Medicine and Health Sciences Commons^™

Comorbid Psychosis In The General Population, Mariam Sankoh

Theses and Dissertations

Psychosis is a complex psychiatric phenotype characterized by substantial heterogeneity in symptom presentation, psychosis diagnosis, comorbidity patterns, and genetic architecture across diverse populations in the general population. Despite advances in psychiatric epidemiology and genomics, important gaps remain in understanding how psychosis symptoms and psychosis-related diagnoses manifest across racial and ethnic groups and how evolutionary genomic factors may contribute to disease risk and cross-ancestry genetic prediction. This dissertation, Characterizing Comorbidity in Psychosis in the General Population, integrates epidemiological, psychometric, and evolutionary genetic approaches to examine psychosis across diverse populations.

Aim 1 examined racial and ethnic differences in psychosis comorbidity patterns …

What’S Sleep Got To Do With It? A Mixed Methods Exploration Of The Feasibility, Acceptability, And Initial Outcomes Of Group Cbt For Insomnia In Parkinson’S Disease, Claire M. Williams

Theses and Dissertations

Parkinson’s disease is a progressive neurodegenerative disease that is commonly associated with sleep disturbances, affecting up to 80 percent of individuals with Parkinson’s. Effective and accessible treatments for sleep problems in Parkinson’s disease remain limited. Cognitive Behavioral Therapy for Insomnia (CBTi) is a well-established, non-pharmacological treatment for insomnia but has been minimally studied in Parkinson’s populations. This study evaluated the feasibility, acceptability, and preliminary outcomes of a group-based CBTi intervention adapted for individuals with Parkinson’s disease. Participants engaged in a six-week group intervention that incorporated Parkinson’s-specific adaptations. Preliminary findings indicated that the adapted group CBTi intervention was generally feasible and …

Survivors Of Historical Intergenerational And Familial Trauma Scale For Black American Descendants Of Enslaved People: A Development And Initial Validation Study, Loryn Chás Kimbrough

Graduate Research Theses & Dissertations

Despite extensive research documenting cultural and racialized trauma, no validated assessment tool had previously captured the intrafamilial mechanisms of trauma transmission specific to the BADEP population, whose trauma lineage is rooted in slavery. The present study addresses this gap through the development and initial validation of the Survivors of Historical Intergenerational and Familial Trauma Scale (SHIFTS), a culturally grounded instrument designed to measure the transmission of historical trauma (HT) and ongoing intergenerational trauma (IGT) among Black American Descendants of Enslaved People (BADEPs). The SHIFTS examines how HT gives rise to the continued transmission of two interrelated legacies: survival-based and trauma-rooted …

The Impact Of Medicaid Policy Limitations On Access To Eating Disorder Treatment: Uncovering The Consequences Of A System Built To Fail, Meghan Frost

DSW Capstone Projects

Individuals who rely on Medicaid face major barriers when trying to access eating disorder (ED) treatment, reflecting broader patterns of structural disadvantage in publicly funded health care. Research shows delayed diagnosis, limited access to ED specialists, and frequent denials for recommended services. These gaps occur because Medicaid policies do not match the needs of evidence based ED care, resulting in delayed or incomplete care for many individuals with eating disorders.

This issue is highly relevant to social work practice because the policies shaping these barriers are complex and difficult for clients and ED providers to navigate. Social workers across clinics, …

Improving Pediatric Emergency Department Lethal Means Safety Documentation Rates For Adolescents With Mental Health Concerns, Cassandra L. Stegall, Ana-Maria Mcgill, John Fanton, Paul C. Mullan

Department Psychiatry & Behavioral Science Faculty Publications

Introduction:

Lethal means safety counseling (LMSC) is recommended for children presenting to the emergency department (ED) for a mental health (MH) evaluation. Currently, no gold-standard guidelines exist for documenting LMSC in the ED.

