Maladaptive emotion regulation strategies and stress sensitivity mediate the relation between adverse life events and attenuated positive psychotic symptoms

Efficacy of the unified protocol for transdiagnostic treatment of comorbid emotional disorders in patients with ultra high risk for psychosis: Results of a randomized controlled trial

BACKGROUND

The most common reason for help-seeking in ultra-high risk (UHR) for psychosis patients is comorbid symptoms, mainly anxiety and depression. However, psychological interventions are mainly focused on subthreshold psychotic symptoms. There is a growing push to include transdiagnostic therapies in specialized intervention teams for psychosis in young people. The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (UP) has demonstrated efficacy in emotional disorders, and its application has recently expanded to other pathologies such as borderline personality disorder (BPD) and bipolar disorder (BD).

METHODS

This pilot study was conducted with 36 patients with UHR for psychosis and symptoms of comorbid emotional disorders who were receiving treatment in an early intervention programme for psychosis. This is a randomised control trial (RCT) with two conditions: treatment as usual (TAU) with the group and online application of the UP (UP+TAU) (n = 18) and TAU (n = 18). Evaluations were conducted at baseline, after treatment, and at the three-month follow-up.

RESULTS

Comorbid anxiety and depression symptoms improved significantly in patients in the UP+TAU group compared to those in the TAU. Significant improvements in negative affect, emotional dysregulation, neuroticism, extraversion, functioning, and quality of life were also observed, and satisfaction with the intervention was high.

CONCLUSIONS

UP may be an acceptable and effective intervention for the treatment of symptoms of comorbid emotional disorders in patients with UHR for psychosis.

LIMITATIONS

The sample size was small, and further studies are needed to test this intervention with larger samples of patients with UHR for psychosis with emotional comorbidities.

Impaired emotional awareness is associated with childhood maltreatment exposure and positive symptoms in schizophrenia

Objectives

Evidence suggests that emotional awareness-the ability to identify and label emotions-may be impaired in schizophrenia and related to positive symptom severity. Exposure to childhood maltreatment is a risk factor for both low emotional awareness and positive symptoms.

Methods

The current investigation examines associations between a performance-based measure of emotional awareness, positive symptom severity, and childhood maltreatment exposure in 44 individuals with a schizophrenia-spectrum disorder and 48 healthy comparison participants using the electronic Levels of Emotional Awareness Scale (eLEAS), Positive and Negative Syndrome Scale (PANSS) and Childhood Trauma Questionnaire (CTQ).

Results

Patients demonstrated significant deficits in emotional awareness overall, which was true for both self and others. In patients, lower emotional awareness was significantly associated with more severe positive symptoms. Emotional awareness was significantly impaired in patients with schizophrenia with self-reported maltreatment exposure, relative to other groups. Severity of maltreatment was not significantly associated with emotional awareness or positive symptoms when looking continuously, and there was no significant indirect effect.

Conclusion

These data suggest that emotional awareness impairments observed in schizophrenia may be exacerbated by exposure to childhood maltreatment, possibly putting individuals at greater risk for experiencing positive symptoms of 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.

Pivotal mental states

This paper introduces a new construct, the 'pivotal mental state', which is defined as a hyper-plastic state aiding rapid and deep learning that can mediate psychological transformation. We believe this new construct bears relevance to a broad range of psychological and psychiatric phenomena. We argue that pivotal mental states serve an important evolutionary function, that is, to aid psychological transformation when actual or perceived environmental pressures demand this. We cite evidence that chronic stress and neurotic traits are primers for a pivotal mental state, whereas acute stress can be a trigger. Inspired by research with serotonin 2A receptor agonist psychedelics, we highlight how activity at this particular receptor can robustly and reliably induce pivotal mental states, but we argue that the capacity for pivotal mental states is an inherent property of the human brain itself. Moreover, we hypothesize that serotonergic psychedelics hijack a system that has evolved to mediate rapid and deep learning when its need is sensed. We cite a breadth of evidences linking stress via a variety of inducers, with an upregulated serotonin 2A receptor system (e.g. upregulated availability of and/or binding to the receptor) and acute stress with 5-HT release, which we argue can activate this primed system to induce a pivotal mental state. The pivotal mental state model is multi-level, linking a specific molecular gateway (increased serotonin 2A receptor signaling) with the inception of a hyper-plastic brain and mind state, enhanced rate of associative learning and the potential mediation of a psychological transformation.

