAD are rising, in particularly after the COVID-19 pandemic. Serotonin and noradrenaline reuptake inhibitors and cognitive-behavioral therapy are effective treatments for SAD. Nevertheless, a significant number of patients do not respond well to these therapeutic options. During the last years, Cannabis and cannabinoid-containing products have been investigated for the treatment of different neuropsychiatric disorders. Nevertheless, their efficacy for the treatment of anxiety disorders is still a matter of debate. The purpose of this review was to investigate subjective, behavioral, and neurobiological effects of Cannabis and cannabinoids in social anxiety and SAD. A search in the PubMed database for articles published between the years of 2003-2023 was conducted. One hundred and seventeen (117) original studies were identified. After the exclusion criteria, eighteen (18) studies were selected. The studies investigated the effects of the cannabinoids Δ9-tetrahydrocannabinol (THC) and cannabidiol (CBD) in patients or healthy volunteers submitted to tasks that assessed social anxiety. Results showed that CBD decreases social anxiety, producing an inverted U-shaped curve, with anxiety measurements being reduced at intermediate doses administered orally (300-600 mg), but not at lower or higher doses. THC either reduces (lower doses, 6-7.5 mg) or increases (higher doses) social anxiety measurements. CBD attenuates the anxiogenic effects of THC. The effects of THC and CBD in anxiety are associated to the modulation of fronto-limbic regions. Further clinical trials, conducted with male and female patients and larger cohorts are still necessary to consolidate these results.

Investigating adverse daily life effects following a psychosocial laboratory stress task, and the moderating role of Psychopathology

Laboratory stress tasks are necessary to closely investigate the stress response in a controlled environment. However, to our knowledge, no study has tested whether participating in such tasks can pose any daily life adverse effect. Fifty-three healthy participants (46 women) took part in a laboratory session where stress was induced using a typical psychosocial stressor: the repeated Montreal Imaging Stress Task (rMIST). Average levels of negative affect (NA), heart rate (HR), root mean square of successive differences (RMSSD), and skin conductance level (SCL), as well as reactivity across all these parameters as measured with the experience sampling method (ESM) in the four days prior to the laboratory session were compared with the four days following the session. We also assessed whether vulnerability to psychopathology moderated these associations. Findings showed that the task did not pose any significant adverse effect on participants. However, there was an unexpected increase in average RMSSD and a decrease in average SCL pre- to post- task. In addition, more vulnerable individuals were more likely to experience an increase in average levels of NA in the days following the task compared to the days preceding it. Our findings suggest that laboratory stress tasks may pose a significant risk to more vulnerable individuals.

The Translational Future of Stress Neurobiology and Psychosis Vulnerability: A Review of the Evidence

Psychosocial stress is a well-established risk factor for psychosis, yet the neurobiological mechanisms underlying this relationship have yet to be fully elucidated. Much of the research in this field has investigated hypothalamic-pituitary-adrenal (HPA) axis function and immuno-inflammatory processes among individuals with established psychotic disorders. However, as such studies are limited in their ability to provide knowledge that can be used to develop preventative interventions, it is important to shift the focus to individuals with increased vulnerability for psychosis (i.e., high-risk groups). In the present article, we provide an overview of the current methods for identifying individuals at high-risk for psychosis and review the psychosocial stressors that have been most consistently associated with psychosis risk. We then describe a network of interacting physiological systems that are hypothesised to mediate the relationship between psychosocial stress and the manifestation of psychotic illness and critically review evidence that abnormalities within these systems characterise highrisk populations. We found that studies of high-risk groups have yielded highly variable findings, likely due to (i) the heterogeneity both within and across high-risk samples, (ii) the diversity of psychosocial stressors implicated in psychosis, and (iii) that most studies examine single markers of isolated neurobiological systems. We propose that to move the field forward, we require well-designed, largescale translational studies that integrate multi-domain, putative stress-related biomarkers to determine their prognostic value in high-risk samples. We advocate that such investigations are highly warranted, given that psychosocial stress is undoubtedly a relevant risk factor for psychotic disorders.

Hippocampal subfields, daily stressors, and resting cortisol in individuals at clinical high-risk for psychosis

INTRODUCTION

The hippocampus, comprised of functionally distinct subfields, both regulates stress and is affected by it during psychosis pathogenesis. Hippocampal abnormalities are evident across psychosis spectrum and are associated with aberrant cortisol levels and greater environmental stressors exposure. These associations, particularly at the subfield-level, are poorly understood in individuals at clinical high-risk (CHR) for psychosis. This represents a significant literature gap given this critical pathogenetic period is characterized by an interplay between environmental stressors and biological susceptibility.

METHODS

A total of 121 participants including 51 CHR (mean age=18.61) and 70 healthy controls (HC; mean age=18.3) were enrolled in the study. Participants completed a structural scan, salivary cortisol assays, and a self-report measure assessing distress from daily stressors exposure (DSI). Hippocampal subfield segmentation was conducted using Freesurfer.

RESULTS

Smaller hippocampal subfields were associated with greater stress levels. Greater DSI was associated with lower volumes in CA1 (r = -0.38) and CA2/3 (r = -0.29), but not in CA4/DG (r = -0.28), presubiculum (r = -0.09), or subiculum (r = -0.17). Higher resting cortisol was associated with lower volumes in presubiculum (r = -0.4) but not subiculum (r = -0.22), CA1 (r = 0.08), CA2/3 (r = 0.1), or CA4/DG (r = -0.005). Regressions indicated effects for CA1 and DSI (β = 0.57, p = .03) and presubiculum and cortisol (β = 0.61, p = .02) are specific to CHR participants relative to HCs.

CONCLUSIONS

The findings provided insights into links between stress and brain vulnerability during psychosis-risk period. Regional differences highlighted potentially different mechanisms by which stress impacts specific subfields. Presubiculum may be more susceptible to the impact of early stress on HPA-axis and cornu amonis to acute stressors.

Stress and reward: A multimodal assessment of childhood sexual abuse

Background

Childhood adversity has been found to impact stress and brain reward systems but it is unclear whether interactions between these systems might explain resilient vs. non-resilient trajectories following childhood sexual abuse (CSA). To address this gap, we adopted a multimodal approach in which cortisol reactivity to an acute stressor was assessed in conjunction with behavioral and neural measures of reward responsiveness in females with major depressive disorder (MDD) or no psychiatric disorders (i.e., resilient) who experienced CSA compared to females with and without MDD who did not experience abuse.

Methods

Latent Class Mixed Modelling (LCMM) identified classes of adults (n = 62; MAge = 26.48, SD = 5.68) characterized by distinct cortisol trajectories in response to a combined social evaluative cold pressor task. Classes were examined for their history of CSA and resilience as well as behavioral and neural measures of reward responsiveness using 128-channel electroencephalography (event-related potentials and source localization analysis).

