Les manifestations subtiles du stress dans le continuum de la psychose

L’étiologie de la schizophrénie est complexe et le modèle de vulnérabilité-stress (Nuechterlein & Dawson, 1984) propose que des facteurs de vulnérabilité d’ordre génétique combinés à une histoire environnementale de stress particulier pousseraient l’individu vers un état clinique de psychose. L’objectif principal de cette thèse est de mieux comprendre la réaction physiologique des personnes schizophrènes face à un stress psychologique, tout en conceptualisant les symptômes psychotiques comme faisant partie d’un continuum, plutôt que de les restreindre sur un plan catégoriel. Afin de faire la différence entre les patients schizophrènes et les individus de la population générale, au-delà de la sévérité de leurs symptômes psychotiques, leur réaction au stress est comparée et le phénomène de seuil critique dans la réaction de cortisol est exploré en tant que point décisif pouvant distinguer entre les deux groupes. La première étude de cette thèse (Brenner et al., 2007) examine la fiabilité, la validité et la structure factorielle du Community Assessment of Psychic Experiences (CAPE) (Stefanis et al., 2002), avec un échantillon francophone et anglophone de la population nord américaine, un questionnaire auto-administré de 42 items qui évalue les expériences quasi-psychotiques présentes dans la population générale : des symptômes positifs (ou psychotiques), négatifs (ou végétatifs) et dépressifs. Ce questionnaire a été complété par un échantillon de 2 275 personnes de la population montréalaise. Les résultats appuient la consistance interne des 3 sous-échelles originales. De plus, l’analyse factorielle exploratoire suggère des solutions de 3-5 facteurs, où les solutions à 4 et 5 facteurs proposent de séparer les symptômes positifs en sous-catégories plus spécifiques. Finalement, cette étude suggère une version plus courte du CAPE, avec seulement 23 items, tout en préservant les mêmes trois échelles originales. La toile de fond de cet article confirme l’existence du phénomène du continuum de la psychose, où une variation de symptômes psychotiques peut se retrouver aussi bien dans la population générale que dans la population clinique. Dans une deuxième étude (Brenner et al., 2009), cette thèse examine à quel point la réponse de l’hormone de stress, le cortisol, à un test de stress psychosocial nommé le Trier Social Stress Test (TSST) (Kirschbaum, Pirke, & Hellhammer, 1993), peut établir une différence entre les sujets témoins et les patients schizophrènes, tout en contrôlant des variables importantes. Un groupe de 30 personnes schizophrènes et un groupe de 30 sujets de la population générale, recrutés lors de la première étude de cette thèse, ont participé à cette recherche qui est construite selon un plan expérimental. Le groupe témoin inclut des personnes légèrement symptomatiques et un chevauchement des scores psychotiques existe entre les deux groupes. Suite au stresseur, les deux groupes démontrent une augmentation significative de leur rythme cardiaque et de leur pression artérielle. Cependant, leur réponse de cortisol a tendance à différer : les patients schizophrènes présentent une réponse de cortisol plus petite que celle des témoins, mais en atteignant un seuil statistique significatif seulement à la mesure qui suit immédiatement le stresseur. Ces résultats significatifs sont obtenus en contrôlant pour la sévérité des symptômes positifs, un facteur discriminant significatif entre les deux groupes. Ainsi, le niveau de cortisol mesuré immédiatement après le stresseur se révèle être un marqueur de seuil critique pouvant établir une distinction entre les deux groupes. Aussi, leur réponse de cortisol maximale a tendance à apparaître plus tard que chez les sujets témoins. De façon générale, la réaction au stress des deux groupes étudiés est un autre moyen d’observer la continuité d’un comportement présent chez les individus, jusqu’à ce qu’un seuil critique soit atteint. Ainsi, il est possible de trancher, à un moment donné, entre psychose clinique ou absence de diagnostic.The aetiology of schizophrenia seems to be complex and the Vulnerability-Stress model (Nuechterlein & Dawson, 1984) proposes that genetic vulnerability factors, in conjunction with a particular history of environmental stress, would act together to drive the individual into a clinical state of psychosis. The principal objective of this thesis is to better understand the physiological reaction to a psychological stressor in people with schizophrenia, while conceptualizing psychotic symptoms along a continuum, rather than as a restrictive dichotomy. In order to distinguish between schizophrenia patients and controls from the general community, beyond the severity of their psychotic symptoms, they are compared on their stress reaction, and the phenomenon of critical threshold is explored within the cortisol reaction for its ability to distinguish between the two groups. The first study of this thesis (Brenner et al., 2007) examines the reliability, validity and factor structure of the Community Assessment of Psychic Experiences (CAPE) (Stefanis et al., 2002), with a French and English speaking sample form the north American population, a 42-item self-report questionnaire assessing psychotic-like symptoms in the general community: positive (or psychotic), negative (or vegetative) and depressive symptoms. This questionnaire was completed by 2 275 individuals from the Montreal area and the results support the internal consistencies of the original three subscales. Further, the exploratory factor analysis suggests 3-5 factor solutions, where the 4- and 5-factor solutions propose separating the positive symptoms into more specific subcategories. Finally, this study suggests a shorter version of the CAPE with 23 items, representing the same three original scales. These results support the existence of the continuum of psychosis, in which variation of psychotic symptoms can be found in the clinical population as well as in the general community. The second study of this thesis (Brenner et al., 2009) examines the extent to which cortisol reaction to a psychosocial stress test, the Trier Social Stress Test (TSST) (Kirschbaum et al., 1993), can discriminate between controls and schizophrenia patients while controlling for important variables. A group of 30 schizophrenia patients and a group of 30 individuals from the general community, recruited from the first study of this thesis, participated in this study designed as a case-control experiment. The control group includes people with subclinical symptoms, and an overlap in the severity of psychotic symptoms exists between the two groups. Following the stressor, both groups have significant increases in heart rate and mean arterial pressure. However, their cortisol responses diverge, with schizophrenia patients exhibiting a smaller response than the controls, but with statistically significant group differences at only one time point, immediately after the stressor. These significant results are obtained after controlling for the severity of positive symptoms, which is a discriminating factor between the two groups. The level of cortisol measured immediately after the stressor is actually a marker of the critical threshold capable of discriminating between the groups. Cortisol levels in patients have a tendency to peak later than that of the controls. As a general conclusion, the two groups’ reactions to stress are another way to observe the continuity of a certain behaviour, up until it reaches a critical threshold, which allows the differentiation between clinical psychosis and absence of illness

