Perceived social stress and symptom severity among help-seeking adolescents with versus without clinical high-risk for psychosis
Introduction
The diathesis-stress model of psychosis suggests that neuromaturational events interact with environmental stressors during adolescence to unmask a vulnerability to positive symptoms among those with a constitutional risk for the disorder (Walker and Diforio, 1997). In support of this model, evidence suggests that multiple forms of stress may be related to symptom severity among youth at clinical high-risk (CHR) for psychosis, including parental expressed emotion (O'Brien et al., 2006), perceived family criticism (Schlosser et al., 2010), daily hassles (Tessner et al., 2011), life events (Trotman et al., 2014), and trauma exposure (Kraan et al., 2015)1. In efforts to refine the understanding of stress effects on behavior, social psychological research has sought to identify the conditions under which physiological and psychological stress responses are most marked. This literature indicates that stressors possessing social features (e.g., negative social evaluation, threats to self esteem) are especially powerful triggers of these stress responses (Dickerson and Kemeny, 2004). Given that social impairment is a prominent and enduring feature of the psychosis spectrum, researchers have suggested that persistent social stress (e.g., social rejection, tension in relationships) in particular may play an important role in the onset of psychosis (Jones and Fernyhough, 2007, Selten et al., 2013).
The impact of a stressor depends partly on constitutional characteristics of the individual exposed (Lazarus and Folkman, 1984). Interestingly, a small but growing number of studies indicates that although the frequency of exposure to various non-traumatic stressors (e.g., life events) may on average be no greater among youth at CHR relative to healthy controls, the degree of distress elicited by these exposures may be more severe in those at CHR (Devylder et al., 2013, Tessner et al., 2011, Trotman et al., 2014); this subjective, self-rated stress response in turn has been shown to predict progression from CHR to psychosis (Trotman et al., 2014). Only a few studies, however, have examined perceived social stress among those at CHR, and those that have tended to use questionnaires of only a few items (e.g., Palmier-Claus et al., 2012, Schlosser et al., 2010), leaving a gap in our understanding of this important relation of stress and psychosis.
A core evidentiary gap in support of the diathesis-stress model of psychosis is that nearly all studies using a control group have compared CHR individuals to healthy, non-clinical peers. Although these studies have been instrumental in demonstrating differential effects of stress on high-risk versus healthy adolescents, they are unable to address the question of whether those with CHR psychopathology are more vulnerable than those with non-CHR psychopathology to elevations in positive symptoms when stressed, a central component of the diathesis-stress model. As social stress influences many adolescent psychiatric disorders (see Harkness et al., 2015), knowledge of whether those with identified clinical psychosis-risk are differentially affected with respect to symptom expression would help characterize the distinctive nature of the CHR construct.
This study aimed to evaluate whether the association between perceived social stress and symptom severity is moderated by psychosis-risk status in a sample of adolescents at CHR and a mixed clinical group of help-seeking controls. Consistent with CHR rating conventions and previous analyses with this sample (Bentley et al., 2016, Millman et al., 2017), we expected the CHR group to endorse more severe positive symptoms and more social stress than the help-seeking control group. Extending these findings, we hypothesized that: (1) elevated levels of perceived social stress would be associated with more severe attenuated positive symptoms in the full sample, and (2) consistent with a diathesis-stress model of psychosis (Walker et al., 2008), the magnitude of this stress-symptom relation would be greater for those at CHR of psychosis than for help-seeking controls. Given the range of symptoms associated with the CHR state, as an exploratory aim we examined whether perceived social stress would be differentially related to negative, disorganized, and general psychopathology symptoms across the CHR and help-seeking control groups.
Section snippets
Overview
This study took place within the context of a longitudinal investigation conducted at the Strive for Wellness clinic at the University of Maryland, Baltimore County's Youth FIRST lab, and the University of Maryland Medical Center. Strive for Wellness is a specialty team of clinicians, researchers, and trainees focused on identification and treatment of transition-aged individuals at CHR for psychosis. The clinic is embedded within the Maryland Early Intervention Program, a multi-institutional
Preliminary analyses
There were N = 110 participants in the study. This sample either overlaps completely, or mostly, with prior studies published by our team (Thompson et al., 2015a, Millman et al., 2017). Examination of skew and kurtosis values (Table 2) and visual inspection of histograms gave no reason to believe there were violations of normality assumptions. Ten participants were missing data related to annual household income, three were missing data related to negative, disorganized, and general symptoms, and
Discussion
We found that adolescents reporting more social stress experienced more severe positive symptoms of attenuated psychosis. Consistent with previous research (see Holtzman et al., 2013), the effect was present for those at CHR. We attempted to extend these findings by evaluating whether the magnitude of this stress-symptom relation was greater in a CHR group than in a mixed clinical sample of help-seeking controls. Contrary to our hypotheses, the results suggest that the relation of perceived
Summary and conclusions
The strong relation observed between perceived social stress and positive symptom severity among adolescents at CHR adds to a growing literature suggesting that social stress may exacerbate vulnerability to the illness. On the other hand, the lack of significant group differences in the strength of this relation implies that the effect of perceived social stress on positive symptoms may not be specific to youth with significant clinical vulnerability to psychosis. Nonetheless, the link between
Funding
This work was supported in part by funding from the Maryland Department of Health and Mental Hygiene, Behavioral Health Administration through the Center for Excellence on Early Intervention for Serious Mental Illness (OPASS# 14-13717G/M00B4400241).