Results

LCMM analysis identified two distinct classes of individuals with increased (Responders) or blunted (Non-Responders) cortisol reactivity to an acute stressor. Unlike Responders, Non-Responders did not modulate reward responses throughout the stress manipulation. No differences emerged between Responders and Non-Responders in terms of CSA or resilience. However, exploratory results showed that blunted cortisol response and non-modulation of reward responses emerged for those who experienced CSA at a younger age.

Conclusions

Co-occurring blunted stress and reward reactivity emerged irrespective of adults' experience of CSA or resilience. However, preliminary findings showed that CSA ending during peripubertal development was associated with blunted cortisol and reward responsiveness. Future research needs to replicate findings in larger samples and could investigate if increasing reward responsiveness during critical times of neurodevelopment could normalize stress reactivity to future stressors and thus promote resilience.

Coordination of autonomic and endocrine stress responses to the Trier Social Stress Test in adolescence

Dysregulations in autonomic and endocrine stress responses are linked to the emergence of psychopathology in adolescence. However, most studies fail to consider the interplay between these systems giving rise to conflicting findings and a gap in understanding adolescent stress response regulation. A multisystem framework-investigation of parasympathetic (PNS), sympathetic (SNS), and hypothalamic pituitary adrenal (HPA) axis components and their coordination-is necessary to understand individual differences in stress response coordination which contribute to stress vulnerabilities. As the first investigation to comprehensively evaluate these three systems in adolescence, the current study employed the Trier Social Stress Test in 72 typically developing adolescents (mean age = 13) to address how PNS, SNS, and HPA stress responses are coordinated in adolescence. Hypotheses tested key predictions of the Adaptive Calibration Model (ACM) of stress response coordination. PNS and SNS responses were assessed via heart rate variability (HRV) and salivary alpha amylase (sAA) respectively. HPA responses were indexed by salivary cortisol. Analyses utilized piecewise growth curve modeling to investigate these aims. Supporting the ACM theory, there was significant hierarchical coordination between the systems such that those with low HRV had higher sAA and cortisol reactivity and those with high HRV had low-to-moderate sAA and cortisol responsivity. Our novel results reveal the necessity of studying multisystem dynamics in an integrative fashion to uncover the true mechanisms of stress response and regulation during development. Additionally, our findings support the existence of characteristic stress response profiles as predicted by the ACM model.

Bullying and social functioning, schemas, and beliefs among youth at clinical high risk for psychosis

BACKGROUND

Individuals at clinical high-risk (CHR) for psychosis experience high rates of bullying. There is little research on the differences between CHR who did and did not experience bullying. However, there is evidence that bullying may be related to negative schemas and social impairment.

OBJECTIVES

To examine differences in core schemas, asocial and defeatist beliefs, and social functioning between those who did and did not report bullying experiences in a large sample of CHR individuals. We hypothesized that bullying in CHR youth would be associated with poorer social functioning, increased maladaptive beliefs, and negative core schemas.

METHODS

CHR participants (N = 203) were split into those who did and did not report experiencing bullying. The two groups were compared on demographic characteristics, social functioning, and belief variables, using the Brief Core Schemas Scale, the Asocial Beliefs Scale, the Defeatist Performance Attitudes Scale, and the First Episode Social Functioning Scale.

RESULTS

72.9% reported experiencing bullying. These participants had greater severity of negative schemas about others and asocial and defeatist performance beliefs, and lower social functioning scores.

CONCLUSIONS

Prevalence of bullying among CHR participants is high. Bullying may be a risk factor for increased asocial and defeatist beliefs, negative core schemas, and poor social functioning. Targeting maladaptive schemas and beliefs during treatment may serve to improve functional outcomes in this group.

Cortisol Levels in Childhood Associated With Emergence of Attenuated Psychotic Symptoms in Early Adulthood

BACKGROUND

In individuals at clinical high-risk for psychosis, elevated cortisol levels predict subsequent onset of psychotic disorder. However, it is unclear whether cortisol alterations are evident at an earlier clinical stage and promote progression of psychosis expression. This study aimed to address this issue by investigating whether cortisol levels in childhood were associated with the emergence of attenuated psychotic symptoms in early adulthood. In exploratory analyses, we examined whether cortisol and psychosocial stress measures interacted in predicting attenuated psychotic symptoms.

METHODS

A sample of children (N = 109) enriched for psychosis risk factors were recruited at age 9-12 years and assessed at age 11-14 years (T1) and 17-21 years (T2). Measures of psychopathology, psychosocial stressors, and salivary cortisol were obtained at T1. Attenuated psychotic symptoms were assessed at T2 using the Prodromal Questionnaire.

RESULTS

Diurnal cortisol (β = 0.915, 95% CI: 0.062-1.769) and daily stressors (β = 0.379, 95% CI: 0.034-0.723) at T1 were independently associated with total Prodromal Questionnaire scores at T2 after accounting for demographic factors and T1 psychopathology. Exploratory analyses indicated a significant interaction between T1 diurnal cortisol and daily stressors (β = 0.743, 95% CI: 0.081-1.405), with the highest predicted T2 total Prodromal Questionnaire scores occurring when both diurnal cortisol and daily stressors were increased.

CONCLUSIONS

Our findings suggest that daily stressors and elevations in diurnal cortisol in late childhood/early adolescence increases risk for developing attenuated psychotic symptoms. These findings emphasize the importance of assessing environmental and biological risk factors for psychosis during neurodevelopmentally vulnerable time periods.

Altered relationship between cortisol response to social stress and mediotemporal function during fear processing in people at clinical high risk for psychosis: a preliminary report

Evidence suggests that people at Clinical High Risk for Psychosis (CHR) have a blunted cortisol response to stress and altered mediotemporal activation during fear processing, which may be neuroendocrine-neuronal signatures of maladaptive threat responses. However, whether these facets are associated with each other and how this relationship is affected by cannabidiol treatment is unknown. We examined the relationship between cortisol response to social stress and mediotemporal function during fear processing in healthy people and in CHR patients. In exploratory analyses, we investigated whether treatment with cannabidiol in CHR individuals could normalise any putative alterations in cortisol-mediotemporal coupling. 33 CHR patients were randomised to 600 mg cannabidiol or placebo treatment. Healthy controls (n = 19) did not receive any drug. Mediotemporal function was assessed using a fearful face-processing functional magnetic resonance imaging paradigm. Serum cortisol and anxiety were measured immediately following the Trier Social Stress Test. The relationship between cortisol and mediotemporal blood-oxygen-level-dependent haemodynamic response was investigated using linear regression. In healthy controls, there was a significant negative relationship between cortisol and parahippocampal activation (p = 0.023), such that the higher the cortisol levels induced by social stress, the lower the parahippocampal activation (greater deactivation) during fear processing. This relationship differed significantly between the control and placebo groups (p = 0.033), but not between the placebo and cannabidiol groups (p = 0.67). Our preliminary findings suggest that the parahippocampal response to fear processing may be associated with the neuroendocrine (cortisol) response to experimentally induced social stress, and that this relationship may be altered in patients at clinical high risk for psychosis.

