Stressful life events and schizophrenia. I: A review of the research

Endophenotype 2.0: updated definitions and criteria for endophenotypes of psychiatric disorders, incorporating new technologies and findings

Recent genetic studies have linked numerous loci to psychiatric disorders. However, the biological pathways that connect these genetic associations to psychiatric disorders' specific pathophysiological processes are largely unclear. Endophenotypes, first defined over five decades ago, are heritable traits, independent of disease state that are associated with a disease, encompassing a broad range of neurophysiological, biochemical, endocrinological, neuroanatomical, cognitive, and neuropsychological characteristics. Considering the advancements in genetics and genomics over recent decades, we propose a revised definition of endophenotypes as 'genetically influenced phenotypes linked to disease or treatment characteristics and their related events.' We also updated endophenotype criteria to include (1) reliable measurement, (2) association with the disease or its related events, and (3) genetic mediation. 'Genetic mediation' is introduced to differentiate between causality and pleiotropic effects and allows non-linear relationships. Furthermore, this updated Endophenotype 2.0 framework expands to encompass genetically regulated responses to disease-related factors, including environmental risks, illness progression, treatment responses, and resilience phenotypes, which may be state-dependent. This broadened definition paves the way for developing new endophenotypes crucial for genetic analyses in psychiatric disorders. Integrating genetics, genomics, and diverse endophenotypes into multi-dimensional mechanistic models is vital for advancing our understanding of psychiatric disorders. Crucially, elucidating the biological underpinnings of endophenotypes will enhance our grasp of psychiatric genetics, thereby improving disease risk prediction and treatment approaches.

Correlation of allostatic load and perceived stress with clinical features in first-episode schizophrenia

BACKGROUND

Stress plays an important role in the etiology of schizophrenia. However, the mechanisms by which chronic physiological stress and perceived stress relate to the clinical features of schizophrenia may differ. We aimed to elucidate the relationships among chronic physiological stress indexed by allostatic load (AL), perceived stress, and clinical symptoms in individuals with first-episode schizophrenia (FES).

METHODS

Individuals with FES (n = 90, mean age = 28.26years old, 49%female) and healthy controls (111, 28.88, 51%) were recruited. We collected data of 13 biological indicators to calculate the AL index, assessed subjective stress with the Perceived Stress Scale-14 (PSS-14), and compared AL and perceived stress between groups. Patients with FES were also evaluated with the Positive and Negative Syndrome Scale (PANSS) and the Calgary Depression Scale for Schizophrenia (CDSS).

RESULTS

Individuals with FES had higher AL and PSS score than healthy controls. There were no significant correlations between AL and PSS score in either patients or controls. Among individuals with FES, the AL index was associated with the severity of positive symptoms, while the PSS score was positively associated with CDSS score. Both elevated AL and PSS were correlated with the occurrence of schizophrenia.

CONCLUSIONS

Physiological stress, as reflected by AL, may be more related to positive symptoms, while perceived stress appear to be associated with depressive symptoms in individuals with FES. Longitudinal studies are necessary to explore the relationships between interventions for different stressor types and specific clinical outcomes in FES.

Time will tell: Associations between unbalanced time perspectives and symptom severity in individuals with schizophrenia spectrum disorders

Patients with schizophrenia spectrum disorder (SSD) experience disrupted temporality on the immediate timescale. However, insufficient information is available for longer time frames, and the interaction of temporal perspectives with the clinical manifestations of SSD is unknown. We explored the association between unbalanced time perspectives and symptom severity. Thirty-seven Italian mental health services participating in the DiAPAson project recruited 620 patients with DSM-5 SSD (68 % males, mean age = 41.3 ± 9.5 years). Time perspective biases were measured using the Deviation from the Balanced Time Perspective-revisited (DBTP-r) indicator, based on Zimbardo Time Perspective Inventory (ZTPI) scores. Psychiatric symptoms were assessed using the Brief Psychiatric Rating Scale (BPRS) and Brief Negative Symptoms Scale (BNSS). Preliminary analyses examined the associations between ZTPI/DBTP-r and BPRS/BNSS total scores. In secondary analyses, we first tested the associations between the ZTPI/DBTP-r and BPRS/BNSS subscales and then compared ZTPI differences between patients with and without hallucinations, delusions, and conceptual disorganisation. Statistical significance was set at Holm-Bonferroni corrected p < 0.05. Low-to-moderate positive correlations were found between the DBTP-r and BPRS/BNSS total scores (r = 0.29/0.22). The strongest associations were between DBTP-r/ZTPI_Past-Negative and anxiety/depression (r = 0.34/0.36), followed by DBTP-r/ZTPI_Present-Fatalistic with thought disturbances (r = 0.22/0.20). DBTP-r was associated with BNSS anhedonia and avolition (r = 0.21/0.24). DBTP-r was higher in patients with hallucinations (ES = 0.391) and conceptual disorganisation (ES = 0.397) than in those without these symptoms. Unbalanced time perspective was positively associated with the severity of primary and secondary SSD features. These findings provide a rationale for empirical tests focused on balancing time perspectives in patients with SSD.

Stress induced exacerbation of Alzheimer's disease brain pathology is thwarted by co-administration of nanowired cerebrolysin and monoclonal amyloid beta peptide antibodies with serotonin 5-HT6 receptor antagonist SB-399885

Alzheimer's disease is one of the devastating neurodegenerative diseases affecting mankind worldwide with advancing age mainly above 65 years and above causing great misery of life. About more than 7 millions are affected with Alzheimer's disease in America in 2023 resulting in huge burden on health care system and care givers and support for the family. However, no suitable therapeutic measures are available at the moment to enhance quality of life to these patients. Development of Alzheimer's disease may reflect the stress burden of whole life inculcating the disease processes of these neurodegenerative disorders of the central nervous system. Thus, new strategies using nanodelivery of suitable drug therapy including antibodies are needed in exploring neuroprotection in Alzheimer's disease brain pathology. In this chapter role of stress in exacerbating Alzheimer's disease brain pathology is explored and treatment strategies are examined using nanotechnology based on our own investigation. Our observations clearly show that restraint stress significantly exacerbate Alzheimer's disease brain pathology and nanodelivery of a multimodal drug cerebrolysin together with monoclonal antibodies (mAb) to amyloid beta peptide (AβP) together with a serotonin 5-HT6 receptor antagonist SB399885 significantly thwarted Alzheimer's disease brain pathology exacerbated by restraint stress, not reported earlier. The possible mechanisms and future clinical significance is discussed.

Subcortical structures associated with childhood trauma and perceived stress in schizophrenia

BACKGROUND

Childhood trauma influences the clinical features of schizophrenia. In this study, we examined how childhood trauma and perceived stress are associated with clinical manifestations and subcortical gray matter volumes (GMVs) in patients with schizophrenia.

METHODS

We recruited 127 patients with schizophrenia and 83 healthy controls for assessment of early childhood trauma, perceived stress, and clinical symptoms. With structural brain imaging, we identified the GMVs of subcortical structures and examined the relationships between childhood trauma, perceived stress, clinical symptoms, and subcortical GMVs.

RESULTS

Compared to controls, patients with schizophrenia showed higher levels of childhood trauma and perceived stress. Patients with schizophrenia showed significantly smaller amygdala and hippocampus GMVs as well as total cortical GMVs than age-matched controls. Childhood trauma score was significantly correlated with the severity of clinical symptoms, depression, perceived stress, and amygdala GMVs. Perceived stress was significantly correlated with clinical symptoms, depression, and hippocampus and amygdala GMVs. Further, the association between childhood trauma (emotional neglect) and stress coping ability was mediated by right amygdala GMV in patients with schizophrenia.

