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

The relation between stress-induced dopamine release in the ventromedial prefrontal cortex, fronto-striatal functional connectivity, and negative urgency: A multimodal investigation using [18F]Fallypride PET, MRI and experience sampling

Negative urgency (NU), or the tendency to act rashly when stress of negative affect is high, could be the result of an insufficient control of the ventromedial prefrontal cortex (vmPFC) over the striatum, through an impaired dopamine (DA) transmission. Therefore, we investigated in vivo human stress-induced DA release in the vmPFC, its relation with fronto-striatal functional connectivity (FC), and NU in daily life. In total, 12 female healthy participants performed a simultaneous [18 F]fallypride PET and fMRI scan during which stress was induced. Regions displaying stress-induced DA release were identified and used to investigate stress-induced changes in fronto-striatal FC. Additionally, participants enrolled in an experience sampling study, reporting on daily life stress and rash actions over a 12-month-long period. Mixed models explored whether stress-induced DA release and FC moderated NU in daily life. Stress led to a lower FC between the vmPFC and dorsal striatum, but a higher FC between the vmPFC and contralateral ventral striatum. Participants with a higher FC between the vmPFC and dorsal striatum displayed more NU in daily life. A higher stress-induced DA release in the vmPFC was related to a higher stress-induced change in FC between the vmPFC and striatum. Participants with a higher DA release in the vmPFC displayed more NU in daily life. In conclusion, stress could differentially impact fronto-striatal FC whereby the connectivity with the dorsal striatum is especially important for NU in daily life. This could be mediated by a higher, but not a lower, stress-induced DA release in the vmPFC.

The experience sampling methodology in psychosis risk states: A systematic review

The experience sampling method (ESM) is a structured diary technique, which is used to assess thoughts, mood and appraise subjective experiences in daily life. It has been recognized as a useful tool for understanding the characteristics, dynamics, and underlying mechanisms of prodromal symptoms of psychosis. The present systematic review aimed to provide a qualitative synthesis of findings provided by the ESM studies conducted in people with psychosis risk states. A systematic review of the MEDLINE, ERIC, Academic Search Ultimate, and Health Source: Nursing/Academic Edition databases, utilizing search terms related to the ESM and the risk of psychosis was conducted. Out of 1069 publication records identified, 77 studies met the inclusion criteria for the review. Data were synthesized around the following topics: 1) assessment of symptoms dynamics and social functioning; 2) assessment of the mechanisms contributing to the emergence of psychotic experiences and 3) assessment of stress sensitivity. The studies have shown that negative emotions are associated with subsequent development of paranoia. The tendency to draw hasty conclusions, aberrant salience, self-esteem, and emotion regulation were the most frequently reported mechanisms associated with the emergence of psychotic experiences. Studies using the ESM also provided evidence for the role of stress sensitivity, in the development of psychotic symptoms. The ESM has widely been applied to studies investigating psychosis risk states, using a variety of protocols. Findings from this systematic review might inform future studies and indicate potential targets for interventions.

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.

Neural correlates of daily-life affective stress reactivity in early psychosis: A study combining functional MRI and experience sampling methodology

Affective reactivity to daily stressors are increased in individuals in the early stages of psychosis. Studies in psychosis patients and healthy individuals at increased psychosis risk show altered neural reactivity to stress in limbic (i.e., hippocampus [HC] and amygdala), prelimbic (i.e., ventromedial prefrontal cortex [vmPFC] and ventral anterior cingulate cortex [vACC]), and salience areas (i.e., Anterior Insula [AI]). We investigated whether a similar pattern of neural reactivity is present in early psychosis individuals and if brain activity in these regions is associated with daily-life stress reactivity. Twenty-nine early psychosis individuals (11 at-risk mental state and 18 first-episode psychosis) completed the Montreal Imaging Stress Task in conjunction with functional MRI. The study was part of a large-scale randomized controlled trial on the efficacy of an acceptance and commitment therapy-based ecological momentary intervention for early psychosis. All participants also provided experience sampling methodology (ESM) data on momentary affect and stressful activities in their everyday environment. Multilevel regression models were used to estimate if daily-life stress reactivity was moderated by activity in (pre)limbic and salience areas. Task-induced stress was associated with increased activation of the right AI and decreased activation in the vmPFC, vACC, and HC. Task-induced changes in vmPFC and vACC activity were associated with affective stress reactivity, whereas changes in HC and amygdala activity were associated with higher overall stress ratings. These preliminary results suggest region-specific roles in affective and psychotic daily-life stress reactivity in early psychosis. The observed pattern suggests that chronic stress plays a role in neural stress reactivity.

Increased affective reactivity to daily social stressors is associated with more severe psychotic symptoms in youths with 22q11.2 deletion syndrome

BACKGROUND

Increased reactivity to minor stressors is considered a risk factor for psychosis, especially in vulnerable individuals. In the present study, we investigated affective and psychotic stress reactivity as well as its link with psychotic symptoms and psychopathology in youths with 22q11.2 deletion syndrome (22q11DS), a neurogenetic condition associated with a high risk for psychosis.

METHODS

A 6-day ecological momentary assessment protocol was used to assess perceived daily-life stress as well as affective and psychotic reactivity to stress in participants with 22q11DS (n = 38, age = 18.4) and healthy controls (HC; n = 53, age = 19.1). Psychotic symptoms, general psychopathology, and coping strategies were also assessed through clinical interviews and questionnaires.

RESULTS

Participants with 22q11DS reported higher levels of perceived social stress (b = 0.21, p = 0.036) but lower levels of activity-related stress (b = -0.31, p = 0.003) in their daily lives compared to HC. The groups did not differ in affective or psychotic reactivity to stress, but individuals with 22q11DS who reported increased affective reactivity to social stressors showed more severe positive psychotic symptoms (rs = 0.505, p = 0.008). Finally, avoidance coping strategies moderated the association between stress and negative affects.

CONCLUSIONS

Our results suggest an increased vulnerability for daily social stress in youths with 22q11DS, and link elevated social stress reactivity to heightened psychotic symptom severity. Given the high risk for psychosis in 22q11DS, interventions should focus on reducing social stress and developing adaptive coping strategies.