HPA Axis in the Pathomechanism of Depression and Schizophrenia: New Therapeutic Strategies Based on Its Participation

The hypothalamic-pituitary-adrenal (HPA) axis is involved in the pathophysiology of many neuropsychiatric disorders. Increased HPA axis activity can be observed during chronic stress, which plays a key role in the pathophysiology of depression. Overactivity of the HPA axis occurs in major depressive disorder (MDD), leading to cognitive dysfunction and reduced mood. There is also a correlation between the HPA axis activation and gut microbiota, which has a significant impact on the development of MDD. It is believed that the gut microbiota can influence the HPA axis function through the activity of cytokines, prostaglandins, or bacterial antigens of various microbial species. The activity of the HPA axis in schizophrenia varies and depends mainly on the severity of the disease. This review summarizes the involvement of the HPA axis in the pathogenesis of neuropsychiatric disorders, focusing on major depression and schizophrenia, and highlights a possible correlation between these conditions. Although many effective antidepressants are available, a large proportion of patients do not respond to initial treatment. This review also discusses new therapeutic strategies that affect the HPA axis, such as glucocorticoid receptor (GR) antagonists, vasopressin V1B receptor antagonists and non-psychoactive CB1 receptor agonists in depression and/or schizophrenia.

Psychotic-like experiences among 9,564 Kenyan adolescents and young adults

OBJECTIVE

To investigate the prevalence and characteristics of psychotic-like experiences (PLE) in a large cohort of Kenyan adolescents and young adults.

METHOD

The Washington Early Recognition Center Affectivity and Psychosis (WERCAP) Screen was used to the study the 12-month prevalence of PLE's among 9,564 Kenyan youths (aged 15-25 yrs), and the rates of psychosis high-risk (HR) and medium-risk (MR) cases, based on cut-off scores. Relationships with clinical, demographic and economic profiles were investigated.

RESULTS

Across all participants, 72% reported having had at least one PLE over the last year. 4.6% and 30.6% were HR and MR based on symptom scores. There were similar PLE rates in females and males. PLE severity correlated with mood (r=0.67), stress (r=0.46), and autistic traits (r=0.18). PLE severity was also related to poverty, lower education attainment, and underemployment. Compared to controls, HR and MR youths were more likely to report lifetime substance use and to have more significant use.

CONCLUSION

Psychosis screening can provide valuable information about individuals and may help identify those who may require clinical assessment and intervention to improve outcomes. This is particularly relevant in many parts of Africa where the resources are limited for treating more advanced illness.

A meta-analysis of blood and salivary cortisol levels in first-episode psychosis and high-risk individuals

Dysregulated cortisol responses and glucose metabolism have been reported in psychosis. We performed a random-effects meta-analysis of cortisol responses in first-episode psychosis (FEP) and psychosis risk states, taking into consideration glucose metabolism. A total of 47 studies were included. Unstimulated blood cortisol levels were significantly higher (g = 0.48, 95 %CI: 0.25-0.70, p < 0.001) in FEP, but not in psychosis risk states (g = 0.39, 95 %CI: -0.42-1.21, p = 0.342), compared to controls. Cortisol awakening response (CAR) was attenuated in FEP (g = -0.40, 95 %CI: -0.68 - -0.12, p = 0.006), but not in psychosis risk states (p = 0.433). Glucose and insulin levels were positively correlated with unstimulated blood cortisol levels in FEP. Our meta-analysis supports previous findings of elevated blood cortisol levels and attenuated CAR in FEP. Future research should focus on identifying the common denominators for alterations in stress hormones and glucose metabolism.

Mild-to-moderate schizotypal traits relate to physiological arousal from social stress

Schizotypy denotes psychosis-like experiences, such as perceptual aberration, magical ideation, and social anxiety. Altered physiological arousal from social stress is found in people with high schizotypal traits. Two experiments aimed to determine the relationship of schizotypy to physiological arousal from social stress. Experiment 1 tested the hypotheses that heart rate from social stress would be greater in high, than mild-to-moderate, schizotypal traits, and disorganized schizotypy would explain this effect because of distress from disorganisation. Experiment 1 tested social stress in 16 participants with high schizotypal traits and 10 participants with mild-to-moderate schizotypal traits. The social stress test consisted of a public speech and an informal discussion with strangers. The high schizotypal group had a higher heart rate than the mild-to-moderate schizotypal group during the informal discussion with strangers, but not during the public speech. Disorganized schizotypy accounted for this group difference. Experiment 2 tested the hypothesis that mild-to-moderate schizotypal traits would have a linear relationship with physiological arousal from social stress. Experiment 2 tested 24 participants with mild-to-moderate schizotypal traits performing the abovementioned social stress test while their heart rate and skin conductance responses were measured. Mild-to-moderate schizotypal traits had a linear relationship with physiological arousal during the discussion with strangers. Distress in disorganized schizotypy may explain the heightened arousal from close social interaction with strangers in high schizotypy than mild-to-moderate schizotypy. Mild-to-moderate schizotypal traits may have a linear relationship with HR during close social interaction because of difficulty with acclimatizing to the social interaction.

Neuroimaging Markers of Resiliency in Youth at Clinical High Risk for Psychosis: A Qualitative Review

Psychotic disorders are highly debilitating and constitute a major public health burden. Identifying markers of psychosis risk and resilience is a necessary step toward understanding etiology and informing prevention and treatment efforts in individuals at clinical high risk (CHR) for psychosis. In this context, it is important to consider that neural risk markers have been particularly useful in identifying mechanistic determinants along with predicting clinical outcomes. Notably, despite a growing body of supportive literature and the promise of recent findings identifying potential neural markers, the current work on CHR resilience markers has received little attention. The present review provides a brief overview of brain-based risk markers with a focus on predicting symptom course. Next, the review turns to protective markers, examining research from nonpsychiatric and schizophrenia fields to build an understanding of framing, priorities, and potential, applying these ideas to contextualizing a small but informative body of resiliency-relevant CHR research. Four domains (neurocognition, emotion regulation, allostatic load, and sensory and sensorimotor function) were identified and are discussed in terms of behavioral and neural markers. Taken together, the literature suggests significant predictive value for brain-based markers for individuals at CHR for psychosis, and the limited but compelling resiliency work highlights the critical importance of expanding this promising area of inquiry.

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.