CONCLUSIONS

Patients with schizophrenia had more exposure to early-life trauma and poorer stress coping. Both childhood trauma and perceived stress were associated with smaller amygdala volumes. The relationship between early-life trauma and perceived stress was mediated by right amygdala GMV in patients with schizophrenia. These findings together suggest the long-term effects of childhood trauma on perceived stress and the subcortical volumetric correlates of the effects in schizophrenia.

Chronic corticosterone improves perseverative behavior in mice during sequential reversal learning

BACKGROUND

Stressful life events can both trigger development of psychiatric disorders and promote positive behavioral changes in response to adversities. The relationship between stress and cognitive flexibility is complex, and conflicting effects of stress manifest in both humans and laboratory animals.

OBJECTIVE

To mirror the clinical situation where stressful life events impair mental health or promote behavioral change, we examined the post-exposure effects of stress on cognitive flexibility in mice.

METHODS

We tested female C57BL/6JOlaHsd mice in the touchscreen-based sequential reversal learning test. Corticosterone (CORT) was used as a model of stress and was administered in the drinking water for two weeks before reversal learning. Control animals received drinking water without CORT. Behaviors in supplementary tests were included to exclude non-specific confounding effects of CORT and improve interpretation of the results.

RESULTS

CORT-treated mice were similar to controls on all touchscreen parameters before reversal. During the low accuracy phase of reversal learning, CORT reduced perseveration index, a measure of perseverative responding, but did not affect acquisition of the new reward contingency. This effect was not related to non-specific deficits in chamber activity. CORT increased anxiety-like behavior in the elevated zero maze test and repetitive digging in the marble burying test, reduced locomotor activity, but did not affect spontaneous alternation behavior.

CONCLUSION

CORT improved cognitive flexibility in the reversal learning test by extinguishing prepotent responses that were no longer rewarded, an effect possibly related to a stress-mediated increase in sensitivity to negative feedback that should be confirmed in a larger study.

Anti-inflammatory effects of 2nd generation antipsychotics in patients with schizophrenia: A systematic review and meta-analysis

BACKGROUND

Schizophrenia is a major psychiatric disorder with unknown aetiology. Recent evidence suggests a potential role for cytokines in its pathophysiology and that antipsychotic medication may alter this. While the aetiology of schizophrenia remains only partly understood, an altered immune function representing an important avenue of further discovery. In this systematic review and meta-analysis we focus on the specific effects of second generation antipsychotics risperidone and clozapine on inflammatory cytokines.

METHODS

A defined systematic search of PubMed and Web of Science databases was performed to identify relevant studies published between Jan 1900 and May 2022. After screening of 2969 papers, 43 studies (27 single-arm and 8 dual-arm) were included that consisted of a total of 1421 patients with schizophrenia in the systematic review. From these, twenty studies (4 dual-arm; 678 patients) had data available on which a meta-analysis could be carried out.

RESULTS

Our meta-analysis showed a significant reduction of pro-inflammatory cytokines post-risperidone treatment in the absence of a similar association with clozapine. Subgroup analyses (First episode v chronic) demonstrated that duration of illness influenced the extent of cytokine alteration; risperidone treatment produced significant cytokine changes (lowered IL-6 and TNF-α) in chronic patients but not in first-episode psychosis (FEP) patients.

CONCLUSION

Varying treatment effects on cytokines can be observed by the use of different antipsychotic drugs. The cytokine alterations post-treatment are influenced by the specific antipsychotic drugs and patient status. This may explain disease progression in certain patient groups and influence therapeutic choices in the future.

Supporting students with empathy: the association between empathy and coping strategies in pre-clinical medical students

How medical students cope with stress predicts their mental health and academic/clinical performances, making the promotion of functional copy strategies a relevant outcome for medical educators. Empathy has been reported to be connected with coping. This study wanted to explore the most used coping strategies and whether gender differences existed, and to investigate whether and to what extent empathy affected coping in a sample of pre-clinical medical students. In a cross-sectional study design, the Interpersonal Reactivity Index (IRI) and the Coping Orientations to the Problems Experienced - New Italian Version (COPE-NIV) were administered to 398 (53% females) Italian second-year medical students. T-tests and multiple regression analyses were used to explore gender differences and the association between IRI and COPE-NIV scores, respectively. Problem Orientation obtained the highest mean score, whereas Avoidance the lowest one. Females outscored males on Social Support (t = 4.95, p < .001) and Transcendent Orientation (t = 4.04, p < .001). After controlling for gender, Empathic Concern was positively associated with Social Support (β = 0.223, p = .001) and Transcendent Orientation (β = 0.234, p = .001). Perspective Taking was positively and negatively associated with Positive Attitude (β = 0.248, p < .001) and Transcendent Orientation (β = − 0.180, p = .008), respectively. Personal Distress was negatively related to Problem Orientation (β = − 0.250, p < .001). Educational and psychological counselling interventions targeting empathy should be implemented in the pre-clinical years to equip medical students to cope functionally with the emotional distress linked to medical school.

Evaluation of cognitive insight, social functionality, and coping attitudes of patients diagnosed with schizophrenia being followed-up in a community mental health center

AIM

This study was conducted to evaluate the cognitive insight, social functionality, and coping attitudes of patients diagnosed with schizophrenia being followed-up in a Community Mental Health Center (CMHC).

DESIGN AND METHODS

The population of this descriptive and relationship-seeking study comprised 170 schizophrenia patients followed-up in the CMHC. Study data were collected using the Information Form, the Beck Cognitive Insight Scale (BCIS), the Social Functioning Assessment Scale (SFAS), and the Coping Orientation of Problem Experience (COPE).

FINDINGS

A moderately significant positive correlation between cognitive insight and social functionality was determined. It was found that participants with high cognitive insight and social functionality used more problem- and emotion-focused coping methods.

APPLICATION IMPLICATIONS

It is thought that practices that improve cognitive insight and social functionality will contribute to the rehabilitation of patients with schizophrenia by supporting their coping skills.

Beyond the γ-aminobutyric acid hypothesis of schizophrenia

Abnormalities in the γ-aminobutyric acid (GABA) system have been reported in the postmortem brains of individuals with schizophrenia. In particular, the reduction of one of the GABA-synthesizing enzymes, the 67-kDa isoform of glutamate decarboxylase (GAD67), has garnered interest among researchers because of its role in the formation of γ-oscillations and its potential involvement in the cognitive dysfunction observed in schizophrenia. Although several animal models have been generated to simulate the alterations observed in postmortem brain studies, they exhibit inconsistent behavioral phenotypes, leading to conflicting views regarding their contributions to the pathogenesis and manifestation of schizophrenia symptoms. For instance, GAD67 knockout rats (also known as Gad1 knockout rats) exhibit marked impairments in spatial working memory, but other model animals do not. In this review, we summarize the phenotypic attributes of these animal models and contemplate the potential for secondary modifications that may arise from the disruption of the GABAergic nervous system.

mHealth in psychiatry: A pathway to person-centered care

Influenced by the field of epidemiology and the early ecological psychologists, my research focused on the role of person-environment interactions in the development and maintenance of psychopathology - a field I would name Contextual Psychiatry. To capture the interaction between the person and the environment, I was one of the early adopters of the Experience Sampling Method (ESM) in mental health research. Using ESM, we demonstrated that there is an affective pathway to psychosis, characterized by increased stress-reactivity. Also altered social interactions have been identified as an important factor in the development of psychopathology. With digital technology quickly evolving, the impact of my work has now been extended to the development and implementation of mHealth and digital Health approaches in mental health, including the clinical application of ESM in routine mental health care as well as the development of Ecological Momentary Interventions. Moving forward, if we want to deliver treatment at moments when it is most needed and adapted to the needs of the individual, we need to advance our understanding of the real-time dynamics of the psychological and physiological processes of psychopathology - thus establishing a more personalised mental health care.