Psychometric Properties and Measurement Invariance of the Cognitive Emotion Regulation Questionnaire in Chinese Adolescents With and Without Major Depressive Disorder: A Horizontal and Longitudinal Perspective

Objective: The purpose of this study was to examine the psychometric properties and posited nine-factor structure of the Chinese version of the Cognitive Emotion Regulation Questionnaire (CERQ-C) in high school students and adolescents with major depressive disorder (MDD), including assessment of measurement invariance of CERQ-C and its subscales across gender, time, and presence of depression. Methods: Chinese high school students from Hunan Province (N = 1,253) and adolescents with major depressive disorder (MDD) from the Medical Psychological Institute outpatient clinic at The Second Xiangya Hospital (N = 205) were enrolled. We examined the reliability, and model fit of the CERQ-C. Multigroup confirmatory factor analysis (CFA) was used to test measurement invariance of the subscales across gender, time, and presence of depression. Results: The CERQ-C subscales showed good internal consistency and moderate test-retest reliability in high school students and excellent internal consistency in adolescents with MDD group. The nine-factor model yielded adequate fit indices in different samples. Multigroup CFA confirmed that CERQ-C is strongly equivalent across gender, time, and presence of depression. Conclusions: The CERQ-C is a valid, reliable, and stable instrument for the evaluation of the cognitive emotion regulation (ER) strategies for different samples, including high school students and adolescents with MDD. The horizontal and longitudinal equivalences are strongly established.

Emotion regulation strategies modulate the effect of adverse childhood experiences on perceived chronic stress with implications for cognitive flexibility

Exposure to early life adversity is associated with chronic stress and a range of stress-related health problems in adulthood. Since chronic stress debilitates activity in the prefrontal cortex (pFC), maladaptive regulatory strategies in response to stress have been proposed as one explanation for the impact of early life adversity on health outcomes in adulthood. We conducted a study to examine the impact of adverse childhood experiences (ACEs) on cognitive flexibility, a key executive function implicated in activity in the pFC, in a sample of adults (N = 486). Additionally, we investigated whether perceptions of chronic stress in adulthood would mediate the influence of ACEs on cognitive flexibility. However, stress is a subjective experience, and emotion regulation strategies can attenuate the stress response. So, we also examined if individual differences in emotion regulation strategies would modulate the relationship between ACEs and chronic stress. Our results demonstrate that early life adversity, as characterized by ACEs, is associated with decreased cognitive flexibility in adulthood. Additionally, number of ACEs was positively correlated with perceived stress, which in turn was negatively correlated with cognitive flexibility. But, individual differences in the habitual use of emotion regulation strategies moderated the influence of ACEs on chronic stress. Specifically, habitual use of cognitive reappraisal attenuated the stress levels whereas habitual use of expressive suppression exacerbated stress levels. Overall, our study highlights the importance of examining emotion regulation in individuals who have experienced early life adversity.

Expressive suppression in psychosis: The association with social context

As emotion regulation deficits have been implicated in psychotic disorders, it is imperative to investigate not only the effect of regulation strategies but also how they are used. One such strategy is expressive suppression, the inhibition of emotion-expressive behavior, which may be influenced by social context. Therefore, this study aimed to investigate whether the use of expressive suppression was associated with social context and affect in daily life and if this differed between patients with psychosis and controls. Multilevel models using experience sampling method (ESM) data of 34 patients with psychotic disorders and 53 controls from the Genetic Risk and Outcome in Psychosis (GROUP) project were conducted. Expressive suppression and social context were assessed once a day for six days and daily affect was averaged per participant per day. Social context was significantly associated with the use of expressive suppression in daily life, so that the use of expressive suppression differed when in the presence of familiar versus non-familiar company when receiving negative feedback. This finding did not differ between patients and controls. This demonstrates that taking the situation into account when studying expressive suppression, and emotion regulation in general, may improve our understanding of how regulation takes place.

