Life events, familial stress, and coping in the developmental course of schizophrenia

Social stress in schizophrenia: Unique contributions to social cognition and social functioning

Schizophrenia-spectrum disorders have been associated with heightened stress sensitivity, which can worsen prognosis, functioning, and quality of life. However, more research is needed to determine whether different types of stress impact specific functional domains. This study used the Psychological Stress Index (PSI)-a self-report instrument designed and validated to measure perceived stress in psychosis-to delineate the unique contribution of social versus non-social stress to social functioning and social cognition. Fifty-nine participants with schizophrenia/schizoaffective disorder and fifty non-clinical controls completed the PSI and a battery of social functioning and social cognition measures. Elevated social stress statistically predicted worse performance on an emotion recognition task and worse interviewer-rated social functioning, over-and-above non-social stress. Higher social stress also statistically predicted worse interviewer-rated social functioning over-and-above performance on emotion recognition and theory-of-mind tasks. These results provide promising evidence that examining social stress separately from non-social stress provides unique information about social difficulties in schizophrenia-spectrum psychopathology. Examining social stress and other specific forms of stress may improve understanding of stress sensitivity in this population and better inform treatments aimed at improving functioning.

COMT but Not 5HTTLPR Gene Is Associated with Depression in First-Episode Psychosis: The Role of Stressful Life Events

Serotonergic and dopaminergic systems are involved in the regulation of mood and reactivity to psychological stress. This study explores, in a sample of first episode psychosis (FEP) patients, whether more severe depressive symptoms were found in those who: (1) experienced a major stressful event in the 6 months preceding illness onset; and (2) were homozygous for the COMT Val158 allele or carrying the S allele of 5-HTTLPR. A total of 186 FEP patients recruited were assessed using the Hamilton Rating Scale for Depression (HAMD) for depressive symptoms. Stressful life events (SLEs) were collected by the List of Events Scale. The genotypes of 5-HTTLPR, rs25531, and COMT Val158 Met were performed. It has been found that higher levels of depression is associated with the presence of SLEs (p = 0.019) and with COMT Val158 allele homozygosity (p = 0.029), but not with carrying the S allele of 5-HTTLPR. The COMT gene moderates the association between depression and SLEs as Val158 allele homozygote patients experiencing SLEs had the highest level of depressive symptoms compared to the others (p = 0.002). The present study provides initial evidence for an effect of the COMT Val158 homozygosity and severe stressful life events on the severity of depressive symptoms in first episode psychosis.

MiRNA Differences Related to Treatment-Resistant Schizophrenia

Schizophrenia (SZ) is a serious mental disorder that is typically treated with antipsychotic medication. Treatment-resistant schizophrenia (TRS) is the condition where symptoms remain after pharmacological intervention, resulting in long-lasting functional and social impairments. As the identification and treatment of a TRS patient requires previous failed treatments, early mechanisms of detection are needed in order to quicken the access to effective therapy, as well as improve treatment adherence. In this study, we aim to find a microRNA (miRNA) signature for TRS, as well as to shed some light on the molecular pathways potentially involved in this severe condition. To do this, we compared the blood miRNAs of schizophrenia patients that respond to medication and TRS patients, thus obtaining a 16-miRNA TRS profile. Then, we assessed the ability of this signature to separate responders and TRS patients using hierarchical clustering, observing that most of them are grouped correctly (~70% accuracy). We also conducted a network, pathway analysis, and bibliography search to spot molecular pathways potentially altered in TRS. We found that the response to stress seems to be a key factor in TRS and that proteins p53, SIRT1, MDM2, and TRIM28 could be the potential mediators of such responses. Finally, we suggest a molecular pathway potentially regulated by the miRNAs of the TRS profile.

Effect of stressful life events on subclinical psychotic symptoms in first-degree relatives and healthy controls

Exposure to Stressful Life Events (SLEs) has been linked to psychosis. However, the combined effect of SLEs and familial risk on subclinical psychotic symptoms over time remains unknown. The objective of the present study was to investigate the effect of SLEs on the level of subclinical psychotic symptoms in individuals with and without familial vulnerability for psychosis. Data were collected from siblings of individuals diagnosed with psychotic disorder and healthy controls at baseline (N = 293) and three years later at follow-up (N = 928). We assessed self-reported and observer-rated subclinical positive, negative, and depressive psychotic symptoms. Participants reported the number of SLEs in the preceding 6 months. A multilevel multivariate regression analysis revealed a positive association between the retrospectively assessed number of SLEs and symptom levels, regardless of vulnerability status (p < .001 for all outcomes). The prospective analysis demonstrated that exposure to SLEs at baseline predicted higher levels of subclinical psychotic symptoms at follow-up. However, after controlling for the level of symptoms at baseline, these associations were no longer significant. Again, the vulnerability status did not modify these results. Nevertheless, siblings in our sample were approximating the end of the critical period for the development of psychotic disorder (mean age at baseline M = 29 and follow-up M = 34). The findings partly support the vulnerability-stress model of psychosis, yet do not confirm the role of familial risk in this association. SLEs may represent a risk factor for psychosis at a population level, thus supporting the continuity of the psychosis spectrum in terms of associated risk factors.

Dynamic interplay between life events and course of psychotic disorders: 10-year longitudinal study following first admission

BACKGROUND

Life events (LEs) are a risk factor for first onset and relapse of psychotic disorders. However, the impact of LEs on specific symptoms - namely reality distortion, disorganization, negative symptoms, depression, and mania - remains unclear. Moreover, the differential effects of negative v. positive LEs are poorly understood.

METHODS

The present study utilizes an epidemiologic cohort of patients (N = 428) ascertained at first-admission for psychosis and followed for a decade thereafter. Symptoms were assessed at 6-, 24-, 48-, and 120-month follow-ups.

RESULTS

We examined symptom change within-person and found that negative events in the previous 6 months predicted an increase in reality distortion (β = 0.07), disorganized (β = 0.07), manic (β = 0.08), and depressive symptoms (β = 0.06), and a decrease in negative symptoms (β = -0.08). Conversely, positive LEs predicted fewer reality distortion (β = -0.04), disorganized (β = -0.04), and negative (β = -0.13) symptoms, and were unrelated to mood symptoms. A between-person approach to the same hypotheses confirmed that negative LEs predicted change in all symptoms, while positive LEs predicted change only in negative symptoms. In contrast, symptoms rarely predicted future LEs.

CONCLUSIONS

These findings confirm that LEs have an effect on symptoms, and thus contribute to the burden of psychotic disorders. That LEs increase positive symptoms and decrease negative symptoms suggest at least two different mechanisms underlying the relationship between LEs and symptoms. Our findings underscore the need for increased symptom monitoring following negative LEs, as symptoms may worsen during that time.