Effect of Cytomegalovirus on the Immune System: Implications for Aging and Mental Health

Human cytomegalovirus (HCMV) is a major modulator of the immune system leading to long-term changes in T-lymphocytes, macrophages, and natural killer (NK) cells among others. Perhaps because of this immunomodulatory capacity, HCMV infection has been linked with a host of deleterious effects including accelerated immune aging (premature mortality, increased expression of immunosenescence-linked markers, telomere shortening, speeding-up of epigenetic "clocks"), decreased vaccine immunogenicity, and greater vulnerability to infectious diseases (e.g., tuberculosis) or infectious disease-associated pathology (e.g., HIV). Perhaps not surprisingly given the long co-evolution between HCMV and humans, the virus has also been associated with beneficial effects, such as increased vaccine responsiveness, heterologous protection against infections, and protection against relapse in the context of leukemia. Here, we provide an overview of this literature. Ultimately, we focus on one other deleterious effect of HCMV, namely the emerging literature suggesting that HCMV plays a pathophysiological role in psychiatric illness, particularly depression and schizophrenia. We discuss this literature through the lens of psychological stress and inflammation, two well-established risk factors for psychiatric illness that are also known to predispose to reactivation of HCMV.

Life Event Stress and Reduced Cortical Thickness in Youth at Clinical High Risk for Psychosis and Healthy Control Subjects

BACKGROUND

A decline in cortical thickness during early life appears to be a normal neuromaturational process. Accelerated cortical thinning has been linked with conversion to psychosis among individuals at clinical high risk for psychosis (CHR-P). Previous research indicates that exposure to life event stress (LES) is associated with exaggerated cortical thinning in both healthy and clinical populations, and LES is also linked with conversion to psychosis in CHR-P. To date, there are no reports on the relationship of LES with cortical thickness in CHR-P. This study examines this relationship and whether LES is linked with cortical thinning to a greater degree in individuals at CHR-P who convert to psychosis compared with individuals at CHR-P who do not convert and healthy control subjects.

METHODS

Controlling for age and gender (364 male, 262 female), this study examined associations between LES and baseline cortical thickness in 436 individuals at CHR-P (375 nonconverters and 61 converters) and 190 comparison subjects in the North American Prodrome Longitudinal Study.

RESULTS

Findings indicate that prebaseline cumulative LES is associated with reduced baseline cortical thickness in several regions among the CHR-P and control groups. Evidence suggests that LES is a risk factor for thinner cortex to the same extent across diagnostic groups, while CHR-P status is linked with thinner cortex in select regions after accounting for LES.

CONCLUSIONS

This research provides additional evidence to support the role of LES in cortical thinning in both healthy youth and those at CHR-P. Potential underlying mechanisms of the findings and implications for future research are discussed.

Endocannabinoid system in trauma and psychosis: distant guardian of mental stability

Central endocannabinoid system (eCBS) is a neuromodulatory system that inhibits potentially harmful, excessive synaptic activation. Endocannabinoid receptors are abundant among brain structures pivotal in different mental disorders development (for example, hippocampus, amygdala, medial-prefrontal cortex, hypothalamus). Here, we review eCBS function in etiology of psychosis, emphasizing its role in dealing with environmental pressures such as traumatic life events. Moreover, we explore eCBS as a guard against hypothalamic-pituitary-adrenal axis over-activation, and discuss its possible role in etiology of different psychopathologies. Additionally, we review eCBS function in creating adaptive behavioral patterns, as we explore its involvement in the memory formation process, extinction learning and emotional response. We discuss eCBS in the context of possible biomarkers of trauma, and in preclinical psychiatric conditions, such as at-risk mental states and clinical high risk states for psychosis. Finally, we describe the role of eCBS in the cannabinoid self-medication-theory and extinction learning.

COVID-19-related psychological distress and engagement in preventative behaviors among individuals with severe mental illnesses

Individuals with severe mental illnesses (SMIs) may be disproportionately vulnerable to COVID-19 infection and psychological distress. This study investigated the prevalence of engagement in COVID-19 preventative behaviors, predictors of these behaviors, and COVID-19-related psychological distress. One hundred and sixty-three individuals with SMIs (94 with schizophrenia spectrum illnesses and 69 with affective disorders) and 27 psychiatrically healthy comparison participants were recruited from ongoing studies across 3 sites, to complete a phone survey querying implementation of 8 specific COVID-19 preventative behaviors that participants engaged in at least once in the past month as well as standard assessments of depression, anxiety, perceived stress, loneliness, and coping. Data were collected between 3 April 2020 and 4 June 2020. The large majority of our SMI sample, which consisted of outpatients with relatively mild symptom severity, endorsed engaging in multiple preventative behaviors. Relatively few differences were found between groups; however, individuals with SMI were less likely to work remotely than healthy individuals and individuals with schizophrenia spectrum illness were less likely to stay home as a preventative measure, wear face masks, and work remotely than individuals with affective disorders. Differences in staying home remained after controlling for potential confounds. Although individuals with SMI reported more psychological distress related to COVID-19, this distress was largely unrelated to engagement in preventative behaviors. The large majority of individuals with SMI in this outpatient sample, regardless of broad diagnostic category, reported performing multiple behaviors intended to prevent COVID-19 infection at least once a month and reported distress associated with the pandemic. These findings suggest a good level of awareness of COVID-19 among stable outpatients with SMI. The degree to which more acutely ill persons with SMI engage in such preventative behaviors, however, remains to be examined.

Assessing the Real-Time Mental Health Challenges of COVID-19 in Individuals With Serious Mental Illnesses: Protocol for a Quantitative Study

Background

The outbreak of coronavirus disease 2019 (COVID-19) has caused significant stress and mental health problems among the general public. However, persons at greatest risk for poor mental health outcomes, such as people with serious mental illness, have been largely overlooked.

Objective

This paper presents the protocol for a study that aims to examine the mental health impact of COVID-19 and social distancing behaviors in people with serious mental illness and the behaviors undertaken to prevent COVID-19 infection in this group.

Methods

Participants will include individuals with serious mental illness (eg, schizophrenia, bipolar disorder) and nonpsychiatric control participants who are currently participating in or have previously participated in several ongoing parent observational studies. Data will be collected from April 2020 through August 2020. Participants will complete phone interviews at 2 time points to assess their current emotional functioning and discuss the measures they have taken to prevent COVID-19 infection. Baseline (pre-COVID-19) mental health, sampled by ecological momentary assessment over an extended period, will be compared with current mental health, also sampled by ecological momentary assessment over an extended period. Demographic, cognitive, and psychosocial factors at baseline will be used to examine risk and resilience to current mental health and coping.

Results

The inclusion of participants for the first round of telephone assessments started on April 3, 2020 and will be completed by May 31, 2020. As of April 30, 2020, 101 individuals had completed these first-round assessments. The second round of telephone assessments will likely occur between June 1, 2020, and August 31, 2020. Study results will be published in peer-reviewed scientific journals.

Conclusions

Our findings will have broad implications for understanding the psychological consequences of COVID-19 among vulnerable persons with serious mental illness and will provide the opportunity to identify targets to reduce negative outcomes in the future. We also hope our efforts will provide a roadmap and resources for other researchers who would like to implement a similar approach.

