Social exclusion as an acute psychosocial stressor in schizophrenia: impact on pathophysiology and social cognition

Project Information

SimpSoCoS

Grant agreement ID: 101030864

DOI

10.3030/101030864

Project closed

EC signature date 21 April 2021

Start date 1 March 2022

End date 31 July 2025

Funded under

• EXCELLENT SCIENCE - Marie Skłodowska-Curie Actions

Total cost

€ 259 398,72

EU contribution

€ 259 398,72

Coordinated by

UNIVERSIDAD DE ALCALA
Spain

Periodic Reporting for period 1 - SimpSoCoS (Social exclusion as an acute psychosocial stressor in schizophrenia: impact on pathophysiology and social cognition)

Reporting period: 2022-03-01 to 2025-02-28

Summary of the context and overall objectives of the project

Schizophrenia (SZ), one of the most stigmatised mental health conditions, deeply affects a person’s self-esteem, relationships, and overall quality of life. It often disrupts social connections, employment, and independence.

This project focuses on social cognition (SC)—the mental processes that help us understand and connect with others. Two key abilities are emotion recognition (the capacity to read, understand and regulate emotions) and Theory of Mind (the ability to imagine what others might think or feel). Difficulties in SC often appear before other symptoms of SZ and can explain many of the challenges people with a DxoSZ face. However, SC difficulties can also occur in people without a psychiatric diagnosis. Understanding how everyday social stress shapes these processes could lead to more supportive interventions.

People with SZ often find it harder to adapt to sudden stressful situations, reporting stronger feelings of fear. They also show higher heart activity and cortisol levels at rest, reflecting the long-term impact of chronic stress. Prolonged exposure to stress can affect almost every system in the body, increasing vulnerability to mental, cardiovascular, and metabolic conditions. Acute stress, a threat to well-being, elicits different bodily and mental processes, mobilise energy and promote flexible responses to changing contexts. The brain areas involved in managing stress are closely linked to those that mediate SC.

Thus, the main goal of this project is to better understand how responses to social stress influence the way people with a diagnosis of schizophrenia (DxoSZ) process social information. To explore this, I compared responses from people with and without a DxoSZ before and after an experimental situation of social exclusion designed to feel realistic and serve as a meaningful psychosocial stressor.

Work performed from the beginning of the project to the end of the period covered by the report and main results achieved so far

We developed the verbal Cyberball (vCB) — a group conversation designed to simulate social exclusion, similar to everyday situations. In this task, one participant and two trained actors discussed their favourite movies for eight minutes. At first, the participant was included in the conversation, but as it went on, the actors gradually excluded them.

We obtained the following preliminary results:

We assessed with a questionnaire how stressed participants felt. The vCB didn’t cause big changes in distress levels for either group. However, people with a DxoSZ tended to feel slightly more stressed before the task, while control participants showed that small increase afterward.

Heart activity recordings showed that before the vCB, participants with SZ showed higher alertness and lower relaxation. These differences faded by the end of the session. For controls, the stress task triggered a short, healthy burst of activation followed by a quick return to calm — a typical stress response. Patients, instead, showed no response and gradually became more relaxed over time, consistent with their reports of feeling calmer as the session went on.

We also measured cortisol in saliva samples collected during the session. Both groups started with similar cortisol levels, but in control participants their cortisol rose briefly and then returned to normal. This suggests they experienced social exclusion as a brief threat. In contrast, patients showed lower cortisol changes in response to vCB, which may suggest their stress system has become less sensitive after repeated experiences of social exclusion in daily life.

The vCB influence how people recognized certain emotions in photos of facial expressions. After the vCB, controls became slightly better at recognizing fear, while patients found it a bit harder. Sadness, an emotion not linked to threat, was a bit more difficult for everyone to recognize after the stressor.

We also tested Theory of Mind (ToM) using a task based on short stories. Both groups performed similarly, and the vCB didn’t change this overall, though some people improved slightly while others found it a bit harder

Finally, we also asked about childhood experiences, which can affect how the body and mind respond to stress later in life. Based on a questionnaire, both groups had faced challenges, but patients reported more frequent emotional abuse and neglect. Some patients also mentioned other difficult experiences, such as bullying or abuse of power at school, work, or during military service.

We will also analyze other factors that might influence the results — such as age, medication, illness duration, number of hospitalizations, symptom severity, daily functioning, early-life stress, and perceived social support. These analyses will help us better understand the differences between individuals in both groups.

Progress beyond the state of the art and expected potential impact (including the socio-economic impact and the wider societal implications of the project so far)

Earlier studies showed that people with SZ often struggle to recognize facial emotions, but little was known about how social stress might influence this. In our study, after the vCB, control participants improved slightly fear recognition, while patients found it a bit harder. Control participants perceived vCB as more threatening, likely activating brain functions that help detect danger and pay attention to fear cues. In contrast, patients seemed to find the task only mildly stressful, showing weaker stress responses and likely, less activation of these brain functions, which could make it harder for them to recognize fear.

When it came to sadness—a non-threat emotion—both groups found it slightly harder to recognize after the vCB. This suggests that everyone, not just patients, may have engaged similar mental processes to cope with the social tension. These include recalling personal experiences of exclusion, trying to understand what others were thinking or feeling during the task, and using emotional or attentional strategies to manage their reactions — processes that have been linked to reduced ability to recognize sadness.

Regarding ToM both groups performed similarly before and after the task. The vCB affected people differently: some improved, while others found it harder. Although many studies report ToM difficulties in SZ, our findings suggest that this ability may change, rather than remain fixed, depending on personal history, personal perception of safety, and the specific context, rather than being a fixed trait. These factors shape people’s ability to use ToM.

The absence of major differences between groups may be because the patients in our study had mild symptoms and good stability. Social and emotional skills can vary with context, past and current experiences, cognitive abilities and perception of safety. Rather than a general deficit, people with SZ may face specific challenges in reading emotions or understanding others during ambiguous or stressful situations—even when these arise unintentionally in research settings. The trust and comfort built during the study sessions likely helped participants perform at their best.

These findings have major socioeconomic implications. People with a DxoSZ may develop a less sensitive stress system after repeated social exclusion. This “blunting” can reduce their natural resilience and ability to cope with stress. Yet, when they are in supportive and safe environments, they can perform social and emotional tasks well. Creating spaces that foster trust and inclusion — in clinic, work, and communities — can strengthen well-being, reduce stigma, and lower the social and economic costs of isolation and chronic stress.

Social stress and understanding others in people with schizophrenia