Stressful experiences affect the course of co-occurring obsessive-compulsive and psychotic symptoms: A focus on within-subject processes

OBJECTIVE

Obsessive-compulsive symptoms (OCS) frequently occur in patients with psychotic disorders and are associated with higher burden and poorer prognosis. This study prospectively investigated the effect of stressful experiences on the severity of OCS and co-occurring psychotic and affective symptoms, with a focus on within-subject processes.

METHOD

Monthly assessments over 6 months in patients with a psychotic disorder (n = 56) and unaffected siblings (n = 49) resulted in 309 and 277 observations, respectively. Linear mixed-effects models investigated the disaggregated effects of within-subject changes and between-subject differences in stressful events on OCS, positive, negative and depressive symptoms. Subsequently, moderating effects of coping strategies and dysfunctional metacognitive beliefs were assessed. Mediation analyses investigated direct and indirect effects of stressful events on OCS four weeks later.

RESULTS

Stressful experiences were associated with severity in almost all symptom domains on the between- and within-subject levels. Dysfunctional coping and metacognitive beliefs moderated these associations. Patients and siblings with a tendency for passive coping showed higher within-subject increase in depressive symptoms, whereas passive coping and dysfunctional beliefs moderated the association between stressful experiences and severity of positive symptoms and OCS on the between-subject level. Effects of stressful experiences on OCS four weeks later were partially mediated by depressive and positive symptoms in patients and siblings.

CONCLUSIONS

Findings suggest that severity and variability of co-occurring psychopathology can partly be explained by recent stressful events and the way individuals cope with these experiences. The implementation of coping-oriented interventions could possibly help to prevent development and/or aggravation of co-occurring symptom severity.

Emotion regulation processes as mediators of the impact of past life events on older adults' psychological distress

OBJECTIVE

Although it is known that certain emotion regulation processes produce a buffering effect on the relationship between life events and well-being, this issue has been poorly studied in the elderly population. Thus, the aim of the present study is to test and confirm a comprehensive model of the impact that past life events have on older adults' psychological distress, exploring the possible mediating roles of emotion regulation processes. These include rumination, experiential avoidance, and personal growth.

METHODS

In this cross-sectional study, 387 people over 60 years old residing in the community were assessed on life events, physical functioning, emotion regulation variables, psychological well-being, as well as symptoms of anxiety and depression.

RESULTS

The structural model tested achieved a satisfactory fit to the data, explaining 73% of the variance of older adults' psychological distress. In addition, the main results suggest possible mediation effects of both the physical functioning and the emotional variables: rumination, experiential avoidance, and personal growth in the face of hardship.

CONCLUSIONS

These findings confirm the importance of emotion regulation processes in the final stages of life. They reveal the various adaptive and maladaptive mechanisms that underlie the relationship between life events and psychological distress. The findings suggest - both in the explanatory models of psychological well-being and in psychotherapeutic interventions - the importance of emotion regulation in the elderly population's health.

The importance of loneliness in psychotic-like symptoms: Data from three studies

Poor social connection or loneliness is a prominent feature of schizotypy and may exacerbate psychosis risk. Previous studies have examined the inter-relationships between loneliness and psychosis risk, but critically, they have largely been conducted in non-clinical samples or exclusively used laboratory questionnaires with limited consideration of the heterogeneity within schizotypy (i.e., positive, negative, disorganized factors). The present study examined links between loneliness and psychotic-like symptoms across the dimensions of schizotypy through cross-sectional, laboratory-based questionnaires (Study 1; N = 160), ambulatory assessment (Study 2; N = 118) in undergraduates, and ambulatory assessment in inpatients in a substance abuse treatment program (Study 3; N = 48). Trait positive schizotypy consistently predicted cross-sectional and state psychotic-like symptoms. Loneliness, assessed via cross-sectional and ambulatory means, was largely linked with psychotic-like symptoms. Importantly, psychotic-like symptoms were dynamic: psychotic-like symptoms largely increased with loneliness in individuals with elevated positive and disorganized schizotypal traits, though there were some inconsistency related to disorganized schizotypy and state psychotic-like symptoms. Negative schizotypy and loneliness did not significantly interact to predict psychotic-like symptoms, suggesting specificity to positive schizotypy. Ambulatory approaches provide the opportunity for ecologically valid identification of risk states across psychopathology, thus informing early intervention.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The ice in voices: Understanding negative content in auditory-verbal hallucinations