Counterpoint. Early intervention for psychosis risk syndromes: Minimizing risk and maximizing benefit

BACKGROUND

Malhi et al. in this issue critique the clinical high risk (CHR) syndrome for psychosis.

METHOD

Response to points of critique.

RESULTS

We agree that inconsistency in CHR nomenclature should be minimized. We respectfully disagree on other points. In our view: a) individuals with CHR and their families need help, using existing interventions, even though we do not yet fully understand disease mechanisms; b) substantial progress has been made in identification of biomarkers; c) symptoms used to identify CHR are specific to psychotic illnesses; d) CHR diagnosis is not "extremely difficult"; e) the pattern of progression, although heterogenous, is discernible; f) "psychosis-like symptoms" are common but are not used to identify CHR; and g) on the point described as 'the real risk,' CHR diagnosis does not frequently cause harmful stigma.

DISCUSSION

Malhi et al.'s arguments do not fairly characterize progress in the CHR field nor efforts to minimize stigma. That said, much work remains in areas of consistent nomenclature, mechanisms of disease, dissecting heterogeneity, and biomarkers. With regard to what the authors term the "real risk" of stigma associated with a CHR "label," however, our view is that avoiding words like "risk" and "psychosis" reinforces the stigma that both they and we mean to oppose. Moreover, patients and their families benefit from being given a term that describes what is happening to them.

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.

Stressor-Cortisol Concordance Among Individuals at Clinical High-Risk for Psychosis: Novel Findings from the NAPLS Cohort

Whilst elevations in basal cortisol levels have been reported among individuals at-risk for psychosis, the extent to which this represents hyperresponsivity of the hypothalamic-pituitary-adrenal (HPA) axis to psychosocial stressors encountered in the natural environment is currently unclear. We aimed to examine stressor-cortisol concordance among youth at clinical high-risk (CHR) for psychosis in the North American Prodrome Longitudinal Study 2 (NAPLS 2) and the relationship with clinical outcome. At baseline, CHR (N = 457) and healthy (N = 205) individuals provided salivary cortisol samples and completed daily stressor, life event, and childhood trauma measures. CHR youth were categorised as remitted, symptomatic, progression of positive symptoms, or psychosis conversion at the two-year follow-up. Within-group regression models tested associations between psychosocial stressors and cortisol; standardised beta coefficients (Stβ) were subsequently derived to enable within-group pooling of effect sizes across stressor types. After adjustment for potential confounders, all CHR subgroups reported greater exposure to life events and daily stressors, and more distress in relation to these events, relative to controls. All CHR groups were also more likely to experience childhood trauma; only CHR converters, however, were characterised by elevated basal cortisol. Daily stressor distress was significantly associated with cortisol in controls (β = 0.60, 95% CI: 0.12-1.08) and CHR youth who converted to psychosis (β = 0.91, 95% CI: 0.05-1.78). In controls only, life event exposure was associated with cortisol (β = 0.45, 95% CI: 0.08-0.83). When pooled across stressors, stressor-cortisol concordance was substantially higher among CHR converters (Stβ = 0.26, 95% CI: 0.07 to 0.44) relative to CHR progressed (Stβ = 0.02, 95% CI: -0.11 to 0.15), symptomatic (Stβ = 0.01, 95% CI: -0.11 to 0.12), and remitted groups (Stβ = 0.00, 95% CI: -0.13 to 0.13); however, unexpectedly, healthy controls showed intermediate levels of concordance (Stβ = 0.15, 95% CI: 0.05 to 0.26). In conclusion, whilst all CHR subgroups showed increased psychosocial stress exposure and distress relative to controls, only those who later converted to psychosis were characterised by significantly elevated basal cortisol levels. Moreover, only CHR converters showed a higher magnitude of stressor-cortisol concordance compared to controls, although confidence intervals overlapped considerably between these two groups. These findings do not support the notion that all individuals at CHR for psychosis show HPA hyperresponsiveness to psychosocial stressors. Instead, CHR individuals vary in their response to stressor exposure/distress, perhaps driven by genetic or other vulnerability factors.

Higher perceived stress is associated with lower cortisol concentrations but higher salivary interleukin-1beta in socially evaluated cold pressor test

The relationship between subjective stress perception and the objective stress response to acute stress stimuli is not sufficiently understood. The aim of the present study was to test the hypothesis that the neuroendocrine response in socially evaluated cold pressor test (CPT) depends on the extent of perceived stressfulness of the stimulus. The test was performed in 24 healthy male volunteers. Subjective stress perception was assessed using nine visual analog scales. The subjects were divided to low and high stress perception groups according to the median split of the scores. Subjects with high stress perception exhibited slightly lower values of systolic blood pressure and lower overall concentrations of salivary cortisol compared to subjects with low stress perception. Salivary alpha-amylase activity did not show significant changes. Salivary aldosterone decreased in time in subjects with low but increased early after the test in subjects with high stress perception. Interestingly, salivary concentrations of the pro-inflammatory cytokine interleukin-1beta were considerably higher in subjects with high stress perception, particularly immediately before the test. The differences in salivary cortisol and interleukin-1beta were confirmed by the analysis with distress as a continuous covariate. Distress scores correlated negatively with salivary cortisol and positively with interleukin-1beta. The rate pressure product, which is a global measure of energy consumption by the heart, was significantly higher immediately before than after the stress exposure. The present findings show that concentrations of interleukin-1beta are a sensitive component of the stress response at the time before the stressful event.Lay summaryIt is generally expected that higher perceived stressfulness of a stimulus is accompanied by higher activation of stress-related systems. This study evaluating a combined psychosocial and physical stress situation in healthy men provides evidence that individual parameters of the stress response are differently related to perceived stress intensity. Subjects with high stress perception exhibited lower systolic blood pressure and salivary cortisol, higher interleukin-1beta, marginal differences in alpha amylase and aldosterone compared to subjects with low stress perception, which might be important for stress coping.

Consistent Exposure to Psychosocial Stressors and Progressive Intolerance to Stress in Individuals at Clinical High Risk for Psychosis

A body of evidence suggests that exposure to psychosocial stressors and stress sensitivity are involved in psychosis pathogenesis. However, little is known about the temporal course of these domains in those with psychosis-risk syndromes. Furthermore, to date, there have been no studies examining associations between psychosocial stressors and impaired stress tolerance, or how these factors might be implicated in symptom progression prior to psychosis onset. A total of 73 clinical high-risk (CHR) participants and 78 healthy controls (HCs) completed baseline measures of life event (LE) exposure and impaired stress tolerance. Additionally, 54 CHR and 57 HC participants returned to complete the same procedures at a 12-month follow-up assessment. Results indicated that when compared to HCs, CHR individuals exhibited increased LE exposure and impaired stress tolerance at baseline. Longitudinal analyses compared subgroups of CHR participants who exhibited positive symptoms worsening over the 1-year course (CHR-Prog), improved or steady (CHR-Remiss/Persist), and HCs. CHR-Prog individuals showed consistently elevated independent LEs exposure while CHR-Remiss/Persist reported a decline and HCs a steady low level across time. Furthermore, CHR-Prog exhibited increased stress intolerance, while the CHR-Remiss/Persist improved and HCs displayed consistently low levels over time. Analyses examining interrelationships between these domains showed a trend level interaction effect predicting follow-up symptoms. Taken together, results from the present study indicate an important role for exposure to stressors and increasing stress intolerance during psychosis pathogenesis. Additionally, findings indicating that decreases in stress exposure may lead to more favorable outcomes provide a promising target for novel targeted interventions.