Methods:

This quality improvement project was conducted in the ED of a tertiary children's hospital. Baseline data were analyzed for access to any LMSC documentation (ALD) for "firearms/guns," "sharps," or "medication," and for complete LMSC documentation (CLD) if access to all 3 types was documented. The first intervention period added open-ended screening questions about access to lethal means to the MH-licensed clinical social worker note template. Intervention …

Examining Firefighter Perceptions Of Stress And Recovery Across A Shift And Engagement In Recovery Activities, Nathan T. Ebersole

College of Graduate Studies: Theses & Dissertations

The occupational demands of firefighting, such as fire suppression and rescue tasks, working in hazardous conditions, inconsistent sleep patterns, and exposure to traumatic events, can lead to work-related injuries, burnout, and feelings of isolation. To date, there is limited research on the impact of a single work-shift on firefighter perceptions of stress and recovery and the recovery activities that may influence these perceptions. Thus, the purpose of this study was to examine the effect of a single work-shift on firefighter perceptions of stress and recovery status as well as the recovery activities firefighters choose to engage in. Forty-three firefighters across …

A Delphi Study Of Ethical Best Practices For Psychedelic Assisted Therapy, Alyssa K. Griskiewicz

Antioch University Dissertations & Theses

The purpose of this Delphi study was to establish areas of ethical consensus regarding psychedelic-assisted therapy (PAT) from the perspectives of an expert panel of practitioners, with attention to issues of equity and access. Participants (N = 29) include individuals with two or more years of experience in one or more of the following domains of psychedelic expertise: clinical/professional practice, scholarly/research contributions, or guided community/ceremonial facilitation. In Round 1, qualitative data were collected through open-ended questions and analyzed using thematic analysis to generate Delphi statements. In Round 2, panelists (N = 24) rated these statements using a Likert-type scale to …

Cross-Domain Identity Development In Bipoc Autistic Adults: A Grounded Theory Study, Ginnylyne Mariano Guisadio

Antioch University Dissertations & Theses

Racial and autistic identity development both involve navigating stigma, seeking community, and contending with dominant frameworks that constrain authentic self-expression, yet existing research has not examined how these processes interact for individuals holding both identities. These interactions unfold within structural conditions such as diagnostic disparities, culturally specific ableism, and racialized consequences of visible autistic expression, which shape how identity development proceeds for BIPOC autistic adults. This study investigated whether and how the core identity processes of exploration and commitment proceeded for this population. Nine BIPOC autistic adults participated in written interviews analyzed through constructivist grounded theory, with identity status theory …

Startle Habituation And Vagally Mediated Heart Rate Variability Influence The Use Of Emotion Regulation Strategies, Xiao Yang, Fang Fang, Angela Ximena Babb

Psychology Faculty Publications

Emotion regulation refers to the processes through which people modulate their emotional experiences and expressions, and difficulties in these processes underpin many forms of psychopathology. According to the process model, emotion regulation encompasses five classes of strategies, commonly grouped into antecedent-focused strategies (e.g., cognitive reappraisal) and response-focused strategies (e.g., expressive suppression). These strategies involve both explicit and implicit processes, which can be objectively assessed using physiological indices. The present study examined the effects of startle habituation and vagally mediated heart rate variability (vmHRV) on the use of cognitive appraisal and suppression. Forty-nine college-aged participants were recruited, and their resting heart …

Gaze Transition Entropy And Automation Trust In Multitasking Workspace, Yusuke Yamani, Austin Jackson, Tetsuya Sato, Feyishola Ashimi, Michael S. Politowicz, Eric T. Chancey, Makoto Itoh

Psychology Faculty Publications

Safe flight operation requires visual scanning across multiple displays in a cockpit, which collectively represent the state of the aircraft and supporting automation. Trust is a crucial factor that drives human-automation interaction, and recent work has suggested a relationship between an operator's visual attention and automation trust. One index that captures predictability of eye movements between different areas of interest is gaze transition entropy. The current work reanalyzed data from Sato et al., which examined eye movement patterns and trust in automation associated with the system monitoring task of the Multi-Attribute Task Battery. Results showed credible positive correlations between the …

Parental Psychological Distress And Perceived Child Externalizing Behaviors: Examining Mediators And Bidirectional Effects, Abigail J. Anderson, Christina M. Rodriguez, James M. Henson

Psychology Faculty Publications

Parental psychological distress is a commonly examined risk factor for the emergence of child problem behaviors, but the factors that contribute to that relationship—such as limited parental resources like greater social support and coping skills—have not been adequately explored, particularly with attention to potential bidirectional relations that incorporate child evocative effects. The current longitudinal study examined maternal and paternal psychological distress in relation to perceived child externalizing behaviors, considering parental resources as mediators within a bidirectional model. The sample included a racially and socioeconomically diverse group of 201 primiparous mothers and 151 fathers. Mothers and fathers reported their current psychological …