Negative voice-content is the best sole predictor of whether the hearer of an auditory-verbal hallucination will experience distress/impairment necessitating contact with mental health services. Yet, what causes negative voice-content and how interventions may reduce it remains poorly understood. This paper offers definitions of negative voice content and considers what may cause negative voice-content. We propose a framework in which adverse life-events may underpin much negative voice-content, a relation which may be mediated by mechanisms including hypervigilance, reduced social rank, shame and self-blame, dissociation, and altered emotional processing. At a neurological level, we note how the involvement of the amygdala and right Broca's area could drive negative voice-content. We observe that negative interactions between hearers and their voices may further drive negative voice-content. Finally, we consider the role of culture in shaping negative voice-content. This framework is intended to deepen and extend cognitive models of voice-hearing and spur further development of psychological interventions for those distressed by such voices. We note that much of the relevant research in this area remains to be performed or replicated. We conclude that more attention needs to be paid to methods for reducing negative voice-content, and urge further research in this important area.

Coping Strategies Mediate the Effect of Stressful Life Events on Schizotypal Traits and Psychotic Symptoms in 22q11.2 Deletion Syndrome

Converging evidence suggests that psychosis emerges from the complex interaction of genetic and environmental factors. Stressful life events (SLEs) play a prominent role in combination with coping strategies and with a dysfunctional hypothalamus-pituitary-adrenal axis (HPAA). It has been proposed that the framework of schizotypy might help disentangle the interaction between genetic and environmental factors in the pathogenesis of psychosis. Similarly, 22q11.2 deletion syndrome (22q11DS) is considered as a genetic model of psychosis vulnerability. However, SLE and coping strategies remain largely unexplored in 22q11DS. Moreover, the HPAA has not been systematically investigated in this population. Here, we explored the correlation between SLE, emotional coping strategies, schizotypal personality traits, subthreshold psychotic symptoms in a sample of 43 healthy controls (HCs) compared with 59 individuals with 22q11DS. In the latter, we also explored the correlation with pituitary volume as estimated from structural magnetic resonance imaging. We found that SLE and negative coping strategies were correlated with schizotypal personality traits in both HCs and 22q11DS, and with psychotic symptoms in the 22q11DS group only, whereas reduced pituitary volume correlated with general psychopathology. Moreover, dysfunctional coping mediated the effect of SLE on schizotypal personality traits and psychotic symptoms in 22q11DS. Our findings recapitulate evidence in nonsyndromic patients and confirm the central role of stress and coping in the pathogenesis of psychosis. More broadly, they highlight the importance of environmental factors in the pathway to psychosis in 22q11DS, suggesting a strong rationale for the implementation of stress and particularly coping-oriented interventions in this population.

The Relationship Between Big Five Personality Traits and Psychotic Experience in a Large Non-clinical Youth Sample: The Mediating Role of Emotion Regulation

Objective: Despite a long history of interest in personality traits and psychosis, the association between personality traits and psychotic experiences in the general population is not yet well understood. One possible factor that could influence the degree of distress from psychotic experiences is emotion regulation. The purpose of this study was to explore whether the association between personality and psychotic symptoms is already apparent in non-clinical youth as well as the mediating role of emotion regulation strategies between personality traits and psychotic experiences. Methods: Three thousand one hundred and forty seven college students were surveyed via self-report questionnaires measuring the Five-Factor model of personality, emotion regulation strategies, and psychotic experiences. Results: Neuroticism was found to be significantly positively correlated with psychotic experiences, while Extraversion, Openness, Agreeableness, and Conscientiousness were found to be significantly negatively correlated. Both the suppression and reappraisal strategies mediated the relationship between personality traits and psychotic experiences. Conclusion: Our findings suggest that youth with certain personality traits are more likely to have psychotic experiences. The reappraisal emotion regulation strategy could serve as a protective factor against the distress of psychotic experiences.