Stressful life events and psychosis: Gender differences

There is evidence that stressful events are associated with psychosis. This study aimed to explore sex differences in the association between stressful life events occurring during childhood and adulthood and psychosis. A total of 78 psychotic patients and 156 controls were enrolled. Childhood adversities were evaluated using a validated semi-structured interview and the Childhood Experience of Care and Abuse Questionnaire. Recent life events were recorded using a semi-structured interview with a normative and contextual approach. The diagnosis of psychosis was made according to Jablensky's criteria. χ² and t-test statistical analyses were run. Odds ratios were calculated in logistic regression. People with psychosis reported more exposure to both childhood adversities and recent events than the general population. An excess of childhood physical abuse was found among male psychotic patients, whereas both childhood sexual abuse and recent life events were overrepresented among female patients in comparison with the general population. There was a cumulative effect of stressful life events on psychosis, although it was stronger among females than in males. It is likely that there are gender differences in the association between stressful life events and psychosis.

Allostatic Load Effects on Cortical and Cognitive Deficits in Essentially Normotensive, Normoweight Patients with Schizophrenia

Reduced cortical gray matter integrity and cognitive abilities are among core deficits in schizophrenia. We hypothesized that higher allostatic load (AL) that accounts for exposure to chronic stress is a contributor to structural and cognitive deficits in schizophrenia. One hundred and sixty-seven schizophrenia patients who were on average with normal weight, normal systolic, and diastolic blood pressure and 72 healthy controls were enrolled in the study. Group differences in subclinical cardiovascular, metabolic, immune, and neuroendocrine biological markers as indexed by AL and contribution of AL components to the structural and cognitive deficits in schizophrenia were explored. Compared with controls, schizophrenia patients who were normotensive, normoweight, and had low total cholesterol levels still had significantly higher AL mainly due to lower high-density lipoprotein cholesterol and higher heart rate, waist-hip ratio, hemoglobinA1c, hypersensitive C-reactive protein, and overnight-urine cortisol levels. Patients also had decreased whole-brain mean cortical thickness, and lower cognition assessed by the MATRICS consensus cognitive battery. AL was inversely correlated with mean cortical thickness and cognition in schizophrenia, while none of these relationships existed in controls. Mediation analyses showed the effect of AL on cognitive deficits in schizophrenia was significantly mediated by cortical thinning, and the most significant mediating cortical area was the left superior frontal gyrus. Cortical thickness may act as a mediator between AL and cognitive deficits in schizophrenia. Early intervention strategies to reduce cortical thinning and cognitive dysfunction in schizophrenia should target specific aspects of their high AL in addition to weight gain, hypertension and high cholesterol levels.

The impact of family environment on self-esteem and symptoms in early psychosis

Expressed emotion (EE) and self-esteem (SE) have been implicated in the onset and development of paranoia and positive symptoms of psychosis. However, the impact of EE on patients’ SE and ultimately on symptoms in the early stages of psychosis is still not fully understood. The main objectives of this study were to examine whether: (1) patients’ SE mediated the effect of relatives’ EE on patients’ positive symptoms and paranoia; (2) patients’ perceived EE mediated the effect of relatives’ EE on patients’ SE; (3) patients’ SE mediated between patients’ perceived EE and patients’ symptomatology; and (4) patients’ perceived EE and patients’ SE serially mediated the effect of relatives’ EE on patients’ positive symptoms and paranoia. Incipient psychosis patients (at-risk mental states and first-episode of psychosis) and their respective relatives completed measures of EE, SE, and symptoms. Findings indicated that: (1) patients’ perceived EE mediated the link between relatives’ EE and patients’ negative, but not positive, SE; (2) patients’ negative SE mediated the effect of patients’ perceived EE on positive symptoms and paranoia; (3) the association of relatives’ EE with positive symptoms and paranoia was serially mediated by an increased level of patients’ perceived EE leading to increases in negative SE; (4) high levels of patients’ distress moderated the effect of relatives’ EE on symptoms through patients’ perceived EE and negative SE. Findings emphasize that patients’ SE is relevant for understanding how microsocial environmental factors impact formation and expression of positive symptoms and paranoia in early psychosis. They suggest that broader interventions for patients and their relatives aiming at improving family dynamics might also improve patients’ negative SE and symptoms.

Adaptability and cohesion in youth at clinical high-risk for psychosis: A multi-informant approach

BACKGROUND

Families can play a critical role in the development of psychosis. Adaptability (i.e., flexibility) and cohesion (i.e., emotional bonding) are important markers of family functioning, but have rarely been studied in youth at clinical high risk for developing psychosis (CHR), especially not from a multi-informant perspective.

METHODS

The current study examined adaptability and cohesion (using youth and mother reports) and clinical symptoms (in youth) among 75 youth at CHR and their mothers (N = 48) and 79 matched healthy controls and their mothers (N = 42).

RESULTS

Findings showed that (1) youth at CHR and their mothers reported lower adaptability and cohesion than their healthy control counterparts. (2) All youth reported lower adaptability than mothers, but only youth at CHR (not control youth) reported lower cohesion than their mothers. (3) There were no significant links between CHR youth and mother reports of adaptability and cohesion and clinical symptoms.

CONCLUSIONS

Findings support existing literature that families with a youth at CHR are at risk for poorer functioning and demonstrate pronounced youth-mother discrepancies with youth at CHR (but not controls) reporting lower emotional bonding than their mothers. Future studies may further probe multi-informant perspectives of family environment as a clinical marker in the clinical high risk state.

Psicosis reactiva breve a situación de confinamiento por PCR positiva para SARS-CoV-2. A propósito de un caso clínico

Algunas personas presentan respuestas muy diferentes a los acontecimientos vitales estresantes. Diversos autores han observado una relación entre una circunstancia de vida que pueda resultar estresante para el individuo y la aparición de un primer episodio psicótico. Se presenta el caso de un varón de 43 años sin antecedentes psiquiátricos que, tras aproximadamente 10 días de confinamiento por PCR positiva para SARS-CoV-2, inicia un cuadro de clínica delirante.

Perceived Stress and Life Events in Patients Affected by Schizophrenia and Schizoaffective and Bipolar Disorder: Is There a Role for Self-Reported Basic Symptoms?

INTRODUCTION

The stress-diathesis model of psychotic disorders describes, in vulnerable individuals, the role of psychosocial stress in the onset and exacerbation of psychotic symptoms. Another interesting approach to the study of vulnerability in the development of psychosis is represented by the basic symptoms concept.