I Can't Stop: The Effects Of Psychological Climate For Overwork On Recovery Experiences, Jeffrey Drake Terry, Konstantin P. Cigularov

Psychology Faculty Publications

Recovery experiences are important for many health and well-being outcomes. One potential threat to an individual's recovery experiences in the workplace is psychological climate for overwork. The purpose of the present study was to examine the relationship between psychological climate for overwork and recovery experiences. Using a multi-wave research design (N = 202), we found that psychological climate for overwork had direct effects on psychological detachment and indirect effects on psychological detachment and relaxation through cognitive workaholism and work-recovery guilt. These results suggest that psychological climate for overwork may contribute to an individual's experience of cognitive workaholism and work-recovery guilt, …

Maternal Child Maltreatment And Intimate Partner Violence: Effects On Perceptions Of Infant Temperment And The Mediating Role Of Emotion Regulation And Responsiveness, Jewelian N. Fairchild, G. Anne Bogat, Amy K. Nuttall, Alytia A. Levendosky, Joseph S. Lonstein, Maria Muzik

Psychology Faculty Publications

Purpose

Maternal adverse experiences, such as maltreatment in childhood and later intimate partner violence (IPV) during pregnancy, can disrupt the mother-child relationship and influence maternal perceptions of infant temperament. The present study explored how these adversities influence mothers’ views of their infants’ temperaments and examined the role of maternal emotion regulation and responsiveness to their infants as mediators of these relationships.

Methods

Using data from a longitudinal study of highly stressed, vulnerable women, 355 mothers retrospectively reported on their own childhood maltreatment, as well as their experiences of IPV and emotion regulation during pregnancy. Maternal responsiveness was coded using mother-infant …

From Molecules To Minds: Integrative Multi-Omics In Psychiatry, Hossein Abbasi, Sage E. Hawn, Arash Javanbakht, Soraya Seedat, Kyle Bourassa, Sinead M. Sinnott, Antonia V. Seligowski, Sian Hemmings, Nathan A. Kimbrel, Alicia K. Smith, Leslie Brick, Divya Mehta

Psychology Faculty Publications

Psychiatric disorders are biologically complex conditions arising from interactions across genomic, epigenomic, transcriptomic, proteomic, metabolomic, and metagenomic layers. Single-omics approaches rarely capture more than a fraction of the variance in complex conditions, underscoring the importance of integrative multi-omics frameworks. This mini-review summarizes key methodologies and their application in psychiatric research, with a focus on systems-level integration of genomic risk scores, transcriptomic networks, and neuroimaging data to advance biological understanding of disorders such as depression, schizophrenia, and Alzheimer’s disease. We also outline the infrastructural requirements for effective multi-omics research, including standardized biobanking, Laboratory Information Management Systems, adherence to FAIR data principles, …

Advancing Models Of Ptsd-Aud Comorbidity: Protocol For A Multimethod Framework Using Genetics And Ecological Momentary Assessment, Elizabeth A. Stinson, Samhita Lellapalli, Sage E. Hawn, Natalie Merrill, Lance M. Rappaport, Christina M. Sheerin, Vasiliki Michopoulos, Silviu-Alin Bacanu, Roseann E. Peterson, Abigail Powers, Ananda B. Amstadter

Psychology Faculty Publications

Background: Posttraumatic stress disorder (PTSD) and alcohol use disorder (AUD), which are moderately heritable, frequently co-occur and contribute to significant public health burdens, particularly among economically disadvantaged urban communities. There are noted sex differences in PTSD and AUD outcomes, with evidence suggesting women have heightened susceptibility to stress-related alcohol use. Preliminary PTSD-AUD ecological momentary assessment (EMA) findings support bidirectional associations across clinical outcomes. However, no studies to date have used PTSD-AUD comorbidity models as organizing frameworks to examine the temporal ordering and stability of within-person symptom dynamics underlying the maintenance or exacerbation of PTSD and AUD symptoms, including bidirectional and …

A Real-Time Examination And Comparison Of Differentiation Among Suicidal Thinking And Affect Items In An Adolescent Sample, Elizabeth A. Edershile, Kinjal K. Patel, Annabelle M. Mournet, Richard T. Liu, Catherine R. Glenn, Evan M. Kleiman

