Social defeat predicts paranoid appraisals in people at high risk for psychosis
Introduction
Only a minority of individuals at Ultra High Risk (UHR) for psychosis goes on to develop a psychotic disorder. Recent research suggests that this may reflect increased exposure to or an increased vulnerability to social stressors (or both) in this subgroup (Corcoran et al., 2003, Corcoran et al., 2012, Thompson et al., 2007). However, the mechanisms by which stress influences the onset of psychosis remain unknown. Previous studies have suggested that lower perceived social rank is associated with paranoid ideation (Atherton et al., 2014, Freeman et al., 2014, Gilbert et al., 2005) and it has been proposed that the cumulative effect of prolonged exposure to social adversity and exclusion can lead to a state of ‘social defeat’, which may confer an increased risk of psychosis (Johnson et al., 2011, Selten et al., 2013, Selten and Cantor-Graae, 2005, Wicks et al., 2005). The concept of social defeat originates from animal research after it was observed that when an animal is put in a cage with another animal, they fight for dominance. If these fights occur over a prolonged period of time the defeated animal develops symptoms of stress and displays behaviour similar to that expressed in depressed humans (Bjorkqvist, 2001). In humans the definition of social defeat is more complex than in animals, because humans also generate a perception or appraisal of their position in the world (Gilbert, 2000, Gilbert and Gerlsma, 1999, Taylor et al., 2011). Appraisal theory proposes that the emotional response and physiological activation that occur in a situation are dependent on the appraisal, or meaning, given to what just occurred and on whether we think we will be able to cope with what just happened (Lazarus, 1991). In line with this theoretical framework, cognitive models of psychosis propose that early stressful events may result in a cognitive vulnerability which influences the interpretation and appraisal of daily stressors, and increases the likelihood that anomalous experiences develop into a psychotic disorder (Bentall et al., 2007, Freeman et al., 2002, Garety et al., 2001, Garety et al., 2007, Morrison and Wells, 2003).
It is difficult to assess real time appraisals in social situations in life. However, research using virtual reality to study in vivo and in situ reactions to social situations allows the measurement of real-time physiological activation and the assessment of thoughts, mood and symptoms as they occur (e.g., (Fornells-Ambrojo et al., 2013, Freeman et al., 2003, Freeman et al., 2005, Stinson et al., 2010, Valmaggia et al., 2007, Veling et al., 2014)).
The aim of the present study was to use Virtual Reality (VR) to contribute to examine the putative relationship between social defeat and paranoid appraisal in social situations in people at UHR for psychosis. Neither social defeat, nor its relationship with experimentally-induced paranoid ideation has been studied in UHR subjects before. Our first hypothesis was that UHR individuals would report higher levels of social defeat than controls. Our second prediction was that when exposed to a virtual social environment, the UHR group would report more paranoid appraisals than controls. Finally, we tested the hypothesis that within the UHR sample, the level of social defeat would predict the severity of paranoid ideation induced by the VR environment.
Section snippets
Design and methods
This was a cross-sectional comparison study. UHR participants and healthy controls (HCs) were compared to establish levels of social defeat and to study the relationship between social defeat and the appraisal of a VR social environment. Regression was then used to investigate which baseline measures predicted paranoid appraisals following the VR experience.
Participant characteristics
Sixty-five UHR participants and 45 HCs were recruited for the study. One HC participant was excluded from subsequent analysis due to a score in excess of 18 on the PQ positive symptom subscale. The VR equipment failed during the testing of one HC participant and one UHR participant, so their data were also excluded from the final analysis. The analysis thus involved data from 64 UHR and 43 HC participants.
The two groups were matched for age, gender, and ethnicity, as well as migration status.
Discussion
Our first hypothesis was confirmed: the UHR sample had higher levels of social defeat than HC participants. Also as predicted, following exposure to the virtual social environment, the UHR group was more likely to make paranoid appraisals of their experiences than the HC group. Finally, within the UHR group, the level of social defeat, was a significant predictor of paranoid ideations in the VR environment. The levels of positive attenuated and disorganised symptoms at baseline were also
Strengths and limitations
A key strength of the study is that it explored the link between social defeat and paranoid ideation in an ecologically valid and standardised social environment that could be manipulated experimentally. Nevertheless, the study had some limitations. There were significant differences between UHR and HC participants in social class, employment status, and level of education, and it is possible that these factors contributed to the higher rate of social defeat in the UHR group. However a between
Contributors
Author LRV designed the study and wrote the protocol and secured funding for the study. Authors LRV & FD managed the literature searches and statistical analysis. LRV wrote the first draft of the manuscript. DF, AA, MS, DS contributed to the study protocol and developed the virtual reality environment used in the study. PG, PMG, DF and IMG contributed to the manuscript. All authors have approved the final manuscript.
Declaration of interest
None.
Ethical approval
Research ethics approval was obtained from the National Research Ethics Service (Ethics REC number 08/H0722/45).
Role of the funding source
NARSAD Young Investigator Award from the Brain and Behaviour Research Foundation, and Peggy Pollack Research Fellowship from the Psychiatry Research Trust. Both awarded to Dr Valmaggia.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
Our special thanks go to the staff and service users of OASIS. Dr Valmaggia was supported by a NARSAD Young Investigator Award from the Brain and Behaviour Research Foundation, by a Peggy Pollack Research Fellowship from the Psychiatry Research Trust. Philip McGuire was supported by a grant from the Medical Research Council. The authors acknowledge financial support from the National Institute for Health Research (NIHR) Biomedical Research Centre for Mental Health at South London and Maudsley
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