OBJECTIVE

The present study aims at proposing an integration between these two models and investigating possible associations between psychotic symptoms, basic symptoms, perceived stress, and life events in a sample of patients affected by schizophrenia (SZ), schizoaffective (SA), and bipolar disorder with and without psychotic symptoms.

METHODS

112 patients were recruited in two university hospitals. Severity of psychiatric symptoms (Positive and Negative Syndrome Scale, PANSS), basic symptoms (Frankfurt Complaint Questionnaire, FCQ), perceived stress (Stress-related Vulnerability Scale, SVS), and life events (Paykel's interview for recent life events) were assessed.

RESULTS

Patients affected by bipolar disorder (both with and without psychotic symptoms) showed a higher number of independent life events (p < 0.01) and tended to report more frequently at least 1 life event in the previous 6 months (p < 0.01) than patients affected by SZ or SA disorder. No differences emerged between the study groups in perceived stress nor in measures of basic symptoms. In the whole sample, a logistic regression analysis showed that the SVS total score (p < 0.05) and PANSS total score (p < 0.001) were associated with the presence of psychotic symptoms.

CONCLUSIONS

In the study sample, life events and basic symptoms did not play a major role in influencing psychotic symptoms, compared to the subjective perception of stress and the severity of psychopathology. Taken together, these results can be informative for rehabilitation therapies aimed at enhancing resilience and coping strategies in this vulnerable group of patients.

Affective and psychotic reactivity to daily-life stress in adults with 22q11DS: a study using the experience sampling method

BACKGROUND

22q11.2 deletion syndrome (22q11DS) is a genetic disorder associated with an increased risk of psychiatric disorders. Vulnerability for psychopathology has been related to an increased reactivity to stress. Here, we examined affective states, perceived stress, affective and psychotic reactivity to various sources of environmental stress using the experience sampling method (ESM), a structured diary technique allowing repeated assessments in the context of daily life.

METHODS

Adults with 22q11DS (n = 31; age, 34.1 years) and matched healthy controls (HCs; n = 24; age, 39.9 years) were included. ESM was used to assess affective states, perceived stress, and stress reactivity. Data were analyzed using multilevel regression models.

RESULTS

Adults with 22q11DS displayed overall higher levels of negative affect but comparable levels of positive affect compared to HCs. Higher levels of perceived stress were reported by individuals with 22q11DS. Comparable affective and psychotic reactivity in relation to all types of environmental stress was observed between the two groups.

CONCLUSION

The results point toward higher levels of negative affect and differences in the perception of daily hassles in 22q11DS but no difference in affective or psychotic reactivity to stress. This study contributes to the growing literature regarding the impact of stress on the development of psychopathology in the 22q11DS population.

Obsessive compulsive-disorder and reproductive life events

We explored the association between reproductive life events and the onset or exacerbation of obsessive-compulsive disorder (OCD) among women in comparison with men with OCD. We chose men because there is some evidence of increased occurrence of OCD in expectant fathers as well. We recruited 150 eligible outpatients (58 men and 92 women) with OCD, who attended a specialty OCD Clinic over a period of one year. Occurrence of any life event including reproductive life events in the year before the onset of OCD was assessed using the Interview of Recent Life Events (IRLE). Reproductive life events in the year prior to onset of OCD were overrepresented in women compared to men. Postpartum onset and worsening of OCD was reported in 14 % and 11 % of women respectively. Menarche and menopause as life events were infrequently reported (3% and 1%). Symmetry obsessions and ordering compulsions were more common in women with post-partum onset of OCD than those without. Post-partum period seems to be associated with onset and exacerbation of OCD; therefore, routine screening for OCD during this period is necessary.

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.

Potentially traumatic events in youth with and at clinical high risk for psychosis

AIM

Previous research has demonstrated a strong association between early trauma exposure and the development of psychotic symptoms. However, few of these studies have included young adolescents and children. This study investigated rates and number of potentially traumatic experiences (PTEs) among typically developing youth (TD; n = 21), youth at clinical high risk for psychosis (CHR; n = 38), and youth with a psychotic disorder (PD; n = 28) between 7 and 18 years of age. CHR participants were further evaluated to determine whether a history of PTEs was associated with prodromal symptom severity.

METHODS

Study group inclusion was determined by structured interviews. Trauma history was assessed using the post-traumatic stress disorder module of the Schedule for Affective Disorders and Schizophrenia for School-Age Children-Present and Lifetime Version. CHR participants with vs without a history of PTEs were compared on severity of prodromal symptoms.

RESULTS

CHR and PD participants reported significantly higher rates and numbers of PTEs than TD participants. Contrary to expectations and prior research, CHR participants with vs without a history of PTEs did not differ in prodromal symptom severity. Explanations and implications for the findings are discussed.

CONCLUSIONS

These findings suggest that the relationship between trauma and the development of psychotic symptoms extends to children and adolescents as young as 7 years of age. This study underscores the importance of screening for trauma exposure among youth seeking treatment for psychotic symptoms.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Life events in schizoaffective disorder: A systematic review

BACKGROUND

Life events play a central role in the development of psychiatric disorders and impact course and outcome. We present a systematic review of the literature on the relationship of life events with the onset and long-term course of schizoaffective disorder.

METHODS

MEDLINE was searched with the combination of the key words: 'life events' plus 'schizoaffective'. The PRISMA method was followed in the review process.

RESULTS

From the identified 66 papers only 12 were considered to be of relevance to the current study and 6 more papers were identified by inspecting the reference lists of the identified papers.

LIMITATIONS

There are very few studies focusing on the role of life events in schizoaffective disorder indicating insufficient data concerning the relationship of life events with onset and long-term course of schizoaffective disorder. Reported effects are not generic but concern specific events like the loss of mother, and females seem to be more vulnerable. Patients with schizoaffective disorder manifest high rates of PTSD.

CONCLUSION

The literature on life events with the development and course of schizoaffective disorder is limited and precludes solid conclusions.

Improving functional outcomes in college and university students with schizophrenia in the Western world

Retrospective research from patients with schizophrenia suggests that remission becomes increasingly less likely the longer psychosis goes untreated. Yet symptoms of schizophrenia are insidious and disease evolution varies between patients, requiring an ongoing diagnostic process. One way of justifying early treatment is by focusing on functionality rather than symptomatology. Most patients are diagnosed with schizophrenia between the ages of 17 and 25-when many young adults are undergraduates or pursuing post-graduate education. The extent to which schools partner with mental health services has implications for the short-term success of students' recovery and their future employability. Translating study findings on schizophrenia to the college setting remains an important area of investigation.