Psychology Faculty Publications

Suicide risk assessments require individuals to differentiate among types of suicidal thoughts (e.g., passive vs. active); yet most research relies on aggregate metrics that obscure this differentiation. Indeed, more severe forms of suicidal thinking are thought to involve the simultaneous experience of multiple forms of thoughts at high intensities. The present study draws on concepts from the affect differentiation literature to (a) examine different ways to operationalize differentiation in suicidal thinking and (b) compare differentiation in suicidal thinking with differentiation in affect. Adolescents (N = 200) recently hospitalized for suicidal thoughts and behaviors completed a 28-day ecological momentary assessment …

Examining The Factor Structure And Subgroup Invariance Of The Deliberate Denial Of Disordered Eating Behaviors Scale, Lindsay Howard, Sage Hawn, Kayla D. Pitchford, Riley Mcgrath, Aubri Farniok, Arturo Sesma, Kristin E. Heron

Psychology Faculty Publications

The denial, concealment, or omission of disordered eating behaviors has received limited attention in the eating disorder literature, partly due to the lack of reliable and valid measures. This study re-examined the factor structure of the Denial of Disordered Eating Behaviors Scale (DDEBS-12) and tested measurement invariance across gender identity, racial identity, and levels of disordered eating in a non-clinical undergraduate sample (N = 3285). Confirmatory factor analyses did not support the original unidimensional structure. Instead, a seven-item model assessing denial of dietary restriction demonstrated the best fit and was renamed the DDEBS-restriction. The revised scale showed good internal consistency …

Rude Awakening: An Examination Of The Incivility-Sleep Relationship Via Affect, Mallory A. Mccord, Gargi Sawhney, Nastassia M. Savage, Kristen M. Fisher

Psychology Faculty Publications

Despite the prevalence of incivility at work and the essential nature of sleep, study of this relationship is comparatively sparse in the organizational sciences literature. Further, although impaired sleep could logically impact how one interprets subsequent interpersonal interactions at work, the dominant approach is to study sleep as an outcome of perceived incivility. Therefore, we drew upon affective events theory, the affect-as-information hypothesis, and sleep physiology to argue that state affect, both positive and negative, can explain the relationship between perceived incivility and sleep quality in either direction. The hypotheses were tested using a between-subjects design with one-month time lags …

Best Practices For Using Biological Data In Psychological Research, Sage E. Hawn, Sinead M. Sinnott, Alicia K. Smith, Kyle Bourassa, Leslie Brick, Sian Hemmings, Soraya Seedat, Arash Javanbakht, Lauren Smith, Antonia V. Seligowski, Nathan A. Kimbrel, Divya Mehta, Hossein Abbasi, Erika Wolf

Psychology Faculty Publications

Advances in statistical techniques for analyzing biological data have driven the need for larger sample sizes, which are ultimately made possible through team science efforts. Findings from these efforts have led to a significant shift in approaches to biological data collection over the past decade, from traditional approaches relying on single measures or assays collected by individual investigators in small lab-based studies to high-dimensional methodologies embedded within large cohorts or multi-site studies. These recent large scale consortium efforts necessitate careful consideration across the full data pipeline, from pre-data generation and sample collection to processing and statistical analysis, while addressing challenges …

Comparison Of Mental Illness Comorbidity Pre-Pandemic Vs. Pandemic-Era And Associations With Clinical And Demographic Characteristics For Virginia Public Hospital Inpatient Discharges With A Substance Use Disorder, Marilyn Bartholmae, Tharidu Gunawardena

Department of Medicine Faculty Publications

The rise in mental illnesses after the COVID-19 pandemic is well documented. However, it is not known whether the rates of mental illness comorbidity increased. The objectives of this study were to compare mental illness comorbidity rates before and after the pandemic among inpatients with SUD and to test associations between mental illness comorbidity, physical illness, and demographics. We used a retrospective cross-sectional design in a sample of inpatient discharges (N = 233,017) at Virginia public hospitals from January 2018 to December 2022. We used Z tests to compare rates of mental illness comorbidity pre- and post-pandemic and Chi-square tests …

Criterion Validity Of The Functional Status And Pain Assessment Scale Versus Pain And Length Of Stay In Hospitalized Adults With Scd, Wally R. Smith, Daniel M. Sop, Yue May Zhang, Margaret S. Guy, Rehan Qayyum

Department of Medicine Faculty Publications

Objectives

In prior research we demonstrated face, construct, discriminant, and preliminary convergent validity of the newly developed, 10-item Functional Status Pain Assessment (FSPA) scale (0-50) in adult SCD patients hospitalized with VOC. We aimed in this study to further demonstrate criterion validity of the FSPA.