Novel digital methods for gathering intensive time series data in mental health research: scoping review of a rapidly evolving field

Recent technological advances enable the collection of intensive longitudinal data. This scoping review aimed to provide an overview of methods for collecting intensive time series data in mental health research as well as basic principles, current applications, target constructs, and statistical methods for this type of data.In January 2021, the database MEDLINE was searched. Original articles were identified that (1) used active or passive data collection methods to gather intensive longitudinal data in daily life, (2) had a minimum sample size of N ⩾ 100 participants, and (3) included individuals with subclinical or clinical mental health problems.In total, 3799 original articles were identified, of which 174 met inclusion criteria. The most widely used methods were diary techniques (e.g. Experience Sampling Methodology), various types of sensors (e.g. accelerometer), and app usage data. Target constructs included affect, various symptom domains, cognitive processes, sleep, dysfunctional behaviour, physical activity, and social media use. There was strong evidence on feasibility of, and high compliance with, active and passive data collection methods in diverse clinical settings and groups. Study designs, sampling schedules, and measures varied considerably across studies, limiting the generalisability of findings.Gathering intensive longitudinal data has significant potential to advance mental health research. However, more methodological research is required to establish and meet critical quality standards in this rapidly evolving field. Advanced approaches such as digital phenotyping, ecological momentary interventions, and machine-learning methods will be required to efficiently use intensive longitudinal data and deliver personalised digital interventions and services for improving public mental health.

Delayed affective recovery to daily-life stressors signals a risk for depression

OBJECTIVE

The aim of this study is to investigate the time to affective recovery from daily-life stressors between healthy controls (HC) and two groups with an increased risk for developing depression: individuals with subclinical symptoms of depression (SSD), and individuals remitted from a depressive episode with residual symptoms of depression (RRS).

METHOD

The experience sampling method (ESM) was used to measure affective recovery to daily-life stressors. Affective recovery was defined as the moment that negative affect (NA) returned to baseline level following the first stressful event of the day. We assessed two different operationalizations of the baseline: NA at the moment before the stressful event (t_-1), and mean-person NA. The effect of stress intensity, and cumulative stress were also assessed.

RESULTS

Survival analyses showed significantly longer recovery times for the at risk groups in comparison to healthy individuals, albeit no significant difference was found between the two at risk groups (i.e. SSD and RRS). There was also an effect of cumulative stress, but not stress intensity on time to recovery in that cumulative stress resulted in significantly longer recovery times for all three groups.

LIMITATIONS

The present study is limited by the ESM sampling design, assessments take place post-stress and therefore do not capture peak stress. Additionally, we are only able to assess patterns at the group level. Finally, there is a significant age difference between groups.

CONCLUSION

Individuals at risk for depression display a delayed recovery to daily-life stressors when compared to healthy controls, which is not explained by differences in stress intensity or cumulative stress. Understanding what is driving this delay may help combat the development of depression.

Positive Affective Recovery in Daily Life as a Momentary Mechanism Across Subclinical and Clinical Stages of Mental Disorder: Experience Sampling Study

BACKGROUND

Identifying momentary risk and protective mechanisms may enhance our understanding and treatment of mental disorders. Affective stress reactivity is one mechanism that has been reported to be altered in individuals with early and later stages of mental disorder. Additionally, initial evidence suggests individuals with early and enduring psychosis may have an extended recovery period of negative affect in response to daily stressors (ie, a longer duration until affect reaches baseline levels after stress), but evidence on positive affective recovery as a putative protective mechanism remains limited.

OBJECTIVE

This study aimed to investigate trajectories of positive affect in response to stress across the continuum of mental disorder in a transdiagnostic sample.

METHODS

Using the Experience Sampling Method, minor activity-, event-, and overall stress and positive affect were assessed 10 times a day, with time points approximately 90 minutes apart on six consecutive days in a pooled data set including 367 individuals with a mental disorder, 217 individuals at risk for a severe mental disorder, and 227 controls. Multilevel analysis and linear contrasts were used to investigate trajectories of positive affect within and between groups.

RESULTS

Baseline positive affect differed across groups, and we observed stress reactivity in positive affect within each group. We found evidence for positive affective recovery after reporting activity- or overall stress within each group. While controls recovered to baseline positive affect about 90 minutes after stress, patients and at-risk individuals required about 180 minutes to recover. However, between-group differences in the affective recovery period fell short of significance (all P>.05).

CONCLUSIONS

The results provide first evidence that positive affective recovery may be relevant within transdiagnostic subclinical and clinical stages of mental disorder, suggesting that it may be a potential target for mobile health interventions fostering resilience in daily life.

Parenting and psychosis: An experience sampling methodology study investigating the inter-relationship between stress from parenting and positive psychotic symptoms

OBJECTIVES

There is a strong association between stress and psychotic symptoms, and this study examined the bidirectional nature of this relationship in parents with psychosis, with negative affect as a mediator and a range of other psychosocial factors included as covariates. It also examined whether stress from parenting had a larger impact on psychosis than non-parenting stress.

DESIGN

The study used a within-participants repeated measures design, using experience sampling methodology (ESM). ESM is a self-report surveying technique completed over an intensive longitudinal period. Participants completed six surveys a day, for 10 days.

METHODS

Thirty-five participants with psychosis who were a parent to a child between the ages of 2 and 16 took part. Study phones alerted participants to complete surveys by beeping at semi-random intervals over 10 days. Multi-level modelling was used with surveys at Level-1 and participants at Level-2. Predictor variables were time-lagged in order to infer directionality.

RESULTS

Parenting stress was found to predict psychotic symptoms, and this relationship was mediated by negative affect. The reverse direction was also confirmed. Few of the additional psychosocial factors were found to have a significant impact on the models' estimations. Parenting stress was not found to have a larger impact on psychosis than other sources of stress.

CONCLUSIONS

This study provides further evidence of the bidirectional relationship between stress and psychosis in the context of parenting. Further research should explore if parenting stress plays a unique role in predicting psychotic symptoms by comparing parents and non-parents with psychosis.

Modelling the temporal interplay between stress and affective disturbances in pathways to psychosis: an experience sampling study

BACKGROUND

One putative psychological mechanism through which momentary stress impacts on psychosis in individuals with increased liability to the disorder is via affective disturbance. However, to date, this has not been systematically tested. We aimed to investigate whether (i) cross-sectional and temporal effects of momentary stress on psychotic experiences via affective disturbance, and (ii) the reverse pathway of psychotic experiences on stress via affective disturbance were modified by familial liability to psychosis.

METHODS

The Experience Sampling Method was used in a pooled data set of six studies with three groups of 245 individuals with psychotic disorder, 165 unaffected first-degree relatives, and 244 healthy control individuals to index familial liability. Multilevel moderated mediation models were fitted to investigate indirect effects across groups cross-sectionally and multilevel cross-lagged panel models to investigate temporal effects in the proposed pathways across two measurement occasions.