Development and validation of the Questionnaire of Stressful Life Events (QSLE)

Stressful life events (SLEs) are important indicators prior to the onset of first-episode psychosis (FEP). Although there are well-validated interviews and self-reports for assessing SLE on proximate events, unfortunately there are no instruments to assess SLE covering an entire lifetime. This study includes detailed specific items of childhood, adolescence, and adulthood focused on the presence of SLE, emotional impact (stressfulness), and the age at which the event occurred. Our research describes 2 studies designed to develop and validate a new scale to assess SLE: the Questionnaire of Stressful Life Events (QSLE). In Study 1, an over-inclusive item pool was generated based on review of group of experts at Parc Sanitari Sant Joan de Déu and content validity was examined by an Expert Survey. The whole scale represents the content domain. In Study 2, item-level analyses revealed good distributional properties, intra-rater reliability, and convergent and discriminant validity. In the sensitivity and specificity analysis, 18 items had high relevance in the discriminability between patients with FEP and healthy controls. We note that there was an AUC of 0.676, indicating a good predictor. Using 7 as a cutoff to predict an individual as a patient would yield a sensitivity of 64.8% and a specificity of 65%. Overall, the QSLE displayed satisfactory psychometric characteristics in a Spanish population. These results suggest that QSLE gives us the opportunity to investigate childhood, adolescent, and adult life events by measuring the stress and age at the moment on a continuous scale.

Recent life events and psychosis: The role of childhood adversities

Life events are commonly reported to be related to psychosis. However, less attention has been given to the role that recent events play on psychosis, in relation to exposure to childhood adversity. The current study aimed to evaluate the relationship between recent events and psychosis, taking into account the role of early adversities. 78 psychotic patients and 156 controls were enrolled. Childhood adversity was evaluated using a validated semi-structured interview and the Childhood Experience of Care and Abuse Questionnaire. Recent events were recorded using a semi-structured interview with a normative and contextual approach. The diagnosis of psychosis was made according to Jablenski's criteria. Chi-square, t-test, odds ratio, and binary logistic regression statistical analyses were performed. Psychotic patients reported an excess of recent events. The occurrence of more than one recent event increased the risk of psychosis; there was a cumulative effect between recent and childhood events on psychosis. Recent events were significantly related to psychosis, even in the absence of childhood adversity or when adjusted for it. Our findings suggested that the effect of recent events on psychosis may be amplified by previous exposure to early adversity. Recent events alone, could be also linked to psychosis independently of childhood adversity.

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).

Incidence of stressful life events and influence of sociodemographic and clinical variables on the onset of first-episode psychosis

This study presents a quantitative analysis of the incidence of stressful life events (SLEs) and the variables gender, age at onset, family history and psychotic symptoms in patients with first-episode psychosis (FEP). A descriptive, cross-sectional methodology was used to interview 68 patients with FEP between 13 and 47 years of age. The Psychiatric Epidemiology Research Interview Life Events Scale collected one-year period prior to onset of FEP - used to analyse the subcategories academic, work, love and marriage, children, residence, legal affairs, finances and social activities-, Positive and Negative Syndrome Scale, and Clinical Global Impression-Schizophrenia scale were used to assess the relevance of certain SLEs during adolescence. Age at onset showed a significant negative correlation with the categories academic and social activities. By contrast, it showed a positive correlation with work and children. A significant relationship was found between paternal family history and social activities and between maternal family history and academic and love and marriage. Finally, an inverse relationship was observed between negative symptoms and the categories children and finance. Depressive symptoms were significantly correlated with the category academic. Our results show the importance of SLEs during adolescence and suggest that there is a clear need to develop preventive actions that promote effective strategies for dealing with the accumulation of psychosocial stress.

Using virtual reality to investigate psychological processes and mechanisms associated with the onset and maintenance of psychosis: a systematic review

PURPOSE

In the last decade researchers have embraced virtual reality to explore the psychological processes and mechanisms that are involved in the onset and maintenance of psychosis. A systematic review was conducted to synthesise the evidence of using virtual reality to investigate these mechanisms.

METHODS

Web of Science, PsycINFO, Embase, and Medline were searched. Reference lists of collected papers were also visually inspected to locate any relevant cited journal articles. In total 6001 articles were potentially eligible for inclusion; of these, 16 studies were included in the review.

RESULTS

The review identified studies investigating the effect of interpersonal sensitivity, childhood bullying victimisation, physical assault, perceived ethnic discrimination, social defeat, population density and ethnic density on the real-time appraisal of VR social situations. Further studies demonstrated the potential of VR to investigate paranoid ideation, anomalous experiences, self-confidence, self-comparison, physiological activation and behavioural response.

CONCLUSIONS

The reviewed studies suggest that VR can be used to investigate psychological processes and mechanisms associated with psychosis. Implications for further experimental research, as well as for assessment and clinical practise are discussed. The present review has been registered in the PROSPERO register: CRD42016038085.

Decreases in perceived maternal criticism predict improvement in subthreshold psychotic symptoms in a randomized trial of family-focused therapy for individuals at clinical high risk for psychosis

Perceived criticism (PC) is a measure of how much criticism from 1 family member "gets through" to another. PC ratings have been found to predict the course of psychotic disorders, but questions remain regarding whether psychosocial treatment can effectively decrease PC, and whether reductions in PC predict symptom improvement. In a sample of individuals at high risk for psychosis, we examined a) whether Family Focused Therapy for Clinical High-Risk (FFT-CHR), an 18-session intervention that consists of psychoeducation and training in communication and problem solving, brought about greater reductions in perceived maternal criticism, compared to a 3-session family psychoeducational intervention; and b) whether reductions in PC from baseline to 6-month reassessment predicted decreases in subthreshold positive symptoms of psychosis at 12-month follow-up. This study was conducted within a randomized controlled trial across 8 sites. The perceived criticism scale was completed by 90 families prior to treatment and by 41 families at 6-month reassessment. Evaluators, blind to treatment condition, rated subthreshold symptoms of psychosis at baseline, 6- and 12-month assessments. Perceived maternal criticism decreased from pre- to posttreatment for both treatment groups, and this change in criticism predicted decreases in subthreshold positive symptoms at 12-month follow-up. This study offers evidence that participation in structured family treatment is associated with improvement in perceptions of the family environment. Further, a brief measure of perceived criticism may be useful in predicting the future course of attenuated symptoms of psychosis for CHR youth.

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.