Cortisol Responses to Naturally Occurring Psychosocial Stressors Across the Psychosis Spectrum: A Systematic Review and Meta-Analysis

BACKGROUND

Individuals with established psychosis and those at high-risk for the disorder have been found to show abnormalities within the hypothalamic-pituitary-adrenal (HPA) axis, including elevations in basal and diurnal cortisol, but a blunted cortisol awakening response. However, the extent to which these features are associated with psychosocial stressors encountered in the natural environment (which are known to be more commonly experienced by these groups, and more distressing) is currently unclear. We therefore conducted a systematic review and meta-analysis to investigate the concordance between naturally-occurring psychosocial stressors and cortisol levels in these populations.

METHODS

PubMed, PsycINFO, and EMBASE were searched up to November 2019 to identify studies examining the concordance between psychosocial stressors and cortisol in healthy controls and individuals on the psychosis spectrum (patients with established psychosis and/or high-risk individuals). An overall meta-analysis (including data for all stressor-cortisol pairings) was performed to determine the degree of concordance irrespective of group status, with meta-regression employed to test whether the degree of concordance differed in established psychosis and high-risk groups compared to controls. Planned stratified analyses were then performed to examine group differences (where established psychosis and high-risk groups were combined) within individual stressor-cortisol pairings.

RESULTS

Eighteen studies (16 datasets) were eligible for inclusion. The overall model, comprising 134 effect sizes, showed that stressors and cortisol measures were only weakly correlated [r=0.05 (95% CI: -0.00 to 0.10), p=0.059] and that neither established psychosis status (r=0.01, p=0.838) nor high-risk status (r=0.02, p=0.477) had a significant effect of the strength of correlation. In stratified analyses, significant differences between healthy controls and psychosis spectrum groups were observed for only one of the six stressor-cortisol pairings examined, where life event exposure and diurnal cortisol were positively correlated in controls [r=0.25 (95% CI: 0.01 to 0.46)], but negatively correlated in the psychosis spectrum group [r=-0.28 (95% CI: -0.49 to -0.04)].

CONCLUSIONS

Overall, we observed poor concordance between naturally-occurring psychosocial stressors and cortisol irrespective of stressor type, cortisol measure, or group status. We consider a range of methodological factors that may have obscured the ability to detect "true" associations and provide recommendations for future studies in this field.

Effects of short-term cannabidiol treatment on response to social stress in subjects at clinical high risk of developing psychosis

RATIONALE

Stress is a risk factor for psychosis and treatments which mitigate its harmful effects are needed. Cannabidiol (CBD) has antipsychotic and anxiolytic effects.

OBJECTIVES

We investigated whether CBD would normalise the neuroendocrine and anxiety responses to stress in clinical high risk for psychosis (CHR) patients.

METHODS

Thirty-two CHR patients and 26 healthy controls (HC) took part in the Trier Social Stress Test (TSST) and their serum cortisol, anxiety and stress associated with public speaking were estimated. Half of the CHR participants were on 600 mg/day of CBD (CHR-CBD) and half were on placebo (CHR-P) for 1 week.

RESULTS

One-way analysis of variance (ANOVA) revealed a significant effect of group (HC, CHR-P, CHR-CBD (p = .005) on cortisol reactivity as well as a significant (p = .003) linear decrease. The change in cortisol associated with experimental stress exposure was greatest in HC controls and least in CHR-P patients, with CHR-CBD patients exhibiting an intermediate response. Planned contrasts revealed that the cortisol reactivity was significantly different in HC compared with CHR-P (p = .003), and in HC compared with CHR-CBD (p = .014), but was not different between CHR-P and CHR-CBD (p = .70). Across the participant groups (CHR-P, CHR-CBD and HC), changes in anxiety and experience of public speaking stress (all p's < .02) were greatest in the CHR-P and least in the HC, with CHR-CBD participants demonstrating an intermediate level of change.

CONCLUSIONS

Our findings show that it is worthwhile to design further well powered studies which investigate whether CBD may be used to affect cortisol response in clinical high risk for psychosis patients and any effect this may have on symptoms.

Stress, Cortisol and NR3C1 in At-Risk Individuals for Psychosis: A Mendelian Randomization Study

INTRODUCTION

The emergence of psychosis in at-risk individuals results from interactions between genetic vulnerability and environmental factors, possibly involving dysregulation of the hypothalamic-pituitary-adrenal axis. Hypercorticism was indeed described in schizophrenia and ultra-high-risk states, but its association with clinical outcome has yet to be demonstrated. The impact of stress through cortisol may vary depending on the expression level of genes related to the stress pathway.

METHODS

To test this hypothesis, we selected NR3C1, the gene encoding the glucocorticoid receptor, and modeled through logistic regression how its peripheral expression could explain some of the risk of psychosis, independently of peripheral cortisol levels, in a French longitudinal prospective cohort of 133 at-risk individuals, adjusted for sex, age, cannabis, and antipsychotic medication intake. We then performed a genome-wide association analysis, stratified by sex (55 females and 78 males), to identify NR3C1 expression quantitative trait loci to be used as instrumental variables in a Mendelian randomization framework.

RESULTS

NR3C1 expression was significantly associated with a higher risk of conversion to psychosis (OR = 2.03, p = 0.03), independently of any other factor. Cortisol was not associated with outcome nor correlated with NR3C1. In the female subgroup, rs6849528 was associated both with NR3C1 mRNA levels (p = 0.015, Effect-Size = 2.7) and conversion (OR = 8.24, p = 0.03).

CONCLUSIONS

For the same level of cortisol, NR3C1 expression increases psychotic risk, independently of sex, age, cannabis, and antipsychotic intake. In females, Mendelian randomization confirmed NR3C1's effect on outcome to be unbiased by any environmental confounder.