RESULTS

Evidence on indirect effects from cross-sectional models indicated that, in all three groups, effects of stress on psychotic experiences were mediated by negative affect and, vice versa, effects of psychotic experiences on stress were mediated by negative affect, with all indirect effects being weakest in relatives. Longitudinal modelling of data provided no evidence of temporal priority of stress in exerting its indirect effects on psychotic experiences via affective disturbance or, vice versa.

CONCLUSIONS

Our findings tentatively suggest a rapid vicious cycle of stress impacting psychotic experiences via affective disturbances, which does, however, not seem to be consistently modified by familial liability to psychosis.

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.

Nutrition and mental health: A review of current knowledge about the impact of diet on mental health

Applied psychopharmacotherapy and psychotherapy do not always bring the expected results in the treatment of mental disorders. As a result, other interventions are receiving increasing attention. In recent years, there has been a surge in research on the effects of nutrition on mental status, which may be an important aspect of the prevention of many mental disorders and, at the same time, may lead to a reduction in the proportion of people with mental disorders. This review aims to answer whether and to what extent lifestyle and related nutrition affect mental health and whether there is scientific evidence supporting a link between diet and mental health. A review of the scientific evidence was conducted based on the available literature by typing in phrases related to nutrition and mental health using the methodological tool of the PubMed database. The literature search yielded 3,473 records, from which 356 sources directly related to the topic of the study were selected, and then those with the highest scientific value were selected according to bibliometric impact factors. In the context of current changes, urbanization, globalization, including the food industry, and changes in people’s lifestyles and eating habits, the correlations between these phenomena and their impact on mental state become important. Knowledge of these correlations creates potential opportunities to implement new effective dietary, pharmacological, therapeutic, and above all preventive interventions. The highest therapeutic potential is seen in the rational diet, physical activity, use of psychobiotics, and consumption of antioxidants. Research also shows that there are nutritional interventions that have psychoprotective potential.

Physiological reactions to acute stressors and subjective stress during daily life: A systematic review on ecological momentary assessment (EMA) studies

Objective

This review aims to provide an overview of ecological momentary assessment (EMA) studies analyzing stress reactivity during daily life in terms of direct and moderated influence of acute stress on physiological responses.

Materials and methods

A systematic literature search was performed on November 29, 2021 using Web of Science, MEDLINE and PsycINFO to identify prospective EMA studies targeting acute stressors or stress under naturalistic conditions, without restrictions of publication date or population. Study quality was assessed for multiple EMA-specific sources of bias.

Results

Out of 4285 non-duplicate records, 107 publications involving 104 unique studies were included. The majority of studies assessed acute physiological stress responses primarily through salivary cortisol (n = 59) and cardiovascular outcomes (n = 32). Most studies performed at least three measurements per day (n = 59), and had a moderate risk of recall bias (n = 68) and confounding (n = 85). Fifty-four studies reported a compliance of ≥80%. Direct, non-moderated positive associations were observed between acute stress exposure and concurrent cortisol levels (44%, n = 11/25), systolic (44%, 8/18) and diastolic blood pressure (53%, 8/15) and heart rate (53%, 9/17). Several inter- and intra-individual moderators were identified, such as age, gender, health status, chronic stress, work-related resources, physical activity and stress coping indicators.

Conclusions

About half of the reviewed EMA studies demonstrated direct associations between everyday acute stress exposure and physiological responses, including increased cortisol levels, blood pressure and heart rate. Results further suggested various moderator variables that could help develop tailored prevention strategies and identify groups at higher risk for dysfunctional stress responses.

Registration

PROSPERO—Reg.-No.: PROSPERO 2020 CRD42020163178.

Economic strain, parental education and psychotic experiences among college students in the United States: Findings from the Healthy Minds Study 2020

AIM

Socioeconomic status (SES) is linked to psychosis, and much can be learned by examining how various indicators of SES-specifically economic strain and intergenerational transfer of resources-are related to sub-threshold psychotic experiences among college students.

METHODS

Using data from the Healthy Minds Survey (September 2020-December 2020), we used multivariable logistic regression models to examine the associations between five SES indicators and 12-month psychotic experiences, adjusting for age, gender and race/ethnicity. We also examined the count of predictors and psychotic experiences.

RESULTS

Each indicator of economic strain was associated with greater odds of psychotic experiences. In particular, increasing levels of financial stress (current, childhood and pandemic-related) were associated with greater odds of psychotic experiences in a dose-response fashion. Food insecurity was associated with double the odds of psychotic experiences. In terms of intergenerational transfer of resources, having either one or no parents who attended college was associated with significantly greater odds of having psychotic experiences, when compared with having both parents who attended college. Examining all predictors in the same model, only childhood and current financial stress and food insecurity were significantly associated with psychotic experiences. The count of predictors was significantly associated with greater odds of having psychotic experiences in a dose-dependent fashion.

CONCLUSIONS

Among college students, economic strain and intergenerational transfer of resources were associated with recent psychotic experiences, highlighting the importance of economic interventions targeting young adults to influence risk for psychosis.

Exploring associations between diurnal cortisol, stress, coping and psychopathology in adolescents and young adults with 22q11.2 deletion syndrome

Background

22q11.2 deletion syndrome (22q11DS) is a neurogenetic condition associated to a high risk for psychiatric disorders, including psychosis. Individuals with 22q11DS are thought to experience increased levels of chronic stress, which could lead to alterations in hypothalamic-pituitary-adrenocortical (HPA)-axis functioning. In the current study, we investigated for the first time diurnal salivary cortisol profiles in adolescents and young adults with 22q11DS as well as their link with stress exposure, coping strategies and psychopathology, including psychotic symptoms.

Methods

Salivary cortisol was collected from adolescents and young adults with 22q11DS (n = 30, age = 19.7) and matched healthy controls (HC; n = 36, age = 18.5) six times a day for two days. Exposure to stressful life events, including peer victimization, coping strategies and general psychopathology were assessed with questionnaires. Psychotic symptoms and psychiatric comorbidities were evaluated with clinical interviews.

Results

We observed similar daily levels and diurnal profiles of salivary cortisol in adolescents and young adults with 22q11DS compared to HCs. However, participants with 22q11DS reported less frequent exposure to stress than HCs. In 22q11DS, we observed a significant association between the use of non-adaptive coping strategies and the severity of psychotics symptoms. Cortisol level was not associated to severity of psychotic symptoms, but elevated cortisol awakening response (CAR) was found in participants with 22q11DS with higher levels of general psychopathology.

