Acute Physiological and Psychological Stress Response in Youth at Clinical High-Risk for Psychosis

Salivary cortisol measures across the clinical stages of psychosis: An individual participant data (IPD) meta-analysis

BACKGROUND

Studies of salivary cortisol levels in psychosis have yielded inconsistent findings, which may be attributable to heterogeneity in cortisol measurement, illness stage, and approaches to dealing with sampling factors and potential confounders. To address these issues, we performed an individual participant data (IPD) meta-analysis comparing individuals at different stages of psychosis to controls using five different salivary cortisol measures and explored potential effect modifiers.

METHODS

Salivary cortisol data from five London-based cohorts were used to derive the cortisol awakening response, total daytime cortisol output, basal cortisol, and diurnal slope measures (wake-to-evening and peak-to-evening). Linear regression models were first performed to obtain standardised beta coefficients (β), representing the difference in each cortisol metric between each clinical stage group (cases) and healthy individuals (controls) after accounting for relevant sampling factors; we then used random-effects meta-analyses and meta-regression models to investigate the effect of psychosis stage and sample characteristics on effect sizes.

RESULTS

Data were available for 352 individuals distributed across psychosis clinical stages (1a - distress disorder: N = 35; 1b - clinical high-risk for psychosis: N = 90; 2a - first-episode psychosis: N = 197; 2b - single episode remitted: N = 5; 3 - relapsing/remitting illness: N = 18; 4 - severe and persistent illness: N = 7) and 292 controls. A significant overall main effect of clinical stage on peak-to-evening diurnal slope was observed (χ2=12.83, p = 0.025), with both the clinical high-risk (β=0.21, 95 % CI: 0.06, 0.36) and first-episode psychosis (β=0.20, 95 % CI: 0.10, 0.31) groups characterised by flatter slopes than controls. The clinical stage groups and controls did not differ on any other cortisol measure. Several sample characteristics were significantly associated with diurnal slope effect sizes, but after accounting for clinical stage, only the association between mean age in cases and wake-to-evening diurnal slope retained significance.

CONCLUSION

Clinical high-risk and first-episode psychosis participants differed from healthy controls in the peak-to-evening diurnal cortisol slope. This measure has not been examined in these populations before, and its potential predictive and prognostic utility for psychotic disorders merits further investigation.

Comorbid health outcomes in patients with schizophrenia: an umbrella review of systematic reviews and meta-analyses

There is no comprehensive umbrella review exploring the connection between schizophrenia and various health outcomes. Therefore, we aimed to systematically review existing meta-analyses about schizophrenia-associated comorbid health outcomes and validate the evidence levels. We performed an umbrella review of meta-analyses of observational studies to explore comorbid health outcomes in individuals with schizophrenia. Searches were conducted across PubMed/MEDLINE, EMBASE, ClinicalKey, and Google Scholar up to September 5, 2023, targeting meta-analyses of observational studies related to comorbid health outcomes in individuals with schizophrenia. We applied AMSTAR2 for data extraction and quality assessment, adhering to PRISMA guidelines. Evidence credibility was evaluated and categorized by evidence quality. Our protocol was registered with PROSPERO (CRD42024498833). Risk and protective factors were analyzed and presented through equivalent odds ratios (eRR). In this umbrella review, we analyzed 9 meta-analyses, including 88 original articles, covering 21 comorbid health outcomes with over 66 million participants across 19 countries. Patients with schizophrenia showed significant associations with multiple health outcomes, including asthma (eRR, 1.71 [95% CI, 1.05-2.78], class and quality of evidence [CE] = non-significant), chronic obstructive pulmonary disease (1.73 [1.25-2.37], CE = weak), pneumonia (2.63 [1.11-6.23], CE = weak), breast cancer of female patients (1.31 [1.04-1.65], CE = weak), cardiovascular disease (1.53 [1.12-2.11], CE = weak), stroke (1.71 [1.30-2.25], CE = weak), congestive heart failure (1.81 [1.21-2.69], CE = weak), sexual dysfunction (2.30 [1.75-3.04], CE = weak), fracture (1.63 [1.10-2.40], CE = weak), dementia (2.29 [1.19-4.39], CE = weak), and psoriasis (1.83 [1.18-2.83] CE = weak). Our study underscores the imperative for an integrated treatment approach to schizophrenia, highlighting its broad impact across respiratory, cardiovascular, sexual, neurological, and dermatological health domains. Given the predominantly non-significant to weak evidence levels, further studies are needed to reinforce our understanding.