Effects of long-term crowding stress on neuro-endocrine-immune network of rainbow trout (Oncorhynchus mykiss)

Low levels of stresses cause eustress while high stressful situations result in distress. Female rainbow trout (Oncorhynchus mykiss) was reared under crowded conditions to mimic the stressful environment of intensive fishery production. Trout was stocked for 300 days with initial densities of 4.6 ± 0.02 (final: 31.1 ± 0.62), 6.6 ± 0.03 (final: 40.6 ± 0.77), and 8.6 ± 0.04 (final: 49.3 ± 1.09) kg/m³ as SD1, SD2 and SD3. We assessed molecular, cellular and organismal parameters to understand the flexibility of neuro-endocrine-immune network during stress. Trout with higher initial density (SD3) displayed the slightly activated hypothalamus-pituitary-interrenal (HPI) axis with positively increased antioxidant enzyme activities and anti-inflammatory cytokine transcriptions on day 60 or 120. These results indicated that low level of stress was capable of exerting eustress by activating neuro-endocrine-immune network with beneficial adaptation. Transition from eustress to distress was induced by the increased intensity and duration of crowding stress on day 240 and 300. The prolonged activation of HPI axis resulted in suppressed growth hormone-insulin-like growth factor (GH-IGF) axis, up-regulated cytokine transcriptions and severe reactive oxygen species stress. Stress means reset of neuro-endocrine-immune network with energy expenditure and redistribution. Digestive ability of trout with distress was also inhibited on day 240 and 300, indicating a decreased total energy supplement and energy distribution for functions are not necessary for surviving such as growth and reproduction. Consequently, we observed the dyshomeostasis of energy balance and neuro-endocrine-immune network of trout during long-term crowding conditions.

Stress during critical periods of development and risk for schizophrenia

Schizophrenia is a neurodevelopmental disorder with genetic predisposition, and stress has long been linked to its etiology. While stress affects all stages of the illness, increasing evidence suggests that stress during critical periods of development may be particularly detrimental, increasing individual's vulnerability to psychosis. To thoroughly understand the potential causative role of stress, our group has been focusing on the prenatal methylazoxymethanol acetate (MAM) rodent model, and discovered that MAM offspring display abnormal stress reactivity and heightened anxiety prepubertally, prior to the manifestation of a hyperdopaminergic state. Furthermore, pharmacologically treating anxiety during prepuberty prevented the emergence of the dopamine dysfunction in adulthood. Interestingly, sufficiently strong stressors applied to normal rats selectively during early development can recapitulate multiple schizophrenia-related phenotypes of MAM rats, whereas the same stress paradigm during adulthood only produced short-term depression-related deficits. Altogether, the evidence is thus converging: developmental disruption (genetic or environmental) might render animals more susceptible to the deleterious effects of stress during critical time windows, during which unregulated stress can lead to the emergence of psychosis later in life. As an important region regulating the midbrain dopamine system, the ventral hippocampus is particularly vulnerable to stress, and the distinct maturational profile of its fast-spiking parvalbumin interneurons may largely underlie such vulnerability. In this review, by discussing emerging evidence spanning clinical and basic science studies, we propose developmental stress vulnerability as a novel link between early predispositions and environmental triggering events in the pathophysiology of schizophrenia. This promising line of research can potentially provide not only insights into the etiology, but also a "roadmap" for disease prevention.

Reward-Related Striatal Responses Following Stress in Healthy Individuals and Patients With Bipolar Disorder

BACKGROUND

Stress has a major impact on the onset and recurrence of mood episodes in bipolar disorder (BD), but the underlying mechanisms remain unknown. Previous studies have shown distinct time-dependent effects of stress on reward processing in healthy individuals. Impaired reward processing is a core characteristic of BD, and altered reward processing during recovery from stress could influence the development and course of bipolar disorder.

METHODS

We investigated brain responses during reward processing 50 minutes after stress using functional magnetic resonance imaging in 40 healthy control subjects and 40 patients with euthymic BD assigned to either an acute stress test (Trier Social Stress Test) or a no-stress condition.

RESULTS

Acute stress increased cortisol levels in both healthy control subjects and patients with BD. Ventral striatal responses to reward outcome were increased in healthy control subjects during stress recovery but not in patients with BD. For anticipation, no differences were found between the groups following stress.

CONCLUSIONS

For the first time, we show altered reward processing in patients with BD during the recovery phase of stress. These data suggest reduced neural flexibility of hedonic signaling in response to environmental challenges. This may increase the susceptibility to stressful life events in the future and play a role in the development of further psychopathology in the longer term.

Lower cortisol levels and attenuated cortisol reactivity to daily-life stressors in adults with 22q11.2 deletion syndrome

BACKGROUND

22q11.2 deletion syndrome (22q11DS) is a genetic disorder associated with neurodevelopmental, anxiety and mood disorders, as well as an increased risk for developing psychosis. Cortisol levels and stress reactivity reflect hypothalamic-pituitary-adrenal (HPA)-axis activity, and are believed to be altered in individuals that often experience daily-life stress, depression, and psychotic symptoms. However, it is unknown whether individuals with 22q11DS display an altered stress reactivity.

METHODS

We included 27 adults with 22q11DS (mean age: 34.1 years, 67% female) and 24 age and sex-matched healthy controls (HC; mean age: 39.9 years, 71% female) into an experience sampling study. Throughout 6 consecutive days, we measured participants' subjective stress related to current activity and at the same time collected salivary cortisol samples. Multilevel regression models were used to analyze cortisol reactivity to activity-related stress.

RESULTS

Diurnal cortisol levels were significantly lower in the 22q11DS group compared to HCs (B=-1.03, p < 0.001). 22q11DS adults displayed significantly attenuated cortisol reactivity to activity-related stress compared to HCs (B = -0.04, p = 0.026). Post-hoc exploratory analysis revealed that these results were independent from 22q11DS psychiatric diagnosis or medication use.

CONCLUSION

These results indicate that adults with 22q11DS have lower cortisol levels and attenuated cortisol response to daily stress, possibly resulting from an increased sensitization of the HPA-axis. This suggests that alterations in HPA-axis functioning, previously reported in several psychiatric disorders including post-traumatic stress disorder (PTSD), psychotic disorder, and mood disorder, also appear to be present in adults with 22q11DS.