International Registered Report Identifier (IRRID)

DERR1-10.2196/19203

Cingulum and abnormal psychological stress response in schizophrenia

Stress is implicated in many aspects of schizophrenia, including heightened distress intolerance. We examined how affect and microstructure of major brain tracts involved in regulating affect may contribute to distress intolerance in schizophrenia. Patients with schizophrenia spectrum disorders (n = 78) and community controls (n = 95) completed diffusion weighted imaging and performed psychological stress tasks. Subjective affect was collected pre and post stressors. Individuals who did not persist during one or both stress tasks were considered distress intolerant (DI), and otherwise distress tolerant (DT). Fractional anisotropy (FA) of the dorsal cingulum showed a significant diagnosis x DT/DI phenotype interaction (p = 0.003). Post-hoc tests showed dorsal cingulum FA was significantly lower in DI patients compared with DI controls (p < 0.001), but not different between DT groups (p = 0.27). Regarding affect responses to stress, irritability showed the largest stress-related change (p < 0.001), but irritability changes were significantly reduced in DI patients compared to DI controls (p = 0.006). The relationship between irritability change and performance errors also differed among patients (ρ = -0.29, p = 0.011) and controls (ρ = 0.21, p = 0.042). Further modeling highlighted the explanatory power of dorsal cingulum for predicting DI even after performance and irritability were taken into account. Distress intolerance during psychological stress exposure is related to microstructural properties of the dorsal cingulum, a key structure for cognitive control and emotion regulation. In schizophrenia, the affective response to psychological stressors is abnormal, and distress intolerant patients had significantly reduced dorsal cingulum FA compared to distress intolerant controls. The findings provide new insight regarding distress intolerance in schizophrenia.

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

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

The Role of Hippocampal Functional Connectivity on Multisystem Subclinical Abnormalities in Schizophrenia

OBJECTIVE

Schizophrenia is associated with excess medical mortality: patients have an average life expectancy one to two decades shorter than the general population. This study investigates the relationship between aberrant hippocampal resting-state functional connectivity in schizophrenia and cumulative subclinical effects of chronic stress on metabolic, cardiovascular, and immune function using the allostatic load index.

METHODS

Cumulative stress was estimated using allostatic load total score (range, 0-13) in 46 patients with schizophrenia and 31 controls matched for age and sex (patients: age = 36.1 [13.7] years, sex = 32/14 male/female; controls: age = 35.5 [14.1], sex = 21/10 male/female). Hippocampal functional connectivity was assessed using resting-state functional magnetic resonance imaging; hippocampal structural connectivity was assessed using fornix fractional anisotropy. Linear regression analysis was used a) to test the hypothesis that aberrant hippocampal resting-state functional connectivity in schizophrenia (identified in analysis of schizophrenia - control differences) is associated with elevated allostatic load scores in patients and b) to determine the association between fornix fractional anisotropy with allostatic load.

RESULTS

In patients, higher allostatic load was significantly associated with reduced resting functional connectivity between the left hippocampus and right cingulate cortex and left precentral gyrus, but higher connectivity between the right hippocampus and left cerebellum lobe VI (corrected p values <. 05). In controls, reductions in both hippocampal structural connectivity and hippocampal-cingulate functional connectivity were associated with higher allostatic load scores.

CONCLUSIONS

These findings support basic neuroscience evidence that cumulative stress and hippocampal function are closely connected and suggest that abnormal hippocampal functional communication in schizophrenia may be related to elevated multisystem subclinical medical issues in patients as indexed by allostatic load.

The Fragile Brain: Stress Vulnerability, Negative Affect and GABAergic Neurocircuits in Psychosis

Persons with schizophrenia exhibit sensitivity to stress and negative affect (NA), both strongly correlated with poor functional outcome. This theoretical review suggests that NA reflects a "fragile brain," ie, vulnerable to stress, including events not experienced as stressful by healthy individuals. Based on postmortem evidence of altered gamma-aminobutyric acid (GABA) function in parvalbumin positive interneurons (PVI), animal models of PVI abnormalities and neuroimaging data with GABAergic challenge, it is suggested that GABAergic disruptions weaken cortical regions, which leads to stress vulnerability and excessive NA. Neurocircuits that respond to stressful and salient environmental stimuli, such as the hypothalamic-pituitary-adrenal axis and the amygdala, are highly dysregulated in schizophrenia, exhibiting hypo- and hyper-activity. PVI abnormalities in lateral prefrontal cortex and hippocampus have been hypothesized to affect cognitive function and positive symptoms, respectively; in the medial frontal cortex (dorsal anterior cingulate cortex and dorsal medial prefrontal cortex), these abnormalities may lead to vulnerability to stress, NA and dysregulation of stress responsive systems. Given that postmortem PVI disruptions have been identified in other conditions, such as bipolar disorder and autism, stress vulnerability may reflect a transdiagnostic dimension of psychopathology.

Preclinical neuroimaging of gene-environment interactions in psychiatric disease

Psychiatric disease is one of the leading causes of disability worldwide. Despite the global burden and need for accurate diagnosis and treatment of mental illness, psychiatric diagnosis remains largely based on patient-reported symptoms, allowing for immense symptomatic heterogeneity within a single disease. In renewed efforts towards improved diagnostic specificity and subsequent evaluation of treatment response, a greater understanding of the underlying of the neuropathology and neurobiology of neuropsychiatric disease is needed. However, dissecting these mechanisms of neuropsychiatric illness in clinical populations are problematic with numerous experimental hurdles limiting hypothesis-driven studies including genetic confounds, variable life experiences, different environmental exposures, therapeutic histories, as well as the inability to investigate deeper molecular changes in vivo . Preclinical models, where many of these confounding factors can be controlled, can serve as a crucial experimental bridge for studying the neurobiological origins of mental illness. Furthermore, although behavioral studies and molecular studies are relatively common in these model systems, focused neuroimaging studies are very rare and represent an opportunity to link the molecular changes in psychiatric illness with advanced quantitative neuroimaging studies. In this review, we present an overview of well-validated genetic and environmental models of psychiatric illness, discuss gene-environment interactions, and examine the potential role of neuroimaging towards understanding genetic, environmental, and gene-environmental contributions to psychiatric illness.

Problematic smartphone use and related factors in young patients with schizophrenia

INTRODUCTION

The present study aimed to examine smartphone use in young patients with schizophrenia and to explore factors that may affect the severity of problematic smartphone use.

METHODS

A total of 148 schizophrenia patients aged 18 to 35 years completed self-administered questionnaires exploring sociodemographic characteristics; Smartphone Addiction Scale (SAS), the Big Five Inventory-10 (BFI-10), the Hospital Anxiety and Depression Scale (HADS), the Perceived Stress Scale (PSS), and the Rosenberg Self-Esteem Scale (RSES). All were also assessed using the Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS) Scale and the Personal and Social Performance (PSP) Scale.

RESULTS

The mean subject age was 27.5 ± 4.5 years. No significant differences in the SAS scores occurred between gender, jobs, and level of education. The Pearson r-correlation test showed that the SAS scores were significantly positively correlated with HADS anxiety, PSS, and BFI-10 neuroticism scores; it was negatively correlated with RSES, BFI-10 agreeableness, and conscientiousness scores. In the stepwise linear regression analysis, the severity of PSU was significantly associated with both high anxiety and low agreeableness.

DISCUSSION

Our results suggest that specific groups of patients with schizophrenia may require special care to prevent problematic smartphone use.