Conclusions

Our results do not support earlier propositions of altered HPA-axis functioning in 22q11DS but highlight the need to further investigate diurnal cortisol as an indicator of HPA-axis functioning and its link with (earlier) stress exposure and psychopathology in this population. Interventions should target the development of adaptive coping skills in preventing psychosis in 22q11DS.

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Adolescents and young adults with 22q11DS report reduced exposure to stress.

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Non-adaptive coping is linked with the severity of psychotic symptoms in 22q11DS.

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Youth with 22q11DS show typical diurnal cortisol profiles.

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Elevated cortisol awakening response is related to greater general psychopathology.

Psychotic experiences among informal caregivers: findings from 48 low- and middle-income countries

PURPOSE

Informal caregivers may be at high risk for psychotic experiences (PE) due to caregiving related stress, sleep issues, or other potential mechanisms, but this has not been previously investigated in the general adult population. Thus, we examined the association between caregiving and PE, and its mediators, in a large sample of adults from 48 low- and middle-income countries (LMICs).

METHODS

Cross-sectional, community-based data from the World Health Organization (WHO) World Health Survey were analyzed. Informal caregivers referred to those who provided help to a relative or friend (adult or child) in the past year, because this person has a long-term physical or mental illness or disability, or is getting old and weak. PE were assessed using the WHO Composite International Diagnostic Interview psychosis screen. Multivariable logistic regression and mediation analyses were conducted.

RESULTS

Data on 224,842 individuals were analyzed. The mean (SD) age was 38.3 (16.0) years (range 18-120 years) and 50.7% were females. After adjustment for age, sex, and country, in the overall sample, caregiving was associated with 1.67 (95%CI = 1.56-1.79) times higher odds for PE. Sleep/energy explained the largest proportion of the association between caregiving and PE (13.9%), followed by pain/discomfort (11.5%), perceived stress (7.6%), depression (6.2%), and cognition (3.5%).

CONCLUSION

Caregivers in LMICs are at higher risk of PE. Future studies are warranted to gain a further understanding of the underlying mechanisms, and to assess whether addressing the identified mediators can lead to lower risk for PE among caregivers.

A Compassion-Focused Ecological Momentary Intervention for Enhancing Resilience in Help-Seeking Youth: Uncontrolled Pilot Study

BACKGROUND

Digital interventions offer new avenues for low-threshold prevention and treatment in young people. Ecological momentary interventions (EMIs) represent a powerful approach that allows for adaptive, real-time, and real-world delivery of intervention components in daily life by real-time processing of ecological momentary assessment (EMA) data. Compassion-focused interventions (CFIs) may be particularly amenable to translation into an EMI to strengthen emotional resilience and modify putative risk mechanisms, such as stress sensitivity, in the daily lives of young help-seeking individuals.

OBJECTIVE

This study aims to investigate the feasibility, safety, and initial therapeutic effects of a novel, accessible, transdiagnostic, ecological momentary CFI for improving emotional resilience to stress (EMIcompass).

METHODS

In this uncontrolled pilot study, help-seeking youth with psychotic, depressive, or anxiety symptoms were offered the EMIcompass intervention in addition to treatment as usual. The EMIcompass intervention consisted of a 3-week EMI (including enhancing, consolidating, and EMA-informed interactive tasks) administered through a mobile health app and three face-to-face sessions with a trained psychologist intended to provide guidance and training on the CFI exercises presented in the app (ie, training session, follow-up booster session, and review session).

RESULTS

In total, 10 individuals (mean age 20.3 years, SD 3.8; range 14-25) were included in the study. Most (8/10, 80%) participants were satisfied and reported a low burden of app usage. No adverse events were observed. In approximately one-third of all EMAs, individuals scored high on stress, negative affect, or threat anticipation during the intervention period, resulting in real-time, interactive delivery of the CFI intervention components in addition to weekly enhancing and daily consolidating tasks. Although the findings should be interpreted with caution because of the small sample size, reduced stress sensitivity, momentary negative affect, and psychotic experiences, along with increased positive affect, were found at postintervention and the 4-week follow-up. Furthermore, reductions in psychotic, anxiety, and depressive symptoms were found (r=0.30-0.65).

CONCLUSIONS

Our findings provide evidence on the feasibility and safety of the EMIcompass intervention for help-seeking youth and lend initial support to beneficial effects on stress sensitivity and mental health outcomes. An exploratory randomized controlled trial is warranted to establish the feasibility and preliminary evidence of its efficacy.

Home confinement during the COVID-19: day-to-day associations of sleep quality with rumination, psychotic-like experiences, and somatic symptoms

Due to the coronavirus disease 2019 (COVID-19) pandemic, populations from many countries have been confined at home for extended periods of time in stressful environmental and media conditions. Cross-sectional studies already evidence deleterious psychological consequences, with poor sleep as a risk factor for impaired mental health. However, limitations of cross-sectional assessments are response bias tendencies and the inability to track daily fluctuations in specific subjective experiences in extended confinement conditions. In a prospective study conducted across three European countries, we queried participants (N = 166) twice a day through an online interface about their sleep quality and their negative psychological experiences for two consecutive weeks. The focus was set on between- and within-person associations of subjective sleep quality with daytime experiences, such as rumination, psychotic-like experiences, and somatic complaints about the typical symptoms of the coronavirus. The results show that daily reports of country-specific COVID-19 deaths predicted increased negative mood, psychotic-like experiences, and somatic complaints during the same day and decreased subjective sleep quality the following night. Disrupted sleep was globally associated with negative psychological outcomes during the study period, and a relatively poorer night of sleep predicted increased rumination, psychotic-like experiences, and somatic complaints the following day. This temporal association was not paralleled by daytime mental complaints predicting relatively poorer sleep quality on the following night. Our findings show that night-to-night changes in sleep quality predict how individuals cope the next day with daily challenges induced by home confinement.

A momentary assessment study on emotional and biological stress in adult males and females with autism spectrum disorder

Prospective momentary psychological and biological measures of real-time daily life stress experiences have been examined in several psychiatric disorders, but not in adults with an autism spectrum disorder (ASD). The current electronic self-monitoring study examined associations between momentary daily life stressors and (i) negative affect (NA; emotional stress reactivity) and (ii) cortisol levels (biological stress reactivity) in males and females with ASD (N = 50) and without ASD (N = 51). The Experience Sampling Method, including saliva sampling, was used to measure three types of daily life stress (activity-related, event-related, and social stress), NA, and cortisol. Multilevel regression analyses demonstrated significant interactions between group and stress (i.e., activity-related and event-related stress) in the model of NA, indicating stronger emotional stress reactivity in the ASD than in the control group. In the model of cortisol, none of the group × stress interactions were significant. Male/female sex had no moderating effect on either emotional or biological stress reactivity. In conclusion, adults with ASD showed a stronger emotional stress (but not cortisol) reactivity in response to unpleasant daily life events and activities. The findings highlight the feasibility of electronic self-monitoring in individuals with ASD, which may contribute to the development of more personalized stress-management approaches.