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 Trier Social Stress Test in first episode psychosis patients: Impact of perceived stress, protective factors and childhood trauma

Psychosis has been associated with abnormalities in hypothalamic-pituitary-adrenal axis functioning, which may emerge through heightened stress sensitivity following early life adversity - ultimately resulting in illness onset and progression. The present study assessed cortisol levels during an established psychosocial stress task and their association with current stress perception, putative protective factors and adverse childhood experiences in patients with a first episode of psychosis (FEP). A total of 100 volunteers participated in the study, 57 of whom were patients with a FEP (mean age 23.9 ± 3.8) and 43 healthy community controls (mean age 23.2 ± 3.9). Salivary cortisol, heart rate and blood pressure were measured at eight time points before and after the Trier Social Stress Test. Subjective stress and protective factors were assessed with the Perceived Stress Scale, the Self-Esteem Rating Scale and the Brief COPE. Early life adversity was assessed with the Childhood Trauma Questionnaire. Patients compared to controls showed significantly lower cortisol levels (F = 7.38; p = .008) throughout the afternoon testing period, but no difference in the cortisol response to the TSST. Heart rate was elevated and protective factors were lower in patients compared to controls. Attenuated cortisol levels were associated with higher levels of perceived stress, poor protective factors and more physical neglect during childhood. Our results suggest that attenuated baseline cortisol levels and not a blunted response during an acute stress task might be an indicator of heightened stress vulnerability and poor resilience in psychosis. The possible influence of childhood adversity and antipsychotic medication is discussed.

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.

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.

Racial discrimination and cortisol in African American emerging adults: The role of neighborhood racial composition

OBJECTIVES

African American (AA) emerging adults may become more vulnerable to the consequences of racial discrimination (discrimination) as many begin to occupy racially mixed contexts. Little is known, however, about whether the effect of discrimination on cortisol concentration varies by neighborhood racial composition. We evaluated whether the percentage of White neighbors qualified the association between discrimination and overall cortisol concentration.

METHOD

We used self-report data from the Flint Adolescent Study and block-level census data linked to the participant's home address. Our sample consisted of 241 AA emerging adults (56.8% Female; 19-22 year olds). We used multilevel regression analyses to evaluate whether the percentage of White neighbors modified the association between discrimination and overall cortisol concentration.

RESULTS

Discrimination experienced in the past year, but not chronic discrimination was linked to lower cortisol concentrations among AA emerging adults living in neighborhoods with a high concentration of White neighbors. Specifically, past year discrimination was negatively associated among AAs residing in neighborhoods with 46.9% of White residents or higher.

CONCLUSIONS

Our results lay the foundation for future research on racial health disparities by suggesting that contextual factors such as neighborhood racial composition can shape the influence race-based discrimination has on health. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

The effects of interpersonal emotional expression, partner responsiveness, and emotional approach coping on stress responses

[Correction Notice: An Erratum for this article was reported online in Emotion on Sep 5 2019 (see record 2019-52812-001). In the article, two text call outs for figures are incorrect. At the end of the "Negative emotional responses" section under the "Psychological Stress Responses" heading, "(see Figure 7)" should have been deleted. Under the "Negative task-related ruminative thoughts" heading in that same section, "(see Figure 5)" in the first paragraph should be "(see Figure 7)."] Expressing emotions is a common strategy for coping with stress. Yet, little is known about the effects of using this strategy in close relationships, or when and for whom emotional expression is effective. This study examined romantic partner responsiveness and the dispositional tendency to use emotional approach coping (EAC; the processing and expression of emotions) as moderators of the effects of experimentally manipulated emotional expression on stress responses to a laboratory stressor. We brought couples (N = 145) to the lab and randomly assigned 1 partner (the participant) to perform a stressful task. We manipulated whether participants expressed their feelings about the task to their partner (expression vs. no-expression), and whether participants received supportive messages from their partners (as an indicator of partner responsiveness; support vs. no-support). We examined physiological stress responses (cortisol and salivary alpha-amylase [sAA]), negative emotional stress responses (anxiety and self-conscious emotions), and post-task ruminative thoughts. Participants high in EAC showed larger sAA and cortisol responses and reported more negative post-task ruminative thoughts after emotionally expressing to their partners, but partner support mitigated the effect on cortisol. Participants low in EAC showed smaller cortisol responses and reported less negative emotional responses and fewer negative post-task ruminative thoughts after emotionally expressing to their partners. Receiving partner support reduced negative emotional responses for people high in EAC, but increased negative emotional responses for those low in EAC. These results may help explain when and for whom emotional expression is an effective means of coping in the immediate context of a stressor. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

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.

Nurses' Experiences in using Physical Activity as Complementary Treatment in Patients with Schizophrenia

INTRODUCTION

Schizophrenia is a common disease with a high risk of comorbidity in both psychiatric and somatic diseases. Physical activity is proven effective in reducing symptoms of schizophrenia and increasing overall health. Still it is not used systematically in the care of persons with schizophrenia.

AIM

The aim of this study is to describe nurses' experience, including personal motivation, in using physical activity as complementary treatment in patients with schizophrenia.

METHOD

Interviews in three focus groups with 12 participating nurses were conducted. Qualitative content analysis was used to analyze data.

RESULTS

Physical activity was commonly used. Although several nurses signaled positive patient response, i.e. less anxiety and better quality of sleep, the overall consensus was an uncertainty regarding the benefits. It was perceived as non-evidence based form of intervention.

CONCLUSION

The uncertainty of the benefits of physical activity is evident in nursing staff and poses a resistance to implement systematic physical activity as a complementary treatment in schizophrenia. A new awareness of evidence based nursing is suggested to promote a wider and more receptive attitude to reduce patient vulnerability in persons with schizophrenia.

Eating Behavior, Stress, and Adiposity: Discordance Between Perception and Physiology

The purpose of the study was to examine the interrelationships among stress, eating behavior, and adiposity in a cohort of normal- and overweight individuals. Clinical markers of physiological stress (fasting serum cortisol) and adiposity (body mass index [BMI] and percent body fat) were obtained from participants selected for a natural history protocol ( n = 107). Self-reported data on eating behavior (using the Three-Factor Eating Questionnaire subscales such as Cognitive Restraint, Disinhibition, and Hunger) and psychological stress (via the Perceived Stress Scale) were evaluated. Demographic information was incorporated using principal component analysis, which revealed sex- and weight-based differences in stress, adiposity, and eating behavior measures. Following a cross-sectional and descriptive analysis, significant correlations were found between the Disinhibition and Hunger eating behavior subscales and measures of adiposity including BMI ( r = .30, p = .002 and r = .20, p = .036, respectively) and percent body fat ( r = .43, p = .000 and r = .22, p = .022, respectively). Relationships between stress measures and eating behavior were also evident in the analysis. Disinhibition and Hunger correlated positively with perceived stress ( r = .32, p .001 and r = .26, p = .008, respectively). However, Disinhibition varied inversely with serum cortisol levels ( r = -.25, p = .009). Future studies are warranted to better understand this paradox underlying the effects of perceived and physiological stress on eating behavior.

Peripheral Cortisol and Inflammatory Response to a Psychosocial Stressor in People with Schizophrenia

Objectives

There is growing evidence of both hypothalamic-pituitary-adrenal (HPA) axis and immune system dysfunction in schizophrenia. Additionally, accumulating evidence has linked dysfunction in the kynurenine pathway to schizophrenia as well as to stress and inflammation. The current pilot tested changes in immune, cortisol and kynurenine and kynurenic acid responses to a psychosocial stressor in people with schizophrenia and healthy controls.