Caring helps: Trait empathy is related to better coping strategies and differs in the poor versus the rich

Coping has been extensively studied in health psychology; however, factors influencing the usage of different coping strategies have received limited attention. In five studies (N = 3702), we explored the relationship between trait empathy and coping strategies, and how subjective socioeconomic status (SES) moderates this relationship. In Studies 1-4, we found that people with higher level of empathic concern use more adaptive coping strategies, seek more social support, and use fewer maladaptive coping strategies. Moreover, higher trait empathy related to more adaptive coping strategies among the poor, and fewer maladaptive coping strategies among the rich. In Study 5, we tested the potential biological basis of the relationship between trait empathy and coping by examining the effect of the oxytocin receptor gene (OXTR) rs53576 polymorphism on coping. We found that individuals with the GG phenotype-who in previous research have been found to be more empathic-were more likely to seek social support than AG or AA individuals. Furthermore, in line with findings in Studies 1-4, amongst people with low SES, individuals with GG genotype used more adaptive coping strategies than AG or AA individuals. Our results highlight the selective role trait empathy plays in influencing coping strategy deployment, depending on the SES of individuals.

Mental and behavioural disorders in the children of mothers diagnosed with cancer: A Danish population-based register study

OBJECTIVE

Maternal cancer may be associated with offspring mental and behavioural disorders through various biological pathways. When postnatally diagnosed, it may cause stress and changes in care, potentially influencing mental health. Prenatally diagnosed cancer could lead to maternal stress and treatment, or influence foetal neural development. This study investigates associations between prenatally or postnatally diagnosed maternal cancers and mental and behavioural disorders in children.

METHODS

The study composed of 2 158 430 children born in Denmark (1978-2012). Children were exposed if their mother received a cancer diagnosis prenatally (2 years prepartum, until birth) or postnatally (birth, until 18 years postpartum). Further analyses considered cancer types and diagnostic delays. Children were followed until 18 years of age or the first of the following: diagnosis of a mental or behavioural disorder, emigration, death, end of follow-up.

RESULTS

During follow-up 79 682 (3.7%) children were diagnosed with mental or behavioural disorders. There was an increased risk among offspring exposed to postnatally diagnosed cancers (HR 1.05; 95% CI, 1.00-1.11); for prenatally diagnosed cancers HR was 1.07 (0.87-1.31). The strongest associations for disorder types were for prenatal diagnoses with mood/affective disorders (HR 2.45; 1.02-5.89) and postnatal diagnoses with mood/affective disorders (HR 1.43; 1.14-1.79).

CONCLUSIONS

The results indicate a link between maternal cancer occurrence during pregnancy or early postnatal life, and mental and behavioural disorders in offspring. This association could be driven by common factors in the two periods, such as psychological stress or genetic factors. No specific foetal programming was identified.

Contribution of stress and coping strategies to problematic Internet use in patients with schizophrenia spectrum disorders

INTRODUCTION

Internet use is already high and increasing rapidly among people with psychotic disorders, but there have been few studies on problematic Internet use (PIU) among patients with schizophrenia spectrum disorders. This study aimed to measure the prevalence of PIU and identify the factors associated with PIU among patients with schizophrenia spectrum disorders.

METHODS

A cross-sectional survey was performed that included 368 outpatients with schizophrenia spectrum disorders: 317 with schizophrenia, 22 with schizoaffective disorder, 9 with schizophreniform disorder, and 20 with other schizophrenia spectrum and psychotic disorders. The severity of psychotic symptoms and levels of personal and social functioning were assessed by the Clinician-rated Dimensions of Psychosis Symptom Severity (CRDPSS) scale and the Personal and Social Performance (PSP) scale, respectively. PIU was evaluated using Young's Internet Addiction Test (IAT). Additionally, the Hospital Anxiety and Depression Scale (HADS), Perceived Stress Scale (PSS), Rosenberg Selfesteem Scale (RSES), and Brief Coping Orientation to Problems Experienced (COPE) Inventory were administered.

RESULTS

PIU was identified in 81 (22.0%) of the 368 patients with schizophrenia spectrum disorders. Subjects with PIU were significantly younger and more likely to be male. Scores on the HADS, PSS, and dysfunctional coping dimension of the Brief COPE Inventory were significantly higher, and RSES scores were significantly lower, in the PIU group. Logistic regression analysis indicated that PIU in patients was significantly associated with scores on the PSS and dysfunctional coping dimension of the Brief COPE Inventory.

CONCLUSIONS

Patients with schizophrenia spectrum disorders and PIU were significantly more likely to have high levels of perceived stress and dysfunctional coping strategies. Patients with schizophrenia spectrum disorders who also engage in PIU may benefit from interventions that help them to develop appropriate skills for coping with stress.

The association between psychotic experiences and traumatic life events: the role of the intention to harm

BACKGROUND

Previous work showed traumatic life events (TLE) with intention to harm, like bullying and abuse, to be more strongly associated with psychotic experiences (PE) than other types of trauma, like accidents. However, this association is subject to reporting bias and can be confounded by demographic characteristics and by differences in dose of exposure across different trauma categories. We studied the association between TLE with and without intention to harm and PE, taking into account potential confounders and biases.

METHODS

A total of 2245 children and adolescents aged 6-14 years were interviewed by psychologists. The interview included the presence of 20 PE (both self-report and psychologist evaluation). In addition, parents provided information on child exposure to trauma, mental health and PE.

RESULTS

Results showed no significant association between TLE without intention to harm only and PE for the three methods of assessment of PE (self-report, parent report and psychologist rating). On the other hand, there was a positive association between PE and TLE in groups exposed to traumatic experiences with intention to harm (with intention to harm only and with and without intention to harm). Results remained significant after controlling for demographic and clinical confounders, but this positive association was no longer significant after adjusting for the number of TLE.

CONCLUSIONS

TLE with intention to harm display a stronger association with PE than TLE without intention to harm, and this difference is likely reducible to a greater level of traumatic exposure associated with TLE with intention to harm.

Stress in Regulation of GABA Amygdala System and Relevance to Neuropsychiatric Diseases

The amygdala is an almond-shaped nucleus located deep and medially within the temporal lobe and is thought to play a crucial role in the regulation of emotional processes. GABAergic neurotransmission inhibits the amygdala and prevents us from generating inappropriate emotional and behavioral responses. Stress may cause the reduction of the GABAergic interneuronal network and the development of neuropsychological diseases. In this review, we summarize the recent evidence investigating the possible mechanisms underlying GABAergic control of the amygdala and its interaction with acute and chronic stress. Taken together, this study may contribute to future progress in finding new approaches to reverse the attenuation of GABAergic neurotransmission induced by stress in the amygdala.

Psychosocial stressors contributing to emergency psychiatric service utilization in a sample of ethno-culturally diverse clients with psychosis in Toronto

BACKGROUND

Understanding the psychosocial stressors of people with psychoses from minority ethnic groups may help in the development of culturally appropriate services. This study aimed to compare psychosocial factors associated with attendance at an emergency department (ED) for six ethnic groups. Preventing crises or supporting people better in the community may decrease hospitalization and improve outcomes.

METHOD

A cohort was created by retrospective case note analysis of people of East-Asian, South-Asian, Black-African, Black-Caribbean, White-North American and White-European origin groups attending a specialized psychiatric ED in Toronto with a diagnosis of psychosis between 2009 and 2011. The psychological or social stressors which were linked to the presentation at the ED that were documented by the attending physicians were collected for this study. Logistic regression models were constructed to analyze the odds of presenting with specific stressors.