Altered Peripersonal Space and the Bodily Self in Schizophrenia: A Virtual Reality Study

Self-disturbances such as an anomalous perception of one's own body boundary are central to the phenomenology of schizophrenia (SZ), but measuring the spatial parameters of the hypothesized self-other boundary has proved to be challenging. Peripersonal space (PPS) refers to the immediate zone surrounding the body where the self interacts physically with the environment; the space that corresponds to hypothesized self-other boundary. PPS is represented by enhanced multisensory integration and faster reaction time (RT) for objects near the body. Thus, multisensory RT tasks can be used to estimate self-other boundary. We aimed to quantify PPS in SZ using an immersive virtual reality visuotactile RT paradigm. Twenty-four participants with SZ and 24 demographically matched controls (CO) were asked to detect tactile vibration while watching a ball approaching them, thrown by either a machine (nonsocial condition) or an avatar (social condition). Parameters of PPS were estimated from the midpoint of the spatial range where the tactile RT decreased most rapidly (size) and the gradient of the RT change at this midpoint (slope). Overall, PPS was smaller in participants with SZ compared with CO. PPS slope for participants with SZ was shallower than CO in the social but not in nonsocial condition, indicating an increased uncertainty of self-other boundary across an extended zone in SZ. Social condition also increased false alarms for tactile detection in SZ. Clinical symptoms were not clearly associated with PPS parameters. These findings suggest the context-dependent nature of weakened body boundary in SZ and underscore the importance of reconciliating objective and subjective aspects of self-disturbances.

Dorsal attention network centrality increases during recovery from acute stress exposure

Stress is a major risk factor for the development of almost all psychiatric disorders. In addition to the acute stress response, an efficient recovery in the aftermath of stress is important for optimal resilience. Increased stress vulnerability across psychiatric disorders may therefore be related to altered trajectories during the recovery phase following stress. Such recovery trajectories can be quantified by changes in functional brain networks. This study therefore evaluated longitudinal functional network changes related to stress in healthy individuals (N = 80), individuals at risk for psychiatric disorders (healthy siblings of schizophrenia patients) (N = 39), and euthymic bipolar I disorder (BD) patients (N = 36). Network changes were evaluated before and at 20 and 90 min after onset of an experimental acute stress task (Trier Social Stress Test) or a control condition. Whole-brain functional networks were analyzed using eigenvector centrality as a proxy for network importance, centrality change over time was related to the acute stress response and recovery for each group. In healthy individuals, centrality of the dorsal attention network (DAN; p = 0.007) changed over time in relation to stress. More specifically, DAN centrality increased during the recovery phase after acute stress exposure (p = 0.020), while no DAN centrality change was observed during the initial stress response (p = 0.626). Such increasing DAN centrality during stress recovery was also found in healthy siblings (p = 0.016), but not in BD patients (p = 0.554). This study highlights that temporally complex and precise changes in network configuration are vital to understand the response to and recovery from stress.

Risk factors for postpartum relapse in women at risk of postpartum psychosis: The role of psychosocial stress and the biological stress system

BACKGROUND

Postpartum psychosis is the most severe psychiatric disorder associated with childbirth, and the risk is particularly high for women with a history of bipolar disorder, schizoaffective disorder or those who have suffered a previous episode of postpartum psychosis. Whilst there is a lot of evidence linking stress to psychosis unrelated to childbirth, the role of stress in the onset of postpartum psychosis has not been fully investigated.

METHODS

A prospective longitudinal study of 112 pregnant women, 51 at risk of postpartum psychosis because of a DSM-IV diagnosis of bipolar disorder (n = 41), schizoaffective disorder (n = 6) or a previous postpartum psychosis (n = 4) and 61 healthy women with no past or current DSM-IV diagnosis and no family history of postpartum psychosis. Women were followed up from the third trimester of pregnancy to 4 weeks' post partum. Women at risk who had a psychiatric relapse in the first 4 weeks' post partum (AR-unwell) (n = 22), were compared with those at risk who remained well (AR-well) (n = 29) on measures of psychosocial stress (severe childhood maltreatment and stressful life events) and biological stress (cortisol and inflammatory biomarkers).

RESULTS

Logistic regression analyses revealed that severe childhood maltreatment (OR = 4.9, 95% CI 0.5-49.2) and higher daily cortisol in the third trimester of pregnancy (OR=3.7, 95% CI 1.2-11.6) predicted psychiatric relapse in the first 4 weeks' post partum in women at risk of postpartum psychosis after adjusting for clinical and sociodemographic covariates.

CONCLUSION

The current study provides evidence for the role of psychosocial stress and the biological stress system in the risk of postpartum relapse in women at risk of postpartum psychosis.

The FKBP5 genotype and childhood trauma effects on FKBP5 DNA methylation in patients with psychosis, their unaffected siblings, and healthy controls

Hypothalamic-pituitary-adrenal (HPA) axis activity mediates the relationship between childhood trauma (CT) and psychosis. The FKBP5 gene, one of the key regulators of HPA axis activity after stress exposure, has been found associated with psychosis. Allele-specific and CT related FKBP5 demethylation in intron 7 was revealed in different psychiatric disorders. However, no studies have investigated FKBP5 methylation in subjects with different genetic liability for psychosis. A total of 144 participants were included in the study: 48 patients with psychotic disorders, 50 unaffected siblings, and 46 healthy controls. CT was assessed by Childhood Trauma Questionnaire. The FKBP5 rs1360780 was genotyped and FKBP5 methylation analyses were performed using bisulfite conversion followed by Sanger sequencing at three CpG sites in intron 7. Mixed linear model was used to assess group differences depending on rs1360780 T allele and CT. Results showed a significant T allele-dependent decrease of FKBP5 methylation in patients compared to unaffected siblings and controls. Effect of interaction between T allele and CT exposure on FKBP5 demethylation was found in controls. No effect of both risk factors (T allele and CT) on FKBP5 methylation level was found in unaffected siblings. We confirmed previous evidence of the association between the FKBP5 rs1360780 T allele, CT, and decreased FKBP5 methylation in intron 7. Allele-specific FKBP5 demethylation found in patients could shed a light on altered HPA axis activity in a subgroup of patients related to stress-induced psychosis. FKBP5 methylation and potential protective mechanisms in unaffected siblings after trauma exposure require further investigation.