Methods

Ten people with schizophrenia/schizoaffective disorder and 10 healthy controls were included. Participants completed the Trier Social Stress Test (TSST) and cortisol, cytokines (IL-6 & TNF-α), kynurenine and kynurenic acid were measured in the plasma at baseline 15, 30, 60 and 90 minutes following the TSST.

Results

Compared to baseline, at 30 minutes post TSST, mean cortisol levels had increased by 7.6 ng/ml (11%) in healthy controls but decreased by 16.3 ng/ml (25%) in schizophrenia (F=4.34, df=3,38.2, p=0.010). While people with schizophrenia had a lower TNF-α level at baseline (χ² ₍₁₎=10.14, p=0.001), no decreases or increases occurred after the TSST in either group. Both groups had a similar increase in IL-6 at 15 minutes post TSST (F=4.17, df=3, 16.3, p=0.023) demonstrating an immune response to the stress in both groups. A trend towards increased kynurenine from baseline was found immediately after the TSST followed by a decrease at 60 minutes in healthy controls but no change was found in people with schizophrenia (F=2.46, df=3, 49.1, p=0.074).

Conclusion

People with schizophrenia showed a decrease in cortisol from baseline following the TSST as compared to an elevation from baseline seen in healthy controls, supporting HPA axis dysfunction in schizophrenia. An immediate inflammatory response with IL-6 was seen in both groups following the TSST. Larger studies should examine psychosocial stress response in schizophrenia and the relationship of immune function and kynurenine pathway.

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.

Working Memory Impairments in Chromosome 22q11.2 Deletion Syndrome: The Roles of Anxiety and Stress Physiology

Stress and anxiety have a negative impact on working memory systems by competing for executive resources and attention. Broad memory deficits, anxiety, and elevated stress have been reported in individuals with chromosome 22q11.2 deletion syndrome (22q11.2DS). We investigated anxiety and physiological stress reactivity in relation to visuospatial working memory impairments in 20 children with 22q11.2DS and 32 typically developing (TD) children ages 7 to 16. Children with 22q11.2DS demonstrated poorer working memory, reduced post-stress respiratory sinus arrhythmia recovery, and overall increased levels of cortisol in comparison to TD children. Anxiety, but not physiological stress responsivity, mediated the relationship between 22q11.2DS diagnosis and visuospatial working memory impairment. Findings indicate that anxiety exacerbates impaired working memory in children with 22q11.2DS.

The relationship between cannabis use and cortisol levels in youth at ultra high-risk for psychosis

Recent studies have posited a relationship between cannabis use and the biological stress system, but this critical relationship has not been evaluated during the ultra high-risk (UHR) period immediately preceding the onset of psychotic disorders. Salivary cortisol samples were collected on 46 UHR and 29 control adolescents; these individuals were assessed for current cannabis use with a urine panel and self-report. UHR participants where separated into two groups: Current Cannabis Use (UHR-CU) and No Current Cannabis Use (UHR-NC). Healthy Control participants (HC) were free of cannabis use. Consistent with the literature, results indicate UHR individuals showed elevated cortisol levels when compared to HC participants. Further, we also observed that UHR-CU participants exhibited elevated levels when compared to both the non-using UHR and HC groups. Findings suggest that cannabis use may interact with underlying biological vulnerability associated with the hypothalamic-pituitary-adrenal (HPA) axis system.

The Clinic for Assessment of Youth at Risk (CAYR): 10 years of service delivery and research targeting the prevention of psychosis in Montreal, Canada

AIM

In the context of an increasing focus on indicated prevention of psychotic disorders, we describe the operation of the Clinic for Assessment of Youth at Risk (CAYR) over 10 years, a specialized service for identification, monitoring and treatment of young individuals who meet ultra-high risk (UHR) criteria for psychosis, and its integration within the Prevention and Early Intervention Program for Psychosis (PEPP) in Montreal, Canada.

METHODS

We outline rationale, development, inclusion and exclusion criteria, assessment, services offered, community outreach and liaison with potential referral sites, and our research focus on risk and protective factors related to the neural diathesis-stress model of psychosis.

RESULTS

Between January 2005 and December 2014, CAYR has received 370 referrals and accepted 177 patients who met UHR criteria based on the Comprehensive Assessment for At Risk Mental States. Conversion rates to a first episode of psychosis were 11%. Our research findings point to high subjective stress levels, poor self-esteem, social support and coping skills, and a dysregulation of the hypothalamus-pituitary-adrenal axis during the high-risk phase.

CONCLUSIONS

Our efforts at community outreach have resulted in increasing numbers of referrals and patients accepted to CAYR, highlighting the relevance of and need for a high-risk programme in the Montreal area. Patients with psychotic symptoms can be immediately assigned to the first-episode psychosis clinic within PEPP, which has likely contributed to the low conversion rates observed in the UHR group. Our research findings on stress and protective factors emphasize the importance of psychosocial interventions for high-risk patients.

Interplay of hippocampal volume and hypothalamus-pituitary-adrenal axis function as markers of stress vulnerability in men at ultra-high risk for psychosis

BACKGROUND

Altered hypothalamus-pituitary-adrenal (HPA) axis function and reduced hippocampal volume (HV) are established correlates of stress vulnerability. We have previously shown an attenuated cortisol awakening response (CAR) and associations with HV specifically in male first-episode psychosis patients. Findings in individuals at ultra-high risk (UHR) for psychosis regarding these neurobiological markers are inconsistent, and assessment of their interplay, accounting for sex differences, could explain incongruent results.

METHOD

Study participants were 42 antipsychotic-naive UHR subjects (24 men) and 46 healthy community controls (23 men). Saliva samples for the assessment of CAR were collected at 0, 30 and 60 min after awakening. HV was determined from high-resolution structural magnetic resonance imaging scans using a semi-automatic segmentation protocol.

RESULTS

Cortisol measures and HV were not significantly different between UHR subjects and controls in total, but repeated-measures multivariate regression analyses revealed reduced cortisol levels 60 min after awakening and smaller left HV in male UHR individuals. In UHR participants only, smaller left and right HV was significantly correlated with a smaller total CAR (ρ = 0.42, p = 0.036 and ρ = 0.44, p = 0.029, respectively), corresponding to 18% and 19% of shared variance (medium effect size).

CONCLUSIONS

Our findings suggest that HV reduction in individuals at UHR for psychosis is specific to men and linked to reduced post-awakening cortisol concentrations. Abnormalities in the neuroendocrine circuitry modulating stress vulnerability specifically in male UHR subjects might explain increased psychosis risk and disadvantageous illness outcomes in men compared to women.