RESULTS

Seven hundred sixty-five clients were included in this study. Forty-four percent of the sample did not have a psychiatrist, and 53% did not have a primary care provider. Social environmental stressors were the most frequent psychosocial stressor across all six groups, followed by issues in the primary support group, occupational and housing stressors. When compared to White-North American clients, East-Asian and White-European origin clients were less likely to present with a housing stressor, while Black-African clients had decreased odds of presenting with primary support group stressor. Having a primary care provider or psychiatrist were predominantly protective factors.

CONCLUSION

In Toronto, moving people with chronic mental health conditions out of poverty, increasing the social safety net and improving access to primary care and community based mental health services may decrease many of the stressors which contribute to ED attendance.

COMT Val158Met and MTHFR C677T moderate risk of schizophrenia in response to childhood adversity

OBJECTIVE

Mesolimbic dopamine sensitization has been hypothesized to be a mediating factor of childhood adversity (CA) on schizophrenia risk. Activity of catechol-O-methyltransferase (COMT) Val158Met increases mesolimbic dopamine signaling and may be further regulated by methylenetetrahydrofolate reductase (MTHFR) C677T. This study investigates the three-way interaction between CA, COMT, and MTHFR.

METHODS

We conducted a nested case-control study on individuals born after 1981, linking population-based registers to study the three-way interaction. We included 1699 schizophrenia cases and 1681 controls, and used conditional logistic regression to report incidence rate ratios (IRRs).

RESULTS

Childhood adversity was robustly associated with schizophrenia. No main genetic effects were observed. MTHFR C677T increased schizophrenia risk in a dose-dependent manner per MTHFR T allele (P = 0.005) consequent upon CA exposure. After inclusion of the significant (P = 0.03) COMT × MTHFR × CA interaction, the risk was further increased per high-activity COMT Val allele. Hence, exposed COMT Val/Val and MTHFR T/T carriers had an IRR of 2.76 (95% CI, 1.66-4.61). Additional adjustments for ancestry and parental history of mental illness attenuated the results with the interaction being only marginally significant.

CONCLUSION

MTHFR C677T and COMT Val158Met interact with CA to increase risk of schizophrenia.

Altered circadian patterns of salivary cortisol in individuals with schizophrenia: A critical literature review

This article focuses on stress vulnerability in schizophrenia through an integrated clinical and biological approach. The objective of this article is to better understand the relationships between vulnerability, stress and schizophrenia. First, the concept of vulnerability is defined and several models of vulnerability in schizophrenia are reviewed. Second, a section is developed on the biology of stress, and more specifically on the stress responses of the hypothalamo-pitutary adrenal (HPA) axis. Then, studies of cortisol circadian rhythms are summarized, suggesting hyper-reactivity of the HPA axis in patients with schizophrenia and high risk individuals for schizophrenia. The results support the models of stress vulnerability in schizophrenia and the hypothesis of high cortisol levels as an endophenotype in this disorder. In conclusion, this article highlights the interest of studying the cortisol circadian rhythms in schizophrenia and opens the perspective to identify high risk individuals for schizophrenia by measuring circadian patterns of salivary cortisol.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

Inflammation and the neural diathesis-stress hypothesis of schizophrenia: a reconceptualization

An interaction between external stressors and intrinsic vulnerability is one of the longest standing pathoaetiological explanations for schizophrenia. However, novel lines of evidence from genetics, preclinical studies, epidemiology and imaging have shed new light on the mechanisms that may underlie this, implicating microglia as a key potential mediator. Microglia are the primary immune cells of the central nervous system. They have a central role in the inflammatory response, and are also involved in synaptic pruning and neuronal remodeling. In addition to immune and traumatic stimuli, microglial activation occurs in response to psychosocial stress. Activation of microglia perinatally may make them vulnerable to subsequent overactivation by stressors experienced in later life. Recent advances in genetics have shown that variations in the complement system are associated with schizophrenia, and this system has been shown to regulate microglial synaptic pruning. This suggests a mechanism via which genetic and environmental influences may act synergistically and lead to pathological microglial activation. Microglial overactivation may lead to excessive synaptic pruning and loss of cortical gray matter. Microglial mediated damage to stress-sensitive regions such as the prefrontal cortex and hippocampus may lead directly to cognitive and negative symptoms, and account for a number of the structural brain changes associated with the disorder. Loss of cortical control may also lead to disinhibition of subcortical dopamine-thereby leading to positive psychotic symptoms. We review the preclinical and in vivo evidence for this model and consider the implications this has for treatment, and future directions.

Stress Sensitivity and Psychotic Experiences in 39 Low- and Middle-Income Countries

Stress has a central role in most theories of psychosis etiology, but the relation between stress and psychosis has rarely been examined in large population-level data sets, particularly in low- and middle-income countries. We used data from 39 countries in the World Health Survey (n = 176 934) to test the hypothesis that stress sensitivity would be associated with psychotic experiences, using logistic regression analyses. Respondents in low-income countries reported higher stress sensitivity (P < .001) and prevalence of psychotic experiences (P < .001), compared to individuals in middle-income countries. Greater stress sensitivity was associated with increased odds for psychotic experiences, even when adjusted for co-occurring anxiety and depressive symptoms: adjusted odds ratio (95% CI) = 1.17 (1.15-1.19) per unit increase in stress sensitivity (range 2-10). This association was consistent and significant across nearly every country studied, and translated into a difference in psychotic experience prevalence ranging from 6.4% among those with the lowest levels of stress sensitivity up to 22.2% among those with the highest levels. These findings highlight the generalizability of the association between psychosis and stress sensitivity in the largest and most globally representative community-level sample to date, and support the targeting of stress sensitivity as a potential component of individual- and population-level interventions for psychosis.

Factors associated with postpartum psychiatric admission in a population-based cohort of women with schizophrenia

OBJECTIVE

We aimed to identify factors associated with postpartum psychiatric admission in schizophrenia.

METHOD

In a population-based cohort study of 1433 mothers with schizophrenia in Ontario, Canada (2003-2011), we compared women with and without psychiatric admission in the 1st year postpartum on demographic, maternal medical/obstetrical, infant and psychiatric factors and identified factors independently associated with admission.

RESULTS

Admitted women (n = 275, 19%) were less likely to be adolescents, more likely to be low income and less likely to have received prenatal ultrasound before 20 weeks gestation compared to non-admitted women. They also had higher rates of predelivery psychiatric comorbidity and mental health service use. Factors independently associated with postpartum admission were age (<20 vs. ≥35 years: adjusted risk ratio, aRR, 0.48, 95% CI 0.24-0.96), income (lowest vs. highest income: aRR 1.67, 1.13-2.47) and the following mental health service use factors in pregnancy: admission (≥35 days/year vs. no days, aRR 4.54, 3.65-5.65), outpatient mental health care (no visits vs. ≥2 visits aRR 0.35, 0.27-0.47) and presence of a consistent mental health care provider during pregnancy (aRR 0.69, 0.54-0.89).

CONCLUSION

Certain subgroups of women with schizophrenia may benefit from targeted intervention to mitigate risk for postpartum admission.

Volumetric, relaxometric and diffusometric correlates of psychotic experiences in a non-clinical sample of young adults

BACKGROUND

Grey matter (GM) abnormalities are robust features of schizophrenia and of people at ultra high-risk for psychosis. However the extent to which neuroanatomical alterations are evident in non-clinical subjects with isolated psychotic experiences is less clear.

METHODS

Individuals (mean age 20 years) with (n = 123) or without (n = 125) psychotic experiences (PEs) were identified from a population-based cohort. All underwent T1-weighted structural, diffusion and quantitative T1 relaxometry MRI, to characterise GM macrostructure, microstructure and myelination respectively. Differences in quantitative GM structure were assessed using voxel-based morphometry (VBM). Binary and ordinal models of PEs were tested. Correlations between socioeconomic and other risk factors for psychosis with cortical GM measures were also computed.