Timing matters in stress appraisal: The relationship between retrospective appraisal and stress responses

BACKGROUND

Although psychosocial stressors are known to impact task performance and trigger neuroendocrine responses, the dynamic nature of the stress appraisal process is often neglected in research.

GOAL

This study aims to explore whether self-reported appraisals at various time points can accurately represent an individual's behavioral and physiological stress responses.

METHODS

A total of 137 participants were recruited to induce individual stress states using the Trier Social Stress Test (TSST). Self-reported appraisals were measured both before (anticipatory appraisal) and after the stressor (retrospective appraisal) to capture the dynamic process. Concurrently, participants' cortisol responses and task performances were documented.

RESULTS

Findings indicate that anticipatory appraisal does not significantly reflect task performance. In contrast, retrospective appraisal is strongly associated with the performance of corresponding tasks. Regarding cortisol levels, significantly negative results of multiple regression analysis revealed that the retrospective appraisal of the speech task is the sole variable to represent the cortisol response under stress.

DISCUSSION

The results highlight that retrospective appraisals could represent individuals' behavioral and physiological responses to stressors more accurately than anticipatory appraisals. These findings provide empirical evidence for choosing the appropriate timing to acquire accurate self-reported appraisals and also help to build a mapping relationship between self-reported, behavioral, and physiological data.

Associations between acute and chronic lifetime stressors and psychosis-risk symptoms in individuals with 22q11.2 copy number variants

BACKGROUND

The 22q11.2 deletion (22q11Del) is among the strongest known genetic risk factors for psychosis. Stress, a known risk factor for psychosis in the general population, has seldom been studied in 22q11Del. We investigated how lifetime stressors related to symptomatic outcomes in patients with 22q11Del. We also explored this association in individuals with 22q11.2 duplications (22q11Dup), which may be potentially protective against psychosis.

METHOD

One hundred individuals (46 with 22q11Del, 30 with 22q11Dup, and 24 healthy controls; Mage = 17.30 years±10.15) were included. Logistic models were used to examine cross-sectional associations between lifetime acute and chronic stressors (severity and count) and the presence (score ⩾3) of positive, negative, and general symptoms, assessed via the Structured Interview for Psychosis-risk Syndromes (SIPS).

RESULTS

The 22q11Dup group reported the greatest number and severity of acute lifetime stressors, but did not differ from 22q11Del in chronic stressor count or severity. Lifetime chronic and acute stressors were uniquely associated with positive symptoms in 22q11Del (chronic count: odds ratio [OR] = 2.35, p = 0.02; chronic severity: OR = 1.88, p = 0.03; acute count: OR = 1.78, p = 0.03), but not with negative or general symptoms (ps > 0.05).

CONCLUSION

Findings suggest that stress may play a role in psychotic symptoms in 22q1Del, while the 22q11Dup CNV appears protective against psychotic symptoms despite higher rates of stressors. Interventions that mitigate effects of stressors in 22qDel may reduce the odds of psychosis in this group. Prospective longitudinal research is needed to replicate these findings.