Methods

This was a prospective observational study of 561 daily functional and pain assessments from 91 hospitalized adults with SCD from January 2018 to June of 2019. Principal Component Analysis (PCA) Partial Least Squares (PLS) models determined the relationship between LOS, pain intensity, and FSPA. A Generalized Linear Model (GLM) to quantified the impact of …

Persistent Peristomal Pain Due To An Exposed Cutaneous Nerve, Iain Noel Encarnacion, Kaylin Beiter, Natasha Hakkal, Emily Hejazi, Paul Hernandez, Melissa Laughter, Shannon Nugent, Samir Thaker, Xiaowei Xu, Misha Rosenbach

Department of Medicine Faculty Publications

[Introduction]

Case description

A 25-year-old woman with a history of ulcerative colitis treated with multiple abdominal surgeries complicated by peristomal pyoderma gangrenosum (PPG) presented with severe peristomal pain and ulceration. Treatment course was complicated; disease control was achieved via combination infliximab 10 mg/kg every 4 weeks, corticosteroids (topical triamcinolone 0.1% ointment, intralesional 10 mg/ml injections, and oral prednisone 30 mg daily with a gradual taper), and cyclosporine 125 mg tapering by 25 mg every 3 weeks, ultimately tapered to infliximab monotherapy.

Regional Pain Is Associated With Functional Performance In People With Parkinson's Disease, Ryan P. Duncan, Monica R. Hendricksen, Luke Ekdahl, Kevin Smaller, Benjamin Friedman, Miriam R. Rafferty

Department of Medicine Faculty Publications

Background and Purpose:

Little is known about how pain influences physical function in people with mild Parkinson disease (PwPD). The purpose of this study was to investigate the association between physical function and pain presence, location, and intensity in PwPD who were evaluated in an early physical therapy program.

Methods:

Retrospective cross-sectional analysis of electronic medical records from patients with PD evaluated at a single center (2016-2023). Pain presence, location, and intensity (0-10 scale) were recorded at the initial physical therapy evaluation. Functional outcomes included 5-time sit-to-stand, 10-meter walk test, 6-minute walk test, timed up and go, mini-BESTest, and Functional …

Accessing Campus Mental Health Services In A Nigerian Southwestern University: Barriers To Academic Success, Caroline Dada

Electronic Theses and Dissertations

Mental health disorders are a significant health concern among higher education institutions in sub-Saharan Africa, including Nigeria. A substantial treatment gap exists in the Nigerian healthcare system, and this gap is further worsened by cultural and religious barriers, which reinforce stigma that discourages students from seeking professional help. This qualitative narrative inquiry explored the barriers students encountered when accessing mental health services at a university in Southwestern Nigeria, to increase service access. Qualitative semistructured interviews were conducted with seven professional mental health providers at a university counseling center between March and April 2025. Inductive thematic analysis was used to identify …

The Effects Of Meditation On Compassion And Cultural Humility In Mental Health Professionals, Jamie Kostek

Antioch University Dissertations & Theses

The purpose of this study was to examine the effects of a brief, secular, Buddhist-inspired meditation program on self-compassion, compassion for others, and cultural humility on mental health professionals. Using a single-group pretest-posttest design, licensed clinicians (N = 13) participated in a five-week Anytime Anywhere Meditation (Tergar International, 2024) program. Results indicated statistically significant increases in mindfulness, self-compassion, and cultural humility. Additionally, strong positive correlations were found between mindfulness and self-compassion, and between self-compassion and compassion for others. Findings suggest that brief, secular meditation programs rooted in traditional Buddhist practices may support both clinician well-being and culturally responsive practice.