The impact of neuropsychological functioning and coping style on perceived stress in individuals with first-episode psychosis and healthy controls

Stress is implicated in the development and course of psychotic illness, but the factors that influence stress levels are not well understood. The aim of this study was to examine the impact of neuropsychological functioning and coping styles on perceived stress in people with first-episode psychosis (FEP) and healthy controls (HC). Thirty-four minimally treated FEP patients from the Early Psychosis Prevention and Intervention Centre, Melbourne, Australia, and 26 HC participants from a similar demographic area participated in the study. Participants completed a comprehensive neuropsychological test battery as well as the Coping Inventory for Stressful Situations (task-, emotion- and avoidance-focussed coping styles) and Perceived Stress Scale (PSS). Linear regressions were used to determine the contribution of neuropsychological functioning and coping style to perceived stress in the two groups. In the FEP group, higher levels of emotion-focussed and lower levels of task-focussed coping were associated with elevated stress. Higher premorbid IQ and working memory were also associated with higher subjective stress. In the HC group, higher levels of emotion-focussed coping, and contrary to the FEP group, lower premorbid IQ, working memory and executive functioning, were associated with increased stress. Lower intellectual functioning may provide some protection against perceived stress in FEP.

Coping with delusions in schizophrenia and affective disorder with psychotic symptoms: the relationship between coping strategies and dimensions of delusion

BACKGROUND

Self-generated coping strategies and the enhancement of coping strategies are effective in the treatment of psychotic symptoms. Evaluating these strategies can be of clinical interest to develop better coping enhancement therapies. Cognitive models consider delusions as multidimensional phenomena. Using a psychometric approach, the relationship between coping and the dimensions of delusion were examined.

METHODS

Thirty schizophrenia spectrum patients with delusions and 29 patients with affective disorder with psychotic symptoms were interviewed using the Heidelberg Coping Scales for Delusions and the Heidelberg Profile of Delusional Experience. Analyses of variance were conducted to investigate differences between the groups, and Spearman's rank-based correlations were used to examine the correlations between coping factors and the dimensions of delusion.

RESULTS

Schizophrenia spectrum patients used more medical care and symptomatic coping, whereas patients with affective disorder engaged in more depressive coping. In the schizophrenia spectrum sample, the action-oriented, the cognitive, and the emotional dimensions of delusion were related to coping factors. In patients with affective disorder, only the action-oriented dimension was related to coping factors.

CONCLUSION

Patients with schizophrenia and affective disorder cope differently with delusions. The dimensions of delusion are related to coping and should be regarded when using cognitive therapy approaches to enhance coping strategies.

Behaviour Therapy and Schizophrenia: An Introduction

This brief article introduces a two-part series of special issues ofBehaviour Changeon the cognitive-behavioural treatment of schizophrenia. Two pervasive myths about schizophrenia inhibit effective psychological treatment and rehabilitation: (1) that schizophrenia inevitably has poor outcome, and (2) that drugs are effective in the management of schizophrenia. Neither of these myths is supported by available data. A stress–vulnerability model is described which provides a framework for understanding the variability in outcome of schizophrenia, and for conducting cognitive-behaviour therapy.

[Review of risks factors in childhood for schizophrenia and severe mental disorders in adulthood]

AIM

To provide scientific evidence, using a literature review on psychosocial risk factors in mental health, that a high exposure to psychosocial stress situations in childhood increases the risk of mental disorders in adulthood,.

DESIGN

A literature review up to December 2011 in the electronic databases from Medline, Universitat de Barcelona, and the Universitat Autonoma de Barcelona. The keywords used were: childhood, prenatal, vulnerability, risk, abuse, neglect, child mental disorder, schizophrenia, and prevention. Inclusion criteria for the studies reviewed: 1) designed to investigate childhood risk factors; 2) Comparative studies with persons without risk factors; 3) Studies with sufficient statistical significance; 4) Studies with "n" participants equal to o more than 30 persons.

RESULTS

There are a group of easily identifiable mental health risk factors in childhood that can help in the prevention of mental disorders in the adulthood. They can be grouped into four categories: A) Pregnancy, birth and perinatal problems; B) Poor interpersonal relations with parents; C) Adverse life events in the first two years of life; D) Cognitive deficits in primary school, and social isolation during school years.

CONCLUSIONS

There are life events that may increase the possibilities of suffering some kind of Psychopathology. It is necessary to consider those events as Risk Factors for Mental Health. The accumulation of these Risk Factors increases vulnerability to Mental Disorders.

Genetic liability, prenatal health, stress and family environment: risk factors in the Harvard Adolescent Family High Risk for schizophrenia study

OBJECTIVES

The familial ("genetic") high-risk (FHR) paradigm enables assessment of individuals at risk for schizophrenia based on a positive family history of schizophrenia in first-degree, biological relatives. This strategy presumes genetic transmission of abnormal traits given high heritability of the illness. It is plausible, however, that adverse environmental factors are also transmitted in these families. Few studies have evaluated both biological and environmental factors within a FHR study of adolescents.

METHODS

We conceptualize four precursors to psychosis pathogenesis: two biological (genetic predisposition, prenatal health issues (PHIs)) and two environmental (family environment, stressful life events (SLEs)). Participants assessed between 1998 and 2007 (ages 13-25) included 40 (20F/20M) adolescents at FHR for schizophrenia (FHRs) and 55 (31F/24M) community controls. 'Genetic load' indexed number of affected family members relative to pedigree size.

RESULTS

PHI was significantly greater among FHRs, and family cohesion and expressiveness were less (and family conflict was higher) among FHRs; however, groups did not significantly differ in SLE indices. Among FHRs, genetic liability was significantly associated with PHI and family expressiveness.

CONCLUSIONS

Prenatal and family environmental disruptions are elevated in families with a first-degree relative with schizophrenia. Findings support our proposed 'polygenic neurodevelopmental diathesis-stress model' whereby psychosis susceptibility (and resilience) involves the independent and synergistic confluence of (temporally-sensitive) biological and environmental factors across development. Recognition of biological and social environmental influences across critical developmental periods points to key issues relevant for enhanced identification of psychosis susceptibility, facilitation of more precise models of illness risk, and development of novel prevention strategies.

A randomized trial of family focused therapy with populations at clinical high risk for psychosis: effects on interactional behavior

OBJECTIVE

This study investigated whether family focused therapy (FFT-CHR), an 18-session intervention that consisted of psychoeducation and training in communication and problem solving, brought about greater improvements in family communication than enhanced care (EC), a 3-session psychoeducational intervention, among individuals at clinical high risk for developing psychosis.

METHOD

This study was conducted within a randomized controlled trial across 8 sites. We examined 10-min problem-solving discussions at baseline and 6-month reassessment among 66 adolescents and young adults and their parents. Trained coders who were blind to treatment and time of assessment achieved high levels of interrater reliability when evaluating family discussions on categories of calm-constructive and critical-conflictual behavior.