RESULTS

GM volume in the left supra-marginal gyrus was reduced in individuals with PEs relative to those with no PEs. The greater the severity of PEs, the greater the reduction in T1 relaxation rate (R1) across left temporoparietal and right pre-frontal cortices. In these regions, R1 was positively correlated with maternal education and inversely correlated with general psychopathology.

CONCLUSIONS

PEs in non-clinical subjects were associated with regional reductions in grey-matter volume reduction and T1 relaxation rate. The alterations in T1 relaxation rate were also linked to the level of general psychopathology. Follow up of these subjects should clarify whether these alterations predict the later development of an ultra high-risk state or a psychotic disorder.

Investigation of the Endogenous Stress Response System in Patients with Chronic Schizophrenia

OBJECTIVE

Cardiophysiological and neuroendocrine studies suggest that the two components of the endogenous stress response system, the sympathetic nervous system (SNS) and the hypothalamic-pituitary-adrenal (HPA) axis, are dysregulated in patients with schizophrenia. However, cardiophysiological measures are influenced by several confounding factors and the secretion of α-amylase in saliva is believed to represent a more reliable index of SNS activity. Therefore, to characterize the functional status of the SNS and HPA axis in schizophrenia we explored the concomitant salivary secretion of cortisol and α-amylase.

METHODS

Saliva cortisol and α-amylase levels were measured after awakening in 30 patients with chronic schizophrenia and 22 healthy subjects.

RESULTS

After awakening, saliva cortisol increased in a similar way in both patients and healthy controls, while saliva α-amylase concentrations showed a clear-cut decrease in healthy subjects but not in patients with schizophrenia. No significant correlation emerged between biochemical measures and patients' demographic or psychopathological characteristics.

CONCLUSIONS

These findings demonstrate normal activity of the HPA axis with an enhanced SNS tone, which suggests a functional dissociation of the two components of the endogenous stress response system in patients with chronic schizophrenia. The pathophysiological significance of such dysregulation needs further studies to be clarified.

Cardiac Coherence Training to Reduce Anxiety in Remitted Schizophrenia, a Pilot Study

Health care that addresses the emotional regulation capacity of patients with schizophrenia confronted with daily stress may contribute to a less anxious life. A psycho-physiological training [cardiac coherence training (CCT)] focusing on emotion regulation is known to decrease anxiety for healthy individuals. We performed a pilot cross sectional survey to explore the benefits of CCT for clinically stable patients with schizophrenia. Ten patients were enrolled in the program consisting of twelve weekly 1-h session programs monitored over a 2-month period. Standardised questionnaires were used before and after the intervention to assess anxiety, well-being outcomes, and how patients deal with stress and stressors. Results showed that this quite-well accepted intervention improved (or tended to improve) well-being outcomes, state-anxiety, and emotional stressors evaluation. The successful transformations were higher for patients with the highest clinical and emotional suffering. Thus, this pilot study revealed that CCT may help patients with schizophrenia to deal with anxiety in daily life.

Fetal exposure to maternal stress and risk for schizophrenia spectrum disorders among offspring: Differential influences of fetal sex

Exposure to adverse life events during pregnancy has been linked to increased risk of schizophrenia spectrum disorders (SSD) in offspring. Nevertheless, much of the previous work inferred maternal stress from severe life events rather than directly assessing maternal reports of stress. The present study aimed to examine maternal reports of stress during pregnancy and risk for offspring SSD. Participants were 95 SSD cases and 206 controls who were offspring from a large birth cohort study that followed pregnant women from 1959 to 1966. During pregnancy interviews, women were asked if anything worrisome had occurred recently. Interviews were qualitatively coded for stress-related themes, including reports of daily life stress, by two independent raters. None of the maternal psychosocial stress themes were significantly associated with increased odds of offspring SSD in analyses of the full sample. However, results indicated a significant daily life stress by infant sex interaction. Maternal daily life stress during pregnancy was associated with significantly increased odds of SSD among male offspring. Findings suggest sex-specific fetal sensitivity to maternal reported daily life stress during pregnancy on risk for SSD, with males appearing to be more vulnerable to the influences of maternal stress during pregnancy.

Psychosis and Suicide

BACKGROUND

The life time risk of suicide among patients with long term psychosis is 5-15%. Suicide prevention in this group is a major clinical challenge.

AIMS

To capture specific characteristics of suicidal communication and critical events preceding suicide in patients with psychosis.

METHODS

Medical records were examined and a life event inventory applied to a one-year cohort of 21 cases of suicide in the clinical group in Stockholm county.

RESULTS

In most cases direct or indirect verbal communication of suicidal thoughts were documented before the suicide. Three months preceeding death, 20 of the 21 subjects had described one or more negative critical experiences, typically physical illness, loss of contact with an important other, loss of "home", and intolerable side effects of medication. In most cases the suicide appeared to be the culmination of prolonged suffering and suicidal deliberations.

CONCLUSIONS

Suicide prevention among patients with psychosis requires sensitivity, active listening, and responsiveness on the part of the care person to the patient's explicit suicidal communication and perceptions of care-related or other incidents or interactions, even when conveyed in an odd manner or with little emotion. To prevent suicide, attentive and long-term planning in collaboration with the patient is essential.

Incidence of childhood abuse among women with psychiatric disorders compared with healthy women: Data from a tertiary care centre in India

Childhood abuse has been recognized as a precursor and a maintaining factor for adult psychopathology. There are very few studies that have investigated the incidence of childhood abuse in adult women with psychiatric disorders. Hence, this current investigation is an attempt to study and compare the incidence of childhood abuse (physical, emotional and sexual) among women seeking treatment for psychiatric disorders to healthy women. Using consecutive sampling, women seeking treatment for psychiatric disorders (N=609) and a group of age-education matched healthy women (N=100) were recruited for the study from a tertiary mental health-care hospital in India. The participants were screened for childhood abuse using the ISPCAN Child Abuse Screening Tool - Retrospective (ICAST)-R (I-CAST R, International Society for the Prevention of Child Abuse and Neglect (ISPCAN) and The United Nations Children's Fund (UNICEF), 2009). Emotional abuse was significantly more common among women with psychiatric disorders compared with healthy women (p<0.05). On overall abuse, there was a trend to significance in women with psychiatric disorders compared with healthy women (p=0.07). There was no statistically significant difference between the two groups on physical and sexual abuse (all p>0.13). There was no statistically significant difference in all three types of abuse across disorder categories, though the report was more among women with severe mental disorders. Women with psychiatric disorders reported more emotional and overall abuse compared with healthy women. Sexual and physical abuse was similar in both groups. It is likely that more emotional abuse predisposes these women to psychiatric disorders.