The Lived Experience Of Tenders Of Community Grief Rituals, Margaret Y. Wilson

Antioch University Dissertations & Theses

The purpose of this research study is to gain an understanding of the lived experience of tenders of community grief rituals, and how tenders make meaning of their experiences. This study utilized photo elicitation and a reflexive thematic analysis. Participants (N = 11) provided one to three photographs that captured their experience of grief and/or tending grief rituals. The results identified 10 themes supported by subthemes: (a) Grief Tender Wisdom About the Nature of Grief, (b) Life’s Many Experiences are Sources of Grief, (c) The Multifaceted Impacts of Grief-Body, Anger, Compassion, Empathy, Resilience, Gratitude, Joy, and Love, (d) The Nuances …

The Lived Experience Of Survivors Of Narcissistic Abuse, Jessica Williams

Antioch University Dissertations & Theses

The purpose of this study is to explore the lived experiences of narcissistic abuse survivors through a grounded theory approach to generate a model that can assist people in recognizing patterns and traits of narcissistically abusive relationships. Guided by relational-cultural theory, this study further seeks to examine the ways narcissistic abuse damages relational connections and to highlight elements of healthy, growth-fostering relationships. The population of focus included self-selected narcissistic abuse survivors who are adults over the age of 18 (N = 8). The results indicated three themes, each with additional subthemes, which include: (a) early behavior – performative displays and …

The Use Of Mindfulness In Empirically Supported Treatments In Psychology, Timothy Stewart

Antioch University Dissertations & Theses

After gaining popularity in the United States of America (USA) in the 1960s and 1970s, Buddhist mindfulness was introduced to clinical psychology and investigated for its potential psychological healing effects. In the years since, mindfulness has been widely used in empirically supported treatments (ESTs) in clinical psychology in the USA to treat a wide variety of psychological conditions and disorders. This dissertation examines and compares conceptualizations and implicit understandings of mindfulness in early (Theravāda) Buddhism and in ESTs in clinical psychology in the USA. Through textual narrative analysis of two Buddhist sutta and 10 clinical psychology journal articles, this study …

Beyond The Rabbit Hole: Dmt, Death, And The Hereafter, Abby Molina

Antioch University Dissertations & Theses

This dissertation explores a proposed relationship between death and N,N-dimethyltryptamine (DMT) within the context of contemporary clinical psychology and the current psychedelic renaissance. Building on Rick Strassman’s hypothesis that DMT may be released at the moment of death and Imants Barušs’ conceptualization of death as an altered state of consciousness, this project examines the phenomenological similarities between DMT-induced experiences (psychedelic “trips”) and near-death experiences (NDEs). Through review of neurobiological research, psychedelic-assisted therapy literature, religious and cultural ceremonial practices, and documented DMT trip and NDE reports, this work evaluates the plausibility that endogenous DMT contributes to altered states of consciousness observed …

The Interplay Between Loneliness, Cortisol, And Nk Cell Function: The Role Of Cortisol In Nk Cell Dysfunction, Abhinav Saurabh, Yvonne Baumer, Laurel G. Mendelsohn, Elizabeth M. Aquino Peterson, Dana Sadler, Shirley J. Lopez De Leon, Ayushi Dave, Andrew S. Baez, Lola R. Ortiz-Whittingham, Mario A. Pita, Manuel A. Cintron, Hannatu A. Tarfa, Sandy T. Reynolds, Shelby R. Hicks, Sonal Sharda, J. Eleanor Seo, Maria Lopez-Ocasio, Pradeep K. Dagur, Skyler A. Kuhn, Neelam R. Redekar, James F. Troendle, Ayanna L. Wells, Marie Marah, Katherine J. Tolentino, Michael J. Corley, Alika K. Maunakea, Lynnette K. Nieman, Marcus R. Andrews, Tiffany M. Powell-Wiley

Department of Biomedical and Translational Sciences Faculty Publications

Chronic psychosocial stressors contribute to cardiovascular disease (CVD) and related risk factors, particularly in under-resourced communities. Psychosocial stressors activate the hypothalamic-pituitary-adrenal (HPA) axis, leading to sustained cortisol action on immune cells. Natural killer (NK) cells are altered in distribution and function in cardio-metabolic diseases; however, pathways linking cortisol as a marker of chronic stress to NK cell dysfunction remain understudied. We recruited 186 African American women from the Step It Up Community-Engaged, Digital Health Physical Activity Intervention study and collected cortisol, NK cell measures, and psychosocial stress measures using validated questionnaires, including chronic stress and loneliness. Plasma cortisol levels were …