RESULTS

Individuals at high risk and their family members who participated in FFT-CHR demonstrated greater improvement from baseline to 6-month reassessment in constructive communication and decreases in conflictual behaviors during family interactions than those in EC. Participants in FFT-CHR showed greater increases from baseline to 6 months in active listening and calm communication and greater decreases in irritability and anger, complaints and criticism, and off-task comments compared to participants in EC. These changes occurred equally in high-risk participants and their family members.

CONCLUSIONS

A 6-month family skills training treatment can bring about significant improvement in family communication among individuals at high risk for psychosis and their parents. Future studies should examine the association between enhancements in family communication and reduced risk for the onset of psychosis among individuals at high risk.

The effect of psychological stress and expectation on auditory perception: A signal detection analysis

Both psychological stress and predictive signals relating to expected sensory input are believed to influence perception, an influence which, when disrupted, may contribute to the generation of auditory hallucinations. The effect of stress and semantic expectation on auditory perception was therefore examined in healthy participants using an auditory signal detection task requiring the detection of speech from within white noise. Trait anxiety was found to predict the extent to which stress influenced response bias, resulting in more anxious participants adopting a more liberal criterion, and therefore experiencing more false positives, when under stress. While semantic expectation was found to increase sensitivity, its presence also generated a shift in response bias towards reporting a signal, suggesting that the erroneous perception of speech became more likely. These findings provide a potential cognitive mechanism that may explain the impact of stress on hallucination-proneness, by suggesting that stress has the tendency to alter response bias in highly anxious individuals. These results also provide support for the idea that top-down processes such as those relating to semantic expectation may contribute to the generation of auditory hallucinations.

The impact of social stress on self-esteem and paranoid ideation

BACKGROUND

Vulnerability-stress models propose that social stress triggers psychotic episodes in high risk individuals. Previous studies found not only stress but also a decrease in self-esteem to precede the formation of delusions. As evidence for causal conclusions has not been provided yet, the present study assessed the direct impact of social stress on paranoid beliefs using an experimental design and considered a decrease in self-esteem as a mediator and the proneness to psychosis and paranoia as moderators of the effect.

METHODS

A nonclinical population sample (n = 76) was randomly assigned to an experimental (EG) or a control group condition (CG). In the EG, participants were excluded during a virtual ball game (Cyberball) by the other two players and received a negative feedback after performing a test. The CG was included in the game and received a neutral feedback. Before and after the experimental conditions, emotions, self-esteem and paranoid beliefs were assessed using state-adapted questionnaires.

RESULTS

After the social stress induction, the EG reported a higher increase in subclinical paranoid beliefs compared to the CG. The impact of social stress on paranoid ideation was mediated by a decrease in self-esteem and moderated by proneness to paranoia. Individuals who felt distressed by paranoid thoughts at baseline were more likely to react with an increase in paranoid ideation under social stress.

LIMITATIONS

The results need to be confirmed in a patient sample to draw conclusions about the processes involved in the formation of delusions in clinically relevant stages.

CONCLUSIONS

The impact of social stress on symptom formation and self-esteem is discussed in terms of recent models of symptom formation and interventions in psychosis.

Risk factors for relapse following treatment for first episode psychosis: a systematic review and meta-analysis of longitudinal studies

BACKGROUND

Preventing relapse is an essential element of early intervention in psychosis, but relevant risk factors and precise relapse rates remain to be clarified. The aim of this study was to systematically compile and analyse risk factors for and rates of relapse in the early course of psychosis.

METHODS

Systematic review and meta-analysis of English and non-English language, peer-reviewed, longitudinal studies, with a minimum 12-month follow-up and at least 80% of participants diagnosed with a first episode of psychosis (FEP) that reported risk factors for relapse.

RESULTS

Of 153 potentially relevant articles, 29 were included in the study. Pooled prevalence of relapse of positive symptoms was 28% (range=12-47%), 43% (35-54%), 54% (40-63%) at 1, 1.5-2, and 3 years follow-up, in that order. A total of 109 predictors were analysed, with 24 being assessed in at least 3 studies. Of those, 20 predictors could be extracted for meta-analysis. Medication non-adherence, persistent substance use disorder, carers' critical comments (but not overall expressed emotion) and poorer premorbid adjustment, increased the risk for relapse 4-fold, 3-fold, 2.3-fold and 2.2-fold, respectively.

CONCLUSIONS

Clinical variables and general demographic variables have little impact on relapse rates. Conversely, non-adherence with medication, persistent substance use disorder, carers' criticism and poorer premorbid adjustment significantly increase the risk for relapse in FEP. Future studies need to address the methodological limitations of the extant research (e.g. definition of relapse), focus on the identification of protective factors and evaluate theoretically derived models of relapse.

Effects and Mechanisms of 3α,5α,-THP on Emotion, Motivation, and Reward Functions Involving Pregnane Xenobiotic Receptor

Progestogens [progesterone (P(4)) and its products] play fundamental roles in the development and/or function of the central nervous system during pregnancy. We, and others, have investigated the role of pregnane neurosteroids for a plethora of functional effects beyond their pro-gestational processes. Emerging findings regarding the effects, mechanisms, and sources of neurosteroids have challenged traditional dogma about steroid action. How the P(4) metabolite and neurosteroid, 3α-hydroxy-5α-pregnan-20-one (3α,5α-THP), influences cellular functions and behavioral processes involved in emotion/affect, motivation, and reward, is the focus of the present review. To further understand these processes, we have utilized an animal model assessing the effects, mechanisms, and sources of 3α,5α-THP. In the ventral tegmental area (VTA), 3α,5α-THP has actions to facilitate affective, and motivated, social behaviors through non-traditional targets, such as GABA, glutamate, and dopamine receptors. 3α,5α-THP levels in the midbrain VTA both facilitate, and/or are enhanced by, affective and social behavior. The pregnane xenobiotic receptor (PXR) mediates the production of, and/or metabolism to, various neurobiological factors. PXR is localized to the midbrain VTA of rats. The role of PXR to influence 3α,5α-THP production from central biosynthesis, and/or metabolism of peripheral P(4), in the VTA, as well as its role to facilitate, or be increased by, affective/social behaviors is under investigation. Investigating novel behavioral functions of 3α,5α-THP extends our knowledge of the neurobiology of progestogens, relevant for affective/social behaviors, and their connections to systems that regulate affect and motivated processes, such as those important for stress regulation and neuropsychiatric disorders (anxiety, depression, schizophrenia, drug dependence). Thus, further understanding of 3α,5α-THP's role and mechanisms to enhance affective and motivated processes is essential.