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.

Reported Affect Changes as a Function of Response Delay: Findings From a Pooled Dataset of Nine Experience Sampling Studies

Delayed responses are a common phenomenon in experience sampling studies. Yet no consensus exists on whether they should be excluded from the analysis or what the threshold for exclusion should be. Delayed responses could introduce bias, but previous investigations of systematic differences between delayed and timely responses have offered unclear results. To investigate differences as a function of delay, we conducted secondary analyses of nine paper and pencil based experience sampling studies including 1,528 individuals with different clinical statuses. In all participants, there were significant decreases in positive and increases in negative affect as a function of delay. In addition, delayed answers of participants without depression showed higher within-person variability and an initial strengthening in the relationships between contextual stress and affect. Participants with depression mostly showed the opposite pattern. Delayed responses seem qualitatively different from timely responses. Further research is needed to understand the mechanisms underlying these differences.

Momentary emotions and salivary cortisol: A systematic review and meta-analysis of ecological momentary assessment studies

An integrated view of the stress response requires consideration of both the emotional and hormonal sequelae of stress, which are regulated by the hypothalamic-pituitary-adrenal (HPA) axis. Understanding the extent of the association between emotions and cortisol at the momentary level can shed light on the biopsychological pathways linking stress to health. Research in this area has adopted heterogeneous approaches and produced mixed findings; thus, it is critical to conduct a systematic review and meta-analysis. Systematic searches in major databases identified 22 studies (negative emotions [k = 19; 38,418 momentary observations]; positive emotions [k = 15; 31,721 momentary observations]). Meta-analysis found a significant positive association between momentary negative emotions and cortisol (r = .06, p < .001) and a significant negative association between momentary positive emotions and cortisol (r = -.05, p = .003). No methodological differences moderated these associations. Our findings suggest that emotional states correlate with cortisol levels at the momentary level. We discuss the health implications of our findings and provide recommendations for advancing this area of research.

Relationship between sexual orientation and psychotic experiences in the general population in England

BACKGROUND

Non-heterosexual individuals are at high risk for a variety of factors associated with the emergence of psychotic experiences (PEs) (e.g. common mental disorders, substance use, and stress). However, there is a scarcity of data on the association between sexual orientation and PEs. Therefore, the aim of this study was to examine the sexual orientation-PE relationship, and to identify potential mediators in this relationship.

METHODS

This study used nationally representative cross-sectional data from the 2007 Adult Psychiatric Morbidity Survey. Sexual orientation was dichotomized into heterosexual and non-heterosexual. Past 12-month PE was assessed with the Psychosis Screening Questionnaire. Regression and mediation analyses were conducted to analyze the association between sexual orientation and PEs, and to identify potential mediators involved in this relationship.

RESULTS

The final sample consisted of 7275 individuals aged ⩾16 years. The prevalence of non-heterosexual orientation and any PE was 7.1% and 5.5%, respectively. After adjusting for sex, age, and ethnicity, non-heterosexual orientation was positively associated with any PE (odds ratio 1.99, 95% confidence interval 1.34-2.93). The strongest mediators involved in this relationship were borderline personality disorder (BPD) traits (mediated percentage = 33.5%), loneliness (29.1%), and stressful life events (25.4%).

CONCLUSIONS

These findings suggest that there is a positive relationship between sexual orientation and PEs in the general population in England, and that underlying mechanisms may involve BPD traits, loneliness, and stressful life events. Future studies with a longitudinal design are warranted to shed more light on how these factors are implicated in the association between sexual orientation and PEs.

Stress coping strategies and their clinical correlates in patients with psychosis at various stages of illness: A case-control study

AIMS

There is evidence that individuals with psychosis adopt inefficient coping styles. Moreover, it has been hypothesized that inefficient coping styles might serve as trait-dependent characteristics of psychosis. Therefore, we aimed to explore coping styles and their clinical correlates at various stages of psychosis.

METHODS

We recruited 37 individuals at familial high risk of psychosis (FHR-P), 42 individuals with first-episode psychosis (FEP), 28 acutely relapsed schizophrenia (SCZ-AR) subjects and 40 healthy controls. Coping strategies were assessed using the Coping Inventory for Stressful Situations.

RESULTS

Individuals with FEP were less likely to use task-focused coping, while SCZ-AR subjects preferred using distraction when compared to controls. Both groups of participants did not differ significantly in terms of using specific coping styles. No significant differences in the use of various coping strategies between FHR-P individuals and controls were found. Higher odds of using emotion-focused coping and distraction were associated with more severe depressive symptoms in individuals with psychosis. Moreover, higher frequency of using distraction was associated with worse functioning in individuals with psychosis. However, this association appeared to be insignificant after adjustment for multiple testing.

CONCLUSIONS

Coping styles are similar in FEP and SCZ-AR subjects. However, decreased use of task-focused coping is more specific for FEP individuals while a preference of distraction might be more typical for SCZ-AR individuals. The use of various coping styles is similar in FHR-P individuals and controls. Preference of distraction and emotion-focused coping might be related to more severe depressive symptoms and poor functioning in individuals with psychosis.

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.

Polygenic liability for schizophrenia and childhood adversity influences daily-life emotion dysregulation and psychosis proneness

OBJECTIVE

To test whether polygenic risk score for schizophrenia (PRS-S) interacts with childhood adversity and daily-life stressors to influence momentary mental state domains (negative affect, positive affect, and subtle psychosis expression) and stress-sensitivity measures.

METHODS

The data were retrieved from a general population twin cohort including 593 adolescents and young adults. Childhood adversity was assessed using the Childhood Trauma Questionnaire. Daily-life stressors and momentary mental state domains were measured using ecological momentary assessment. PRS-S was trained on the latest Psychiatric Genetics Consortium schizophrenia meta-analysis. The analyses were conducted using multilevel mixed-effects tobit regression models.

RESULTS

Both childhood adversity and daily-life stressors were associated with increased negative affect, decreased positive affect, and increased subtle psychosis expression, while PRS-S was only associated with increased positive affect. No gene-environment correlation was detected. There is novel evidence for interaction effects between PRS-S and childhood adversity to influence momentary mental states [negative affect (b = 0.07, P = 0.013), positive affect (b = -0.05, P = 0.043), and subtle psychosis expression (b = 0.11, P = 0.007)] and stress-sensitivity measures.