Contributors
Authors Millman, Thompson, Demro, Reeves, and Schiffman designed and ran the study as well as wrote the protocol. Author Millman managed the literature searches. Authors Millman and Pitts undertook the statistical analysis. Author Millman wrote the manuscript with conceptual and written assistance from authors Kline, Weintraub, DeVylder, Mittal, and Schiffman. All authors contributed to and have approved the final manuscript.
Conflict of interest
All authors declare that they have no conflicts of interest.
Acknowledgements
There are no acknowledgements.
References (55)
- et al.
High-risk diagnosis, social stress, and parent-child relationships: A moderation model
Schizophr. Res.
(2016) - et al.
Deconstructing vulnerability for psychosis: meta-analysis of environmental risk factors for psychosis in subjects at ultra high-risk. Euro
Psychiatry
(2017) - et al.
Stress and neurodevelopmental processes in the emergence of psychosis
Neuroscience
(2013) - et al.
Schedule for affective disorders and schizophrenia for school-age children-present and lifetime version (K-SADS-PL): initial reliability and validity data
J. Am. Acad. Child Adolesc. Psychiatry
(1997) - et al.
Trauma and psychosis symptoms in a sample of help-seeking youth
Schizophr. Res.
(2016) - et al.
Trauma and recent life events in individuals at ultra high risk for psychosis: review and meta-analysis
Schizophr. Res.
(2015) - et al.
Mismatch and lexical retrieval gestures are associated with visual information processing, verbal production, and symptomatology in youth at high risk for psychosis
Schizophr. Res.
(2014) - et al.
Differential relations of locus of control to perceived social stress among help-seeking adolescents at low vs. high clinical risk of psychosis
Schizophr. Res.
(2017) - et al.
Hypothalamic-pituitary-adrenal axis dysfunction in non-clinical psychosis
Psychiatry Res.
(2013) - et al.
Increased stress-induced dopamine release in psychosis
Biol. Psychiatry
(2012)
Positive family environment predicts improvement in symptoms and social functioning among adolescents at imminent risk for onset of psychosis
Schizophr. Res.
Predicting the longitudinal effects of the family environment on prodromal symptoms and functioning in patients at-risk for psychosis
Schizophr. Res.
Much ado about much: stress, dynamic biomarkers and HPA axis dysregulation along the trajectory to psychosis
Schizophr. Res.
Emotional and behavioral symptomatology reported by help-seeking youth at clinical high-risk for psychosis
Schizophr. Res.
Stress exposure and sensitivity in the clinical high-risk syndrome: initial findings from the North American Prodrome Longitudinal Study (NAPLS)
Schizophr. Res.
Premorbid teacher-rated social functioning predicts adult schizophrenia-spectrum disorder: a high-risk prospective investigation
Schizophr. Res.
Context matters: the impact of neighborhood crime and paranoid symptoms on psychosis risk assessment
Schizophr. Res.
North American Prodrome Longitudinal Study (NAPLS 2): The prodromal symptoms
J. Nerv. Ment. Dis.
Multiple Regression: Testing and Interpreting Interactions
Diagnostic concepts in the context of clinical high risk/attenuated psychosis syndrome
Schizophr. Bull.
Statistical Power Analysis for the Behavioral Sciences
A global measure of perceived stress
J. Health Soc. Behav.
From epidemiology to daily life: linking daily life stress reactivity to persistence of psychotic experiences in a longitudinal general population study
PLoS One
The stress cascade and schizophrenia: etiology and onset
Schizophr. Bull.
Psychosis prevention: a modified clinical high risk perspective from the recognition and prevention (RAP) program
Am. J. Psychiatry
The robustness of test statistics to nonnormality and specification error in confirmatory factor analysis
Psychol. Methods
Temporal association of stress sensitivity and symptoms in individuals at clinical high risk for psychosis
Psychol. Med.
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