Utilization of the supports intensity scale with psychiatric populations: psychometric properties and utility for service delivery planning

In agreement with the new paradigm of supports, this study examines the adequacy and psychometric properties of the Supports Intensity Scale (SIS) in a sample of 182 participants with severe mental illness (mean Global Assessment of Functioning [GAF] score = 60.2). The measure focuses on identifying the profile and intensities of support needs and on the planning and service delivery rather than on weaknesses and limitations. Internal consistency indexes ranged from .83 to .97; interrater reliability indexes ranged from .67 to .98. Intercorrelations among SIS subscales supported its construct validity. SIS scores correlated to GAF scores and length of disease. Discriminant analysis correctly classified 60.9% of participants. Therefore, the SIS demonstrated adequate reliability and validity, and it can be used by nursing professionals to plan for required supports in this population.

Comparison of Experiences of Stress and Coping Between Young People at Risk of Psychosis and a Non-Clinical Cohort

Background:Although the experience of stress and associated coping responses are thought to play a role in the onset of schizophrenia and other psychotic disorders, there is little empirical evidence to support such a relationship. The relatively recent development of validated and reliable criteria for identifying young people at “ultra” high-risk (UHR) of psychosis has enabled the process of illness onset to be studied more closely than was previously possible.Method:This longitudinal study compared the experiences of stress and coping between a UHR cohort (N= 143) and a healthy comparison group (HC group,N= 32).Results:The UHR group experienced significantly fewer life events over a 12-month period than the HC group, but there was no difference in the experience of minor events or “hassles”. However, the UHR group reported feeling significantly more distressed by events, felt they coped more poorly and utilized different coping strategies.Conclusions:The appraisals made about stressors differentiated the groups and was associated with differences in coping and distress levels. This suggests that treatment strategies focusing on stress management and enhancing coping skills might be important components of preventive interventions.

Progesterone reduces hyperactivity of female and male dopamine transporter knockout mice

There are gender differences in prevalence, course, and/or prognosis of schizophrenia. Yet, neurobiological factors that may account for the more favorable outcomes of women with schizophrenia are not well understood. Evidence that the steroid hormone, progesterone (P(4)), may influence mood and/or arousal among some people with schizophrenia led us to examine the effects of P(4) on dopamine transporter knockout (DATKO) mice, an animal model of schizophrenia. Our hypothesis was that P(4) would have greater effects than vehicle to improve the behavioral phenotype of DATKO, more so than wildtype, mice. Young adult, male and female DATKO mice and their wildtype counterparts were subcutaneously administered P(4) (10mg/kg) or vehicle 1h prior to testing in pre-pulse inhibition (PPI), activity monitor, or open field. DATKO mice had impaired PPI compared to their wildtype counterparts, but there was no effect of P(4). In the activity monitor, DATKO mice showed significantly greater distance traveled during the 60min test compared to wildtype controls. In the open field, DATKO mice made a significantly greater number of total, but fewer central, entries than did wildtype mice. Administration of P(4) decreased the hyperactivity of DATKO mice in the activity monitor and open field, but did not alter motor behavior of wildtype mice. P(4) increased the number of central entries made by DATKO and wildtype mice. Thus, P(4) administration to DATKO female or male mice partially attenuated their hyperactive phenotype.

Emotion word use in the conversational speech of schizophrenia patients

INTRODUCTION

Many recent studies have found that, although schizophrenia patients tend to display diminished facial expressions of emotion, they report levels of emotional experiences that are similar to those of controls. Although these findings are very informative, it is unknown whether such dissociation exits for other modalities such as verbal expression of emotion. The purpose of this study was to investigate the association between the use of emotion words during a free speech task and subjective experience of emotion in schizophrenia patients and controls.

METHODS

Speech samples of 48 schizophrenia patients and 48 nonpsychiatric control individuals were compared on the type and amount of emotional words used, as well as on the level of self-reported stress experienced while providing descriptions of themselves.

RESULTS

Groups did not differ in the amount or type of emotion words uttered during the free speech task. Patients, however, found the task more stressful than controls. Emotion word use and subjective emotional experience were not related in either group.

CONCLUSIONS

Results do not fully support prior findings, but are consistent with the notion of a lack of correspondence between the expression and experience of emotion.

COMT Val158Met moderation of stress-induced psychosis

BACKGROUND

Exposure to stressful life events increases the risk of developing a psychotic disorder. Moreover, increased reactivity to stress seems to represent part of the vulnerability for psychosis. This study aimed to investigate whether a functional polymorphism in the catechol-O-methyltransferase (COMT Val(158)Met) gene moderates the psychosis-inducing effects of stress.

METHOD

A semi-experimental stress exposure paradigm was used in a sample of 306 genotyped young men (aged 19-24 years), in whom measures of psychotic symptoms were obtained at recruitment in the Greek army (exposed condition) and again after 18 months of military training (unexposed condition).

RESULTS

Stress exposure at army induction was associated with an increased level of psychotic symptoms. In addition, carriers of the COMT Val(158)Met Val allele were more susceptible to the effect of stress on the psychosis outcome than those with the Met/Met genotype (test for interaction: chi2 = 5.02, df = 1, p = 0.025).

CONCLUSION

The COMT Val(158)Met genotype may moderate the effect of stress on psychotic symptoms.

Stress-reactivity in psychosis: evidence for an affective pathway to psychosis

This paper will review a series of studies using the Experience Sampling Method that suggest that altered sensitivity to stress is an endophenotype for psychosis. The Experience Sampling Method is a structured diary technique allowing the assessment of emotional reactivity to stressors occurring in normal daily life. Elevated emotional reactivity to stress was found in subjects vulnerable to psychosis, suggesting that affective responses to stressors in the flow of daily life are an indicator of genetic and/or environmental liability to psychosis. Indeed, the small stressors in daily life associated with affective responses also predict more intense moment-to-moment variation of subtle positive psychotic experiences. Increased emotional reactivity was found to be independent from cognitive impairments, and argued to constitute evidence of an affective pathway to psychosis that may underlie a more episodic, reactive, good-outcome type of psychosis. Evidence for this hypothesis was found in data suggesting that the experience of stressful life events and early trauma were associated with increased stress-sensitivity, and that women were more likely to display elevated stress-reactivity. These findings are discussed in the light of recent biological and psychological mechanisms.