Psychosocial stress, interpersonal sensitivity, and social withdrawal in clinical high risk for psychosis: a systematic review

Stress has repeatedly been implicated in the onset and exacerbation of positive symptoms of psychosis. Increasing interest is growing for the role of psychosocial stress in the development of psychosis symptoms in individuals at Clinical High Risk (CHR) for psychosis. A systematic review was therefore conducted to summarize the existing evidence base regarding psychosocial stress, interpersonal sensitivity, and social withdrawal in individuals at CHR for psychosis. An electronic search of Ovid (PsychINFO, EMBASE, MEDLINE, and GLOBAL HEALTH) was conducted until February 2022. Studies that examined psychosocial stress in CHR were included. Twenty-nine studies were eligible for inclusion. Psychosocial stress, interpersonal sensitivity, and social withdrawal were higher in CHR individuals compared to healthy controls and there was some evidence of their association with positive symptoms of psychosis. Two types of psychosocial stressors were found to occur more frequently with CHR status, namely daily stressors, and early and recent trauma, while significant life events did not appear to be significant. Greater exposure to psychosocial stress, emotional abuse, and perceived discrimination significantly increased risk of transition to psychosis in CHR. No studies examined the role of interpersonal sensitivity on transition to psychosis in CHR. This systematic review provides evidence for the association of trauma, daily stressors, social withdrawal, and interpersonal sensitivity with CHR status. Further studies investigating the impact of psychosocial stress on psychosis symptom expression in individuals at CHR and its effects on transition to psychosis are therefore warranted.

Cognitive Stress Regulation in Schizophrenia Patients and Healthy Individuals: Brain and Behavior

Stress is an important factor in the development, triggering, and maintenance of psychotic symptoms. Still, little is known about the neural correlates of cognitively regulating stressful events in schizophrenia. The current study aimed at investigating the cognitive down-regulation of negative, stressful reactions during a neuroimaging psychosocial stress paradigm (non-regulated stress versus cognitively regulated stress). In a randomized, repeated-measures within-subject design, we assessed subjective reactions and neural activation in schizophrenia patients (SZP) and matched healthy controls in a neuroimaging psychosocial stress paradigm. In general, SZP exhibited an increased anticipation of stress compared to controls (p = 0.020). During non-regulated stress, SZP showed increased negative affect (p = 0.033) and stronger activation of the left parietal operculum/posterior insula (p < 0.001) and right inferior frontal gyrus/anterior insula (p = 0.005) than controls. Contrarily, stress regulation compared to non-regulated stress led to increased subjective reactions in controls (p = 0.003) but less deactivation in SZP in the ventral anterior cingulate cortex (p = 0.027). Our data demonstrate stronger reactions to and anticipation of stress in patients and difficulties with cognitive stress regulation in both groups. Considering the strong association between mental health and stress, the investigation of cognitive regulation in individuals vulnerable to stress, including SZP, has crucial implications for improving stress intervention trainings.

A longitudinal study on physiological stress in individuals at ultra high-risk of psychosis

INTRODUCTION

Individuals at ultra high-risk (UHR) of psychosis exhibit significantly higher stress levels than healthy controls (HC). This study investigates how physiological stress measures differ between HC and UHR individuals and how physiological stress is associated with attenuated psychotic symptoms and changes over time in UHR individuals. Additionally, it examines how the use of medication affects physiological levels of stress.

METHOD

The study included 72 UHR individuals and 36 HC. UHR were included according to the comprehensive assessment of at-risk mental state (CAARMS); a total-CAARMS score measured the attenuated psychotic symptoms and was calculated from the four psychosis subscales. HC and UHR were examined at baseline, and 47 UHR individuals were followed up after six months. Physiological stress measures were salivary cortisol, alpha-amylase (SAA) and heart-rate variability (HRV). Saliva was collected at four-time points during the day.

RESULTS

There was no significant difference regarding cortisol (awakening response) or SAA measures between HC and UHR individuals. The use of antipsychotics and antidepressants was associated with low HRV in UHR individuals. In an exploratory analysis of 19 UHR individuals, we found an association between the change in total-CAARMS (six months total-CAARMS minus baseline total CAARMS) and the change in HRV during sleep (six months HRV minus baseline HRV).