Predator Stress-Induced CRF Release Causes Enduring Sensitization of Basolateral Amygdala Norepinephrine Systems that Promote PTSD-Like Startle Abnormalities

The neurobiology of post-traumatic stress disorder (PTSD) remains unclear. Intense stress promotes PTSD, which has been associated with exaggerated startle and deficient sensorimotor gating. Here, we examined the long-term sequelae of a rodent model of traumatic stress (repeated predator exposure) on amygdala systems that modulate startle and prepulse inhibition (PPI), an operational measure of sensorimotor gating. We show in rodents that repeated psychogenic stress (predator) induces long-lasting sensitization of basolateral amygdala (BLA) noradrenergic (NE) receptors (α1) via a corticotropin-releasing factor receptor 1 (CRF-R1)-dependent mechanism, and that these CRF1 and NE α1 receptors are highly colocalized on presumptive excitatory output projection neurons of the BLA. A profile identical to that seen with predator exposure was produced in nonstressed rats by intra-BLA infusions of CRF (200 ng/0.5 μl), but not by repeated NE infusions (20 μg/0.5 μl). Infusions into the adjacent central nucleus of amygdala had no effect. Importantly, the predator stress- or CRF-induced sensitization of BLA manifested as heightened startle and PPI deficits in response to subsequent subthreshold NE system challenges (with intra-BLA infusions of 0.3 μg/0.5 μl NE), up to 1 month after stress. This profile of effects closely resembles aspects of PTSD. Hence, we reveal a discrete neural pathway mediating the enhancement of NE system function seen in PTSD, and we offer a model for characterizing potential new treatments that may work by modulating this BLA circuitry.

SIGNIFICANCE STATEMENT

The present findings reveal a novel and discrete neural substrate that could underlie certain core deficits (startle and prepulse inhibition) that are observed in post-traumatic stress disorder (PTSD). It is shown here that repeated exposure to a rodent model of traumatic stress (predator exposure) produces a long-lasting sensitization of basolateral amygdala noradrenergic substrates [via a corticotropin-releasing factor (CRF)-dependent mechanism] that regulate startle, which is exaggerated in PTSD. Moreover, it is demonstrated that the sensitized noradrenergic receptors colocalize with CRF1 receptors on output projection neurons of the basolateral amygdala. Hence, this stress-induced sensitization of noradrenergic receptors on basolateral nucleus efferents has wide-ranging implications for the numerous deleterious sequelae of trauma exposure that are seen in multiple psychiatric illnesses, including PTSD.

Cumulative stress pathophysiology in schizophrenia as indexed by allostatic load

BACKGROUND

The etiopathophysiology of schizophrenia has long been linked to stress and the influence of stress is important in all stages of the illness. Previous examinations of perceived stress and acute stress responses may not capture this longitudinal stress pathophysiology. We hypothesized that the cumulative negative effects of stress, indexed by allostatic load (AL), would be elevated in schizophrenia, and that the AL paradigm would be relevant to our understanding of pathophysiology in schizophrenia.

METHODS

We assessed allostatic load in 30 patients with schizophrenia (SZ; mean age = 33; 17 males) and 20 healthy controls (HC; mean age = 35; 12 males) using 13 cardiovascular, metabolic, neuroendocrine and immune biomarkers. Participants' perceived stress over the past month, functional capacity and psychiatric symptoms were also measured.

RESULTS

Controlling for age, SZ had significantly higher AL as compared to HC (p = 0.007). Greater AL was present in both early course and chronic SZ, and was associated with reduced functional capacity (p = 0.006) and more psychotic symptoms (p = 0.048) in SZ. Current level of perceived stress was not significantly elevated in SZ or associated with AL in either group.

CONCLUSIONS

The higher AL found in SZ may reflect increased bodily "wear and tear", possibly caused by more chronic stress exposure or maladaptive responses to stress over time, although additional research is required to differentiate these causes. The higher AL is similarly present in early and chronic SZ, suggesting primary maladaptive stress physiology rather than secondary effects from medications or chronic illness.

Cognitive emotion regulation in patients with schizophrenia: Evidence for effective reappraisal and distraction

Negative emotions trigger psychotic symptoms, according to a growing body of evidence. Thus, there is a need for effective emotion regulation in schizophrenia. Reappraisal is an effective, cognitive emotion regulation strategy in healthy individuals. However, it is an open research question whether individuals with schizophrenia have difficulties in successfully applying reappraisal. This study experimentally tests the efficacy of reappraisal compared to distraction in patients with schizophrenia and non-clinical controls. An experimental design with group as between-subject factor (non-clinical controls versus patients with schizophrenia) and emotion regulation during anxiety induction as within-subject factor (reappraisal, distraction, no regulation). Seventeen patients with schizophrenia and 27 healthy participants were instructed to respond to anxiety-inducing stimuli by either using reappraisal, distraction or by just watching. Both reappraisal and distraction were effective in down-regulating anxiety, compared to no regulation. The main effect of group and the interaction of emotion regulation condition and group were not significant indicating that the efficacy of both cognitive emotion regulation strategies was independent of group. Patients with schizophrenia are able to apply reappraisal successfully under experimental conditions. Conclusions are limited by the small sample size of this pilot study. Clinical implications for cognitive behavioral therapy for psychosis are discussed.

Cortisol Reactivity to Stress and Its Association With White Matter Integrity in Adults With Schizophrenia

OBJECTIVES

Although acute hypothalamic-pituitary-adrenal axis response to stress is often adaptive, prolonged responses may have detrimental effects. Many components of white matter structures are sensitive to prolonged cortisol exposure. We aimed to identify a behavioral laboratory assay for cortisol response related to brain pathophysiology in schizophrenia. We hypothesized that an abnormally prolonged cortisol response to stress may be linked to abnormal white matter integrity in patients with schizophrenia.

METHODS

Acute and prolonged salivary cortisol response was measured outside the scanner at pretest and then at 0, 20, and 40 minutes after a psychological stress task in patients with schizophrenia (n = 45) and controls (n = 53). Tract-averaged white matter was measured by 64-direction diffusion tensor imaging in a subset of patients (n = 30) and controls (n = 33).

RESULTS

Patients who did not tolerate the psychological stress task and quit had greater acute (t = 2.52 [p = .016] and t = 3.51 [p = .001] at 0 and 20 minutes) and prolonged (t = 3.62 [p = .001] at 40 minutes) cortisol reactivity compared with patients who finished the task. Abnormally prolonged cortisol reactivity in patients was significantly associated with reduced white matter integrity (r = -0.468, p = .009). Regardless of task completion status, acute cortisol response was not related to the white matter measures in patients or controls.

CONCLUSIONS

This paradigm was successful at identifying a subset of patients whose cortisol response was associated with brain pathophysiology. Abnormal cortisol response may adversely affect white matter integrity, partly explaining this pathology observed in schizophrenia. Prolonged stress responses may be targeted for intervention to test for protective effects against white matter damages.

Schizophrenia: a tale of two critical periods for prefrontal cortical development

Schizophrenia is a disease of abnormal brain development. Considerable evidence now indicates that environmental factors have a causative role in schizophrenia. Elevated incidence of the disease has been linked to a wide range of disturbances in the prenatal environment and to social factors and drug intake during adolescence. Here we examine neurodevelopment of the prefrontal cortex in the first trimester of gestation and during adolescence to gain further insight into the neurodevelopmental processes that may be vulnerable in schizophrenia. Early embryonic development of the prefrontal cortex is characterized by cell proliferation, including renewal of progenitor cells, generation of early transient cell populations and neurogenesis of subcortical populations. Animal models show that curtailing early gestational cell proliferation produces schizophrenia-like pathology in the prefrontal cortex and mimics key behavioral and cognitive symptoms of the disease. At the other end of the spectrum, elimination of excitatory synapses is the fundamental process occurring during adolescent maturation in the prefrontal cortex. Adverse social situations that elevate stress increase dopamine stimulation of the mesocortical pathway and may lead to exaggerated synaptic pruning during adolescence. In a non-human primate model, dopamine hyperstimulation has been shown to decrease prefrontal pyramidal cell spine density and to be associated with profound cognitive dysfunction. Development of the prefrontal cortex in its earliest stage in gestation and in its final stage in adolescence represents two critical periods of vulnerability for schizophrenia in which cell proliferation and synaptic elimination, respectively, may be influenced by environmental factors.