Involvement of neuropeptide systems in schizophrenia: human studies

Neuropeptides are heterogeneously distributed throughout the digestive, circulatory, and nervous systems and serve as neurotransmitters, neuromodulators, and hormones. Neuropeptides are phylogenetically conserved and have been demonstrated to regulate numerous behaviors. They have been hypothesized to be pathologically involved in several psychiatric disorders, including schizophrenia. On the basis of preclinical data, numerous studies have sought to examine the role of neuropeptide systems in schizophrenia. This chapter reviews the clinical data, linking alterations in neuropeptide systems to the etiology, pathophysiology, and treatment of schizophrenia. Data for the following neuropeptide systems are included: arginine-vasopressin, cholecystokinin (CCK), corticotropin-releasing factor (CRF), interleukins, neuregulin 1 (NRG1), neurotensin (NT), neuropeptide Y (NPY), opioids, secretin, somatostatin, tachykinins, thyrotropin-releasing hormone (TRH), and vasoactive intestinal peptide (VIP). Data from cerebrospinal fluid (CSF), postmortem and genetic studies, as well as clinical trials are described. Despite the inherent difficulties associated with human studies (including small sample size, variable duration of illness, medication status, the presence of comorbid psychiatric disorders, and diagnostic heterogeneity), several findings are noteworthy. Postmortem studies support disease-related alterations in several neuropeptide systems in the frontal and temporal cortices. The strongest genetic evidence supporting a role for neuropeptides in schizophrenia are those studies linking polymorphisms in NRG1 and the CCKA receptor with schizophrenia. Finally, the only compounds that act directly on neuropeptide systems that have demonstrated therapeutic efficacy in schizophrenia are neurokinin receptor antagonists. Clearly, additional investigation into the role of neuropeptide systems in the etiology, pathophysiology, and treatment of schizophrenia is warranted.

[Group interventions for people with refractory psychosis]

Various types of group interventions exist for people with severe mental disorders such as schziophrenia. The content and theoretical backgrounds vary according to the therapeutic goals as well as the clientele targeted. This article describes three group interventions : 1) one aiming at improving self-esteem, 2) one aiming at improving competence through stress management, and 3) one aiming at diminushing distress linked to psychotic symptoms with cognitive behavior therapy. Details on how to conduct these three group interventions, as well as their clinical and theoretical relevance for individuals with refractory psychosis will be described.

Stressful life events in recent-onset schizophrenia: reduced frequencies and altered subjective appraisals

While research strongly supports the notion that stressful life events may trigger the exacerbation of psychotic symptoms in schizophrenia, the mechanisms through which affected individuals respond to life events during the early course of this disorder have received limited attention. This 12-month longitudinal study compared the frequencies, qualitative characteristics, and subjective appraisals of life events in recent-onset schizophrenia patients (n=78) and a nonpatient comparison sample (n=63). Negative and positive life events were assessed using a semi-structured interview every 4 weeks among patients and approximately every 4 months among controls, and participants appraised each event they experienced in terms of emotional impact, controllability, and effectiveness in handling the event. Schizophrenia patients reported significantly lower rates of life events than their nonpsychiatric counterparts across nearly every type of negative and positive event examined. In the context of generally lower event frequencies, patients appraised the negative and positive events they did experience as less controllable and more poorly handled than controls, and also appraised positive events as less desirable. Results are discussed in terms of their implications for understanding susceptibility to stress during the early course of schizophrenia.

Explaining transitions over the hypothesized psychosis continuum

OBJECTIVES

It is crucial to understand the psychological mechanisms that mediate transition from having one or two psychotic symptoms to becoming a patient with a psychotic disorder. This study investigated whether: (i) a delusional interpretation and/or a depressed response to hallucinatory experiences predicts the later onset of clinical psychotic disorder; and (ii) the presence of need for care in relation to psychotic disorder was associated with the use of particular coping strategies.

METHOD

A general population sample of 4672 individuals with no lifetime evidence of any psychotic disorder were interviewed with the Composite International Diagnostic Interview Schedule (CIDI) at baseline and 1 and 3 years later. At year 3, individuals with CIDI evidence of psychotic symptoms were interviewed by clinicians to identify onset of psychotic disorder with need for care. Coping, subjective distress with and perceived control over the psychotic experience were assessed using the Maastricht Assessment of Coping Strategies (MACS).

RESULTS

Given the presence of hallucinatory experiences at baseline, the increase in risk on the additive scale of having the psychosis outcome at T2 was higher in the group with delusional ideation at T1 than in those without delusional ideation at T1. Similarly, presence of depressed mood at T1 increased the risk of having the psychosis outcome at T2, but this effect overlapped partly with the risk-increasing effect of delusional ideation. Individuals with a need for care were much more likely to display symptomatic coping, whereas the presence of the other coping types was not different across the groups with and without need for care.

CONCLUSION

Transitions over the psychosis continuum are, at least in part, driven by the emotional, cognitive and behavioural responses to the initial psychotic or psychosis-like experiences. Individuals who react with a delusional interpretation, negative emotional states and/or a symptomatic coping style have an increased risk for developing clinical psychosis.

Emotional reactivity to daily life stress in psychosis and affective disorder: an experience sampling study

OBJECTIVE

To investigate the emotional reactivity to small disturbances in daily life in patients with non-affective psychosis (NAP), bipolar disorder (BD) and major depression [major depressive disorder (MDD)].

METHOD

Forty-two patients with NAP, 38 with BD, 46 with MDD, and 49 healthy controls were studied with the experience sampling method to assess (i) appraised subjective stress of small disturbances in daily life and (ii) emotional reactivity, reflected in changes in positive affect (PA) and negative affect (NA).

RESULTS

Multilevel regression analyses showed an increase in NA in MDD, a decrease in PA in BD and both an increase in NA and a decrease in PA in NAP in association with the subjectively stressful situations, compared with the control subjects.

CONCLUSION

Individuals with NAP, MDD and BD display differences in emotional stress reactivity. Type of mood disorder may exert a pathoplastic effect on emotional reactivity in individuals with MDD and BD. Individuals with NAP may be most vulnerable to the effects of daily life stress.

Boredom and psychotic disorders: cognitive and motivational issues

CHRONIC BOREDOM and the conditions that induce boredom are associated with a host of undesirable outcomes. It is proposed that the course and treatment of schizophrenia and other severe mental illnesses (SMI) that require extended care in community-based treatment facilities are often complicated by such outcomes. Brief case studies are used to illustrate how sustained boredom can contribute to (1) postpsychotic mood disturbances, (2) increased risk-taking and substance-seeking behaviors in the residual phases of the illness, (3) the exacerbation of positive symptoms such as paranoia and hallucinations, (4) changes in distractibility and overall cognitive efficiency, and (5) a hypohedonic state of highly generalized uninterest. The observation is made that despite the potential value of boredom as a prodomal marker, few, if any, of the instruments commonly used to assess clinical change include a measure of boredom. It is suggested that training in covert boredom coping skills should be integrated into the social skills training and rehabilitation strategies currently employed with individuals with severe and persistent mental disorders.