CONCLUSION

Our findings indicate that the use of antipsychotics and antidepressants could be associated with lower HRV in UHR individuals. There might be potential to investigate how HRV develops during the course of illness in UHR individuals.

Psychotic-like experiences in the lonely predict conspiratorial beliefs and are associated with the diet during COVID-19

The COVID-19 pandemic has increased the occurrence of conspiracy theories. It has been suggested that a greater endorsement of these theories may be associated with psychotic-like experiences (PLEs), as well as with social isolation. In this preregistered study, we investigated whether both PLEs and measures of social isolation (e.g., loneliness) can predict conspiratorial beliefs and, if so, which of these variables can mediate the association with conspiratorial beliefs. Furthermore, based on previous studies on schizophrenia, we explored whether the diet is associated with PLEs and conspiratorial beliefs. Participants (N = 142) completed online questionnaires measuring PLEs, social isolation, mental well-being, and conspiratorial beliefs. They also submitted their daily food intake for a week using a smartphone app. We found that loneliness predicted the endorsement of conspiracy theories during the COVID-19 lockdown. Strikingly, the proneness to experience subclinical psychotic symptoms played an underlying mediating role. In addition, these subclinical symptoms were associated with lower fruit, carbohydrate, and iron intakes, as well as with higher fat intake. Our results add insights into how conspiratorial beliefs can affect individuals’ mental health and relationships. Moreover, these results open the avenue for potential novel intervention strategies to optimize food intake in individuals with PLEs.

Psychotic experiences among Black college students in the United States: The role of socioeconomic factors and discrimination

BACKGROUND

Psychosis is more prevalent among Black individuals compared with White individuals. However, it is unknown whether this disparity exists among college populations in the United States, and if so, what factors contribute to the disparity.

METHODS

We analyzed data from Black and White young adult students using the Health Minds Study (2020-2021), which is a survey administered at 140 colleges in the U.S. Using mediation analysis, we examined the extent to which the relation between race and psychotic experiences was mediated by socioeconomic factors (past and current financial distress, food insecurity, parental education) and discrimination.

RESULTS

Approximately 38 % of Black students and 30 % of White students reported lifetime psychotic experiences. Including all socioeconomic factors together in the same model accounted for just over half (50.2 %) the association between race and psychotic experiences. We then conducted additional analyses examining discrimination, all the socioeconomic factors plus discrimination accounted for 81.5 % of the association between race and psychotic experiences. When disentangling the mediators, food insecurity and discrimination accounted for the largest percentages of the association. The effects of past financial distress and parental education were modified by race.

CONCLUSION

Black college students were more likely to report lifetime psychotic experiences than their White counterparts. Moreover, socioeconomic factors and discrimination made significant contributions to this racial difference.

COVID-19 dimensions and psychotic experiences among US college students: Findings from the Healthy Mind Study 2020

BACKGROUND

The COVID-19 pandemic has caused tremendous changes in daily living, which may be related to mental health problems, including psychotic experiences, though research has only begun to assess these associations.

METHODS

We analyzed data from the Healthy Minds Survey (Fall Semester Cohort 2020), which is a non-probability sample of students attending one of 36 universities in the United States, who completed an online survey during the COVID-19 pandemic (September-December 2020). We used multivariable logistic regression to examine the associations between several COVID-19 dimensions (anxiety, discrimination, financial distress, infection, illness of loved one, death of loved one, caregiving) and 12-month psychotic experiences, adjusting for age, gender, race/ethnicity, and international student status.

RESULTS

Each individual COVID-19 dimension was significantly associated with greater odds of having 12-month psychotic experiences, with the exception of being a caregiver. When accounting for all COVID-19 dimensions simultaneously in the same model, only COVID-19 related anxiety, financial distress, and infection were associated with psychotic experiences.

CONCLUSION

COVID-19 dimensions were linked to psychotic experiences among university students, which may also apply to the larger population. This can potentially inform assessment and treatment during the pandemic.