Cultural differences in positive psychotic experiences assessed with the Community Assessment of Psychic Experiences-42 (CAPE-42):a comparison of student populations in the Netherlands, Nigeria and Norway

BACKGROUND: Previous studies have suggested that culture impacts the experience of psychosis. The current study set out to extend these findings by examining cultural variation in subclinical positive psychotic experiences in students from The Netherlands, Nigeria, and Norway. Positive psychotic experiences were hypothesized to (i) be more frequently endorsed by, and (ii) cause less distress in Nigerian vs. Dutch and Norwegian students. METHODS: Psychology students, aged 18 to 30 years, from universities in the Netherlands (n = 245), Nigeria (n = 478), and Norway (n = 162) were assessed cross-sectionally with regard to the frequency of subclinical positive psychotic experiences and related distress, using the Community Assessment of Psychic Experiences (CAPE-42). Multi-group confirmatory factor analysis and multivariate analysis of covariance were performed to assess measurement invariance of the positive symptom dimension (CAPE-Pos) and compare mean frequency and associated distress of positive psychotic experiences across study samples. RESULTS: Only CAPE-Pos items pertaining to the dimensions 'strange experiences' and 'paranoia' met assumptions for (partial) measurement invariance. Frequencies of these experiences were higher in the Nigerian sample, compared to both the Dutch and Norwegian samples, which were similar. In addition, levels of experience-related distress were similar or higher in the Nigerian sample compared to respectively the Dutch and Norwegian samples. CONCLUSION: Although positive psychotic experiences may be more commonly endorsed in non-Western societies, our findings do not support the notion that they represent a more benign, and hence less distressing aspect of human experience. Rather, the experience of psychotic phenomena may be just as, if not more, distressing in African than in European culture. However, observed differences in CAPE-Pos frequency and distress between samples from different cultural settings may partly reflect differences in the measure rather than in the latent trait. Future studies may therefore consider further cross-cultural adaptation of CAPE-42, in addition to explicitly examining cultural acceptance of psychotic phenomena, and environmental and other known risk factors for psychosis, when comparing and interpreting subclinical psychotic phenomena across cultural groups