CONCLUSION

Exposure to childhood adversities, particularly in individuals with high PRS-S, is pleiotropically associated with emotion dysregulation and psychosis proneness.

Momentary predictors of compliance in studies using the experience sampling method

The influence of momentary experiences on compliance has not yet been studied extensively in diary methods such as the experience sampling method (ESM). This study investigated to what extent momentary experiences at the moment of responding (hereafter 'beep') can predict compliance in high frequency ESM protocols. Lagged-analyses were conducted using a pooled dataset of seven studies including 1,318 healthy volunteers and individuals with different mental health conditions. All studies used an ESM design of 10 beeps per day over 4 to 6 days. Overall compliance was 86% (to beeps where a subject was compliant at the previous beep). Results indicated that participants who reported higher positive affect overall were more compliant. Feeling disturbed by a beep, being outside the home, medication use, or longer inter-prompt interval decreased the chances of compliance to the subsequent beep. While participants with depression tended to be more compliant, chances to be compliant decreased in the evenings and over the course of the study days. When more beeps were missed consecutively, the chances to miss the subsequent beep increased. Findings suggest that disturbance of the beep, being outside the home, medication use, and inter-prompt interval might decrease the chances of compliance to the subsequent beep.

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.

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.

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.

Allostatic load index and its clinical correlates at various stages of psychosis

Accumulating evidence indicates systemic biological dysregulations in patients with psychosis that have been conceptualized as the "allostatic load" (AL) index. We aimed to investigate the AL index in 37 subjects at familial high risk of psychosis (FHRP), 42 first-episode psychosis (FEP) patients, 25 acutely relapsed schizophrenia (SCZ-AR) patients and 42 healthy controls (HCs), taking into account psychopathology and cognitive impairment. The AL index was calculated based on 15 biomarkers (cardiovascular markers, anthropometric measures, inflammatory markers, glucose homeostasis parameters, lipids and steroids). Cognition was assessed using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The AL index was significantly higher in patients with psychosis and FHR-P individuals compared to HCs. Patients with FEP and FHR-P individuals had similar AL index. Moreover, the AL index was significantly higher in SCZ-AR patients compared to other groups of participants. Higher AL index was associated with more severe general psychopathology and depressive symptoms, lower scores of attention (total score, digit span and digit coding tasks) and semantic fluency, as well as worse general functioning in patients with psychosis. There was a significant negative correlation between the AL index and the scores of attention (total score and digit coding task) in FHR-P individuals. No significant correlations between the AL index and cognition were found in HCs. Our results indicate that biological dysregulations, captured by the AL index, appear already in FHR-P individuals and progress with psychotic exacerbations. Elevated AL index might contribute to cognitive impairments in FHR-P individuals and patients with psychosis.

Investigating associations between momentary stress and cortisol in daily life: What have we learned so far?

Since cortisol measurement in saliva has been established, it has been used as an indicator of stress-related hypothalamic-pituitary-adrenocortical axis activity. Concurrent development of methodological frameworks such as ambulatory assessment, ecological momentary assessment, and experience sampling have provided opportunities to combine both approaches in daily life research. The current review provides a summary of basic methodological principles and recommendations, as well as abstracts of findings of studies investigating momentary associations between stress and cortisol in daily life with an emphasis on within-subject associations (i.e. average covariance in repeated momentary assessments of stress and cortisol, and individual-specific deviations from the average covariance). Methodological challenges related to stress measurement, sampling principles, and appropriate statistical modeling are discussed, followed by a description of the historical development of studies on within-subject associations between momentary daily life stress and cortisol. The review concludes with a discussion of controversial methodological characteristics of these studies regarding operationalizations of stress, compliance, timing and frequency of stress and cortisol sampling, and reporting of effect sizes. Future research in this area would benefit from automated cortisol assessment, broadening of the scope of stress response measures, use of advanced statistical models that better account for dynamics in the stress process in daily life, and attempts to replicate findings. While previous studies of momentary stress and concurrent cortisol assessments have reliably confirmed some fundamental predictions from stress theory in daily life, future studies should aim at providing progress by testing innovative research questions and utilizing new technological developments.

Identifying psychosis spectrum disorder from experience sampling data using machine learning approaches

The ubiquity of smartphones opened up the possibility of widespread use of the Experience Sampling Method (ESM). The method is used to collect longitudinal data of participants' daily life experiences and is ideal to capture fluctuations in emotions (momentary mental states) as an indicator for later mental ill-health. In this study, ESM data of patients with psychosis spectrum disorder and controls were used to examine daily life emotions and higher order patterns thereof. We attempted to determine whether aggregated ESM data, in which statistical measures represent the distribution and dynamics of the original data, were able to distinguish patients from controls in a predictive modeling framework. Variable importance, recursive feature elimination, and ReliefF methods were used for feature selection. Model training, tuning, and testing were performed in nested cross-validation, based on algorithms such as Random Forests, Support Vector Machines, Gaussian Processes, Logistic Regression, and Neural Networks. ROC analysis was used to post-process these models. Stability of model performance was studied using Monte Carlo simulations. The results provide evidence that patterns in emotion changes can be captured by applying a combination of these techniques. Acceleration in the variables anxious and insecure was particularly successful in adding further predictive power to the models. The best results were achieved by Support Vector Machines with radial kernel (accuracy = 82% and sensitivity = 82%). This proof-of-concept work demonstrates that synergistic machine learning and statistical modeling may be used to harness the power of ESM data in the future.

Association of Air Pollution Exposure With Psychotic Experiences During Adolescence

IMPORTANCE

Urbanicity is a well-established risk factor for clinical (eg, schizophrenia) and subclinical (eg, hearing voices and paranoia) expressions of psychosis. To our knowledge, no studies have examined the association of air pollution with adolescent psychotic experiences, despite air pollution being a major environmental problem in cities.

OBJECTIVES

To examine the association between exposure to air pollution and adolescent psychotic experiences and test whether exposure mediates the association between urban residency and adolescent psychotic experiences.

DESIGN, SETTING, AND PARTICIPANTS

The Environmental-Risk Longitudinal Twin Study is a population-based cohort study of 2232 children born during the period from January 1, 1994, through December 4, 1995, in England and Wales and followed up from birth through 18 years of age. The cohort represents the geographic and socioeconomic composition of UK households. Of the original cohort, 2066 (92.6%) participated in assessments at 18 years of age, of whom 2063 (99.9%) provided data on psychotic experiences. Generation of the pollution data was completed on October 4, 2017, and data were analyzed from May 4 to November 21, 2018.