Exploration of trauma, dissociation, maladaptive schemas and auditory hallucinations in a French sample

OBJECTIVES

The main goal of the present study was to explore the associations between several key variables that have been shown to partially mediate the link between specific trauma exposure and auditory hallucinations (AH), that is, maladaptive schemas and dissociation in the general population.

METHODS

In total, 425 voluntary participants were recruited from the general population and completed online the Childhood Trauma Questionnaire, the Young schema questionnaire, the Dissociative Experiences Scale, and the Launay-Slade Hallucination Scale. Data were analysed using Partial Least Squares Structural Equation Modelling.

RESULTS

Our model showed that: (1) sexual and emotional abuse impact on AH both through the effect of maladaptive schemas and dissociation; (2) physical abuse impact on AH only through the effect of dissociation. More specifically, we found that four maladaptive schemas impact on AH: Abandonment, Vulnerability, Self-sacrifice and Subjugation.

CONCLUSIONS

Overall, our findings indicate that specific early maladaptive schemas may play a fundamental role in the association between exposure to trauma and auditory hallucination together with dissociation symptoms in the general population. Consequently, our study suggest considering maladaptive schemas as an important therapeutic target when working with individuals experiencing AH with or without a psychiatry disorder.

Investigating the association between emotion regulation and distress in adults with psychotic-like experiences

Many individuals in the general population experience psychotic-like experiences in the absence of a psychotic disorder. The degree of psychological distress associated with these experiences is a key predictor of clinical outcomes. One factor that may influence the degree of distress from psychotic-like experiences is emotion regulation. Although it has been demonstrated that emotion regulation deficits are present in psychotic disorders, the association between emotion regulation and subclinical psychotic-like experiences is not well understood. Here, we examined the associations between frequency of and distress from psychotic-like experiences and several key components of emotion regulation: difficulties with emotion regulation; emotion regulation self-efficacy; and emotion regulation strategy use. Difficulties with emotion regulation and maladaptive patterns of emotion regulation strategy use were associated with the frequency of both positive and negative psychotic-like experiences. In addition, results suggest that habitual acceptance use and reappraisal self-efficacy may serve as protective factors against the distress associated with psychotic-like experiences.

Mediators Linking Childhood Adversities and Trauma to Suicidality in Individuals at Risk for Psychosis

Suicidality is highly prevalent in patients at clinical high risk (CHR) for psychosis. Childhood adversities and trauma are generally predictive of suicidality. However, the differential effects of adversity/trauma-domains and CHR-criteria, i.e., ultra-high risk and basic symptom criteria, on suicidality remain unclear. Furthermore, the underlying mechanisms and, thus, worthwhile targets for suicide-prevention are still poorly understood. Therefore, structural equation modeling was used to test theory-driven models in 73 CHR-patients. Mediators were psychological variables, i.e., beliefs about one's own competencies as well as the controllability of events and coping styles. In addition, symptomatic variables (depressiveness, basic symptoms, attenuated psychotic symptoms) were hypothesized to mediate the effect of psychological mediators on suicidality as the final outcome variable. Results showed two independent pathways. In the first pathway, emotional and sexual but not physical adversity/trauma was associated with suicidality, which was mediated by dysfunctional competence/control beliefs, a lack of positive coping-strategies and depressiveness. In the second pathway, cognitive basic symptoms but not attenuated psychotic symptoms mediated the relationship between trauma/adversity and suicidality. CHR-patients are, thus, particularly prone to suicidality if adversity/trauma is followed by the development of depressiveness. Regarding the second pathway, this is the first study showing that adversity/trauma led to suicidality through an increased risk for psychosis as indicated by cognitive basic symptoms. As insight is generally associated with suicidality, this may explain why self-experienced basic symptoms increase the risk for it. Consequently, these mediators should be monitored regularly and targeted by integrated interventions as early as possible to enhance resilience against suicidality.