EXPOSURES

High-resolution annualized estimates of exposure to 4 air pollutants-nitrogen dioxide (NO2), nitrogen oxides (NOx), and particulate matter with aerodynamic diameters of less than 2.5 (PM2.5) and less than 10 μm (PM10)-were modeled for 2012 and linked to the home addresses of the sample plus 2 commonly visited locations when the participants were 18 years old.

MAIN OUTCOMES AND MEASURES

At 18 years of age, participants were privately interviewed regarding adolescent psychotic experiences. Urbanicity was estimated using 2011 census data.

RESULTS

Among the 2063 participants who provided data on psychotic experiences, sex was evenly distributed (52.5% female). Six hundred twenty-three participants (30.2%) had at least 1 psychotic experience from 12 to 18 years of age. Psychotic experiences were significantly more common among adolescents with the highest (top quartile) level of annual exposure to NO2 (odds ratio [OR], 1.71; 95% CI, 1.28-2.28), NOx (OR, 1.72; 95% CI, 1.30-2.29), and PM2.5 (OR, 1.45; 95% CI, 1.11-1.90). Together NO2 and NOx statistically explained 60% of the association between urbanicity and adolescent psychotic experiences. No evidence of confounding by family socioeconomic status, family psychiatric history, maternal psychosis, childhood psychotic symptoms, adolescent smoking and substance dependence, or neighborhood socioeconomic status, crime, and social conditions occurred.

CONCLUSIONS AND RELEVANCE

In this study, air pollution exposure-particularly NO2 and NOx-was associated with increased odds of adolescent psychotic experiences, which partly explained the association between urban residency and adolescent psychotic experiences. Biological (eg, neuroinflammation) and psychosocial (eg, stress) mechanisms are plausible.

Childhood abuse and psychotic experiences - evidence for mediation by adulthood adverse life events

AIMS

We have previously reported an association between childhood abuse and psychotic experiences (PEs) in survey data from South East London. Childhood abuse is related to subsequent adulthood adversity, which could form one pathway to PEs. We aimed to investigate evidence of mediation of the association between childhood abuse and PEs by adverse life events.

METHODS

Data were analysed from the South East London Community Health Study (SELCoH, n = 1698). Estimates of the total effects on PEs of any physical or sexual abuse while growing up were partitioned into direct (i.e. unmediated) and indirect (total and specific) effects, mediated via violent and non-violent life events.

RESULTS

There was strong statistical evidence for direct (OR 1.58, 95% CI: 1.19-2.1) and indirect (OR 1.51, 95% CI: 1.32-1.72) effects of childhood abuse on PEs after adjustment for potential confounders, indicating partial mediation of this effect via violent and non-violent life events. An estimated 47% of the total effect of abuse on PEs was mediated via adulthood adverse life events, of which violent life events made up 33% and non-violent life events the remaining 14%.

CONCLUSIONS

The association between childhood abuse and PEs is partly mediated through the experience of adverse life events in adulthood. There is some evidence that a larger proportion of this effect was mediated through violent life events than non-violent life events.

The role of cortisol and prolactin in the pathogenesis and clinical expression of psychotic disorders

For many years, the study of the psychotic phenotpe and approach to treatment of schizophrenia has been focused on positive psychotic symptoms, although the functional outcome is more clearly associated with negative and cognitive symptoms. Recently, there has been a growing interest in identifying biomarkers associated with these symptoms at early stages of the illness, including the risk of psychosis in vulnerable individuals (at-risk mental states [ARMS]). In this paper, the role of cortisol and prolactin in the clinical expression of psychosis will be reviewed. In examination of the role of these hormones and the risk of developing a psychotic disorder in ARMS individuals, previous studies have suggested potential roles for both cortisol and prolactin. The study of cognitive abilities in recent-onset psychotic patients has suggested that affected cognitive domains differ depending upon the studied hormones: cortisol (processing speed, verbal and working memory) and prolactin (processing speed), with several studies suggesting that there are sex-differences in these associations. All of these results suggest that both cortisol and prolactin contribute to the pathogenesis and clinical expression of psychotic disorders.

Recurrent Neural Networks in Mobile Sampling and Intervention

The rapid rise and now widespread distribution of handheld and wearable devices, such as smartphones, fitness trackers, or smartwatches, has opened a new universe of possibilities for monitoring emotion and cognition in everyday-life context, and for applying experience- and context-specific interventions in psychosis. These devices are equipped with multiple sensors, recording channels, and app-based opportunities for assessment using experience sampling methodology (ESM), which enables to collect vast amounts of temporally highly resolved and ecologically valid personal data from various domains in daily life. In psychosis, this allows to elucidate intermediate and clinical phenotypes, psychological processes and mechanisms, and their interplay with socioenvironmental factors, as well as to evaluate the effects of treatments for psychosis on important clinical and social outcomes. Although these data offer immense opportunities, they also pose tremendous challenges for data analysis. These challenges include the sheer amount of time series data generated and the many different data modalities and their specific properties and sampling rates. After a brief review of studies and approaches to ESM and ecological momentary interventions in psychosis, we will discuss recurrent neural networks (RNNs) as a powerful statistical machine learning approach for time series analysis and prediction in this context. RNNs can be trained on multiple data modalities simultaneously to learn a dynamical model that could be used to forecast individual trajectories and schedule online feedback and intervention accordingly. Future research using this approach is likely going to offer new avenues to further our understanding and treatments of psychosis.

Daily-life stress differentially impacts ventral striatal dopaminergic modulation of reward processing in first-degree relatives of individuals with psychosis

Emerging evidence shows that stress can impair the ability to learn from and pursue rewards, which in turn has been linked to motivational impairments characteristic of the psychotic disorder. Ventral striatal dopaminergic neurotransmission has been found to modulate reward processing, and appears to be disrupted by exposure to stress. We investigated the hypothesis that stress experienced in the everyday life has a blunting effect on reward-induced dopamine release in the ventral striatum of 16 individuals at a familial risk for psychosis compared to 16 matched control subjects. Six days of ecological momentary assessments quantified the amount of daily-life stress prior to [¹⁸F]fallypride PET imaging while performing a probabilistic reinforcement learning task. Relative to the controls, individuals at a familial risk for psychosis who encountered more daily-life stress showed significantly diminished extent of reward-induced dopamine release in the right ventral striatum, as well as poorer performance on the reward task. These findings provide the first neuromolecular evidence for stress-related deregulation of reward processing in familial predisposition to psychosis. The implication of daily-life stress in compromised modulation of reward function may facilitate the design of targeted neuropharmacological and ecological interventions.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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